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Chairside® 

A Publication of Glidewell Laboratories • Volume 6, Issue 2 

Photo Essay 

BruxZir ® Is Given an 

Esthetic Challenge 

Page 14 

CEREC ® Connect 

Dr. Carlos Boudet on 

Digital Impressions 

and the Lab 

Page 38 

Dr. Len Boksman 

Optimizing Occlusal Results 

for Crown & Bridge Prostheses 

Page 47 

One-on-One Interview 

Steve Thorne Discusses the Pacific Dental 

Services Approach to Quality Dentistry 

Page 24 

Dr. Michael DiTolla’s 

Clinical Tips 

Page 9

Contents 

9 Dr. DiTolla’s Clinical Tips 

In this issue, I highlight four products that may be 

new to you: SpeedCEM , a self-etching resin cement 

from Ivoclar Vivadent; Z-PRIME Plus, a special silane 

I place inside BruxZir ® restorations prior to bonding 

or cementation; the Garrison Dental Solutions TN010 

Double Cord Packer; and Isodry Ti from Isolite Systems, 

which provides an impressive combination of 

mouth prop, tongue retractor, cheek retractor and 

suction device. 

14 Photo Essay: Anterior BruxZir ® 

Solid Zirconia Crown 

When we realized that dentists wanted to use BruxZir 

in the anterior, we knew that we needed to increase 

the material’s translucency. So, R&D quietly worked on 

this, and they recently asked me to test the result. This 

photo essay walks through a common esthetic challenge 

we face as dentists: the single-unit central incisor 

crown adjacent to natural dentition. While you won’t 

mistake BruxZir for a natural tooth, you’ll be surprised 

by the esthetics we achieved in this case. 

24 One-on-One with Dr. Michael DiTolla: 

Interview of Stephen Thorne 

Have you ever wished you only had to worry about 

delivering great clinical dentistry? Steve Thorne, 

founder, CEO and president of Pacific Dental Services, 

gives PDS dentists the ability to do just that. In this 

issue’s One-on-One interview, I speak with Steve about 

the services offered by PDS. This unique company 

provides practically all of the business and marketing 

services a dentist needs, in return for shared ownership 

of the practice. It’s a fascinating win-win concept, 

and I think you’ll enjoy our conversation. 

COVER ILLUSTRATION by Wolfgang Friebauer, MDT 

Contents 1

Contents 

38 CEREC ® Connect: A Welcomed Upgrade 

for CEREC Users 

Purchasing a digital impression system requires a 

significant financial investment. At the lab, our customers 

are slowly warming up to the idea of sending cases 

digitally, which saves $20 per unit when model-free 

restorations are prescribed. There are many systems 

available — Sirona CEREC AC, E4D Dentist , Lava 

C.O.S., CADENT iTero and IOS FastScan . In his 

article, Dr. Carlos Boudet outlines the steps for sending 

a digital file to the lab via CEREC Connect. 

47 Optimizing Occlusal Results for 

Crown & Bridge Prostheses 

Dr. Len Boksman discusses various impression-taking 

techniques and materials. He explains that, in order to 

achieve predictability in mounting or articulating models, 

it is important to use materials of matching accuracy. 

Dr. Boksman also presents his recommendations for 

reducing occlusal adjustments on restorations. These 

tips will ultimately save time and reduce stress at the 

delivery appointment. 

57 The Wynne Hybrid 

Advancements in material technology have presented 

us with many opportunities to improve our patients’ 

smiles. However, as Dr. William Wynne explains, there 

is not one superior dental restoration or material 

combination for all cases. For conservative restorations, 

he advocates using his Wynne Hybrid-designed 

Captek Nano crowns that combine the versatility of 

a metal-ceramic system with the benefits of pressed 

ceramic porcelains. 

CORRECTION: In the 2011 winter issue (Vol. 6, Issue 1), on page 

14 of the article titled “Are you Using ‘Gray-Market’ or Counterfeit 

Dental Products,” Chairside published a photo of popular product 

Septocaine. Glidewell Laboratories, by choosing this photo, was not 

insinuating that Septocaine or other Septodont products are inferentially 

more subject to gray-market sales than are similar products. 

2 

www.chairsidemagazine.com

Publisher 

Jim Glidewell, CDT 

Editor-in-Chief and Clinical Editor 

Michael C. DiTolla, DDS, FAGD 

Managing Editors 

Jim Shuck 

Mike Cash, CDT 

Creative Director 

Rachel Pacillas 

Senior Copy Editor 

Melissa Manna 

Copy Editors 

Jennifer Holstein, Eldon Thompson 

Statistical Editor 

Darryl Withrow 

Digital Marketing Manager 

Kevin Keithley 

Graphic Designers/Web Designers 

Jamie Austin, Deb Evans, Joel Guerra, 

Phil Nguyen, Kelley Pelton, Ty Tran 

Photographers/Clinical Videographers 

Sharon Dowd, James Kwasniewski, 

Sterling Wright 

Illustrator 

Wolfgang Friebauer, MDT 

Coordinator and Ad Representative 

Teri Arthur 

If you have questions, comments or complaints regarding 

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

chairside@glidewelldental.com. Your comments may be 

featured in an upcoming issue or on our website: 

www.chairsidemagazine.com. 

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Chairside is a registered trademark of Glidewell Laboratories. 

Chairside ® Magazine is a registered trademark of Glidewell Laboratories. 

Editor’s Letter 

First and foremost, I’d like to give a big thanks to everyone 

who voted for me in the 2011 DrBicuspid Dental Excellence 

Awards. Being voted “Most Effective Dentist Educator” is a 

true testament to the talent and dedication of many people 

who work behind-the-scenes here at the lab. 

Every person named on the Chairside magazine masthead 

to the left contributes to the success of this publication. As 

editor-in-chief, I focus on content that will be of interest to 

a large number of dentists. And while I am responsible for 

the content, it is our creative director, Rachel Pacillas, and 

the members of her editorial and design team who make 

the magazine come together so beautifully. 

My goal with Chairside is to share with you what I see at the 

laboratory — whether I am looking at preps and impressions 

or noticing what doctors prescribe. Even if you don’t 

read every article, my hope is that you will at least look at 

the pictures and read the captions, so I try to keep those as 

informative as possible. 

This honor also acknowledged the clinical DVDs we’ve 

been producing at the lab for the past decade. We have 

come a long way in improving the visual quality of our 

clinical footage. It took a $30,000 camera lens investment 

to be able to fill the screen with tooth #8 and #9 when 

it is desirable to do so. We recently upgraded the rest of 

our equipment, and now everything we shoot is in full 

1920x1080 HD. Soon you will be able to request Blu-ray 

DVDs as well. Videographer James Kwasniewski acts as my 

cameraman, and he has to be the best dental editor in the 

U.S. I strongly believe in our video education because you 

can’t Photoshop live video — what you see is what you get, 

versus still images, which can always be edited. 

Last but not least, I’d like to thank Jim Glidewell for paying 

to produce this educational material, and then providing it 

to the dental community free of charge. It’s one thing to say 

you want to give back to the profession that has given you 

so much, and quite another to send 4 million free DVDs and 

2 million free magazines to U.S. dentists each year. 

Yours in quality dentistry, 

Dr. Michael C. DiTolla 

Editor-in-Chief, Clinical Editor 

mditolla@glidewelldental.com 

Editor’s Letter 3

Letters to the Editor 

Dear Dr. DiTolla, 

I am very interested in subscribing to Chairside. 

I came across the 2011 winter issue, 

and I was fascinated by its concise yet 

powerful information. 

I have worked as a dentist for the past 12 

years at a dental health center in New Jersey. 

Although I am thankful for the stability 

provided by my job, I must confess: There 

were times I felt like “half a dentist” because 

of the type of dentistry I was forced to render. 

It seemed like it was all about numbers, 

or the quantity of patients the system demanded 

I see. I began to wonder, whatever 

happened to quality instead of quantity? 

Over the past decade, I started to hate the 

profession of dentistry — to the point that 

I avoided reading anything related to it! 

(I am ashamed to admit this.) That changed 

last summer. I was reading the local newspaper 

and spotted an ad for the practice 

of a dental school friend. Very happy to 

have seen his ad, I decided to surprise 

him at his office. I told him about my big 

mistake: Going into a health center and 

getting sucked into the system. Also, I told 

him that I was intimidated by the idea of 

leaving the system because I was not up 

to speed with the latest dental products 

and procedures. He welcomed me to train 

in his office, in order to re-acquire skills in 

4 

www.chairsidemagazine.com 

cosmetic dentistry and to learn about the 

newest technologies. In fact, the first thing 

he did was give me your DVD series. After 

that, I became your fan. 

Today I can say, for the first time, that I am 

in love with this incredible and lucrative 

profession. I was in a dormant state for so 

many years that I often feel overwhelmed — 

I still have so much catching up to do — but 

it was time for me to wake up! Because of 

your mission and vision, dentistry has become 

easier, cleaner and more fascinating 

for me! 

– Ninoska Fergusson, DMD 

Clifton, N.J. 

Dear Ninoska, 

Thanks for the kind words! I also went 

through a period where I wondered if 

I had picked the right profession. I am 

thrilled that I was able to play a small 

part in helping you rekindle your love 

for dentistry — it’s definitely an exciting 

time to be a part of it. In this issue’s 

One-on-One interview (page 24), I 

speak with Steve Thorne, founder, 

CEO and president of Pacific Dental 

Services. I love how his company is 

helping dentists find the happiness 

you’ve already discovered. 

