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Chairside Magazine Volume 1, Issue 3 - Glidewell Dental Labs

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<strong>Chairside</strong><br />

A Publication of <strong>Glidewell</strong> Laboratories • <strong>Volume</strong> 1, <strong>Issue</strong> 3<br />

CAD/CAM Technology<br />

Interview with Jim <strong>Glidewell</strong><br />

The State of<br />

Fixed Prosthodontic<br />

Impressions<br />

According to<br />

Dr. Gordon Christensen<br />

Occlusal Splints<br />

Minimal Adjustments<br />

and Case Acceptance<br />

A Case Study<br />

Handling and Explaining<br />

Occlusal Disease<br />

<strong>Dental</strong> Care for Children


Contents<br />

6 The State of Fixed Prosthodontic<br />

Impressions: Room for Improvement<br />

Dr. Gordon J. Christensen takes a look at the state<br />

of dental impressions. He concludes that there is<br />

room for improvement. Here, he presents several<br />

common mistakes made when taking impressions<br />

as well as potential solutions.<br />

12 CAD/CAM PFMs: Interview with<br />

James R. <strong>Glidewell</strong><br />

Computer-aided manufacturing is a hot topic in<br />

dentistry. <strong>Glidewell</strong> Laboratories’ president, CEO<br />

and founder Jim <strong>Glidewell</strong> speaks openly about his<br />

change of heart on the subject, from a skeptic in<br />

the early days to a true believer today. Mr. <strong>Glidewell</strong><br />

talks about the benefits and potential of CAD/CAM.<br />

He says that 10 years from now, 90% of restorations<br />

could be fabricated using CAD/CAM.<br />

20 Portrait of a Technician: Lynda Anderegg<br />

Lynda Anderegg, a technical advisor in <strong>Glidewell</strong>’s<br />

Fixed department, dedicates her time and talent to<br />

<strong>Dental</strong> Care for Children, a nonprofit group that<br />

provides free dental care for orphans in Mexico.<br />

12<br />

25 Clinical Zirconia: Photo Essay<br />

This collection of case photos illustrates the benefits<br />

of Prismatik Clinical Zirconia. We take a look at several<br />

different cases, which presented an array of esthetic<br />

challenges. The beauty of Prismatik CZ is apparent, the<br />

strength is unparalleled, and the patients couldn’t have<br />

been happier with their new smiles.<br />

33 Building the Cosmetic Component<br />

of Your Practice: A Path to Greater<br />

Profitability and Enjoyment<br />

Gary Takacs presents strategies for building the<br />

cosmetic component of your practice. “Helping<br />

patients achieve their cosmetic goals can be quite<br />

rewarding and lead to a renewed enthusiasm in your<br />

work,” Takacs writes.<br />

Cover photo by Kevin Keithley<br />

Illustration by Wolfgang Friebauer, MDT<br />

6


Editor’s Letter<br />

Publisher<br />

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

Contents<br />

Welcome to the third issue of <strong>Chairside</strong> magazine!<br />

Dr. Gordon Christensen, Cofounder of Clinical Research Associates, brings us a<br />

comprehensive article on impression taking called The State of Fixed Prosthodontic<br />

Impressions – Room for Improvement. Dr. Christensen reviews the most common<br />

impression taking mistakes made by dentists and provides some helpful suggestions<br />

for avoiding these problematic errors. I can’t tell you how many of these problem<br />

impressions show up at the lab on a daily basis, but the numbers would surprise you<br />

and I think everyone can benefit from reading this technique rich article.<br />

I was fortunate enough to sit down with Jim <strong>Glidewell</strong>, Chief Executive Officer of<br />

<strong>Glidewell</strong> Laboratories, to discuss the rapid growth spurt of CAD/CAM restorations<br />

in the dental lab industry. I was able to inquire how Jim, as an industry leader,<br />

sees this trend affecting his own laboratories and also the dental laboratory industry<br />

as a whole.<br />

I recently met up with Dr. Anton Misleh who is one of <strong>Glidewell</strong> Laboratories’ top<br />

customers for occlusal splints. It just so happens that Dr. Misleh is a dental school<br />

classmate of mine, and despite our lack of TMD education in school, he has fully<br />

embraced conservative splint therapy. Together, we explore his philosophy on<br />

splints and Dr. Misleh explains how he incorporates them into his practice.<br />

Last month, we featured an article on Prismatik Clinical Zirconia, or CZ for short.<br />

These high-strength all-ceramic restorations are our fastest growing product in the<br />

lab. This month, I am following up on the inquiries I received from that article with<br />

a Clincial Zirconia Photo Gallery. The photo essay gives you a glimpse into my own<br />

dental operatory where patients have elected to seat this popular PFM alternative. I<br />

present some case studies that best exemplify the beauty and natural looking esthetics<br />

possible with these crowns and bridges.<br />

I want to take this opportunity to encourage you to provide us with your feedback.<br />

If you have any comments, questions, or suggestions regarding this issue of<br />

<strong>Chairside</strong> or past issues, please email us at chairside@glidewell-lab.com. We will be<br />

featuring your comments in future issues.<br />

Associate Publisher<br />

Jim Shuck<br />

Editorial Director<br />

Kim Watkins<br />

Creative Director<br />

Rachel Pacillas<br />

Clinical Editor<br />

Michael DiTolla, DDS, FAGD<br />

Designers<br />

Jamie Austin<br />

Jeanne Bogert<br />

Kevin Keithley<br />

Phil Nguyen<br />

Rachel Pacillas<br />

Ty Tran<br />

Copy Editors<br />

Deb Evans<br />

Georgann Gall<br />

Lindsey Lauria<br />

Gary O’Connell<br />

Kim Watkins<br />

Photo Editors<br />

Jamie Austin<br />

Eric Chou<br />

Kevin Keithley<br />

Lindsey Lauria<br />

Rachel Pacillas<br />

Photographers<br />

Kevin Keithley<br />

Ed Pelissier<br />

39 Occlusal Splints: Interview with Dr. Anton<br />

Misleh<br />

Occlusal splints are becoming more integrated in<br />

general dentistry practices. Some say this is an area<br />

with tremendous growth potential for dentists. In this<br />

article, Dr. Michael DiTolla talks with Dr. Anton Misleh,<br />

<strong>Glidewell</strong>’s top occlusal-splint customer. Dr. Misleh<br />

shares his thoughts on the importance of these devices<br />

and offers advice on how the general dentist can implement<br />

them in his or her practice.<br />

49 Seeing is Believing: A Case Study in<br />

Handling and Explaining Occlusal Disease<br />

The use of 3D animation is an extraordinary new<br />

tool for dentists. Dentists can better explain difficult<br />

concepts such as occlusal disease thanks to the<br />

BiteFX program.<br />

60 CAD/CAM Porcelain Fused to Captek<br />

In this article, the symmetry of Captek and CAD/CAM<br />

are explored. Dr. Dean Mersky explains why the beauty<br />

and strength of Captek are enhanced with the use of<br />

this new technology. Captek’s esthetics and biocompatibility<br />

combined with computer-aided design and manufacturing<br />

is redefining the PFM.<br />

49<br />

4<br />

Sincerely,<br />

Illustrator<br />

Wolfgang Friebauer, MDT<br />

39<br />

Dr. Michael DiTolla<br />

Clinical Editor<br />

Editor’s Letter<br />

Contents


Contributors<br />

Gordon J. Christensen, DDS, MSD, PhD<br />

Gordon J. Christensen, DDS, MSD, PhD, is founder and director of Practical Clinical Courses (PCC), an international<br />

continuing-education organization for dental professionals initiated in 1981, and based in Provo, Utah. For many<br />

years, thousands of dentists and dental staff persons have participated in PCC courses, and viewed PCC videos. Dr.<br />

Christensen has presented over 45,000 hours of continuing education throughout the world and has published hundreds<br />

of articles or books. Gordon and Rella Christensen are co-founders of the non-profit Clinical Research Associates<br />

(CRA), which Rella directed for many years. Since 1976, CRA has conducted research in all areas of dentistry and<br />

published the findings to the profession in the well-known CRA Newsletter. The CRA Newsletter is now read throughout<br />

the world in 10 languages. In addition to his education pursuits, Gordon practices in Provo, Utah. Contact PCC at<br />

800-223-6595, or e-mail info@pccdental.com. For more information, visit www.pccdental.com.<br />

Anton Misleh, DDS<br />

Dr. Misleh is a 1988 graduate of the University of the Pacific School of Dentistry. He has been in private practice in San<br />

Diego since ’88. Dr. Misleh is a proponent of using occlusal splints to help preserve the dentition of bruxism patients.<br />

Dr. Misleh has attended various seminars and training sessions on the topic, including a course at the University of<br />

Southern California.<br />

James R. <strong>Glidewell</strong>, CDT<br />

Jim <strong>Glidewell</strong> began his career in dental technology after completing a two-year dental technology program at Orange<br />

Coast College. He formally opened <strong>Glidewell</strong> Laboratories in January 1970, and by 1981, he operated nine laboratories<br />

in Southern California. He has led his laboratories to the forefront of dental technology. Jim has been instrumental<br />

in developing new equipment and techniques with the objective of keeping dental laboratory expenses at a minimum.<br />

An important part of his work began with the creation of the lab’s own in-house Research & Development Department,<br />

which Jim oversees. The R&D team conducts rigorous tests on all materials used in the lab, and also creates innovative,<br />

cost-effective new products.<br />

Don Reid, DDS<br />

Don Reid, DDS, practices dentistry in Lake Tahoe, California. Don believes dentistry is primarily a behavioral science.<br />

His philosophy: A paperless office and complete treatment planning contribute to client/practice success. In addition<br />

to being a recognized speaker, Don is a founder of the “Congress of Microscope Enhanced Dentistry.” He is a member<br />

of the American Academy of Cosmetic Dentistry, International Congress Of Oral Implantology, American Academy of<br />

Implantology, American <strong>Dental</strong> Association and the Organization for Conscious Sedation.<br />

Don was featured in “On Achieving Excellence” by management guru and best-selling author Tom Peters. He has been<br />

a behavioral consultant for Selection Research Institute in Lincoln, Nebraska, and is co-developer of BiteFX Software<br />

for understanding TMJ anatomy and disorders.<br />

Michael DiTolla, DDS, FAGD<br />

Dr. DiTolla is the Director of Clinical Research and Education at <strong>Glidewell</strong> Laboratories in Newport Beach, California.<br />

He performs clinical testing on new products in conjunction with the Research & Development department. <strong>Dental</strong><br />

technicians who work for <strong>Glidewell</strong> Laboratories have the privilege of rotating through Dr. DiTolla’s operatory and<br />

experiencing his commitment to excellence through his prepping and placement of their restorations. He is a CRA evaluator<br />

and lectures nationwide on both restorative and cosmetic dentistry. He also teaches hands-on courses on digital<br />

photography and digital-image editing for the entire team. Dr. DiTolla has several clinical programs available on DVD<br />

through <strong>Glidewell</strong> Laboratories. For information on receiving your free copy of one of Dr. DiTolla’s clinical DVDs,<br />

e-mail him at mditolla@glidewelldental.com or call 800-854-7256.<br />

Dean Mersky, DDS<br />

Dr. Dean Mersky, a 1976 graduate of the University of Detroit School of Dentistry, practiced in Manhattan Beach,<br />

California, for 26 years. Currently, Dr. Mersky serves as the Director of Clinical Communication for Captek.<br />

Dr. Mersky’s dental practice was concentrated in the areas of treatment of the TMJ, dental reconstruction and cosmetic<br />

dentistry. His expertise with Captek restorations comes from the almost 2,000 Captek crowns and bridges that he has<br />

placed, and the many different uses and clinical trials he has contributed to. Dr. Mersky has authored many articles<br />

on the use of Captek and has lectured on the subject for several years. He is a member of the American Association of<br />

<strong>Dental</strong> Aesthetics.<br />

Gary Takacs<br />

Gary’s seminars, highly acclaimed audio and videotape programs, and in-office consulting services have helped many<br />

dentists develop a more profitable and enjoyable practice. Gary frequently addresses dentists and team members at<br />

national dental meetings, regional seminars, and study club meetings in the United States and internationally. His<br />

seminars are recognized for being both highly educational and entertaining. He has published over 250 articles on<br />

practice management in professional publications. His articles have been published in leading journals including<br />

Dentistry Today and <strong>Dental</strong> Economics. Gary is the founder of Ride and Learn, and Race and Learn. With Ride and<br />

Learn, Gary leads a small group of dentists on Harley Davidson motorcycle tours through some of the most scenic<br />

parts of the country several times per year. The group convenes each evening for stimulating CE in the lodge. Gary is<br />

a summa cum laude alumnus of the University of Oregon. He can be reached at 480-951-1652 or gary@garytakacs.<br />

com.<br />

Contributors<br />

Contributors


CAD/CAM Technology<br />

Dr. Michael DiTolla recently had the chance to sit down with Jim <strong>Glidewell</strong>, C.E.O. of<br />

<strong>Glidewell</strong> Laboratories. Jim shares his thoughts on the evolution of CAD/CAM technology<br />

and the effect of this evolution on restorative and cosmetic dentistry. Later in the interview,<br />

Jim provides an historical analysis of CAD/CAM production at <strong>Glidewell</strong> and his vision for how<br />

it will impact laboratory case fabrication in the future.<br />

– INTERVIEW of James R. <strong>Glidewell</strong>, CDT<br />

by Michael DiTolla, DDS, FAGD<br />

– PHOTOS by Kevin Keithley<br />

Michael DiTolla: Good afternoon, Jim. I wanted to ask you first<br />

about CAD/CAM. What was your first exposure to it in the dental<br />

industry and what were your first thoughts on it at that time?<br />

Jim <strong>Glidewell</strong>: The first thing I encountered were crowns that<br />

were manufactured by Francois Duret back in the middle 70’s<br />

when he and Jack Preston were at USC. It was in the mid-<br />

70’s that they were exposing people to this technology. The<br />

technology at that time, I think, had been around about 15-20<br />

years. I think at that point in time there were just too many<br />

problems involved with scanning. The manufacturing of the<br />

part wasn’t as difficult as getting the data into the computer<br />

to manufacture the part. So my first experience was between<br />

1975-1978.<br />

MD: When you saw the technology did it seem like something that<br />

you thought would one day fit into the dental business?<br />

JG: No, I absolutely felt the opposite. I felt that there was no<br />

way you were ever going to be able to duplicate what we do<br />

as technicians with a machine and have it be cost-effective.<br />

Back then, I just didn’t see far enough ahead to see that it<br />

would ever be cost-effective. Today I feel completely different<br />

about it. We don’t have to have the massive computers that<br />

were required 30 years ago. Today we have everything at a<br />

low cost, from software to hardware. All of it seems to be very,<br />

very inexpensive.<br />

MD: I don’t think in the early days that they thought those types<br />

of CAD/CAM systems could mass produce restorations, necessarily.<br />

The rise of the PC from something that took up an entire room to<br />

today’s desktop PC that can do what that computer used to do in<br />

half the time really changed things.<br />

JG: I think it is probably the number-crunching ability of<br />

computers that has changed and the money attached to that<br />

ability. In those days a mini-computer like a Burroughs was<br />

probably a $200,000 - $300,000 investment to run a machine.<br />

Then there was software to be written, which was very pricey<br />

in those days. Today there’s an affordable computer for every<br />

household. In those days, there was not.<br />

MD: I believe Procera was the first milled restoration that<br />

you began doing here at the laboratory. Were you still skeptical<br />

at that point that these types of crowns would ever replace<br />

handmade restorations?<br />

JG: I think Procera is probably the very first thing we ever<br />

outsourced. I didn’t look favorably upon outsourcing because<br />

we were losing control of the product. We found out that the<br />

outsourced quality was equal to ours, after just a few units<br />

were made. It made us very comfortable with outsourcing.<br />

Initially, the thought was that it wouldn’t be equal to what<br />

we do here, from a pride standpoint, probably. We thought<br />

nobody could do it as well as we do it here. In reality, the<br />

results were just as good or better than what we were producing<br />

with alumina at the time.<br />

MD: Now your laboratory has many CAD/CAM machines, including<br />

multiple brands of CAD/CAM, one of which is your own. How<br />

do you feel about the state of CAD/CAM today as opposed to 20<br />

years ago?<br />

JG: I think we’re very, very close to CAD/CAM as a solution to<br />

the “human input” problem that we have. <strong>Dental</strong> technicians,<br />

invariably, put their subjective judgments into every crown,<br />

whereas a CAD/CAM system only interprets its information<br />

digitally and repeats it digitally every time. It has a perfect<br />

recall, if you will. The technicians produce good crowns one<br />

day, then maybe they didn’t feel good the second day – so<br />

each technician’s work can even look somewhat different<br />

from day to day. Then across the spectrum of technicians that<br />

we have here, the up-and-down quality variations are much<br />

more noticeable. With a CAD/CAM system, it tends to reproduce<br />

the same quality again and again.<br />

MD: And you see the words “ceramic artistry” used to represent<br />

what a ceramist can do. Some people appreciate that art and some<br />

people look at it and can’t stand it. It does vary from time to time,<br />

but it sounds like you are saying that the computer will base it on<br />

the ideal anatomy for a certain tooth and the other parameters<br />

that influence the final 3 dimensional form.<br />

JG: My whole career has been based upon the theory that<br />

there really is no artistry in dental technology whatsoever. If<br />

we are to use our artistic ability to change the contours, where<br />

do we place them? How can we make it better than what is<br />

already in the mouth? All we can do is make it different, but<br />

we can’t make it better than what already exists, because that<br />

mouth has been honed by genetics for millions of years. In<br />

my background, I’ve also thought about teeth being a threedimensional<br />

mathematic product. All of a sudden CAD/CAM<br />

comes along and meets exactly where I’ve been trying to go<br />

my whole career. I wanted to find a way to take all the subjective<br />

judgment out of making a tooth and create it strictly<br />

objectively or make it objectively with a machine to have it<br />

produced objectively every time. We could almost eliminate<br />

the Quality Control station if the machine will make that part<br />

– if the software is done right, if all the collective knowledge<br />

went into that software that designed the crown and it was<br />

done correctly, we should not have varying quality at all. Í<br />

CAD/CAM Technology<br />

CAD/CAM Technology


Varying quality is what drives most dentists away because they<br />

seem to get a different product from the laboratory they use<br />

every time, whether it’s a small lab or a large lab. We all fight<br />

for the same thing – consistency of product. Also, as we’ve<br />

found out from a digital standpoint, we can make the occlusal<br />

clearance tolerances and contact tolerances much, much closer<br />

than the human hand can. For me, that’s been the biggest single<br />

breakthrough I’ve seen – the ability to make the contacts<br />

perfect without having a plus contact on one side or a minus<br />

contact on the other side. Contact adjustments are the most<br />

difficult thing to do chairside. Occlusal adjustments are fairly<br />

easy, but contact adjustments are hard. With these CAD/CAM<br />

systems, we can make contacts with precise accuracy.<br />

MD: As a dentist, it makes me feel confident that we somehow now<br />

are able to scientifically address the contact issue. Before, it was<br />

scraping the adjacent tooth just to make sure the contact wouldn’t<br />

be open. Dentists would use floss to check it, technicians would<br />

use articulating paper. We weren’t even using the same standard<br />

to check it. It’s a nice feeling to know that it’s getting more<br />

scientific, as opposed to all of these homespun techniques that<br />

have evolved over the years. One of the more frustrating things<br />

chairside is tight contacts. Yes, they can be adjusted, but it’s very<br />

easy to open a contact and that contact will not close itself. If you<br />

accidentally take a crown slightly out of occlusion, most dentists<br />

will cement that knowing that supereruption will put it back into<br />

occlusion. But that open contact is immediately going back to the<br />

lab and that is frustrating.<br />

JG: I think that when the technicians adjust the contacts, they<br />

leave them tight. They’ve already scraped the adjacent teeth.<br />

When the dentist puts the crown in the mouth, he first adjusts<br />

the distal, then he adjusts the mesial, then he goes maybe<br />

back to the distal if he has the time, or the concentrated effort<br />

to be able to do that in a routine. Invariably at some point he’s<br />

going to adjust the wrong contact at the very end and have<br />

an open contact. It’s just part of the system. So, I can’t believe<br />

what a boom this is for cementations! All of a sudden you’ll be<br />

able to pull a crown out of the box and walk out of the room<br />

knowing you’re mixing the cement.<br />

MD: Of course that assumes that your assistant had proper contacts<br />

on the temporary, something many dentists seem to forget<br />

about. But I do think there is an ideal contact most dentists could<br />

agree on.<br />

JG: Remember I mentioned one time that most dentists are<br />

looking for a tight fit and they check it with a piece of dental<br />

floss. The dental floss, probably, is 75-100 microns in thickness.<br />

So even a 15 micron open contact will give you a very<br />

solid click. You’ll consider that a closed contact at 15 microns<br />

of opening. And for all intents and purposes, it really is. So, if<br />

we can give you a contact that’s 15 microns open mesial and<br />

distal, the crown is going to fall in place and you’ve still got<br />

acceptable contacts.<br />

Scanners create a complete 3D digital reproduction of the prep area.<br />

The 3D System replicates the margins and calculates the occlusion<br />

when we scan the opposing model.<br />

MD: There is at least that much physiological movement of teeth<br />

on a daily basis. You’re right, that would be clinically acceptable.<br />

JG: And we don’t have food particles that are smaller than 15<br />

microns that would cause problems. So I really think that we<br />

are on the verge of a massive change of quality, more than<br />

anything else. I think that scanning and digital manufacturing<br />

are going to improve the quality.<br />

MD: As far as I know, <strong>Glidewell</strong> is the only laboratory that has a<br />