– Mike 


I enjoy and look forward to each new issue 

of Chairside magazine. I’m writing to you 

because I am confused by the new types 

of all-ceramics. I suppose you could call 

me a “blue-collar dentist,” in the sense that 

almost all of the crowns I do are standard 

PFMs. However, I would like to start doing 

some all-ceramic crowns for anterior and 

posterior teeth. Where do I start? There 

are so many all-ceramics to choose from: 

IPS Empress ® , IPS e.max ® , BruxZir ® , and 

probably others. 

Will you help me sort through these materials? 

Which all-ceramic material should 

I use for anterior crowns & bridges and 

posterior crowns & bridges? I know this is 

a lot to ask, but I’m just so confused by all 

these new products! Also, I just received a 

New Doctor Kit from Glidewell Laboratories, 

and I’d like to start sending cases to the lab. 

However, before I do, I need help determining 

which all-ceramic material I should 

be using for crown & bridge cases. 

– Robert Israel, DDS 

Pleasanton, Calif. 

Dear Robert, 

Many dentists ask the same exact question. 

You are not alone! First, know 

that there is nothing wrong with PFMs. 

This restoration has served dentistry 

well for nearly five decades. However, 

use of PFMs does come with liabilities: 

As a bilayered restoration, a PFM 

can be prone to chipping, especially 

on multiple-unit restorations, such as 

large bridges. The lab is working to 

solve this issue by “re-inventing” PFM 

restorations, by fusing a ceramic that 

is three times stronger than currently 

available ceramics to the metal coping. 

Second, some of the current ceramics 

used on PFMs cause an unacceptable 

amount of wear on opposing teeth. We 

have all seen upper anterior PFMs that 

have done a number on lower anterior 

teeth. Third, the average PFM crown 

is not as esthetic as the average allceramic 

crown. Opaquing a metal coping 

so that the final restoration looks 

like a natural tooth requires a skilled 

technician and ideal reduction from 

the dentist. 

As the strength of all-ceramic restorations 

has improved, making cementation 

an option, more dentists 

have looked to using all-ceramics in 

anterior situations in hopes of satisfying 

more patients. Today, two of the 

fastest-growing products in the lab are 

monolithic: IPS e.max and BruxZir. 

A monolithic restoration is fabricated 

from just one material, whereas a PFM 

restoration is two materials: porcelain 

and metal, which are fused together.

The oldest monolithic material we 

have is cast gold, which scores well 

in every restorative category except 

esthetics. Like cast gold, IPS e.max 

and BruxZir are less prone to chipping 

than PFMs — and even than porcelain 

fused to zirconia restorations, which 

are also bilayered. In the 2011 winter 

issue of Chairside magazine, Dr. Gregg 

Helvey compared monolithic and bilayered 

restorations. You might enjoy 

reading his article to learn more. 

I can tell you that almost every restoration 

I place today is monolithic — 

I have that much confidence in IPS 

e.max and BruxZir. For the last two 

years, I have been using BruxZir for 

posterior crowns & bridges and IPS 

e.max for anterior crowns and 3-unit 

anterior bridges. As BruxZir becomes 

more translucent and thus esthetically 

acceptable, I also have been using it in 

the anterior for bridges over 3 units. As 

for IPS e.max, I love the idea that it is 

three times stronger than IPS Empress. 

I even did my last three minimal-prep 

veneer cases in IPS e.max. 

If I had to do a single anterior veneer 

adjacent to a natural tooth, I would 

still use IPS Empress. If it were a single-unit 

anterior crown adjacent to 

a natural tooth, I would go with IPS 

e.max. And BruxZir is catching up 

esthetically. In fact, in the photo essay 

on page 14, I place a single-unit anterior 

BruxZir crown that is a pretty darn 

good match. 

That said, I think BruxZir in the posterior 

and IPS e.max in the anterior 

is a great place to start. Both restorations 

can be cemented or bonded 

into place, based on your preferences 

or retentive requirements. You will 

need to place Z-PRIME Plus (Bisco 

Inc; Schaumburg, Ill.) into the crown 

prior to bonding BruxZir. The bonding 

steps for IPS e.max are the same as 

typical all-ceramic restorations. 

– Mike 


What anti-snoring device do you recommend 

for a young woman with no history of 

sleep apnea? Thanks. 

– David S. Hornbrook, DDS, FAACD 

La Mesa, Calif. 

Dear David, 

There are two choices: a mandibular 

advancement device (e.g., Silent Nite ® ) 

or a tongue stabilizing device (e.g., 

aveoTSD ® [Innovative Health Technologies 

(NZ) Limited]). I prefer aveoTSD 

because I have a hard time sleeping 

with the Silent Nite appliance in my 

mouth — it makes me feel claustrophobic. 

Most people, however, don’t 

feel that way; Silent Nite outsells 

aveoTSD by approximately 20 percent 

(although it had a 15-year head start). 

The aveoTSD is pre-made, which 

means it does not require impressions. 

It works through gentle suction 

to hold the tongue forward, thus keeping 

the airway open. We have also noticed 

that aveoTSD provides an added 

benefit: It stops bruxism because the 

tongue sticks out between the anterior 

teeth. While aveoTSD looks a little 

silly, the patient has no bite change 

issues upon waking. Check out www. 

getaveo.com for more information. 

Silent Nite also moves the tongue forward, 

but it does so by moving the 

whole mandible forward. The downside 

to this is that it can take the 

patient a few minutes each morning 

to “find” centric occlusion. Other patients 

actually see an improvement in 

their TMJ symptoms because it moves 

the mandible downward and forward. 

There is a slight learning curve for the 

patient when using aveoTSD. That’s 

because the patient is the one who 

determines how much suction will 

be on the tongue. Silent Nite, on the 

other hand, has no learning curve. 

The patient just puts it in and goes to 

sleep. If the appliance needs titration, 

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the patient will need to return to his 

or her dentist. 

As for side effects, some aveoTSD users 

report tip-of-the-tongue numbness 

from the suction. Many of my patients 

actually prefer to use both Silent Nite 

and aveoTSD, alternating between the 

two to minimize their side effects. I 

am beginning to think this is the best 

approach: Present the aveoTSD and 

Silent Nite together as an anti-snoring 

package, as opposed to a choose-oneof-these-appliances 

approach. 

– Mike 

Letters to the Editor 5

Contributors 

Michael C. DiTolla, DDS, FAGD 

Dr. Michael DiTolla is a graduate of University of the Pacific Arthur A. Dugoni School of Dentistry. As director 

of clinical education & research at Glidewell Laboratories in Newport Beach, Calif., he performs clinical 

testing on new products in conjunction with the company’s R&D department. Glidewell dental technicians 

have the privilege of rotating through Dr. DiTolla’s operatory and experiencing his commitment to excellence 

through his prepping and placement of their restorations. He is a CR evaluator and lectures nationwide on 

both restorative and cosmetic dentistry. Dr. DiTolla has several clinical programs available on DVD through 

Glidewell Laboratories. For more information on his articles or to receive a free copy of Dr. DiTolla’s clinical 

presentations, call 888-303-4221 or e-mail mditolla@glidewelldental.com. 

Leendert Boksman, BSc, DDS, FADI, FICD 

Dr. Leendert “Len” Boksman is director of clinical affairs for Clinical Research Dental/CLINICIAN’S CHOICE 

and an adjunct clinical professor at the Schulich School of Medicine and Dentistry. He maintains a private 

practice in London, Ontario, Canada. Dr. Boksman was the first International Editorial Board Member of 

REALITY and consulted for 3M ESPE and Caulk/DENTSPLY for more than 20 years. Contact him via e-mail at 

lboksman@clinicalresearchdental.com. 

Carlos A. Boudet, DDS, DICOI 

Dr. Carlos Boudet graduated from Medical College of Virginia (now VCU Medical Center) in 1980 with a DDS 

degree. Soon after, he became a commissioned officer for the United States Public Health Service. His tour 

ended in 1982, when he was asked to serve as director of four dental clinics around Lake Okeechobee, Fla. 

Dr. Boudet established his dental practice in West Palm Beach in 1983 and has been in the same location for 

26 years. He is a Diplomate of the International Congress of Oral Implantologists, a member of the Central 

Palm Beach County Dental Society and sits on the board of directors of the Atlantic Coast Dental Research 

Clinic. Contact him at www.boudetdds.com or 561-968-6022. 

Stephen E. Thorne, BA, MHA 

Stephen Thorne is founder, CEO and president of Pacific Dental Services, a dental practice services company 

located in Irvine, Calif. Started in June 1994, PDS has grown an estimated 445 percent since 2003, and by 

year-end 2011, the company will provide services to approximately 250 practices throughout California, 

Arizona, Nevada, Colorado, Texas and New Mexico. Steve is also president of the Dental Group Practice Association, 

the largest association of dental group practices in America. He is a graduate of UCLA and received 

his Master of Health Administration from Chapman University. Contact him at www.pacificdentalservices. 

com or chairside@glidewelldental.com. 

William P.D. Wynne, DDS, PA 

Dr. William Wynne graduated from UNC at Chapel Hill School of Dentistry in 1971. Today, he maintains a 

private practice focused on aesthetic and restorative dentistry in Raleigh, N.C. Dr. Wynne is a Pankey Scholar 

and former teaching associate of The Pankey Institute, where he helped form coursework on aesthetics. He is 

a member of the AACD and American Academy of Dental Practice Administration. Dr. Wynne has also published 

numerous articles on aesthetic dentistry, occlusion and eating disorders, and he has lectured across the 

U.S. on these topics. Contact him at www.raleighareadentist.com or 919-851-3716. 

6 


Congratulations, 

Dr. DiTolla! 