digital manufacturing center. When did you start that and what<br />

have you seen from it so far?<br />

JG: We have started our digital manufacturing in earnest.<br />

In fact, we’ve been doing digital manufacturing in one form<br />

or another for five years. The involvement with Cercon and<br />

the Wol-Ceram systems probably began about five years ago.<br />

Then, about 18 months ago, we hired an industry respected<br />

3D specialist to help put the rest of our systems together – to<br />

marry the software, the hardware and the application into<br />

one workable system. So with the addition of Mervyn Rudgley<br />

from 3D Systems, we started in earnest. We brought in<br />

a software engineer and gave the digital manufacturing<br />

team a really big research budget – probably up to $1 million<br />

in the first year. We decided we were going to spend it on<br />

all the equipment and systems needed. We have had<br />

breakthrough after breakthrough. We’ve been very, very<br />

fast because our specialist has not had to go to a committee<br />

looking for approval. We’re not a publicly owned corporation<br />

where we’re having to drain profits. It’s just that our commitment<br />

to doing this has distinguished us and we’ve grown very,<br />

“I think over a 10-year period of time,<br />

we’ll see a phasing out of traditional porcelain-stacking<br />

technology into digital<br />

manufacturing. I would be surprised if in<br />

10 years less than 90% of all crowns are<br />

fabricated through digital means.”<br />

very rapidly.<br />

MD: And for the dentists who aren’t familiar or haven’t read any<br />

articles about digital manufacturing, can you explain what it<br />

means, for example, how the scanning takes place and how parts<br />

are printed ?<br />

JG: By and large the process starts with a model supplied by<br />

the dentist, created exactly the way things have been created<br />

traditionally. We take that model, scan it and let the system<br />

calculate where the margins are, while creating a complete<br />

reproduction of prep area, the prepped tooth. We also have<br />

the ability to scan the opposing in an articulated acquired centric<br />

mode. From that point we go to a CAD system, which is<br />

Computer Aided Design, and the CAD system software allows<br />

us to design, manipulate with many tools and to fabricate a<br />

digital crown. We transfer that digital crown design from the<br />

software to another system, the CAM operation, which takes<br />

our information and reduces it to machine tool path instructions<br />

and we can either machine a part from this software or<br />

we can go to a printer. It’s a process whereby we print with<br />

a wax-like material an exact replica of the restoration we<br />

designed using the CAD system. We can do that down to a<br />

15 micron accuracy, which is about a quarter of the thickness<br />

of a human hair. With that printed part, we can cast it into<br />

metal or we can press ceramic material into it. Also from the<br />

CAM, we are able to machine mill out of zirconia or metals<br />

a coping or a full-contour crown without even using the wax<br />

process. We can actually machine out a gold part if we want<br />

to as well.<br />

MD: So this new system is totally unlike the Procera system where<br />

you would scan the die, then the coping is made for you offsite<br />

and then returned to you to stack the porcelain on it by hand.<br />

With the CAD/CAM system you’re describing now, the coping is<br />

manufactured digitally from the scan of the master die, and then<br />

the actual contours, the shell if you will, is also digitally manufactured<br />

and then the two parts are assembled.<br />

JG: That’s correct.<br />

MD: To me as a dentist, the shell part, the outer contours of the<br />

crown, are more important to me than the other part – than the<br />

coping. My issue with restorations over the years has been with the<br />

anatomy and esthetics – not necessarily with the fit itself. That is<br />

why I think digital manufacturing is such a big step forward.<br />

JG: Throughout the industry, that’s why making the coping<br />

was a very safe thing to do. It doesn’t have contacts, it doesn’t<br />

have occlusion, it doesn’t have morphology, it doesn’t have<br />

shape. Most all the people involved in the CAD/CAM industry<br />

looked to designing the coping only. Procera is a coping,<br />

Cercon is a coping, Lava and Clinical Zirconia, those are all<br />

just copings. The dentist shouldn’t get up and make a big<br />

deal out of these things. But what we’ve done here is we’ve<br />

advanced on to the process of actually making the superstructure<br />

that goes on top of that – we’ve done that digitally also.<br />

MD: And this one day will include anterior teeth as well?<br />

JG: Yes, absolutely. We should be able to have a complete<br />

host of different shapes and mold sizes much like you see in<br />

a denture mold chart. You would choose the anterior restorations<br />

you want and we could absolutely duplicate that with<br />

this process we’re referring to. Also, the same thing with morphology.<br />

You choose one of your idols and we can take that<br />

type of a gnathological occlusal arrangement, print that out<br />

and have that cast into a ceramic part with absolute fidelity –<br />

like we say within 15 micron tolerances throughout the whole<br />

mouth. Its done very easily compared to the laborious way of<br />

stacking porcelain up or stacking up and carving it back and<br />

having to deal with a 14% shrinkage of porcelain.<br />

MD: Which is why full-mouth cases scare a lot of dentists because<br />

of having to deal with the occlusion. Imagine having a computer<br />

take care of all that for you. And imagine a patient being able to<br />

look at a book of teeth arrangements and smiles, rather than having<br />

a ceramist, by hand, trying to match that, you’d actually be<br />

able to print that pattern right in the computer.<br />

JG: Yeah. I think that would not only save time and money,<br />

but you take the guesswork out. You get to decide with the<br />

patient and have the patient commit to the teeth that they<br />

want. Later on, they have exactly the smile they want. The<br />

patient isn’t going to get a huge shock.<br />

MD: If you had to look 10 years into the future, what<br />

percent of crowns – PFM and All-Ceramic – do you think will be<br />

digitally manufactured?<br />

JG: I think over a 10-year period of time we’ll see a phasing<br />

CAD/CAM Technology<br />

CAD/CAM Technology


you think these crowns, being superior, are they going to be more<br />

expensive, less expensive…?<br />

JG: It has the potential to decrease laboratory prices. I think<br />

anything that gets mechanized and gets away from human<br />

labor tends to become a commodity, much like computer<br />

chips have. You’re going to see a dramatic drop in the laboratory<br />

cost over the next 5-10 years.<br />

MD: How long do you think it will be before the other labs in the<br />

country, starting with the large ones, get involved with this type<br />

of technology?<br />

JG: I think the information age is upon us and they’re already<br />

seeing the light and they know they’ve got three to four years<br />

before they’re going to be left out in the cold. They’ll all be<br />

buying systems. And the systems are going to be fairly inexpensive.<br />

For under $200,000 a laboratory can set up a 3D<br />

printing system and a zirconia design and milling system. I<br />

don’t see it as expensive… Lava is a little on the pricey side.<br />

There’s a lot of great research behind it. But at $230,000 to set<br />

up a lab system, that’s a little on the high side. There’s going<br />

to be a lot of people coming under that price.<br />

The Computer Aided Design software allows us to choose from a<br />

proprietary library of morphology or to design very accurate anatomy<br />

when matching crowns. Proximal contacts are refined by the user<br />

and occlusion is computer-equilibrated.<br />

out of traditional porcelain-stacking technology into digital<br />

manufacturing. I would be surprised if in 10 years less than<br />

90% of all crowns are fabricated through digital means. Í<br />

Only 10%, perhaps the “art” cases, or maybe veneering situations<br />

will not be fabricated by digital manufacturing.<br />

MD: How about single-unit anterior teeth, for example?<br />

JG: Perhaps. Although with our technology we can scan it<br />

today and we can flip the crown over to mirror image the<br />

other side, the morphology becomes very accurate because we<br />

are able to use the anatomy of the adjacent tooth. I’ve always<br />

maintained that if you have the right morphology, the shade<br />

seems to match. If the morphology is off just a little bit, everybody<br />

thinks it’s the shade. If you just match the morphology,<br />

90 percent of the job is done.<br />

MD: If you had to look at the eight criteria that make a restoration<br />

match a natural tooth, shade would probably be No. 4 on the list<br />

of importance.<br />

JG: I would say so.<br />

MD: After contour, shape, size…<br />

JG: At our company, we find that most of the adjustments we<br />

have to do, do not involve shade. They’re mostly poor fits, bad<br />

impressions or whatever. Shade is usually down the list.<br />

MD: What do you think, nationwide, digital manufacturing is<br />

going to do to the average price a dentist pays for a crown? Do<br />

MD: Do you see any connection – direct or indirect – between<br />

digital manufacturing and offshore laboratories?<br />

JG: Offshore laboratories – I think the reason people go there<br />

is that they’re driven by low labor costs. When we look at the<br />

cost of manufacturing offshore vs. the U.S., even though our<br />

labor is much, much higher here, the offshore labs lose a little<br />

in shipping costs. The time lapse is always about an extra<br />

week in turnaround time. Remember, we own two offshore<br />

laboratories, so we’re well aware of what these costs really<br />

are. I’ve always felt that if you had a free crown, an absolutely<br />

free crown, just to get the impression, pour the model, log it<br />

in, put it in a box and send it back out you probably needed<br />

about $50 per crown just to accomplish that – if there was NO<br />

labor involved in the crown, if it was FREE. There’s a transaction<br />

cost of having a box, receiving it, handling it, sending<br />

it out. And then you’ve got your rent and overhead and all<br />

that. If you had free labor, you’d literally have to get $50 for a<br />

crown. People who sell it for underneath that, bless them! But<br />

I think they’re slowly going out of business.<br />

MD: And dentists are familiar with that too because there’s a<br />

cost for having a patient come in and sit down, before you even<br />

do anything!<br />

JG: Absolutely.<br />

MD: Even if you did nothing, CRA estimates that cost at $12-18<br />

just to seat the patient in the chair.<br />

JG: Absolutely the same thing. That’s the transaction cost.<br />

There might be a $30 difference between an offshore crown<br />

and a domestic crown in terms of savings. You might be<br />

paying $30 less for an offshore crown. Of course, some labs<br />

are quite a bit higher than we are – it might be in the $150-<br />

200 range. The average laboratory charges maybe $100 for<br />

CAD/CAM Technology


a crown, and I think that an offshore laboratory needs to get<br />

almost $60. Í<br />

MD: But you’re willing to bet that given the choice between a $60<br />

offshore crown that’s hit or miss every time the dentist gets it and<br />

the $90-100 digital manufactured crown that drops into place<br />

almost every time, that they’re going to be smart enough and like<br />

that consistency enough to be willing to pay for that.<br />

JG: I think the dentist would pay more than the price of an<br />

offshore crown for crowns that fit perfectly every time that<br />

are machine made and not handmade, regardless of where it’s<br />

made – whether overseas or here. But I also think that digital<br />

manufacturing may actually lower the cost to equal the cost of<br />

offshore laboratories. Eventually we might be able to see our<br />

way to offering crowns that are $60 that are actually digitally<br />

manufactured. It’s not here today but we may be looking at it<br />

in the next few years.<br />

MD: That would be the best of both worlds, wouldn’t it?<br />

JG: Yes, a crown that really, really fits and it’s the same price<br />

as an offshore crown.<br />

MD: And it’s built so intelligently that it’s able to be offered at the<br />

same price as the offshore labs offer.<br />

The 3D Printing Machine creates an exact duplicate of the CAD<br />

design and can print down to a 15 micron accuracy.<br />

JG: Exactly. And what if it gets lost in the mail somehow – we<br />

have the digital information to fire it up again. We don’t need<br />

a model or anything. We can work completely in the dark<br />

without any kind of a model.<br />

MD: And you’re also working with a company that is building an<br />

intraoral scanner so at one point, if the dentist was onboard with<br />

you, he could scan it in his office – not even take an impression<br />

– and send you a file and you’d be able to manufacture the crown<br />

simply from that.<br />

JG: We would be able to manufacture a crown from a file<br />

without ever manufacturing a model. We have only a model<br />

that exists in the computer, and it only assists us in design<br />

work. There’s never a physical model.<br />

MD: That’s amazing to think about that. And that saves the doctor<br />

even more money by not having to take that $10 impression.<br />

JG: And it saves us $7 or $8 in shipping costs one way and<br />

a lower shipping amount the other way because we’re not<br />

shipping a pound and a half of plaster back. That is the<br />

future. The future is going to be intraoral scanning and<br />

digital manufacturing.<br />

A proprietary, pre-blended high-strength ceramic is pressed to the<br />

final shape of the printed pattern. The anatomy of the design is<br />

replicated for precise contacts and occlusion. The ceramic esthetics<br />

are fine-tuned to match your Rx.<br />

CAD/CAM Technology


Laboratory<br />

PORTRAIT<br />

Technical Advisor, Fixed Department<br />

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

Acold concrete floor. Poor lighting. Old equipment. Despite<br />

these makeshift conditions, the volunteers work on. They<br />

have traveled hundreds of miles to get here, to this little<br />

orphanage in Maneadero, Mexico. Here, children have come<br />

to anticipate these biannual visits from their friends across the<br />

border.<br />

This is the work of <strong>Dental</strong> Care for Children. Founded by<br />

Dr. Chuck Tozzer some 15 years ago, the mission of this<br />

nonprofit group is to bring quality dental care to less<br />

fortunate children across Mexico. This is the work of Lynda<br />

Anderegg, a <strong>Glidewell</strong> Laboratories technical advisor for the<br />

Fixed Department.<br />

A clinical assistant for more than 30 years, Lynda was ready<br />

for a change. While working at a practice in Mission Viejo,<br />

Lynda read a classified ad in the newspaper that asked,<br />

“Tired of chairside?” She answered to herself, “Yes!” With<br />

that, her career at <strong>Glidewell</strong> Laboratories began. That was last<br />

December.<br />

When Lynda made the move to <strong>Glidewell</strong>, she brought with<br />

her a passion for volunteerism. She made connections at the<br />

lab and began to network with others in her department – and<br />

caught the attention of Jim <strong>Glidewell</strong> himself.<br />

On her next trip to Mexico, in March, <strong>Glidewell</strong> Laboratories’<br />

products and services were part of the program. <strong>Glidewell</strong><br />

donated its Capture Impression Material to aid in the clinical<br />

procedures performed by the <strong>Dental</strong> Care for Children volunteers.<br />

In addition, <strong>Glidewell</strong> fabricated approximately six<br />

product cases for the children treated in Mexico. Í<br />

– ARTICLE by Kim Watkins<br />

– LYNDA ANDEREGG PHOTO by Kevin Keithley<br />

<strong>Dental</strong> Care for Children’s photos,<br />

© 2006 Ray Sanford<br />

Lynda Anderegg, RDA<br />

Title of Article<br />

Laboratory Portrait


Volunteers – dental assistants, dentists and others – see children<br />

ages 3-18 twice a year for dental checkups. The children<br />

have fillings (composites and amalgams) placed. The<br />

crew takes impressions for services such as crowns, veneers<br />

and removables. Dr. Tozzer returns to the orphanage several<br />

weeks later to seat the completed cases. At this point, most of<br />

the children have good dentition, Lynda says.<br />

For many volunteers like Lynda, a bond with the young<br />

patients is formed.<br />

“Many of the kids never get adopted out,” Lynda said. But<br />

there is hope. “Some of the boys have completed their education<br />

and have actually been accepted to American universities.<br />

It just warms your heart to see these underprivileged kids<br />

make something of their lives,” she added.<br />

Now that some of the children have grown and their dentition<br />

improved, the <strong>Dental</strong> Care volunteers make time to treat<br />

the orphanage staff and family members. In total, $28,580 in<br />

dental services was provided during the March 2006 trip to<br />

Maneadero.<br />

The care this seven year old boy receives would be otherwise<br />

financially impossible for him to obtain. Initiating dental treatment<br />

at a young age is important not only to keep his mouth<br />

on a healthy track, but also to start good habits for his future.<br />

<strong>Dental</strong> Care for Children<br />

Lynda, who resides in La Habra, Calif., with her 22-year-old<br />

daughter, wants to expand into even more volunteer work. “I’d<br />

really like to see emphasis and publicity on the local level,”<br />

Lynda says. She loves the work but concedes that, at times, it<br />

isn’t easy. “Sometimes we have to use flashlights because the<br />

lighting isn’t sufficient,” she said. “Sometimes we laugh about,<br />

‘How are we going to do this?’ But we get it done.”<br />

The hard work of <strong>Dental</strong> Care for Children is gaining attention.<br />

On May 12, Dr. Tozzer and <strong>Dental</strong> Care for Children were<br />

recognized by the Soroptomist Club of Huntington Beach. As<br />

for <strong>Glidewell</strong>’s contribution to his program, Dr. Tozzer was<br />

“delighted.”<br />

“Dr. Tozzer thanks <strong>Glidewell</strong> from the bottom of his heart,”<br />

Lynda says.<br />

To learn more about <strong>Dental</strong> Care for Children, or to make a<br />

donation, visit www.dentalcareforchildren.org.<br />

The children shown here<br />

along side the staff of <strong>Dental</strong><br />

Care for Children show their<br />

appreciation in their smiles<br />

after treatment. The benefits<br />

of the dental care come<br />

secondary to the education<br />

and awareness the children<br />

receive on the importance<br />

of good dental hygiene.<br />

Laboratory Portrait<br />

Laboratory Portrait


Prismatik CZ<br />

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

– PHOTOS by Kevin Keithley, Ed Pelissier<br />

Before<br />

After<br />

The search for a high-strength, esthetic, biocompatible<br />

metal-free material that could be used for multi-unit frame<br />

works and single-unit restorations has been the focus of<br />

many R&D efforts during the last decade. Some dentists<br />

have wanted these materials to avoid the use of metals in<br />

the mouth, while most dentists have just wanted to provide<br />

the most esthetic restoration possible. Several materials have<br />

attempted to meet these needs, yet have fallen short of expectations.<br />

Laboratory tests have shown that the fracture toughness<br />

and flexural strength of zirconia are significantly higher<br />

than that of alumina or any other esthetic ceramic. Prismatik<br />

Clinical Zirconia (CZ) is the material used to fabricate zirconia<br />

understructures in the <strong>Glidewell</strong> Digital Manufacturing center.<br />

These CZ restorations meet or exceed the physical and esthetic<br />

properties of other current zirconia systems, while representing<br />

the best value in high-strength all-ceramic restorations.<br />

In the last issue of <strong>Chairside</strong>, we looked in depth at the physical<br />

properties and preparation guidelines for CZ restorations.<br />

In this issue I would like to take a closer look at a number of<br />

these cases rather than just focusing on one. I think you will<br />

see by looking through these cases that Clinical Zirconia is a<br />

versatile material that allows us to conventionally cement an<br />

all-ceramic restoration in nearly all clinical situations.<br />

Prismatik Clinical Zirconia: Photo Gallery


Case A<br />

Case B<br />

Figure 1: Clinical case A is a 37-year-old male<br />

with multiple failing composites, recurrent decay<br />

and broken incisal edges due to parafunctional<br />

activity. For these reasons, CZ crowns were a<br />

better choice than porcelain veneers.<br />

Figure 2: Even though the patient decided<br />

not to treat the entire arch, the CZ crowns on<br />

teeth 7-10 have made a significant esthetic<br />

improvement in his smile. Because of the zirconia<br />

coping, there is no possibility of a gray margin<br />

ever appearing.<br />

Figure 3: The close-up photograph of the CZ<br />

crowns on a black background highlights the natural<br />

incisal edge translucency of these restorations.<br />

The beauty of all-ceramics and the strength<br />

of a PFM is a winning combination.<br />

Figure 1: Clinical case B consists of a full upper<br />

arch of CZ restorations. In addition to the other<br />

esthetic challenges that are present here, notice<br />

the shades of teeth 9 and 10, which have both<br />

been endodontically treated.<br />

Figure 2: The prep shade of the teeth are within<br />

normal limits with the exception of teeth 9 and<br />

10. The discoloration of these teeth presents a<br />

difficult esthetic challenge for all-ceramic restorations.<br />

While I might prefer to use an esthetic<br />

PFM such as Captek, the patient insisted on allceramic<br />

crowns.<br />

Figure 3: This lateral view of the finished restorations<br />

focuses on the discolored teeth, which<br />

have been completely blocked out by the CZ<br />

crowns. With all-ceramic restorations it can be a<br />

challenge to get restorations to blend on a case<br />

like this.<br />

Case C<br />

Figure 1: Clinical case C consists of CZ crowns<br />

on teeth 8 and 9. Due to the dark shade of these<br />

endodontically treated teeth, it is not possible to<br />

use a pressed all-ceramic crown. Zirconia copings<br />

will keep the prep from showing through<br />

regardless of how dark they are.<br />

Figure 2: A digital X-ray of the CZ crowns at<br />

try-in shows how dense the underlying zirconia<br />

copings are; they almost appear to be metal.<br />

The X-ray is also used to verify the fit of the CZ<br />

crowns prior to cementation.<br />

Figure 3: With the CZ crowns backlit, the translucency<br />

of the crowns is apparent even though<br />

the copings are dense enough to block out the<br />

prep shades.<br />

Figure 4: The CZ crowns blend in well with<br />

surrounding dentition, and there is no fear that<br />

one day gray margins will appear if any gingival<br />

recession happens to occur.<br />

Prismatik Clinical Zirconia: Photo Gallery<br />

Prismatik Clinical Zirconia: Photo Gallery


Case D<br />

Case E<br />

Figure 1: Clinical case D is a 31-year-old male<br />

who was born without his left maxillary central<br />

incisor. Because there is no room to place an<br />

implant to replace this missing tooth, CZ crowns<br />

and Vivaneers no-prep veneers were used to<br />

correct the smile.<br />

Figure 2: The CZ crown placed on tooth 10 was<br />

shaped to look like tooth 9. The CZ crown placed<br />

on tooth 11 was shaped to look like tooth 10.<br />

The CZ crown on tooth 8 was reduced heavily<br />

on the mesial to move the midline back to the<br />

right. Vivaneers no-prep veneers were utilized to<br />

complete the smile.<br />

Figure 1: Clinical case E is a 47-year-old female<br />

who has chewed through two cast gold crowns<br />

on teeth 2 & 3. Additionally, tooth 4 has a vertical<br />

fracture through the mesial marginal ridge and<br />

requires a full-coverage restoration as well.<br />

Figure 2: CZ crowns were placed on teeth 2,<br />

3 & 4 with no fear of fracture, due to its proven<br />

clinical record of high strength and longevity.<br />

As a result, all CZ restorations can be cemented<br />

with conventional cements such as 3M ESPE’s<br />

RelyX Luting Cement Plus.<br />

Case F<br />

Case G<br />

Figure 1: Clinical case F is a 29-year-old male<br />

with multiple failing interproximal incisors and<br />

recurrent decay on teeth 7, through 9. Tooth 10<br />

had a failing PFM crown with a gray margin starting<br />

to appear on the facial.<br />

Figure 2: CZ crowns were placed on teeth<br />

7, 8, 9 & 10 to accommodate the patients wish<br />

for “no more metal margins.” Vivaneers no-prep<br />

veneers were used on teeth 4-6 and 11-13 to<br />

finish the smile.<br />

Figure 1: Clinical case G is a 25-year-old female<br />

who had endodontic treatment on teeth 7, 8 & 9<br />

due to accidental trauma. Because of concerns<br />

about the preps turning darker with time, it was<br />

decided to do CZ crowns on these teeth rather<br />

than veneers.<br />

Figure 2: CZ crowns were placed on teeth<br />

7, 8 & 9 and individual Vivaneers no-prep<br />

veneers were placed on teeth 4 through 6, 10<br />

through 13. The combination of all-ceramic<br />

crowns and no-prep veneers is an excellent way<br />

to enhance a smile.<br />

Prismatik Clinical Zirconia: Photo Gallery<br />

Prismatik Clinical Zirconia: Photo Gallery


Case H<br />

Case I<br />

Figure 1: Clinical case H is a 37-year-old female<br />

with an existing PFM on tooth 8 with recurrent<br />

decay. She also doesn’t like how tooth 7 is<br />

severely rotated.<br />

Figure 2: CZ crowns were used on teeth 7 & 8<br />

to improve the alignment and esthetics. We used<br />

Vivaneers no-prep veneers on teeth 4, 5, 6, 9, 10,<br />

11 & 12 to complete the smile makeover.<br />

Figure 1: Clinical case I is a 47-year-old female<br />

who was unhappy with several aspects of her<br />

smile. Her chief complaint was a PFM bridge<br />

from teeth 5-7 that had exposed metal margins<br />

on both abutments.<br />

Figure 2: An all-ceramic CZ bridge was placed<br />

on teeth 5-7 and single-unit CZ crowns were<br />

placed on 8 through 12. The patient no longer<br />

covers her mouth with her hand when smiling.<br />

Case J<br />

Figure 1: Clinical case J is a 43-year-old male<br />

with multiple failing PFM crowns. Also, tooth 7<br />

needs to be removed due to a failed endodontic<br />

re-treatment. Due to the patient’s dislike of<br />

exposed metal margins, we decided to use allceramic<br />

CZ restorations.<br />

Figure 2: We placed a three-unit CZ bridge<br />

from teeth 6-8 and single-unit CZ crowns on<br />

teeth 5, 9, 10 & 11. A laser was used to create<br />

an ovate pontic receptor site for the pontic on<br />

tooth 7. We were able to eliminate the metal<br />

margins and the open gingival embrasures with<br />

the new CZ restorations.<br />

Prismatik Clinical Zirconia: Photo Gallery<br />

Prismatik Clinical Zirconia: Photo Gallery


Building the<br />

Cosmetic<br />

Component<br />

of Your<br />

Practice:<br />

A Path to Greater<br />

Profitability and<br />

Enjoyment<br />

– ARTICLE by Gary Takacs<br />

T<br />

he dental profession presents an interesting dichotomy.<br />

In my travels over the past 25+ years I have noticed that<br />

dentists seem to neatly divide into two distinct camps.<br />

One group of dentists (let’s call them The Disgruntled) seems<br />

to treat their work as another day at the salt mine. Members<br />

of this camp seem to be very frustrated, are fundamentally<br />

unhappy with their profession, and are often counting down<br />

the number of days until retirement. The other group of dentists<br />

(let’s call them The Enthusiasts) are thrilled with their<br />

career choice and genuinely enjoy their work. Members of<br />

this camp derive a great deal of satisfaction (monetary and<br />

emotional) from their work and they truly enjoy coming to<br />

work each day. What is the distinction? How could there be<br />

such a radical difference in how these two camps feel about<br />

their profession?<br />

I’m sure there are a myriad of reasons, but I think it has a lot to<br />

do with the nature of the treatment provided. The Enthusiasts<br />

are enjoying themselves because they are absolutely changing<br />

people’s lives. What better way to change a person’s life than<br />

by helping them have the smile of their dreams. This article<br />

will outline how to build the cosmetic component of your<br />

practice, which will go a long way toward placing you firmly<br />

in the Enthusiast camp!<br />

In this article, I will discuss five specific steps to follow to<br />

develop the cosmetic component of your practice to full<br />

potential. These five steps are:<br />

n Make a Massive Commitment to Cosmetic<br />

Continuing Education<br />

n Make Whitening a Core Element of Your Practice<br />

n Remove Money as a Barrier for Your Patients<br />

n Use Digital Photography for Patient Education<br />

n Master Case Presentation Í<br />

Become a CE Junkie<br />

Building the Cosmetic Component of Your Practice


The first step to developing the cosmetic component of your<br />

practice to full potential is to make a massive commitment to<br />

cosmetic continuing education. There are no shortcuts here.<br />

Our profession is changing so radically with regard to dental<br />

materials, armamentaria, and techniques that it is imperative<br />

that you invest in yourself by taking extensive continuing<br />

education. Whatever your state requirements for CE are, they<br />

are not enough! The Disgruntled take the minimum number<br />

of hours necessary to maintain their dental license. The<br />

Enthusiasts embrace the concept of continuous learning and<br />

are constantly attending the best CE courses.<br />

The reason why this step is so important is that you simply<br />

must have the product on your shelf before you can sell it to<br />

your patients. You need to be able to confidently look the<br />

patient in the eyes and say, “Yes, I understand your concerns<br />

and I can help you have the smile of your dreams!” The best<br />

way to develop this confidence is to become so well trained<br />

that you recognize the problems and immediately know how<br />

to address them. The best cosmetic CE courses will provide<br />

you with these skills and more! Our profession has some terrific<br />

instructors who will share everything they know if you<br />

will simply make the effort to attend their courses.<br />

I recommend that my clients offer both tray whitening and<br />

chairside whitening. We can offer tray whitening if money is<br />

more of a concern and the patient is not in any particular rush.<br />

We’ll offer chairside whitening if the patient wants immediate<br />

results (most do) or just wants the entire process done by<br />

professionals. Following are four specific things you can do to<br />

make whitening a core element of your practice.<br />

1. Ask all patients if they would like whiter teeth.<br />

Don’t overlook the obvious. Try a soft approach like,<br />

“If there was a simple way for you to have whiter,<br />

brighter teeth would you be interested?”<br />

2. Take a shade match at the beginning of all hygiene<br />

appointments. Show the patient their shade on a<br />

chromatically ordered shade guide. This is an excellent<br />

way to visually demonstrate to patients the opportunity<br />

to have whiter teeth.<br />

3. Set up a culture in your practice to provide whitening.<br />

People are impatient, f igure out how to deliver<br />

whitening today.<br />

month, you will be making this care accessible to a huge<br />

segment of the population that could not obtain it otherwise.<br />

Ford or Chevrolet would not sell many cars if the only way<br />

consumers could pay for them was to write a check or put it<br />

on their credit card!<br />

The solution to removing money as a barrier for your patients<br />

is to install a third party financing service such as CareCredit.<br />

This will allow you to provide affordable payment options yet<br />

do so in a manner that works for your practice.<br />

Use Digital Photos for Patient Education<br />

Another step to take in maximizing your cosmetic component<br />

is to use digital photography for patient education. We have<br />

all heard the saying that a picture is worth a thousand words.<br />

This axiom could never be more true than in the realm of<br />

patient education. You could talk about treatment until you<br />

are blue in the face and often the patient’s eyes just gloss over<br />

and they are secretly longing for you to stop talking! However,<br />

show them a picture of their teeth and they often show immediate<br />

interest in improving their smile. I won’t belabor this<br />

Before<br />

After<br />

One of the most powerful byproducts of taking good CE<br />

courses is that you improve your diagnostic acumen. A client<br />

of mine recently viewed Dr. Michael DiTolla’s ‘Prep & No-prep<br />

Comprehensive Porcelain Veneer Techniques’ DVD. My client<br />

told me after viewing this course that he now sees what he<br />

simply was not seeing before. As a result, he is confidently<br />

diagnosing more cosmetic cases and we are seeing a subtle,<br />

but important, shift in his case mix. He is doing more cosmetic<br />

cases than he has ever done before.<br />

Embrace Whitening<br />

One of the most powerful ways to build the cosmetic component<br />

of your practice is to make whitening a core element of<br />

your office. People want whiter teeth. A recent USA Today survey<br />

reported that 85% of the population would like to improve<br />

their smile by having whiter teeth. Yet few offices are even<br />

close to maximizing their whitening potential.<br />

I like to think of whitening as the gateway to doing more ideal<br />

care. Whitening makes better patients! Hygienists tell me that<br />

they often notice that their patients brush better, floss more<br />

often, and become more faithful about keeping their appointments<br />

after whitening their teeth. It makes sense. Patients take<br />

a greater interest in their teeth after whitening.<br />

So that we can accommodate as many patients as possible<br />

4. Recommend whitening as an elective part of the<br />

treatment plan for any patient having restorative<br />

treatment. You or your team members can suggest<br />

that now would be an excellent time to whiten since<br />

we could get a great foundation color that the doctor<br />

could then match the restorations to.<br />

Outsource Financing to Make Ideal Care Affordable<br />

A next step to maximize your cosmetic potential is that you<br />

must develop a system to remove money as a barrier for your<br />

patients. Let’s face it, cosmetic treatment can require a considerable<br />

investment from the patient. If the only payment<br />

options you have for your patients are cash, check, or major<br />

credit card you will frustrate a great number of potential<br />

patients because they cannot pay with those limited options.<br />

Plastic surgeons have learned this lesson. In 2005, 73% of elective<br />

cosmetic surgery procedures were provided to patients<br />

who have less than $45,000 per year in household income.<br />

And a significant percentage of these cases were financed via<br />

third party finance companies that made these procedures<br />

affordable for patients. Think about a typical smile design<br />

case of eight units of upper anterior porcelain veneers.<br />

Depending on your fee schedule, this case is likely to cost<br />

$8,000 - $10,000. That is a lot of money for most Americans.<br />

However if that case could be financed at $180 - $200 per<br />

Building the Cosmetic Component of Your Practice<br />

Building the Cosmetic Component of Your Practice


point here since a previous issue of <strong>Chairside</strong> had an excellent<br />