“Most Effective Dentist Educator” 

Congratulations to our editor-in-chief, and Glidewell 

Laboratories’ in-house educator and director of clinical 

education & research, Dr. Michael DiTolla! 

DrBicuspid members, in the 2011 DrBicuspid Dental Excellence 

Awards, voted Dr. DiTolla “Most Effective Dentist Educator.” The 

winners in 12 categories were announced Jan. 24, 2011. 

Dr. DiTolla has worked at Glidewell since 2001, after spending 

13 years in private practice. His unique laboratory perspective 

provides him with intimate knowledge of U.S. dentists and 

their crown & bridge habits. He uses 

this knowledge to put together case 

studies, preparation techniques and 

clinical videos that demonstrate to 

dentists how to most efficiently handle 

everyday dental situations. 

Congratulations, Dr. DiTolla, on this 

very exciting honor!

Numbers 

by the 

An elephant’s molars 

measure 1 foot wide and 

weigh between 8 and 10 

pounds each. 

In the U.S., the average 

person purchases 

approximately 18 yards 

of dental floss per year. 

However, that average 

should be much higher — 

approximately 122 yards 

of floss per year — based 

on using one foot per day. 

China 

recognizes Sept. 20 as a 

national holiday known as 

“Love Your Teeth Day.” 

360% 

Percentage increase of modelfree 

crown fabrication from 

intraoral scans at Glidewell 

Laboratories (Feb. 2011 

compared to Feb. 2010) 

Brush your teeth every night? 

Ninety-four percent of the 

U.S. population does too. 

But beware morning breath: 

Only 81 percent admits to 

brushing each morning. 

Lucy Hobbs Taylor 

was the first woman to 

receive a DDS degree. 

The year was 1866 

and the school was 

Ohio College of Dental 

Surgery in Cincinnati. 

The concept of the 

electric chair is most 

often credited to 

Alfred P. Southwick — 

a dentist. 

50% 

Percentage of dentists in 

Rhode Island who sent 

a case 6,000 miles to 


in 2010 

5,800,000 

Number of BioTemps 

provisionals fabricated at 


8 


PRODUCT........ SpeedCEM 

Dr. DiTolla’s 

CLINICAL TIPS 

SOURCE........... Ivoclar Vivadent 

Amherst, N.Y. 

800-533-6825 

www.ivoclarvivadent.us 

I was never as good at total-etch bonding as the masters, 

always getting more postoperative sensitivity 

than I was comfortable with. This was particularly 

bothersome on some veneer cases, where the patient 

was asymptomatic when we started and definitely 

symptomatic when we ended. 

Today, nearly all of my veneers are minimal prep, 

where dentin is not even exposed. Because all of my 

bonding to dentin is using full crowns with enough 

retention, I don’t need total etch. Instead, I use 

a self-etching resin cement such as SpeedCEM . 

SpeedCEM is self-curing, but it also has a 

light-curing option if you prefer to eliminate 

the wait time. With easy cleanup and 

three available shades (transparent, 

opaque and yellow), SpeedCEM is a 

great middle ground between cementing 

and total-etch bonding. 

Dr. DiTolla’s Clinical Tips 9


CLINICAL TIPS 

PRODUCT........ Z-PRIME Plus 

SOURCE........... Bisco Inc. 

Schaumburg, Ill. 

800-247-3368 

www.bisco.com 

I receive lots of questions — via e-mail, telephone 

and at lectures — about how to bond BruxZir ® Solid 

Zirconia into place. Because zirconia is unaffected by 

sandblasting, hydrofluoric acid and typical ceramic 

silanes, you need to use a special silane. 

I currently use Z-PRIME Plus, whether I am bonding 

a BruxZir crown with a resin cement (e.g., Multilink ® 

Automix [Ivoclar Vivadent]) or cementing one with a 

resin-reinforced glass ionomer (e.g., RelyX Luting 

Plus [3M ESPE; St. Paul, Minn.]). Just apply one to two 

coats inside the BruxZir Solid Zirconia restoration, 

dry for three to five seconds with an air syringe, and 

you are ready to go! 

10 www.chairsidemagazine.com


CLINICAL TIPS 

PRODUCT........ TN010 Double Cord Packer 

SOURCE........... Garrison Dental Solutions 

Spring Lake, Mich. 

888-437-0032 

www.garrisondental.com 

If you had bet me $1,000 in July 2010 that there would 

be a really cool improvement in cord packer technology, 

you would have won that bet. And while gently 

cramming a piece of string subgingivally does seem 

so last century, I have yet to find a replacement that 

retracts tissue so well without removing healthy tissue. 

While I’m stuck with packing cord for now, the TN010 

Double Cord Packer from Garrison Dental Solutions 

makes this task more efficient. When I pack cord on a 

molar, I might flip the instrument six or seven times 

while looking at the tooth through my loupes. I have 

whacked enough anterior teeth with the instrument 

to wonder if there was a better way, and with the 

TN010 there is! Stop flipping and keep packing with 

this great product. 

Dr. DiTolla’s Clinical Tips11


CLINICAL TIPS 

PRODUCT........ Isodry Ti 

SOURCE........... Isolite Systems 

Santa Barbara, Calif. 

800-560-6066 

www.isolitesystems.com 

It is pretty difficult to decide what I like best about 

Isolite — it does so many things! An impressive 

combination of mouth prop, suction device, intraoral 

illuminator, tongue retractor and cheek retractor, 

Isolite does not disappoint. 

I have always disliked placing mouth props because 

they limit my assistant’s access — and because the 

patient’s mouth turns into a lake. Tongue retraction is 

a difficult skill and can spell trouble for the patient if 

the tongue breaks loose and bumps the bur. 

I started using Isolite’s little brother, Isodry Ti 

, when 

I converted to digital impressions. Because Isodry Ti 

has no light, it does not interfere with scanning. And, 

at half the price of Isolite, it is a steal! See everything 

the systems can do at www.isolitesystems.com. 


Photo Essay 

® 

Anterior BruxZir 

Solid Zirconia Crown 

– ARTICLE by Michael C. DiTolla, DDS, FAGD 

BruxZir ® Solid Zirconia crowns & bridges were originally designed by Glidewell Laboratories as a replacement for 

posterior cast gold or metal occlusals, when the patient did not want any metal showing in his or her mouth. As 

dentists began placing BruxZir restorations and were repeatedly satisfied with the results, they started to prescribe 

BruxZir for bicuspids, as well. The lab realized that if dentists wanted to prescribe BruxZir in the anterior, the translucency 

of this material needed to increase. Our R&D team worked on this quietly and finally told me when they were 

ready to test it. They asked me for an esthetic challenge, so I decided to give them the tough one we all face: the 

single-unit central incisor crown adjacent to a natural tooth. This photo essay shows the clinical steps for placing an 

anterior BruxZir crown. For a crown that is 100 percent zirconia with no ceramic facing, the lab pretty much nailed it. 


Figure 1: Tooth #9 is going to be prepped for a BruxZir crown. I 

chose this case for a couple of reasons. First, tooth #8 is a natural 

tooth, and it will be a good test of how the light interacts with the 

BruxZir restoration versus the natural tooth. Second, tooth #7 is an 

all-ceramic crown, which will be replaced later, and tooth #10 and 

#11 are a PFM cantilever bridge. So, we will be able to compare 

the BruxZir crown to those two restorations, as well. 

Figure 2: I place PFG topical anesthetic gel (Steven’s Pharmacy; 

Costa Mesa, Calif.) into the sulcus using an Ultradent syringe. I 

used to use a cotton-tipped applicator, but this made it difficult to 

get PFG into the sulcus. Because I am using single-tooth anesthesia 

for this case, the needle is going into the sulcus, so that’s where 

the topical needs to go. The tufted tip on the syringe makes it easy 

to place the topical subgingivally. 

Figure 3: The 30-gauge extra short needle of the STA System 

(Milestone Scientific; Livingston, N.J.) is placed in the sulcus. I 

prefer using the Rapid Anesthesia Technique for injections, and 

a few drops of anesthetic are given as I penetrate the base of the 

sulcus and contact bone. (An in-depth look at this technique is 

available at www.glidewelldental.com.) I started using this technique 

for single mandibular molars to avoid blocks, until I realized 

patients hate anterior infiltrations just as much. So I began using 

single-tooth anesthesia here, as well. 

Figure 4: I use the Reverse Preparation Technique to prep the 

tooth. (View a step-by-step clinical technique video online.) The 

first step of this technique is to break the proximal contacts. 

Because we are only preparing tooth #9, we are going to do this 

with a thin 56 carbide bur on both the mesial and distal. The goal 

is to break contact with the adjacent teeth just enough to place our 

first retraction cord. 

Photo Essay: Anterior BruxZir Solid Zirconia Crown15

Figure 5: The first retraction cord is an Ultrapak ® Cord #00 

(Ultradent; South Jordan, Utah). It is a hollow, braided cord that has 

no EPI and has not been soaked in any medicament. The cord is 

flossed into place on the mesial and distal, and the two loose ends 

are grabbed on the lingual and pulled until the cord rests against 

the facial surface of the tooth. A non-serrated cord packer is used 

to pack the cord on the facial, and the two ends are cut on the 

lingual to be flush in the lingual sulcus. 

Figure 6: Now that the first cord has retracted the tissue approximately 

0.5 mm, it’s time to prep the gingival margin. I call this technique 

the Reverse Preparation Technique because we prep the 

gingival margin first, not last (as I was taught in dental school). We 

use an 801-021 bur to trace around the gingival margin, taking this 

bur to nearly half its depth, about 1 mm. It cuts a perfect half circle 

into the gingival third. 