article written by Dr. Tarun Agarwal titled, “Succeeding<br />

with Digital Photography” covering how to incorporate digital<br />

photography into your practice. I encourage you to read this<br />

article and apply the concepts.<br />

Master Case Presentation<br />

The last step to build the cosmetic component of your<br />

practice is to master case presentation to your patients. This<br />

step is critically important. While this topic is worthy of an<br />

entire article on its own, let me suggest some concepts you<br />

can immediately apply.<br />

Here’s how I might approach the new patient:<br />

“Mrs. Jones, first of all let me welcome you to our practice.<br />

We love seeing new patients and I am thrilled that<br />

you have selected our office for your care. We will take<br />

great care of you! Let me start be telling you a little about<br />

our approach.<br />

Our goal, as with every new patient, is to help you enjoy<br />

great oral health. We want you to look good, feel good,<br />

have strong teeth and gums and have a healthy, attractive<br />

smile for life. Does that sound good to you?<br />

The way I look at it is that it is my job as the dentist<br />

to identify every area of concern in your mouth and<br />

recommend what we can do to get you as healthy as<br />

possible. It’s your job as the patient to decide what, if<br />

anything, you want to do about it. Does that sound fair<br />

to you?<br />

You probably noticed that one of our team members took<br />

some photos of you earlier in the appointment. We take<br />

these photos because they help you and I to see things<br />

we can’t see with the naked eye. They really help me do<br />

a thorough diagnosis. Let’s take a look at those photos<br />

together. As I am pulling those photos up on the computer,<br />

let me ask you a question. As we are looking at<br />

the photos together, do I have your permission to identify<br />

every area of concern that I see?”<br />

Now you can just do a simple slideshow of the five photos<br />

and identify problem areas and provide a treatment plan to<br />

address the issues. You will be absolutely amazed at how<br />

effective the photos are in motivating the patient to move<br />

forward with ideal treatment.<br />

Consider the five recommendations provided in this article<br />

as a blueprint to follow to develop the cosmetic component<br />

of your practice to its full potential. Doing so will bring you<br />

great satisfaction as you help your patients get the smile of<br />

their dreams!<br />

Gary’s life’s work and passion is helping dentists and their team members<br />

develop a more profitable and enjoyable practice. He is a sought after<br />

speaker at national and international dental meetings where his informational<br />