Crowns often look fake in the 

gingival third, but this gingival 

depth cut ensures that we 

will deliver an esthetic crown. 


Figure 7: Crowns often look fake in the gingival third, but this 

gingival depth cut ensures that we will deliver an esthetic crown. 

Because the depth cut is a perfect half circle, we will be left with a 

perfect quarter circle — which is a precision deep chamfer or shallow 

shoulder — after we do our axial reduction. There is no easier 

way to prep a perfect margin. 

Figure 8: I prepare a 2 mm depth cut in the incisal edge because 

we are restoring the tooth to its original length. I typically place two 

of these cuts, which help me quickly reduce the incisal edge while 

keeping it level. Under-reduction of incisal edges leads to crowns 

that are facially prominent in the incisal third, which gives them a 

bulky look. 

Figure 9: With the depth cut bur perpendicular to the facial surface 

of the tooth, at the junction of the incisal third and the middle, we 

make a 1.5 mm depth cut. This depth cut should be just apical to 

the incisal edge depth cuts. Depth cuts ensure that we get enough 

facial reduction to have an esthetically pleasing crown that is the 

same size as the adjacent natural tooth. This is difficult to achieve. 

Figure 10: At this point, all depth cuts are finished. This allows me 

to fly through the rest of the prep because the gingival is essentially 

done. The incisal edge takes about 15 seconds, and the facial 

reduction is marked with a depth cut. There is no guessing about 

how much to reduce. 


Figure 11: The 856-025 bur is the workhorse of the Reverse Preparation 

Technique. I find this bur extremely easy to cut with because 

of its coarse grit and wide surface area. As I move the bur mesiodistally, 

I am doing the facial reduction to the bottom of the depth 

cut. I am really not doing any reduction in the gingival third. The tip 

of the bur almost floats in space as I make the facial depth cut and 

blend it with the gingival. 

Figure 12: I turn the 856-025 bur perpendicular to the incisal edge 

and connect the two 2 mm depth cuts I made in Figure 8. As the bur 

moves mesiodistally, it is pretty easy to make quick work of incisal 

edge reduction. Because the tip of the bur is pointed at the lingual, 

I roll the tip of the bur about 20 degrees toward the lingual margin. 

Figure 13: I now do the lingual reduction using a 379-023 football 

bur. This bur is convex and cuts a concave surface, which is the 

shape of the lingual surface of a natural tooth. You don’t really need 

to place a lingual depth cut because you have the opposing tooth 

to use as reference, but you could certainly place a 1 mm depth 

cut here, if you wished. 

Figure 14: This image explains why I will never switch from an electric 

handpiece. I am able to turn down the handpiece speed to 

5000 RPM, which allows me to turn off the water. Even with the 

water turned off, I will not generate excessive heat because the bur 

is only spinning at 5000 RPM. This is the only way I can really dial 

in and smooth the margins. With the water turned off, it is easy to 

see what I am doing. 


Figure 15: The prep is essentially done. I now place the top cord, 

an Ultradent Ultrapak Cord #2E. The first cord (#00) retracts the 

tissue for the prep and also helps ensure we get a slightly subgingival 

margin. This means we never have to take a bur subgingival, 

which often causes bleeding. 

Figure 16: The top cord (#2E) is now placed. This cord is 

responsible for displacing the tissue laterally, to make room for 

the impression material. The #2E cord can’t be used in all clinical 

situations because it is simply too big for many lower anteriors or 

upper bicuspids with minimal attached tissue. For those cases, 

a smaller top cord, such as Ultrapak Cord #1, can be used to 

achieve similar results. 

Figure 17: With the top cord in place, you have one final opportunity 

to get a great look at the prep. Typically, I spend about 45 seconds 

polishing the prep, especially the gingival margin. I again turn 

the handpiece down to 5000 RPM and the water off, and I use a 

red-striped fine grit 856-025 bur to give the prep a mirror-like finish. 

Figure 18: Here is an incisal view of the finished prep. The top cord 

is in place with just a small tail protruding on the lingual for easy 

removal. The gingival margin is smooth and uniform all the way 

around the preparation. This is due to the use of the round bur early 

in the procedure, when the hard tissue landmarks were still in place. 


Figure 19: The last step of the preparation sequence is to place 

a ROEKO Comprecap anatomic (Coltène/Whaledent; Cuyahoga 

Falls, Ohio) on the prep. Slightly wet the inside of the Comprecap 

before placing it to keep the tooth moist and to prevent the cotton 

from sticking to the prep. Comprecap compression caps help keep 

the retraction cord in place and prevent the patient’s tongue from 

dislodging the cord. 

Figure 20: The patient bites down on the ROEKO Comprecap 

anatomic for 8–10 minutes. This ensures you have plenty of retraction. 

The other day, I pulled the Comprecap after just two minutes 

to take the impression. I did not have a wide-open sulcus. It is 

important to leave the Comprecap in place for 8–10 minutes. 

Figure 21: The result of waiting 8–10 minutes is a sulcus that cannot 

be missed with an intraoral tip. I could fling alginate into the 

sulcus from the other side of the operatory and still get a good 

impression. When your assistant pulls the top cord, look down 

from the incisal with a mirror to see what I mean. The impression 

material will flow into the sulcus. 

Figure 22: Blood or other gingival fluids have not contaminated 

the impression because the bottom cord (#00) was left in place. 

As a result, you will also get an impression of the 1 mm of tooth 

structure apical to the gingival margin. This allows the dental technician 

to precisely see the exact gingival margin and enables him 

or her to build a proper emergence profile into the restoration — 

an important determining characteristic for whether the crown will 

have a natural and lifelike appearance. 


Depth cuts ensure that we 

get enough facial reduction to 

have an esthetically pleasing 

crown that is the same size 

as the adjacent natural tooth. 

This is difficult to achieve. 

Figure 23: I try in the BruxZir crown on tooth #9 and find the fit 

to be acceptable. The patient has approved the esthetics, so we 

clean it out prior to cementation. I decide to cement the restoration 

rather than bond it into place because I have sufficient prep 

length and it is not overtapered. I use RelyX Luting Plus Cement 

(3M ESPE) because of its natural bond to dentin and simple cleanup. 

An orange pinewood stick is used to provide pressure while 

the cement sets. 

Figure 24: Here is the final BruxZir restoration on tooth #9, on the 

day of cementation. It probably won’t be mistaken for a natural 

tooth, but it blends well with the adjacent natural tooth, tooth #8. 

When I compare it to the existing all-ceramic and PFM crowns in 

the anterior segment, I think it looks better, although those other 

crowns are a few years old. While I don’t recommend that you 

jump into prescribing BruxZir for single-unit central incisors, I think 

BruxZir is one step closer to being a material that is as well suited 

for anterior restorations as it is for posterior restorations. CM 



Interview with Stephen Thorne 

– INTERVIEW of Stephen E. Thorne, BA, MHA 

by Michael C. DiTolla, DDS, FAGD 

Pacific Dental Services was founded in 1994, with 

Steve Thorne and his team entering into their first 

dental practice management contract in Costa Mesa, 

Calif. Today, PDS has opened close to 250 practices, 

nearly all of them from scratch. But unlike most of the 

“dental chains” we commonly associate with recent 

dental school graduates who are looking to build up 

their speed and make beginner mistakes, PDS takes 

a completely different approach. Dentists who work 

with PDS share ownership of their practice with the 

company. In return, PDS provides practically all of 

the business and marketing services for the practice, 

freeing the dentist to concentrate on delivering great 

clinical dentistry (in some of the most high-tech practices 

you will ever see!). Steve is a visionary in our 

profession, and I think you will enjoy our conversation. 

Interview with Stephen Thorne25

Dr. Michael DiTolla: Steve, for those readers who haven’t heard of Pacific Dental Services, 

how would you describe the services that your company provides to dentists? 

Stephen Thorne: Pacific Dental Services is a B2B business. We’re really the backbone 

of a well-run, well-distributed group of high-performing, decentralized dental 

practices. PDS provides a full scope of business services to dentists: accounting, real 

estate, payroll, specialty systems, services and capital, to name a few. 

MD: That sounds pretty much A to Z. Just as a little background for our readers, our dads 

went to dental school together. Then I went to dental school, and I know your brother went 

to dental school, as well. You did not go to dental school, but you ended up in dentistry anyway. 

Was that by design? Or did your career path just happen to unfold into this profession? 

ST: What I do now is the service business. And how I got started in dentistry was by 

helping my father out in his dental practice. It was 1989, and my dad needed some 

help putting in a computer system. He also needed help with billing, collections and 

other things. It wasn’t planned. It just evolved from helping my dad out for a short 

period of time 22 years ago. 

MD: How long did that evolution take? Were you helping in his practice for a couple weeks, 

a couple months, a couple years? 

ST: I worked for my father for a couple years and helped him develop a total of five 

practices. I discovered there was a real business need there, and that I could help 

more dentists with the business services in their practices to help them get started. 

I branched out in 1993 and started Pacific Dental Services in 1994. The first practice 

we affiliated with was in Costa Mesa, Calif., in June 1994. 

MD: Did your dad already have five practices when you came onboard? Or was he expanding 

as you were there, giving you the opportunity to see what it takes to open a dental office 

from scratch? 

ST: When I started working for my dad in 1989, he only had one practice. Between 

the two of us — I was helping run the business side and he was running the clinical 

side — we opened four more practices. 

MD: That’s pretty amazing. There aren’t many dentists, I’d say less than 2 or 3 percent of 

dentists in the U.S., who have the opportunity to open a second practice — let alone four 

more in addition to that first one! That just sounds like an amazing education on what it 

takes to start a dental practice. 

ST: I learned from the ground up. I started working as a receptionist and pulling 

charts. I was on the old pegboard system; that’s probably around the time you started 

practicing dentistry. I helped clean rooms. I helped sterilize instruments. I worked in 

a dental lab. I owned my own lab for many years. Getting my hands wet at the very 

base level of dentistry really helped me understand the operations of a dental office. 

MD: It sounds like, short of spending four years getting your dental degree, that’s about 

the best education you could have gotten. Not to just observe, but to actually work in all 

the different positions in a dental office. And to work in and then own a dental lab, as 

well, so that you could see the other side of what goes out of an office and how that affects 

quality and profitability in the office. 

When you started PDS in 1994, did you know there was definitely a need for something 

like this in the dental market? Was it just a matter of finding dentists you could work with? 

Or was it something where you said: If this doesn’t work out, I can always go back and do 

something else? 


ST: No, it was definitely the former. I knew 

there was a need from the time I spent 

in my dad’s practice and from talking to 

so many dentists out there, including my 

dad’s friends who asked for my help — 

I did some consulting work back then, too, 

with other dentists. Working through the 

practice broker network of these dentists 

who needed help, I realized there was a 

real opportunity. 

When I started PDS in 1994, this business 

model was relatively new. It wasn’t well 

received by dentists, except for those who 

got involved early. We’ve had to work our 

way through this the past 15 years. For the 

most part, however, the business model is 

fairly well accepted and understood, and 

the roles and responsibilities are clear. It’s 

been a big growth segment. 

MD: I would imagine that you are met with 

a lot less suspicion from dentists today than 

you may have been met with back in 1994. 

Is that true? 

ST: That is absolutely true. 

MD: PDS has a well-established track record 

now and so many affiliated offices. How 

many offices does PDS currently work with? 

ST: We’re approaching 250 practices. 

MD: I don’t think you can get to 250 practices 

if you’re not doing things correctly, treating 

people right and empowering dentists to have 

success with your system. 

ST: Our turnover at what we call the 

Owner Dentist level is extremely low. 

MD: And what criteria does PDS use to find 

prospective dentists? Do you go out and look 

for them, or do they find you? How does the 

process work? 

ST: It works both ways. We go out and 

look for them and they come to us. We 

actively recruit in the dental schools and 

local markets. 

We have fairly rigid criteria we’re looking 

for, the different talents and skill sets. 

After doing this for 20 years, I’ve sort of 

figured out what will make a dentist be 

fairly successful in his or her practice. 


We try to use all that experience in our assessment and screening. 

More and more, we’re getting dentists in their mid-30s to mid-40s who are searching 

us out. And they are just tired or stressed out from operating their practice, or they see 

the opportunity in the business model and say: “Look, I can work with an organization 

like PDS. They can handle all the business stuff. I can run the practice, which I’m good 

at. And, together, we win! Together it’s a better fit.” That’s a pretty cool development 

that’s starting to take place. 

MD: That is a cool thing. That’s really the main reason I wanted to interview you. It’s 

kind of become my mission to help dentists: Help dentists lower their remakes, increase 

the longevity of their restorations and consistently produce esthetic restorations they can 

be proud of. 

We tend to focus on helping the dentists who work with Glidewell Laboratories, and I can 

only share with them what’s worked for me as a dentist with an average set of hands. I’ve 

had to come up with systems for preparing teeth and systems for taking impressions to get 

good restorative results. But once you get past the clinical skills, you’ve still got to take care 

of the whole business side of things. 

Knowing what PDS does, and talking to some of the dentists who are affiliated with 

your company, makes me really excited to share this story with other dentists. There may 

be dentists reading this article who have been out of school for 15 years, who are right 

around 40 years old and think: “Well, I don’t feel like I’ve made a mistake. I think I picked 

the right career, but things just aren’t going the way I wanted.” You talk to dentists who 

hate hiring and firing. They hate the business aspect. Before a service like PDS was available, 

I don’t know what those dentists did. Maybe they retired or sold their practice and 

got into real estate. So, I think it’s so great that PDS is able to step in and help those dentists 

who have dedicated so much time and money to this career, and show them there’s 

another way to do it, where they can concentrate on the clinical and make more money 

when they turn some of this stuff over to PDS. 

ST: I think our results speak for themselves. Our average Owner Dentist is approaching 

$400,000 in income and works slightly more than 32 hours per week. These 

Owner Dentists tend to spend about one to two hours per week on administrative 

time; maybe reviewing finances or something like that. 

What’s really cool about this, for me too, after doing this for 22 years, is that the 

clinical side is getting more and more fun. We’re able to provide an environment in 

our infrastructure systems so that the dentist can just get better and better clinically. 

We have a saying at PDS: Clinicians Leading Clinicians in Clinical Excellence. We’re 

trying to position our company as a true leader of modern dentistry. We are really 

positioning the practices and the clinicians as leaders in fast, easy, efficient and great 

clinical environments for patients. And we’re the world’s leader in CEREC ® (Sirona 

Dental Systems). PDS affiliate dentists have done more than 250,000 CEREC restorations. 

Affiliate dentists are doing a lot of implant work — doing a lot of great dentistry. 

I think we’re now the world’s leader in laser therapy for periodontal disease. The 

results have been, from a clinical perspective, absolutely fantastic. 

When you have this many dentists pushing each other to improve their skills, it can 

weed out those dentists with no desire to improve. But it also allows the dentists who 

want to improve their clinical skills to really step up to a whole new level than they 

might if they were practicing alone. Isolation is the biggest downside for a dentist in a 

solo practice. The solo practitioner is so isolated. Who do they go to or where do they 

go when they need help? In our organization, BOOM, there are 500 different dentists 

they can pick up the phone and talk to, who they can e-mail, and with whom they 


can share a blog. There are many times 

they’ll actually get in the car and drive to 

personally help each other out. 

MD: It’s funny: The solo practitioner model 

is the one that has existed for so long. And I 

think it’s the one that a lot of us who went to 

dental school thought of when we thought of 

owning our practice. But it is lonely. I don’t 

know that there is any other word for it. It’s 

lonely, in the sense that you don’t have somebody 

else to bounce things off of. And you’re 

right, there is sort of a friendly competition 

that takes place when you put a few dentists 

together. But it’s really in the spirit of cooperation 

that everybody gets better. 

I do triathlons, for example. So, as part of the 

swim technique, you do these master swim 

classes, where there are eight of you swimming 

together. You push one another to get better 

because you swim faster together than you 

would alone. It’s an informal competition. 

That informal competition certainly applies 

to dentistry, as well. I can understand how 

with a disruptive technology like CEREC, 

this in-office CAD/CAM dentistry, that one 

dentist is going to learn it a little better than 

another dentist. But he is going to share that 

knowledge and get that other dentist excited, 

and they’re going to kind of spur each other 

on. I completely understand what you mean 

when you talk about this cooperative effort 

between the dentists that, in the end, gives 

the patient a better clinical result. 

From a lab standpoint, we get more digital 

impressions from PDS practices than we do 

from anybody else. You guys are No. 1 by a 

long shot. We get lots of digital impressions — 

mainly for monolithic BruxZir ® (Glidewell 

Laboratories) restorations that you send 

via CEREC Connect to the lab. So we can 

see that you are quite obviously using these 

units a lot. And I’m sure that of the 250,000 

crowns made, most of those were probably 

IPS e.max ® (Ivoclar Vivadent) done in 

office. That’s fantastic. In fact, your CEREC 

purchase is almost legendary. How many 

machines did you buy? 

ST: Oh, shoot, I have no idea what number 

we’re up to. From what I understand, 

there’s at least one machine in every practice. 

There might be a few old docs out 

there who have not adopted CEREC, but 

More and more, we’re 

getting dentists in their 

mid-30s to mid-40s 

who are searching us 

out. And they are just 

tired or stressed out 

from operating their 

practice, or they see 

the opportunity in 

the business model. 


for the most part our dentists have seen 

the light. When you get people like yourself 

and Dr. Gordon Christensen talking 

about digital dentistry, and about CEREC 

specifically, it’s pretty powerful. 

I was recently at Glidewell Laboratories, 

and I saw your investment in digital infrastructure 

and technology. Realistically, 

when you look into the future of dentistry, 

only a portion of restorations will 

be done using in-office CEREC. We don’t 

know what that percentage will be, but 

there will be a percentage of restorations 

done that way — single units and maybe 

2-unit restorations. 

However, for the foreseeable future, when 

you’re doing multiple-unit cases or a full 

arch or any large cases, they have to be 

done in a laboratory setting like yours. It’s 

great. So we’re a big fan of CEREC Connect. 

And our dentists tell me that the fit with 

CEREC Connect is off the charts. 

MD: It is. It’s really good. In fact, I think 

the only better fit you get is with the restorations 

you guys make in office. Here I am 

practicing in a dental laboratory but, to be 

completely honest, I just don’t think there’s 

anything better than same-day dentistry. I 

don’t think anything good happens during 

the two weeks the patient wears a temporary. 

In fact, I can list five or six bad things that 

happen! So I think this is where it’s all heading. 

And patients are the big winners in 

all this because they aren’t going to have to 

wear plastic on their tooth that keeps falling 

off for two weeks in order to get a definitive 

restoration. Same-day treatment is always 

going to be in the patient’s best interest. 

You mentioned that you are able to tell if a 

dentist is going to fit into the PDS organization 

pretty quickly. Can you tell this through 

an interview, or do you actually have to 

watch him or her practice to get an idea of 

who is going to fit in with you guys? 