courses are often recognized as the most fun and entertaining courses<br />

that attendees have ever experienced.<br />

Gary is also the founder of Ride and Learn and Race and Learn, perhaps the<br />

most unique continuing education programs in dentistry today.<br />

Ride and Learn combines a Harley Davidson motorcycle tour with dental<br />

CE and Race and Learn combines high performance driving with dental<br />

CE. For more information about Gary’s courses visit his websites at<br />

www.garytakacs.com or www.rideandlearn.com or feel welcome to e-mail<br />

Gary at gary@garytakacs.com.<br />

Building the Cosmetic Component of Your Practice


Occlusal Splints<br />

– INTERVIEW of Anton Misleh, DDS<br />

by Michael DiTolla, DDS, FAGD<br />

– PHOTOS by Ed Pelissier, Kevin Keithley<br />

Dr. Michael DiTolla recently sat down with Dr. Anton Misleh,<br />

one of <strong>Glidewell</strong> Laboratories’ top customers for occlusal<br />

splints and a dental school classmate of Dr. DiTolla. Dr.<br />

Misleh shares his thoughts on the importance of bite splints<br />

and how he includes their use in his practice.<br />

Michael DiTolla: Good morning, Anton. We’re going to talk a<br />

little bit about splints. I’ve always liked occlusal splints. I think<br />

it’s one of the most conservative things we do. You are one of our<br />

most active doctors regularly doing splints, and I wanted to ask<br />

you a few questions. Let’s talk about what you learned about TMD<br />

and splints when you attended University of the Pacific School<br />

of Dentistry.<br />

Anton Misleh: Well, that’s simple – not a lot. But I’ll be honest,<br />

I didn’t pay a lot of attention to it. It was kind of boring<br />

to me at the time. The information, I’m sure, was there, but<br />

I didn’t give it the attention it needed. When I got out in my<br />

practice, I started seeing a lot of busted up teeth, traumatic<br />

occlusion and had to start thinking about occlusion. So after<br />

taking a lot of classes I became more familiar with it. And<br />

of course after finally starting to do a thorough TMD exam<br />

instead of a cursory one, I started taking it really seriously.<br />

That’s the key – a thorough TMD exam. When you start looking<br />

for it, you start finding it. It’s amazing how many people<br />

have TMD-type issues: soreness, headaches – you name it.<br />

Stuff they never really attributed to their jaw until you explain<br />

to them why their neck hurts, why their jaw hurts. It’s amazing<br />

– you can get really quick, instant results with a splint. Then<br />

they come back and thank you for it.<br />

MD: So when you finished these classes and<br />

came back to your practice and started presenting<br />

these concepts to your patients, did you<br />

meet with a lot of resistance from patients?<br />

AM: The majority of patients would tell<br />

me that they do not grind their teeth,<br />

yet I could look at their mouths and see<br />

this obviously wasn’t the case. What<br />

helped me was to say “let me take an<br />

impression and I will pour up some<br />

models to show you, since it’s too<br />

hard for you to see in your mouth.”<br />

I gave up on the intraoral camera a<br />

long time ago. I have one in the<br />

closet with a bag on it. But the<br />

interesting thing was, I’d show<br />

them on the models where the<br />

wear was, how their teeth<br />

fit together and once they<br />

saw that, I would ask them:<br />

“Where could this wear be<br />

coming from if you’re not<br />

grinding your teeth? It’s<br />

got to be coming from<br />

somewhere.” And the<br />

answer is, you’re<br />

mouth breathing<br />

part of the<br />

night, you’re Í<br />

Clinician Spotlight: Occlusal Splints


grinding part of the<br />

night, you’re sleeping<br />

on your right, you’re<br />

sleeping on your left<br />

– you’re moving. If we<br />

took a video of you<br />

while you’re sleeping,<br />

you’d be amazed how much<br />

activity you get from all of your<br />

muscles while you’re asleep.<br />

MD: So patients begin to accept that<br />

they are grinding their teeth?<br />

AM: Yes, but you know what the next<br />

question is: “Why am I grinding?”<br />

Because everyone grinds. I tell them,<br />

you’re grinding, your parents ground,<br />

their parents ground. Unfortunately, it’s<br />

a very stressful life we live in.<br />

It’s pleasurable in some instances but<br />

stressful at the same time. We just have to<br />

understand that. We have to do something.<br />

The only thing we can do – you’re never<br />

going to stop grinding, you can’t stop grinding,<br />

I don’t know of a way to make anyone<br />

stop grinding – but the one thing we can do is<br />

if we put a piece of plastic between your teeth,<br />

you’ll damage plastic and quit damaging yourself.<br />

I like to speak to my patients in very simple,<br />

very basic terms. I’m not into scientific conversations<br />

with people because, let’s face it, this is an<br />

abstract concept that we’re not too familiar with.<br />

And that’s what we look for: worn teeth, popping<br />

of cusps tips, abfractions and recession. Recession<br />

is more important than we think. Most dentists will<br />

just bond mesiofacial distal composites on receded<br />

areas and tell the patients “Oh, you’re brushing too<br />

hard.” To be honest with you, and I don’t mean to<br />

criticize anybody, but I don’t believe anybody is<br />

brushing too hard. I think it’s the abfractions and the<br />

recessions caused from occlusal trauma such as bruxism<br />

that exposes the softer part of the root, and then<br />

you brush away tooth structure. I really think it’s the<br />

traumatic occlusion that starts the whole process.<br />

MD: I would agree. In fact, when I heard about toothbrush<br />

abrasion in school and people brushing too hard and even<br />

patients saying, “Oh, I’ve been told that I brush too hard,”<br />

I always found it amazing that they were able to brush<br />

too hard on a first bicuspid but they weren’t brushing too<br />

hard on the adjacent cuspid or the 2nd bicuspid. The only<br />

way to explain it is if they had like a 3mm wide toothbrush and<br />

they just constantly brushed that one tooth.<br />

AM: You know what? You just hit the nail on the head. Very<br />

good example.<br />

MD: It just doesn’t make sense if they’re brushing too hard, why do<br />

I see it in only one area and why does that happen to be the area<br />

that has a lateral occlusal interference at the same time?<br />

AM: You got it.<br />

MD: Explain to me a little bit what you do – it sounds like you’re<br />

pretty comprehensive in looking for TMD symptoms and bruxism<br />

symptoms in all your patients. Can you explain how you work it<br />

into the new patient exam?<br />

AM: Every new patient, standard exam. They come in, they get<br />

their FMX, we probe, we do cancer screening – I’m very big<br />

on that too – we have actually discovered some cancer cases<br />

while it was still early. Then we do the TMD exam. We start<br />

with just asking them about their jaw joints, headaches, any<br />

symptom in their neck, back of the head, radiating up to their<br />

head, then I palpate the muscles of mastication. Invariably,<br />

there’s always a little tenderness on one of the lateral<br />

pterygoids or on the medial pterygoid – that’s a tough one to<br />

palpate, some people think you can’t, but they have a little<br />

tenderness there as well. When you see the occlusal wear and<br />

document it – and we do document the recession – where the<br />

abfractions are, and once you see all that coupled with their<br />

personal history about their pains, their sensations that they<br />

feel (if they wake up in the morning and their jaw is tight,<br />

etc.), they’ll tell you all kinds of things in their words that<br />

mean something to us. You have to listen to them, as well<br />

as look at them. After we do that part of the exam, we give<br />

them a head and neck screening as well, we palpate from the<br />

neck up. We were very successful in finding thyroid disorders<br />

on many patients already – which dentists usually don’t look<br />

for. And I’ll be honest with you – we don’t have time in our<br />

day, but we make the time. It’s amazing how many physicians<br />

have called me and said, “I can’t believe you guys found that.<br />

Good job.”<br />

MD: That’s a great point. That’s an incredible service as a dentist<br />

for you to be providing. Now, do you find any benefit in devices to<br />

help diagnose TMD problems? For example, a JVA (Joint Vibration<br />

Analysis) device is advocated by some clinicians.<br />

AM: Well, I’ll be honest with you, I don’t use any of those<br />

devices. I’m strictly looking for trauma to the dentition,<br />

to the gingiva, and when I palpate the muscles and take the<br />

patient’s history. It’s not that I don’t believe in those machines,<br />

but other than seeing them on a slide at a lecture, I’ve never<br />

touched one. I learned one main thing as a result of all the<br />

TMD courses I took: Refer out all TMD. It’s not something I<br />

want to treat on a complicated basis. The simple things that<br />

require a splint, the patients that a nightguard will help, I treat<br />

them. Anyone that requires a more extensive diagnosis, more<br />

extensive treating such as an anatomical splint, which gets<br />

into a whole other area of splints, we have a wonderful TMD<br />

specialist in the building who just moved in. Prior to that I was<br />

using a few others nearby. Now I refer my cases to him and he<br />

has all those machines, and he enjoys treating those patients.<br />

MD: Do you err on the cautious side if you have somebody who<br />

might be a more complicated TMD patient in referring them to<br />

the specialist, or are you gaining enough experience now where<br />

you’re more willing to try to treat those people in your office?<br />

AM: I’m gaining more experience to err more on the cautious<br />

side. When I didn’t have enough knowledge in the matter, I<br />

think I probably erred too much on the “treat it” side. As you<br />

learn more and more, you learn to be more cautious and you<br />

learn to more judiciously think about what you’re treating and<br />

how you’re going to treat it and why.<br />

MD: It’s funny because I ask many dentists, “Why don’t you<br />

provide more splints in your practice?” A lot will say that TMD<br />

patients are crazy or they say you end up being married to those<br />

patients. Yet you still do many splints despite referring out the<br />

TMD patients.<br />

AM: I’m doing a ton of splints because here’s my philosophy<br />

on splints, and this is important to know. I’m doing the splints<br />

to prevent the wear to the dentition. I’m not doing the splints<br />

so much to treat the TMD. That’s key, because if they have<br />

true TMD, you’re right, you’re married to the patient. And,<br />

you know, different guys charge different amounts for these<br />

splints. I charge $450. I don’t know where that stands in the<br />

range, but the point is, you don’t want to be married to the<br />

patient for $450. But the interesting thing about it is if you get<br />

proficient at properly diagnosing these TMD issues and properly<br />

referring them out like you’re supposed to, the specialists<br />

are very good at charging a much higher fee and they are very<br />

happy to be married to the patient.<br />

MD: Well, we talked about new patients, can we talk about recall<br />

patients? Let’s say there’s a patient who’s been in your practice<br />

seven or eight years and maybe you weren’t treating TMD as thoroughly<br />

or as aggressively as when they first came into the practice<br />

and now you know more and they’re in with the hygienist.<br />

Typically with these recall patients, is this something your hygienists<br />

bring up or do they bring it to your attention and you start the<br />

conversation? How do you go about communicating treatment to<br />

patients who have this problem.<br />

AM: Classic question. My hygienists dive right in. They’re<br />

on the TMD bandwagon. My hygienists – if they just did<br />

hygiene they’d be bored. They like trying new things<br />

and looking at new things. It just makes their day more<br />

exciting. Something you touched on earlier, you just<br />

touched on it again. You talked about the resistance<br />

to this whole concept of bruxism. Where the most<br />

resistance is, the most resistance I get to the concept<br />

of telling someone that they’re bruxing their teeth is,<br />

“How come I was never told this before? I’ve been<br />

coming here for years. How come now?” That could<br />

be a very awkward situation. I’ll be honest with<br />

you, when I first started recognizing malocclusion<br />

“...the most resistance I get to the concept<br />

of telling someone that they’re<br />

bruxing their teeth is, ‘how come I<br />

was never told this before?’”<br />

and traumatic occlusion and the wear and<br />

first started bringing this up to patients, that<br />

presented a big problem for me. You find<br />

yourself having to backpedal and you say,<br />

“Uh, uh, uh….” And you don’t want to<br />

say, “Because I completely ignored it<br />

for the last 18 years.” In reality, we do<br />

ignore it. It’s probably one of the most<br />

ignored aspects of dentistry. So I just<br />

told them, I’ll be honest with you, I’ve<br />

been doing some studying on this,<br />

and I’ve become more and more<br />

aware about this and you’re being<br />

told now because I know more<br />

about it now and that’s that.<br />

I was very surprised how<br />

quickly I gained acceptance<br />

because it’s a very truthful<br />

and straightforward answer<br />

and it doesn’t scream of<br />

incompetence that it was<br />

not recognized before,<br />

but it’s very truthful.<br />

That is exactly the<br />

way we present it.<br />

We gained great<br />

acceptance with<br />

that. It’s a new<br />

concept for Í<br />

them just like<br />

Clinician Spotlight: Occlusal Splints


it’s a new concept for<br />

us – it’s not supposed to<br />

be, but frankly we can’t<br />

learn everything in one<br />

night. I wish we could, but<br />

we can’t. So this is just one<br />

more tool we’re adding. Why<br />

did you break your tooth? Well,<br />

before we would’ve just fixed<br />

the tooth. Now we’re finding out<br />

“...mom never told us, don’t<br />

get TMD. So it’s really important<br />

to make ourselves aware<br />

of it, educate ourselves about<br />

it. Once we do, then we can<br />

educate our patients about it.”<br />

why so you don’t break it again and so you<br />

don’t break others. So I tell them to be grateful<br />

that we finally figured this one out.<br />

MD: Exactly. And there is no dental condition that<br />

I’ve seen where a patient can have so much denial<br />

– maybe periodontal disease there’s some denial too.<br />

But the patient denial that goes along with bruxism<br />

is amazing.<br />

AM: Like I touched on earlier, it’s a new concept<br />

for the patient. When we tell them, “You have a<br />

cavity, you need a filling.” Well, everyone has had<br />

a cavity, everyone has had a filling, they’re going to<br />

keep getting them. It’s such an old concept, there’s<br />

no need to accept it, it’s just already been accepted<br />

that we get cavities. And there’s a lot of advertisement<br />

to it. You know, you just turn on the TV and<br />

Crest is advertising, “We’ll help you prevent cavities.”<br />

And Colgate is doing the same and so cavities have<br />

always been addressed in the media, in advertising,<br />

everywhere. And our mother told us to brush our teeth<br />

so we don’t get a cavity. So it became a very important<br />

concept early on. But mom never told us, don’t get<br />

TMD. So it’s really important to make ourselves aware<br />

of it, educate ourselves about it. Once we do, then we<br />

can educate our patients about it. And they’re starting<br />

to learn. They’re starting to accept TMD. You know, as I<br />

started becoming more aware of TMD, I started noticing<br />

more articles in the paper about it and in magazines. I<br />

never noticed it before when you read the papers or magazines<br />

because it wasn’t there.<br />

MD: I love giving those types of things to the patients. In fact, I’d<br />

rather give something like that to a patient than one of those preprinted<br />

dental brochures marketing some product you can buy. I love<br />

when it’s in a neutral, third-party press. If you find something in<br />

San Diego <strong>Magazine</strong> or the Union-Tribune and you can give that to<br />

a patient, written by an outside reporter, I think that almost carries<br />

more credibility than a pamphlet our office can print up and hand<br />

to a patient.<br />

AM: You’re 100 percent right. We maintain good relationships<br />

with our patients, we’ve always enjoyed good relationships,<br />

a trust. Dentistry is still one of the highly trusted professions.<br />

But unfortunately, in society, just in our minds, in everyone’s<br />

minds, there’s still that element of distrust. So you bring<br />

in something that is trusted, like you said, San Diego <strong>Magazine</strong>.<br />