ST: Oh, no. The Owner Dentists do all the 

final hiring. So the way it works is, we’ll 

do some phone interviews and some talent 

assessments, from which we can figure out 

a lot. There’s even an online clinical assessment 

that we’ll do, and we have a dentist 

that does all the Q&A for quality assurance. 


After those steps, Owner Dentists try to do a working interview with the dentist. That 

working interview takes place over one to two days. Then they can get an idea of 

how the dentist works under pressure. Some dentists make the potential hire assist 

them for the day. Others will actually go and assist a potential associate to see how 

they perform. 

What we operate are large, multi-specialty group practices. Through numerous studies, 

we know that patients really like it when all their services under one roof — oral 

surgery, ortho, endo, pedo, hygiene — so they don’t have to move around offices. 

We’ve tried very hard to integrate all those specialties under one roof for each practice. 

And the associate plays a vital role. Because, what we still believe and what we 

coach on is the “gatekeeper model.” We believe that most patients still access dental 

care through their general dentist. The general dentist then moves the patient to 

wherever they need to be. A healthy patient may stay with the dentist and his or her 

hygienist. Patients with poor oral health will move out to various specialties. At PDS, 

the associate dentist, the new dentist, is extremely important to our organization. 

MD: It sounds like most of the practices you get involved with are dental practices that 

have already been in existence for say 10 to 20 years, and the dentist is interested in 

getting some help from you guys. Do you ever start practices from scratch, or is that 

something you might do with one of the Owner Dentists if he or she decides they’d like to 

expand and have a second practice? 

ST: It’s actually the opposite, to be honest. We focus on what we call “new” offices. 

That’s kind of our specialty. So what we do for dentists is get out in front of the curve. 

We find the best real estate and locations and markets, sometimes two years before 

that real estate becomes available. 

Then, we try to match a dentist with the real estate. We actually focus on the development. 

I can’t think of an instance in which a dentist sells his or her old practice. 

PDS actually focuses on the de novo-style practice. 

MD: Interesting. I guess part of the reason for that is maybe they chose a bad location and 

that’s a reason their practice is struggling. So, you guys want to find this “high traffic” 

area, where you can put a practice on a piece of real estate and be assured of a certain 

number of new patients. Is location really important to PDS? 

ST: Location is extremely important. We opened an office recently with a dentist in 

Scottsdale, Ariz., which has got to be one of the most competitive dental markets in 

the U.S. Lots of dentists practice in Scottsdale. The very first day we opened, we had 

170 patients already booked out. 

MD: Did you open it in the middle of the freeway? 

ST: Exactly! Something’s going on there. Between my various companies, I’ve opened 

or helped open 275 practices. 

MD: I don’t know if anybody keeps track of this, but that might be a record. 

ST: It might be. There are others who are up there, too. I once held the record, but 

I don’t think I do anymore. Nevertheless, we’re pretty good at opening offices and 

getting them ramped up pretty quickly for dentists. In fact, we’ll open 41 or 42 new 

practices this year. 

MD: Wow! Forty-two is significant! So, most of the time, I take it, you’re probably not going 

to an area like Scottsdale. The friends I talk to now that seem to be doing well seem to be 

located in rural parts of California — Blythe, Bakersfield, Modesto, Fresno, places like 

that. Is it kind of uncommon for you to go into a place like Scottsdale or Newport Beach? 


Location is extremely 

important. We opened an 

office recently with a dentist 

in Scottsdale, Ariz., which 

has got to be one of the most 

competitive dental markets in 

the U.S. The very first day we 

opened, we had 170 patients 

already booked out. 

Do you tend to be more in the outlying suburbs? 

Are you allowed to talk about that? 

ST: Well, I don’t mind talking about it. I’m 

sure our game plan is in the corporate 

offices of all my competitors. (It’s a 

friendly group; we all know each other 

pretty well.) At PDS, we stay very focused. 

Our target market is the middle to upper 

middle. We didn’t go into the ritzy area 

of Scottsdale; we went pretty far out, so 

that may have played into it. We stay away 

from upper income areas, and we are 

selective in lower income areas. We will 

do areas like Bakersfield, which has done 

very well. Again, the dentists have to be a 

good fit. 

We recently opened practices in Southern 

California — in Lakewood, La Habra, Pasadena 

— and we’ve done extremely well 

in those areas. We’ve also done very well 

in various parts of Texas that you’ve probably 

never heard of. The same goes for 

Arizona, Colorado and mid-areas of central 

California, too. 

MD: So Pacific Dental Services is in six or 

seven states at this point? 

ST: We are getting ready to open in our 

sixth state, New Mexico. That will happen 

shortly. 

MD: And is opening a dental practice in 

another state much different from opening 

a dental practice in California? Or is it the 

same formula based on the same values, 

and just kind of getting to know the local 

real estate a little bit better? 

ST: There are definitely differences in 

each state’s laws and regulations, whether 

you’re looking at the laws that PDS has to 

comply with or the laws of what dental 

assistants and dental hygienists are allowed 

to do, their licensure and extended functions. 

Rules vary from state to state. And 

there are nuances in operating these offices. 

But in our target market — the middle to 

upper middle — it’s more nuances than 

major differences. 

MD: Right. I noticed that I don’t see a lot of 

advertisements from PDS. That’s why I was 

wondering how you reach out and make 

yourself known. But you said that you go to 


dental schools, and I thought that was interesting. Many people go to dental school but 

don’t necessarily have a relative or a mentor who they are going to work with. They are 

probably a little bit daunted by the task of borrowing all that money and starting a practice 

from scratch, whereas you’ve started a couple hundred practices from scratch. When 

you said that you talk to dental students, is it more for associate positions? Or, if they can 

line up the financing, does PDS ever take a chance on a recent graduate as an Owner 

Dentist? Or does that not work out that well? 

ST: We have a mantra in our organization: Hire owners. We’re looking for future 

owners. That being said, the odds of a dentist coming right out of dental school and 

being successful, day one, in a group-style model are very slim. I can’t think of one 

we’ve done. We have had some dentists who had a prior business background, so this 

is their second career. And these dentists became owners quickly — maybe within 

months. But for the typical student, who came from undergrad and went to dental 

school, they just do not yet have that leadership ability or the business knowledge. 

Frankly, they are still working on some of their clinical competencies and efficiencies. 

MD: So they are potential associates who might be good Owner Dentists in five years, or 

something like that? 

ST: Exactly. And what we’re trying to do is say: Look, in the large group practice 

model, which is where we’re kind of lumped, most of the large group practices have 

not invested — and this isn’t a knock on any of my competitors, by the way — in 

the infrastructure and technologies like we have at PDS. We are the world’s largest 

CEREC provider. We have a digital infrastructure that is second to none. We are the 

first large group practice to go to all-digital health records, all-digital patient records. 

I believe we are the first large group to be all-digital X-rays and all-digital panorex. 

We’re now beta-testing several 3-D cone beam machines. So we’ve really tried to step 

up not only the actual but also the image of a large group practice among the dentists 

entering the marketplace. We’ve very carefully positioned ourselves there. 

MD: You guys are really, in a sense, the anti-large group practice — at least from my perspective, 

that of a dentist who graduated in 1988. The large group practices back then, the 

Western Dental’s and others, were places you’d go if you had no other option. Maybe you’d 

go for a year or two to improve your speed, but you’d get out of there as soon as possible 

to start building your career. So there has always kind of been this negative connotation 

associated with the large group practice. 

I’ve always liked how none of the Pacific Dental practices are named Pacific Dental. They 

are all named for the communities in which they are located. In fact, if someone looked 

from the outside, I don’t think they would ever necessarily know it was a PDS practice, 

except for the fact that the practice has every piece of high-tech equipment known to man. 

ST: We’ve been very focused on our positioning in the marketplace. We are actually 

calling it Private Practice + . The “plus” is all about the modern dentistry, infrastructure, 

systems and support. But we view PDS as more on the private practice side. 

Yes, we have structure. Yes, we have systems. But we look at it as a very autonomous 

practice. The practices are locally branded. A local dentist owns it, and his or her 

name is on the door. Typically, that dentist will even put the names of his or her 

associates on the door, too. The dentist’s credentials are hanging in the office. Many 

dentists hang pictures of their family on the wall. What I’ve found, after doing this 

for so many years, is dentists want that. They want to feel like: This is mine. This is 

where I practice, and I own it. The dentists we affiliate with don’t just want a job. 

They’re looking for a fulfilling career, where they feel part of something bigger and 

better, an organization that’s going to help them be the best clinician. And this is 

true of most of my experience with dentists: Dentists want to be great clinicians. 

I know there’s a bell curve in clinical skill with 150,000 practicing dentists. But in 


my experience, I’ve found that most dentists want to be really good dentists. So we 

want to provide an environment where they can be as good as they want to be. 

MD: And you guys do that. I think every dentist would love to have a practice where he 

or she is able to afford digital X-rays and a CEREC machine and a cone beam machine. 

Every dentist would love to have that stuff around, but sometimes they don’t have the cash 

flow or the patient flow to justify it. So it’s got to be a fantastic way to practice. 

And I think you’re right: Dentists do want to do the best dentistry they can. But there are 

things that get in the way. I think it helps to have multiple dentists in one location, like you 

do in your centers, for reasons as simple as other people might be looking at your impressions! 

When I started working at the lab, all of a sudden I was forced to get better because 

I had hundreds of technicians looking at my impressions. For the first time, I couldn’t 

hide back in my office because they knew where I was and they knew I might be working 

on them soon. Being part of that group absolutely forced me to get better. So I agree that 

every dentist wants to be a good dentist. We want to put things in that are going to be long 

lasting for the patient. We want to put in a crown on tooth #9 that is going to blend in 

esthetically because being able to reduce enough and take a good shade and a good digital 

photograph is a skill. That’s what is fulfilling for dentists. It sounds like PDS is the perfect 

partner for dentists who want to pursue that kind of dream without having to worry so 

much about the business side of things. 

ST: We try to do that in a very nice, structured format. We have a structured regional 

and national dental advisory board. Everyone on the board is a licensed dentist of the 

group. Every decision goes through a process. A lot of eyes look at it so we don’t make 

bad decisions. We try to make very focused, thoughtful decisions on technologies and 

about different supplies or whatever dentists want to use. We are very thoughtful about 

the approaches. It is helpful that we have so many specialists in the organization, too. 

MD: I know you guys have had me come over a couple of times and do some programs 

with the dentists. You can just tell that the commitment is there. The dentists are at those 

continuing education courses voluntarily. The few times I’ve been over to PDS, it has been 

with a group of dentists where it’s definitely a different vibe than if you were to step onto 

the floor of the CDA meeting and interact with a group of dentists. The dentists at PDS 

are some of the most excited, intelligent dentists that you’ll meet. If you were looking for a 

group of dentists who love dentistry, and who would encourage their children to go into 

the profession, it would have to be the group of PDS dentists that I’ve met over the years. 

ST: Thanks. I take that as a great compliment. I appreciate it. 

MD: Really! I get the feeling that you guys are as concerned about the dentist’s happiness 

in life and his or her career as much as you are concerned about the success achieved in 

the practice. Is that true? I remember seeing a mission statement or some of your guiding 

principles on the wall at PDS headquarters. 

ST: Absolutely. Maybe this goes back to some of the early education and training I 

received, but dentistry is a tough job, physically and mentally. You’re working on 

generally stressed out people, and the patient’s stress level reverberates from the 

patient to the dentist. You’re working in a hole the size of a silver dollar. People 

expect perfection. They don’t want to be in pain. So it’s a physically demanding job. 

It’s a stressful job. And I don’t think, as a whole, we put enough weight on that in 

order to create a balanced approach to the career and lifestyle of being a dentist. 

Think about how many dentists you and I know who are burnt out at age 45! 

We had a dentist come aboard — he’s an owner who obviously got on quick — 

who is 72 years old. He just signed up at 72 years old, and he’s got the energy of a 

30-year-old dentist! So it’s really cool to see. We do try to take a lifestyle approach 


all the way through retirement. And one 

of my jobs at the company is working 

with some of the veteran dentists who are 

starting to think about retirement. How 

are they going to bring on an associate? 

How much is the associate going to buy 

in for? If they have multiple offices, how 

many do they want to keep? Do they just 

want to get out and retire? Do they want 

to teach? Do they want to train? So, we try 

to coach them through that, too. 

MD: Wow, that’s fantastic. So, as dentists 

reach the end of their careers, in addition 

to practicing, it sounds like there are some 

other opportunities they can take advantage 

of with PDS. That is fantastic. 

ST: After 15 to 20 years of practice, my 

experience has been that dentists want 

to do something a little bit different. So 

we’ve got a lot of our affiliate dentists doing 

training and education, or they get 

involved in schools or the societies. And 

we’re really working with vendors, with 

manufacturers, and what they’re seeing in 

the real world. We’re trying to create all 

that for the dentists to help them achieve 

a lifelong career. Dentistry is a great field. 

I think that with a balanced approach, you 

can sustain it for 30 to 40 years. 

MD: I agree. I know that in my day-to-day 

work, there’s just nothing better than that 

e-mail you get from another dentist — in fact, 

I just got one the other day. The dentist said: 

“I was struggling with this or that, but then I 

saw that prep technique you do. I tried it and 

it’s really helped me out. I feel so much more 

confident when I do this type of crown prep 

or when I’m doing this and it is dropping into 

place.” I find that incredibly rewarding. 

I hope this interview reaches at least one 

dentist who is struggling. Maybe it is the 

dentist who gets up in the morning and 

dreads going to the office. Perhaps it’s the 

dentist who wonders, what happened to the 

career I once loved? I hope this conversation 

excites at least one dentist — whether it be 

the idea of letting go of the business aspects 

of the practice, working 32 hours and making 

$400,000 as an Owner Dentist, having 

new technology in the office, or the comfort 

of knowing he or she is providing patients 

with the best possible dentistry. It has to be

very rewarding for you to hear from some of these Owner Dentists who say eight to 10 

years later: I was ready to walk away from this profession, but now I can’t wait to go to 

work. 

ST: PDS dentists work very hard, and it can still be very stressful. But I think PDS 

can take a load off. I think, in this case, we win together. In this instance, two plus 

two is not four. I think two plus two can be eight or 10 in what we do. But it is hard 

work. It can be stressful at times. We have a lot of great dentists. I can’t say enough 

good things about these awesome dentists. They are true leaders and great clinicians. 

MD: PDS Owner Dentists still have to be doing an awful lot of dentistry to make that kind 

of money, right? 

ST: Yeah. The top 26 affiliate dentists each did more than $1.25 million in dentistry 

last year. So they are working. They are working very hard! 

MD: The Owner Dentists don’t just come in and put their feet up on the desk while the 

associates go do all the work? 

ST: No, no. Here’s a quote we live by at PDS: “The perfect choice for practicing 

dentists.” And those were very carefully chosen words. We want to affiliate with 

dentists who like to practice dentistry. Then we’re going to do everything we can 

to support them. 

MD: That’s fantastic. So, if somebody does read this and gets motivated by what was said, 

what’s the best way for them to get in contact with Pacific Dental Services, if they happen 

to be in a state where the company exists? 

ST: Yeah, or a state we want to get to. The best person to contact would be Ken Davis. 

Ken is the head of all PDS recruiting. Also, you can call us directly at our main line: 

714-508-3600. Or dentists can also visit our website: www.pacificdentalservices.com. 

MD: I encourage any dentist who feels like he or she is working really hard but not necessarily 

getting anywhere to take a look at PDS. Steve, I think it’s terrific what you guys are 

doing and how you’re able to help dentists attain a practice that’s not only fulfilling but 

can lead to a life that’s fulfilling as well. Thank you for your time today, I appreciate it. 

ST: Thank you for the opportunity. I appreciate it, Michael. CM 

To learn more about the services offered by Pacific Dental Services, visit www.pacificdentalservices.com or 

call 714-508-3600. Contact Steve Thorne at chairside@glidewelldental.com. 


CEREC ® Connect: 

A Welcomed Upgrade 

for CEREC Users 

– ARTICLE by Carlos A. Boudet, DDS, DICOI 


CEREC Connect: A Welcomed Upgrade for CEREC Users39

Many CEREC ® dentists find making digital 

impressions to be as routine as taking 

polyvinyl impressions, and they prefer making a 

digital impression that is transmitted to the lab. 

NOTE FROM the EDITOR 

Digital impressions are slowly catching on with our customers at the lab. The majority of the digital impressions we 

receive are from Sirona CEREC ® owners, who typically use this digital impression system to design and mill a crown, such 

as IPS e.max ® CAD, in their own offices. However, we are seeing more CEREC dentists who want to take advantage of highstrength 

monolithic restorations that cannot be milled in the office, such as BruxZir ® Solid Zirconia. 

Many CEREC dentists find making digital impressions to be as routine as taking polyvinyl impressions, and they prefer 

making a digital impression that is transmitted to the lab. Sending a digital impression automatically saves dentists $7 on 

inbound FedEx shipping. If a dentist orders a monolithic restoration, such as BruxZir, IPS e.max or cast gold, Glidewell 

Laboratories can make the restoration model-free (no model work is fabricated), and we pass on that $20 savings. That 

means a $99 BruxZir crown becomes a $79 BruxZir crown when the case is prescribed via digital impression. For a 3-unit 

posterior BruxZir bridge, that’s a savings of $60. I don’t foresee many dentists investing in this technology and adopting 

digital impressions without laboratories offering an incentive, such as a discount on every crown prescribed. 

In this article, Dr. Carlos Boudet outlines the steps transmitting a digital file to the lab via CEREC Connect. 

Introduction 

A common fear among dentists who purchase the latest technology in the form of a new piece of equipment is the uncertainty 

of how soon it will be made obsolete. This fear is greater when it is unclear if the manufacturer will offer system 

upgrades that allow the dentist to continue using the equipment when improved features and new options become available. 


Cadent iTero creates a precise 

model that allows the clinician to 

choose virtually any material for 

crown & bridge fabrication. 

IOS FastScan , which is in limited 

release across Southern 

California, scans 40 mm 

of dentition per second. 

Lava C.O.S. (Chairside Oral 

Scanner), captures 3-D data in 

video sequence and models 

the data in real time. 

The CEREC CAD/CAM System 

There are two chairside CAD/CAM systems available today: CEREC (Sirona Dental Systems; Charlotte, N.C.) and E4D 

Dentist (D4D Technologies; Richardson, Texas). Also available are three chairside digital impression systems: Lava C.O.S. 

from 3M ESPE, iTero from CADENT 1 and IOS FastScan from IOS Technologies Inc. (The last was recently released to a select 

group of dentists in Southern California. A fourth chairside digital impression system developed in Israel, Densys, is not yet 

available to U.S. dentists but is expected to be released stateside in late 2011.) I own a CEREC 3D Redcam system, which 

now has been replaced by faster hardware and better software with Sirona’s CEREC Bluecam. 