They make good restaurant recommendations, why wouldn’t<br />

they talk about TMD properly? So then it creates more trust,<br />

and it’s in a medium the patient has long experienced trust<br />

with.<br />

MD: And the reason you need more trust with your patient, I think, to<br />

treat something like bruxism and make a splint for them is because it<br />

is, by and large, a painless condition. When a patient comes in pain<br />

with an abscess or they’ve broken a cusp off and it’s shredding the<br />

side of their tongue, they are ready to have that thorn pulled out of<br />

their foot. But when it’s an asymptomatic -- to them -- condition, they<br />

need to have some trust that you are in fact treating something that<br />

does need to be treated.<br />

AM: Seeing is believing.<br />

MD: What types of splints do you use in your practice now? Is there<br />

a particular one that you’re using in your practice as kind of your<br />

go-to splint?<br />

AM: I’ve settled on your splint, actually, the Comfort H/S. For<br />

the most part, the Hard/Soft goes in really simple, really easy,<br />

doesn’t take a lot of thinking. There’s a little bit of adjustments,<br />

but nothing like an acrylic splint like we learned to<br />

make. After the first 12, I’ll probably admit that as I stuck<br />

those things in there, I wasn’t sure if I did it right. Again, it<br />

was a learning curve for me. Then they’d come back and I’d<br />

have to make a couple adjustments, and then I knew I didn’t<br />

do it right. After a couple times of that, I’d really learn quick.<br />

Plus I’d get on the phone with your technician, I believe his<br />

name is Greg, I believe he is the head of your thermoforming<br />

department. I’d get on the phone with him and I’d ask him<br />

questions: “How do I adjust this thing? It didn’t quite fit right.<br />

What do I do?” And he’d give me little tricks. In fact, I was


talking to Í him just this week because I was having trouble<br />

getting one to fit just right, and he gave me a trick that you<br />

guys do in the lab. It was very interesting because I told him<br />

what I did and he said, yeah, dentists will do that but we don’t<br />

like it when you do that because you guys usually don’t do<br />

it right.<br />

MD: What trick was that?<br />

AM: That was carefully grinding the inside of the splint, the<br />

soft material, with a little carbide bur. He said you have to<br />

grind it very, very gently. If you don’t, it will shred inside.<br />

Guess what? He was right!<br />

MD: I think with most dentists and the splints that they have made,<br />

the impression appointment goes pretty easy. Do you use alginate or<br />

polyvinyl siloxane for your impressions that you send?<br />

AM: I use two different materials. Mostly, I use the alginate,<br />

and I’ve been using alginate for a long, long time. How accurate<br />

that is, I don’t know because you guys recommend the<br />

polyvinyl. But I’ve just been using alginate since dental school<br />

days. Then, 3M came out with a product that seems pretty<br />

nice called Impregum Penta Quick Step. So I bought a whole<br />

bunch of that and told my staff members to start using that<br />

because I thought that would be a really nice intermediate<br />

material to use between vinyl and at the same time, vinyl is<br />

expensive, but I told them to use that. What was very interesting<br />

is that they went back to the alginate; they like it better.<br />

They’ve just been using it so long, and they’re older, more<br />

experienced assistants. We’re set in our ways sometimes.<br />

MD: Do you pour the models before you send them up to us?<br />

typically take you to deliver a splint?<br />

AM: We schedule 15 minutes.<br />

MD: Nice.<br />

AM: Most of the time, I don’t even need the 15 minutes<br />

because it goes right in. I always have to adjust<br />

a little off the #2 area and very little off the #15, and<br />

that’s it. We’re trying to figure out a way not to have<br />

to even do that. I flame it lightly and rub it with<br />

the wet gauze and it polishes up beautifully, which<br />

is nice. I bought the Brassler Denture Adjustment<br />

Kit. It comes with two carbide burs and a series<br />

of three acrylic polishers. The kit is magnificent.<br />

That made my life a billion times easier, because<br />

if you adjust with it, it’s already smooth after<br />

you’ve finished your adjustment, so there’s very<br />

little polish or anything to do to it. For the most<br />

part, not to compliment you guys, but let’s face<br />

it – it comes back very good most of the time.<br />

Because of that, there is very little adjustment<br />

to be made.<br />

MD: Do you heat up—dip—most of them in hot<br />

water before you try them in or do you try them<br />

in first to see how the fit is?<br />

AM: I always just try it in dry first. Your<br />

tip and technique is to dip it in hot<br />

water first, but I always just try it in<br />

because I want to get the feel. If the<br />

feel is good, then I ask the patient if<br />

AM: We pour them right away. In fact, I<br />

have three assistants in my office, I<br />

kind of have a busy office and I have<br />

extra assistants, and one of the things<br />

we do is as one assistant is making<br />

the impression, the other walks<br />

down the hall and grabs it and begins<br />

pouring it right away. I don’t know<br />

if you have to pour it that quickly,<br />

but we just do because we have<br />

the team.<br />

MD: Exactly. That’s a great point. Now<br />

on the delivery appointment, that’s the one<br />

the dentists don’t tend to enjoy it if they’re<br />

having to make a ton of adjustments. Do you<br />

have any tips or tricks or a standard way that<br />

you deliver these appliances? How long does it<br />

Clinician Spotlight: Occlusal Splints


The Open Bite<br />

Technique:<br />

A construction bite can help<br />

reduce or eliminate adjustments<br />

at the bite splint adjustment<br />

appointment. This is the<br />

only bite we can use in the lab<br />

for splint fabrication. This type<br />

of bite is taken at an open vertical<br />

dimension and is more accurate for<br />

us to construct a splint without having<br />

premature occlusal contact in the area<br />

of the 2nd molars. Sending a fully closed<br />

bite will not help reduce the chances of<br />

having to make occlusal adjustments to<br />

the splint.<br />

Figure 1: Have the patient bite down on two cotton<br />

rolls that are placed in the area of the first bicuspids.<br />

Have the patient open and close onto the cotton<br />

rolls several times.<br />

it feels too tight or if it feels just right because once I pop it<br />

in and pop it out myself, I know if it’s too tight or if it’s just<br />

Í right, especially since now I’ve done so many of them. And,<br />

again, experience is part of the game. As I got more experienced<br />

with them, they required less and less adjustment. Most<br />

of the time the fit is just a little too tight, so we just microwave<br />

some water, get it plenty good and hot (in a little cup) and<br />

then just soak it in there just for seconds. Maybe 10 seconds.<br />

Then I pop it out and put it in and they say that feels better.<br />

So, that’s been a very, very easy thing to do. Something else<br />

that made me stop adjusting these things, and I wish you<br />

guys would’ve mailed this to me sooner, but you mailed me<br />

a card that demonstrated how to do the open bite technique.<br />

It was just a little card that showed how to squirt the material<br />

in, then have them bite on two pieces of cotton around the<br />

second bicuspids. Once we started doing that, that’s when we<br />

stopped doing any kind of real adjusting. That was probably<br />

one of the most useful things you guys have sent me.<br />

MD: We sent those postcards out to about 80,000 dentists, but you<br />

never really know the impact that it has on someone until they mention<br />

it!<br />

AM: Not only did that help in having us stop making adjustments,<br />

but then I went to my study club and we were talking<br />

about splints, and a lot of the guys were saying it’s such a<br />

pain. I mentioned to them how, one, it’s not a pain and two,<br />

it’s been profitable. And three, I discussed with them how to<br />

do that bite. Right before the study club I happened to get that<br />

postcard instructing me how to do it. It was very interesting<br />

because the next day I got a call from one of my buddies, and<br />

he said, “Go over with me again how to do that bite.” I did,<br />

and then about a month later at the study club he says, “Hey,<br />

Anton. Thanks. You made that bite real simple.” I got all the<br />

credit for it!<br />

worth of syringes, needles, burs, handpieces and restorations 10 years<br />

from now.<br />

AM: Yes, tens of thousands of dollars over the patient’s lifetime.<br />

It doesn’t all have to be at once: You crack a tooth, we<br />

make a crown; you crack another one, we make a crown.<br />

We’ll be doing that the rest of your life if you don’t prevent<br />

the problem now. It goes back to what we talked about earlier<br />

– recognizing it. Not just treating it, but recognizing the cause<br />

and then implementing prevention. Like, the cause of cavities<br />

is too much sugar, not flossing, all the things that we know.<br />

So we push them to brush and floss and they have extra<br />

cleanings. Well, now the cause for what we’re talking about is<br />

traumatic occlusion. Shouldn’t we be pushing the prevention<br />

of that as well?<br />

MD: You are absolutely right. It’s always amazing to me how many<br />

parents, when asked, will say that they hear their children grinding<br />

their teeth down the hallway at night, and yet they are still shocked<br />

to hear from their dentist that their kids might actually be grinding<br />

their teeth.<br />

AM: Something interesting you touched on, and this is actually<br />

a double-edged sword; it’s become a problem. They all<br />

understand bruxism from their kids’ point of view, because<br />

they do hear it, they hear it every time. And it is loud! When a<br />

kid bruxes his teeth – and I have a child who does – it’s loud.<br />

This is always the response I get: “My kid does it and I can<br />

hear him down the hall. Why can’t I hear myself or how come<br />

my husband doesn’t complain or my wife doesn’t complain?”<br />

I tell them that my theory and my reality is that adults brux<br />

differently. It’s as simple as that. You don’t hear it, your husband<br />

doesn’t hear it, nobody hears it because we don’t brux<br />

like our kids; we brux differently. How we brux differently, I<br />

don’t know, but we must.<br />

MD: I want to thank you for giving our readers a couple of<br />

great tips today. As we wrap this up, I want to congratulate you<br />

on your commitment to preventive dentistry. I think it’s admirable<br />

that you’re trying to save enamel, not destroy enamel. I<br />

don’t know if you’re a hero to your patients now, but I know<br />

you will be in 20 years when they realize that your splints<br />

have allowed them to get into their later years with, hopefully,<br />

a full and healthy dentition. Congratulations!<br />

AM: Thank you very much.<br />

The Finished Splint:<br />

Figure 2: Have the patient close onto the cotton<br />

rolls, just hard enough to ensure that they are in a<br />

stable position. Express bite registration posterior to<br />

each of the cotton rolls and in the anterior segment<br />

between the cotton rolls.<br />

Figure 3: Remove the 3 segments of bite registration<br />

material and cut off the cotton rolls if they are<br />

attached to the bite registrations. Mail the bites to<br />

the lab with the impressions or models.<br />

MD: Good for you! We’re going to run those pictures here with this<br />

article (See Figures 1-3), since you brought it up. Tell me a little about<br />

what your front office staff has found with insurance coverage for<br />

these splints.<br />

AM: If they have coverage, they cover it in the basic or the<br />

major category. The basic is the 80 percent category if you’re<br />

familiar with dental insurance billing, the major is 50 percent<br />

typically. Several of them don’t cover it at all. When that happens,<br />

the patient balks at the procedure. They’ll say they don’t<br />

know if they want to spend the money. I tell them either<br />

spend the money on crown and bridge procedures, or you<br />

spend the money on a little cheap splint that’s going to save<br />

you from cracking your teeth.<br />

MD: It’s either a conservative $450 procedure now or $10,000<br />

MD: I always assumed it had to do with primary teeth vs. permanent<br />

teeth. When you look at kids who brux their teeth, you notice that<br />

they are just flat. It looks like a veterinarian went in and floated the<br />

teeth like they do on a horse! When you look at adults and you see<br />

bruxism, you notice it on the cuspids, it’s on the laterals, there are a<br />

few abfraction lesions. But it’s very rare except the most extreme cases<br />

that you see all the teeth flattened off. I think the kids just have more<br />

tooth-to-tooth contact than the adults do because the primary teeth<br />

are so easy to wear through, and bruxism is louder with kids because<br />

of the increased surface area in contact. Now, I don’t know if that’s<br />

true or not, but that’s always been what I thought.<br />

AM: That’s a good theory. That’s reasonable. At least there is<br />

an explanation or something we can look at and say that’s a<br />

reasonable explanation. Whether or not it’s true, I don’t know,<br />

but it’s certainly reasonable to look at it in that way.<br />

Clinician Spotlight: Occlusal Splints


S– ARTICLE by Don Reid, DDS<br />

eeing is believing...<br />

– PHOTOS & ILLUSTRATIONS<br />

provided by D2Effects LLC<br />

A case study in handling and explaining occlusal disease<br />

Occlusal disease is one of the most destructive and neglected elements in dentistry<br />

and plays a major role in reducing the longevity of our finest restorative efforts.<br />

It can present itself in the form of painful, clicking TM joints, sore facial muscles,<br />

headaches, tooth wear, tooth looseness, sensitivity, and migration. It is a dominant<br />

factor in the fracture of restorations on posterior teeth.<br />

Although a dentist may understand the cause and effect of these destructive forces,<br />

explaining these concepts to patients and their families can be very difficult. It is<br />

much easier to discuss the solution for caries or fractured teeth than it is to describe<br />

how excess wear is caused by a movement of the mandible from maximum intercuspation,<br />

in and out of a centric relation position. Likewise, understanding how Í<br />

A Case Study in Handling and Explaining Occlusal Disease


Case Report<br />

Clinical Findings<br />

ABFRACTIONS<br />

TOOTH<br />

WEAR<br />

ABFRACTIONS<br />

TOOTH WEAR<br />

Fig. 1 Existing implant in lower left #18 area.<br />

Fig. 2 Lower left arch for implant crown.<br />

Fig. 3 Upper occlusal view before treatment.<br />

Figs. 4, 5, 6 Tooth wear and abfractions.<br />

interferences on the balancing or non-working side during lateral excursions occur<br />

is difficult enough for dentists to see and detect, this difficulty is only compounded<br />

when we try to explain these problems to patients. Difficult or not, we are obligated<br />

to offer a treatment plan for the resolution of all disease categories which fall within<br />

our scope of health care service.<br />

CASE REPORT<br />

A middle-aged lady reported to my office with a request to have an implant crown<br />

placed on an integrated implant in the lower left #18 area (Fig. 1). Upon cursory<br />

examination, I observed signs of severe wear, occlusal disease, throughout the<br />

mouth and quite notably in the lower left quadrant (Fig. 2). I informed her of my<br />

concern, that implant success or failure after osteointegration was largely dependent<br />

on having proper distribution of the biting forces. I assured her we’d restore the<br />

implant for the greatest potential for long term success and asked for the opportunity<br />

to study her case further prior to making restorative decisions. She rescheduled<br />

for a complete examination which included (1.) full mouth x-rays, (2.) nine intraoral<br />

photographs (Canon Digital Rebel), (3.) Panorex, and (4.) mounted study models<br />

(SAM III) in centric relation.<br />

A complete examination was conducted evaluating the TMJ, muscles, periodontal<br />

structures, occlusion, and an oral cancer screening was performed. The tooth by<br />

tooth exam, looking for excess wear, looseness, fractures and caries, was aided by<br />

the use of a dental operating microscope (Global Protégé).<br />

Due to facial muscle tightness, I fabricated an anterior deprogramming device and<br />

asked her to wear it at night and monitor the effects on her muscles and jaw. She<br />

was then scheduled for a treatment plan consultation.<br />

THE HISTORY<br />

The patient’s history included tooth loss of #18 due to a fracture of the crown as<br />

well as a recent history of loosening, fracturing and early replacement of all-ceramic<br />

restoration on #8 and 9 (Figs. 2 & 3). She stated she has a habit of grinding her teeth<br />

and felt that was contributing towards the crown failure. Additionally, the patient<br />

was not pleased with the appearance of her smile as she felt her teeth were too<br />

short. Her long term goal was to keep her natural teeth for life and avoid repeated<br />

dental treatment.<br />

CLINICAL FINDINGS<br />

The periodontal structures were quite healthy and there was minimal evidence of<br />

caries. There was muscle tenderness upon direct palpation of the masseters, temporalis,<br />

and medial pterygoids as well as the lateral pterygoids upon indirect palpation.<br />

There was excessive hypertrophy of the masseters as well as the temporalis muscles.<br />

The mandible had full range of motion in all possible movements. There were no<br />

intracapsular disorders of the TMJ as determined by Doppler auscultation and load<br />

testing. There was severe wear throughout the mouth as well as abfractions along<br />

with slight tooth mobility. There was a CR contact on the distal of #19, with a 2mm<br />

vertical component and a 2mm forward component into maximal intercuspation<br />

(MI). There were interferences in lateral excursions on the working and non working<br />

sides bilaterally. Protrusive was WNL.<br />

The potential for repeated crown fracturing, as well as potential implant failure due<br />

to destructive forces of occlusion, was very high. Allowing these destructive forces<br />

to persist could cause implant failure, restorative failure, or tooth loss. Not treating<br />

A Case Study in Handling and Explaining Occlusal Disease<br />

A Case Study in Handling and Explaining Occlusal Disease


Demonstrating Joint Position<br />

Muscle Function /Anterior Guidance<br />

Figs. 7, 8 Animation<br />

showing muscle function<br />

and removing tension<br />

in pterygoids.<br />

Figs. 9 & 10<br />

Animations contrasting<br />

stable (top) and unstable<br />

(bottom) bites.<br />

Figs. 11, 12 Normal<br />

muscle function (top)<br />

compared with muscle<br />

hyperactivity (bottom).<br />

Figs. 13, 14<br />

Animations illustrating<br />

anterior guidance.<br />

this disease would have severe implications for the patient. Í<br />

CONSULTATION TIME<br />

Using her mounted models, I was able to show my client how worn her natural<br />

teeth had become. The models were mounted in CR so the first contact was on<br />

tooth #19 and there were lateral interferences in all eccentric jaw movements.<br />

In the past, these findings were important yet difficult for the patient to understand<br />

even with mounted models. My goal in creating BiteFX was to show patients the<br />

relevance of proper joint position, normal muscle function, the role of proper anterior<br />

guidance, and finally the value of ideal tooth contacts in a way that could be<br />

easily understood.<br />

The patient had experienced remarkable relief of facial muscle soreness with the<br />

deprogrammer so I began by educating her on the reason behind this success.<br />

Through animations (illustrated in Figs. 7 & 8), the client could see how the muscles<br />

closed the jaw and allowed the joint to fully seat, removing the tension in the pterygoid<br />

muscles. This had the net effect of changing the mandible position and causing<br />

the teeth to fit differently after nighttime usage.<br />

PROPER JOINT POSITION<br />

I was able to show the patient the difference between a stable bite, with CR in harmony<br />

with MI and no ability to slide forward and backwards on the back teeth, and<br />

an unstable bite by showing two contrasting BiteFX animations (Figs. 9 &10).<br />

NORMAL MUSCLE FUNCTION<br />

To explain her muscle tenderness I showed her two animations; one illustrating normal<br />

muscle function (Fig. 11) and the other showing hyper-muscle activity (Fig. 12).<br />

It was easy to illustrate, that when the jaw closes into a stable bite, it requires no<br />

usage of the muscles that position the jaw forward and sideways.<br />

PROPER ANTERIOR GUIDANCE<br />

The patient exhibited severe wear and lateral interferences on both the working and<br />

balancing sides. Using BiteFX animations she could visualize the destructive effects<br />

of her existing occlusal disease, and the benefits of proper anterior guidance as<br />

snapped in figures 13-16.<br />

PROPER TOOTH CONTACTS<br />

The animations illustrated in figures 17 and 18 showed the patient proper tooth<br />

contacts which minimize the contact, wear and stress to the teeth as compared to<br />

destructive contacts which can wear, move or break teeth.<br />

ATTAINING CENTRIC RELATION POSITION<br />

I’m often asked how I determine the proper position of the joint. In this case, I replicated<br />

the action of the closing muscles of the jaw by using bimanual manipulation.<br />

In addition, I had her clench repeatedly on an anterior de-programmer. I was able<br />

to attain CR records using both techniques.<br />

TREATMENT PLANNING FOR SUCCESS<br />

Once the patient began to understand the advantages of a stable occlusion, she<br />

A Case Study in Handling and Explaining Occlusal Disease<br />

A Case Study in Handling and Explaining Occlusal Disease


Proper Tooth Contacts<br />

Figs. 15, 16<br />

Animation illustrating<br />

the effects of lost anterior<br />

guidance.<br />

Figs. 17, 18<br />

Animations showing<br />

ideal tooth contacts<br />

(left) and comparing<br />

proper and destructive<br />

tooth contacts (right).<br />

started to focus on the esthetics of her smile. The occlusal attrition was dramatic<br />

and the central incisors were as long as they were wide. To establish longer upper<br />

front teeth required opening the vertical dimension as determined by mandibular Í<br />

translation and the closest speaking space. Evaluation of this parameter combined<br />

with the patient’s desires, I requested maxillary centrals 12mm long and corresponding<br />

lowers 10mm in the diagnostic wax up.<br />

TREATMENT PLAN<br />

Step 1.. Continued anterior deprogrammer therapy followed by occlusal equilibration<br />

to include anterior guidance using composite build-ups on<br />

the cuspids.<br />

Step 2..<br />

Step 3..<br />

New impressions for mounted study models in CR and a full mouth diagnostic<br />

wax up to the desired tooth lengths.<br />

Preparation, impression taking, and provisionalization of both arches<br />

simultaneously.<br />

Step 4.<br />

period (6 months).<br />

Evaluation of the form, function, and comfort during the provisionalization<br />

Step 5.<br />

Step 6..<br />

Final shade selection, fabrication of all ceramic restorations from first<br />

bicuspid to first bicuspid, and porcelain fused to gold on the remaining<br />

posterior teeth.<br />

The final phase is impressions and fabrication of the lower implant crown<br />

#18. Ironically, this last procedure was the first item requested at the initial<br />

A Case Study in Handling and Explaining Occlusal Disease


Temporaries<br />

Implants / Final Restorations<br />

Figs. 19, 22<br />

The patient’s<br />

temporaries.<br />

Figs. 23, 24 Placing<br />

the implant for #3.<br />

Figs. 25, 26<br />

Final restorations.<br />

office visit. Í<br />

TREATMENT PHASE<br />

Visit #1 - Equilibration and Diagnostic Wax-up<br />

Wearing the anterior deprogrammer had relaxed the muscles, which allowed for<br />

an easy and complete occlusal equilibration. Full arch impressions using VPS were<br />

made. A SAM III axiomatic bite fork and face bow were taken, as well as CR bite<br />

records using Futar D.<br />

Since centric relation is independent of tooth contact or position, I take the record at<br />

a 2-4mm vertical opening to maintain adequate thickness of the recording material.<br />

This enables the laboratory to avoid breakage due to thinness of material. The client<br />

selected a smile she liked and that guided the Rx for the diagnostic wax up.<br />

Digital photos of the client’s existing smile were included with the prescription. The<br />

vertical dimension of occlusion (VDO) was determined by the height necessary to<br />

accommodate adequate speaking space.<br />

Visit #2 - Preparation<br />

Preplanning and visualization of both the occlusal scheme and final tooth shape and<br />

position are essential for predictable and efficient treatment.<br />

Beginning with ‘The end in mind’ includes having clear provisional matrices, ‘suck<br />

down’ prep guides, replica stone models of the diagnostic wax up, as well as mounted<br />

waxed models available at the start of treatment.<br />

An electric hand piece and new Brasseler diamonds allowed for an effective 5 hour<br />

visit during which both arches were prepped, final impressions were taken, and<br />

A Case Study in Handling and Explaining Occlusal Disease<br />

provisionals placed. CR bite records as well as facebow were taken.<br />

Visit #3 - The Test Drive<br />

This is the period where the newly increased VDO is evaluated with emphasis on<br />

speech and esthetics. The temporaries (Figs. 19 - 22) were modified to the patient’s<br />

desires (i.e. more pointed canines), and alginate impressions, digital photos and facebow<br />

records were given to the lab to create the final restorations.<br />

Visit #4 - Shade Selection<br />

The client opted for very white teeth. The Vitapan 3D shade guide was used. A<br />

single incisor was fabricated and tried in to get the patient’s approval prior to completing<br />

the entire case.<br />

Visit #5 - Expect the Unexpected<br />

During the 6 month trial test drive, the pulp of #3 was irreversibly inflamed. The<br />

tooth had a prior history of severe pain after a crown was placed several decades<br />

ago. The client rejected the option of saving the tooth with root canal therapy and<br />

chose extraction and bone grafting, followed by implant placement and implant<br />

retained crown (Figs. 23 - 24). The extraction and bone graft were completed using<br />

Grafton matrix and Pepgin N -15.<br />

After 4 months, a 6mm x 9mm Biohorizons D4 Maestro implant was placed and<br />

simultaneously a “Sinus Lift” of 3mm was performed with flat ended osteotomes and<br />

a conservative tissue punch access rather than a full flap.<br />

Visit #6 - Completion<br />

The final restorations (Figs. 25 - 30) were placed using RelyX bonding agent for the<br />

A Case Study in Handling and Explaining Occlusal Disease


Final Restorations<br />

Figs. 27-30<br />

Final restorations.<br />

refractory porcelain and Fuji GC luting cement for the posterior PFMs. The delivery<br />

appointment went smoothly and required only ‘spot adjusting’ in several areas. Í<br />

There was no hint of a CR slide and all eccentric jaw motions were WNL!<br />

CONCLUSION<br />

Placing an implant or any final restoration in an environment where it has the potential<br />

to fail due to destructive occlusal forces is unwise. Communicating the effect of<br />

occlusal disease can be frustrating and difficult yet nonetheless it is our responsibility<br />

as health professionals.<br />

Realizing that all patients may not require nor want extensive full mouth reconstruction,<br />

a simpler solution would have been to equilibrate and restore anterior guidance<br />

with a minimal approach using composites. Her muscle soreness would be eliminated<br />

and the potential for repeated porcelain failure would be very minimal.<br />

The beauty of understanding and presenting solutions to occlusion disease is that<br />

whether you are doing something very minimal or, as in this case, major, the case<br />

can be completed in phases (one arch or anterior segment at a time). The treatment<br />

principles are the same regardless of scope of treatment. This case started with a<br />

desire to do a single implant crown on #18. The patient was also concerned about<br />

repeated crown loosening and fracture and she was aware of grinding her teeth.<br />

With the help of 3D animations, I was able to demonstrate the destructive effects<br />

caused by an unstable occlusion which increased her understanding and confidence<br />

to accept a rather extensive treatment plan. The result is a beautiful, healthy smile<br />

that will last.<br />

A Case Study in Handling and Explaining Occlusal Disease


CAD/CAM<br />

Porcelain fused to CAPTEK<br />

– ARTICLE by Don Mersky, DDS<br />

– PHOTO (opposite page) by Kevin Keithley<br />

All other photos/illustration provided by Precious Chemical Co., Inc.<br />

For years I have wondered why some seat appointments go so smoothly while so many others take<br />

so long. I never could figure out if blame fell on the patient, the lab or me. One thing I never considered<br />

was the material. The truth is, the limitations of the materials and techniques that labs are forced<br />

to use in traditional PFM fabrication can sometimes lead to these inconsistencies. Fortunately, we live<br />

in an era of great innovations. One of those innovations is pressed-to-metal merged with the accuracy<br />

of CAD/CAM.<br />

This combination is making patient visits easier. That’s because margins fit better, esthetics are more consistent,<br />

and adjustments & seat times are greatly reduced. Plus, we get these advantages while using our<br />

standard protocol and cements because it’s still a PFM.<br />

One of the most precise phases of full-crown fabrication is the waxing stage. That is because wax<br />

is more controllable and easier to manipulate than porcelain. As a result, it is easier to perfect the<br />

contours, the occlusion and the contacts. CAD/CAM technology goes well beyond just waxing. The<br />

full contour wax pattern is actually computer generated (digitally designed) to create a perfect tooth form<br />

over a Captek coping.<br />

The traditional layering and baking of porcelain can be quite challenging. Porcelain condenses and shrinks<br />

up to 10% with each application and bake. These stresses can sometimes cause a natural deflection of<br />

the thin buccal margins of traditional PFMs. This is why at times we find our PFMs will fit too snug and<br />

possibly fall short of the margin. As hard as we all try, these natural inconsistencies only add to the time<br />

spent on chairside corrections.<br />

Internal skeleton of platinum/palladium: hard, strong, stable particles<br />

that provide the rigidity necessary to support porcelain.<br />

97.5% gold, 2.5% silver filler that provides the stress relieving,º vibration<br />

absorbing qualities to the crown in addition to the warm gold color.<br />

Capbond or UCP layer - metal irregular fingerlike projections that provide complete<br />

interlocking and transition zone where Captek and porcelain combine. Also<br />

provides light diffusion qualities for ideal esthetic results.<br />

Patented “Reinforced Gold” or “Composite Metal”<br />

CAD/CAM Porcelain fused to Captek


Captek restorations with a porcelain butt margin, metal to the edge, and a metal collar all provide great esthetics.<br />

Unlike typical PFMs, Captek requires no oxides and will never turn black.<br />

Under a microscope the internal<br />

structure resembles a metal<br />

sponge, increasing the bond of<br />

opaque layer to the porcelain.<br />

THE BEAUTY OF CAD/CAM Traditional PFM porcelain is<br />

applied in layers that are formed from a mix of ceramic powders<br />

and liquid. The resulting paste of each layer is then separately<br />

baked, each bake with a potential for internal stresses.<br />

It is a laborious process that results in a different shape with<br />

each bake. The porcelains that are used are shades of pink,<br />

white and gray. Although the technician works very hard on<br />

our behalf to meet our expectations, the limitations of the<br />

technique can lead to the occasional inconsistent shading for<br />

a traditional crown. Contours, contacts and occlusion can also<br />

be affected.<br />

CAD/CAM’s ability to digitally design the pressing process<br />

means there is no need for powders or multiple bakes.<br />

Instead, it begins by scanning all dimensions important to the<br />

final restoration. The next step is the computer-generated fullcontour<br />

waxing that is applied directly over the high-noble<br />

Captek coping. The result is a full-contour wax pattern<br />

with very accurate contours, contacts and occlusion. The fully<br />

waxed pattern and coping is then invested and made ready for<br />

the actual porcelain pressing.<br />

In this next step, a highly esthetic ceramic ingot matching<br />

the prescribed shade is heated to a liquified state and then<br />

injected, or pressed, into the mold created by the burned-out<br />

wax pattern. At this point, the restoration can be finished with<br />

any customization desired.<br />

The advantages of combining pressed ceramic with CAD/CAM<br />

have become very clear. Because there is no dimensional<br />

change to the ceramic, seat appointments require a lot less<br />

time. Additionally, as with any PFM, we can use any margin<br />

of our choice, even a porcelain butt margin, and expect an<br />

excellent fit.<br />

But this is not the end of the story. If there was no metal<br />

under the porcelain we would lose many of the advantages<br />

offered by CAD/CAM-designed PFMs. On the other hand, if<br />

that metal was cast we would have the challenges posed by<br />

oxidation and corrosion.<br />

CAPTEK, REDEFINING THE PFM There has been confusion<br />

on exactly how to define Captek. Some have called it a<br />

foil, pure gold or electroplated. Actually, it is none of these.<br />

Captek has been referred to as a composite metal because its<br />

component particles, pure Pt, Pd, Au, with a trace of Ag, are<br />

arranged similarly to the components of resin composite.<br />

Unlike cast metals, a cross section of Captek would reveal an<br />

interconnected reinforcing matrix of pure Pt and Pd particles<br />

surrounded in a sea of gold. The strong Pt-Pd internal reinforcing<br />

structure is thermally stable and rigid. It is these<br />

characteristics that neutralize the forces that can lead<br />

to distortion. While eliminating distortion helps Captek achieve,<br />

according to Dr. Dan Nathanson of Boston Universtity, margin<br />

gaps of 15 microns, there are other reasons that Captek is<br />

a better choice.<br />

Research conducted at Forsythe <strong>Dental</strong> Center and Boston<br />

University (funded by the NIH) has shown that Captek<br />

reduces bacterial plaque by at least 71% when compared to<br />

non-restored teeth in the same mouth. Many of us have<br />

actually seen tissue heal and become healthier subsequent<br />

to placing a Captek restoration. This is because the nature<br />

of the pure particles creates an environment that inhibits<br />

bacterial colonization.<br />

Captek doesn’t require oxidation to bond to porcelain.<br />

Instead, the porcelain bonds to a unique material called UCP<br />

that is applied to the surface of the coping. The UCP particles<br />

extend from the surface like thousands of microvilli, allowing<br />

for a true mechanical porcelain bond. According to research<br />

at Boston University, this combination increases the porcelain<br />

shear bond strength and shock absorption qualities well<br />

beyond most all other materials.<br />

Although these are all important advantages, the most obvious<br />

advantage would be esthetics. There simply is no way to<br />

compare traditional cast PFMs to Captek when considering<br />

esthetics. The elimination of the oxidation layer means that<br />

there will never be black lines at the margin, black gums or<br />

darkened roots. Surprisingly, patients can tell the difference.<br />

This was confirmed during a Harvard-Boston Universities study. Their presentation<br />

to the American Association of <strong>Dental</strong> Research in 2005 illustrated that even when<br />

compared to all-ceramics and cast PFMs with porcelain butt margins, Captek with<br />

metal to the edge provided the most natural esthetics near the normally difficult<br />

crown margins.<br />

As we all know, there is nothing more predictable or easier to use than a PFM. And<br />

the same would also be true for Captek. And just like any other PFM, there are<br />

guidelines we need to follow that will help us to realize its full potential.<br />

Porcelain requires adequate thickness in order to maintain its strength. I suggest that<br />

2mm of occlusal clearance be gained at preparation, and no less than 1.5mm of total<br />

occlusal thickness of the crown at cementation. For axial reduction, 1mm is minimal.<br />

Additionally, according to research published by Dr. Charles Goodacre, Loma Linda<br />

University in 2001, all PFMs should have preparation of 10-20 degrees.<br />

Margin design for Captek is no different than any other PFM, and the same could be<br />

said for cementation, with one exception. In those instances that crown retention is<br />

compromised, it is recommended that Captek crowns be air abraded with 50 micron<br />

aluminum oxide at 40 lbs of pressure. The air abrasion will remove the internal<br />

22 micron surface of high gold, and leave a more retentive surface for your cement<br />

of choice.<br />

Like other PFMs, Captek can be used anywhere: single crowns (posterior and anterior)<br />

and bridges (up to 15 mm pontic span); and they are fantastic over implants.<br />

CAD/CAM AND CAPTEK Like many of us, I have used PFMs with success for<br />

decades. Sure, they have their shortcomings, and the all-ceramics have done a pretty<br />

decent job of addressing these challenges. But PFMs have proven long-term predictability,<br />

and can be easier to manage than all-ceramics.<br />

Now, old PFM technology has been updated with new technology. But this time,<br />

instead of having to learn an entirely new paradigm, instead of having limitations<br />

and new guidelines thrust upon us, we have the ability to continue using familiar<br />

techniques and principles that have been proven over time.<br />

CAD/CAM designed porcelain pressed-to-Captek provides incredible predictability in<br />

esthetics, fit, form and function. Moreover, when compared to the past, the increased<br />

density of the ceramic provides for greater strength and a better fit.<br />

Captek can be used for implant<br />

cases and the final restoration.<br />

The tissue around the Captek<br />

crown on tooth number 4 is<br />

healthier than even the nonrestored<br />

teeth.<br />

This after photo shows that the<br />

Captek crown imparts a natural<br />

gingival color.<br />

62<br />

CAD/CAM<br />

Porcelain fused to Captek<br />

CAD/CAM Porcelain fused to Captek


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