Soon after I purchased the CEREC Redcam system, I had the opportunity to test out the CADENT iTero. 2 I liked the system’s 

ability to create a very precise model that allowed me to choose virtually any material for the fabrication of crowns 

& bridges from a digital impression. This got me thinking: Wouldn’t it be nice if I could take digital impressions with my 

CEREC unit and send them to the lab for cases that, because of the choice of materials 3 or other reasons, cannot be fabricated 

using the compact milling unit? 

Before long, I found out that Sirona engineers had already been working on that. The company soon released newly developed 

software that gave users the ability to send digital impressions to their dental laboratory of choice, not only for 

CAD/CAM but also for practically all conventional restorations and materials. Sirona made this possible by first creating 

a new software program called CEREC Connect, and then by allowing some owners of older hardware configurations to 

upgrade their software and take advantage of this very useful feature. 

I had the opportunity to work with my regular laboratory, which also happens to be an experienced CEREC Connect lab, 

on a case that involved a combination of thin veneers and porcelain crowns in the mandibular anterior region. The lab’s 

knowledge and guidance ensured a digital case that proceeded without trouble and according to plan. 


Figure 1 Figure 2 

CEREC Connect Procedure 

The case highlighted is a rehabilitation in which the patient transitioned from nonrestorable maxillary anteriors and severe 

attrition damage in the mandibular anteriors (Fig. 1) to interim partial dentures and, finally, implant-supported prostheses. 

CEREC Connect was utilized to restore the four mandibular incisors. For the benefit of new CEREC Connect users, a brief 

outline follows of the procedural steps for sending a case via CEREC Connect. 

1. Register online at www.cerec-connect.com. Start by clicking on “Dentist Registration” and choosing a User ID and password that 

you can remember easily. Fill out the required information. For ease of use, the acquisition unit should have a high-speed Internet 

connection. A CEREC Connect representative will contact you within three business days to finalize the registration. NOTE: Write 

down your User ID and password. You will need it every time you send a case through the Internet portal. 

2. Download the latest CEREC Connect software. You can find the software online at www.cerec-connect.com. Follow the required 

steps to send a case using CEREC Connect. Start by clicking the program icon. You will see the same familiar interface. 

3. Start the digital impression by scanning the preparation(s) and defining the margins (Fig. 2). Move the cursor over the antagonist 

and scan the opposing arch. Then, using the newly developed “buccal bite,” take a scan of the buccal while the patient bites in 

maximum intercuspation. This eliminates the need for a bite registration. 

4. Manually correlate the three impressions. You can do this by dragging the buccal bite into the antagonist model; when placed correctly, 

they will attach. Then drag the buccal bite over the preparation model. All three models should correlate and stitch together. 



5. If there are several preparations in the impression, you do not have to trim the preparations. This step is optional. However, you 

should draw the prep margins because you should be able to recognize them more easily than the laboratory. 

6. Once the margins are finished, the “Connect” icon will become available. Click the icon to go to the CEREC Connect portal. 

7. Enter your CEREC Connect User ID and password, which will open the “Restoration Data” tab. 

8. Enter the data for each individual restoration. NOTE: If all restorations are the same design, you can enter the data once 

for all restorations. This saves valuable time, given that there is good communication between you and your lab. 

9. Follow the steps to your shopping cart, where you will find the case. Enter your User ID and password under “Confirmation.” Then 

click “Prescription” to send the case to the laboratory. 

10. When the green bar appears, you will know the file was transmitted successfully to the lab. 

On the following business day, you will receive a confirmation e-mail. It will state that the lab accepted your 

case for fabrication of your prescribed restorations. The laboratory can create your restorations from the digital 

data alone (Fig. 3). Or, if necessary, you can order digitally produced models from infiniDent, which you 

see holding the milled Bluecam IPS e.max crowns in Figure 4. The case can be in your office in a few days. 

The bonded restorations in this CEREC Connect case showed excellent marginal adaptation and were a great service for the 

patient. You can see the finished case on page 44 (Figs. 5, 6). 



Conclusion 

CEREC Connect has increased the versatility and usefulness of the CEREC chairside CAD/CAM system. It has also allowed 

dentists who significantly invested in the CEREC system to expand its capabilities and to continue offering state-of-the-art 

technology to their patients. CM 

Dr. Carlos Boudet is in private practice in West Palm Beach, Fla. Contact him at www.boudetdds.com or 561-968-6022. 

ACKNOWLEDGMENTs 

The author would like to credit Jay Black, CDT, of Winter Springs Dental Lab, for the photos and lab work used in this article. 

References 

1. Lowe RA. CAD/CAM Dentistry and Chairside Digital Impression Making. www.ineedce.com publication. 2008. 

2. Zweig A. Improving impressions: go digital. Dent Today. 2009;100–04. 

3. Giordano R. Materials for chairside CAD/CAM produced restorations. J Am Dent Assoc. 2006;137(suppl):14–21. 

4. CEREC Connect Version 3.82 Operators Manual. Sirona Documentation. Aug 2010. 

Disclosure: The author has no financial interest in CEREC or Sirona Dental Systems. This article has not been sponsored. The following information is the sole opinion of the 

author and does not reflect the views of Chairside magazine and/or Glidewell Laboratories. 


— ARTICLE and PHOTOS by Leendert Boksman, BSc, DDS, FADI, FICD 

Optimizing 

Occlusal Results 

for Crown & Bridge Prostheses 

When preparing a single-unit crown or multipleunit 

bridge, dentists inevitably follow a similar 

routine. The prepared teeth are impressed in a 

good-quality impression material, such as a polyether, or 

the most widely used impression material, an addition 

silicone vinyl polysiloxane (VPS), 1 which accounts for 95 

percent of the impressions sent to the dental laboratory. 2 

The impressions are taken in a full-arch stock or custom 

tray, the bite registration is taken after the preparations are 

completed, and an opposing model is fabricated from alginate 

to allow mounting of the case in the laboratory. The 

prosthesis is then returned to the dental practitioner and 

inserted. If it is found to be high in occlusion, the dental 

technician is often blamed for an error in technique. 3 In 

reality, it is the built-in variability of the above technique 

sequence and material selection, which is still routinely 

taught in many dental faculties, that leads to clinical frustration 

and valuable time wasted in trying to make the unit(s) 

“fit.” Why is it that a 12 times greater accuracy in the maximal 

intercuspal position is found with the dual-arch cast? 4 

This article looks at the “normal” sequence described above, 

identifies the variables and describes how to minimize them. 

BITE REGISTRATIONS 

Why is it that as dental students we are taught to take 

the bite registration after tooth preparation and after the 

patient has been anesthetized? This approach certainly 

makes sense for extensive restorations, or when involving 

terminal teeth in the arch as abutments for a multiple-unit 

restoration. However, if the clinician is preparing a singleunit 

restoration, which represents the majority of the crown 

& bridge impressions at dental laboratories, 5 why not take 

the bite registration before the patient is anaesthetized and 

still has proprioception? In doing so, there is an increased 

likelihood that the casts will be mounted in the patient’s 

acquired centric. In addition, if the dentition is intact, the 

Optimizing Occlusal Results for Crown & Bridge Prostheses47

working stone model of the single preparation will be 

mounted more accurately using this bite registration. 

Figure 1: Typical wax bite wafer on a lower model 

Why is it that as dental students 

we are taught to take the bite 

registration after tooth 

preparation and after the patient 

has been anesthetized? 

Figure 2: Side view of Figure 1 showing obvious distortion of the wax 

bite registration 

Bite registration or interocclusal records are taken with 

many different registration materials in many different ways; 

can the dental laboratory technician actually use them to 

relate the models in their proper orientation? Laboratories 

still receive wax bite registrations, which are unreliable due 

to dimensional changes when cooling. 6 Furthermore, wax 

bite registrations are easily distorted on removal from the 

mouth, in transit or with temperature changes (Figs. 1, 2). 7 

The use of resin copings to record centric relation has been 

described by Anselm Wiskott and Nicholls, 8 and a comparison 

between using impression plaster, wax and DuraLay 

acrylic resin (Reliance Dental Mfg. Co.) showed that hand 

articulation was the most accurate method of relating casts 

to maximum intercuspation. 9 The use of polyether bite 

registration materials has been shown to result in vertical 

discrepancies in the interocclusal relationships of casts. 10 

Elastomeric materials may deform 11 or distort when pressure 

is applied during mounting of a case (elastics are often used 

to hold the casts together), resulting in faulty restorations. 12 

Of course, VPS impression materials, designed to flex when 

withdrawing a full-tray impression from the mouth, cannot 

be used. It is critical not only for these bite registration 

materials to be dimensionally accurate but to be very 

stiff to resist distortion (such as AFFINITY Quick Bite 

[CLINICIAN’S CHOICE], which has a durometer hardness of 

90). When looking at impression materials — VPSs Imprint 

Bite (3M ESPE), Silagum Automix Bite (DMG America), 

O-Bite (DMG America), Blu-Mousse ® Classic (Parkell), 

Exabite II (GC America); one polyether, Ramitec (3M ESPE); 

and one dimethacrylate base material, Luxabite ® (DMG 

America) — Chun, et al. 13 found that these materials presented 

significantly different polymerization shrinkage 

kinetics and showed dimensional changes even after the 

setting time indicated by the respective manufacturers. 

However, a study by Millstein and Hsu 14 looking at Coe Bite 

Crème (GC America), Blu-Mousse, Correct Bite (Pentron 

Clinical Technologies), Blue Velvet (J. Morita), Memosil D.D. 

(Heraeus Kulzer), and Ramitec showed that all brands were 

highly accurate and dimensionally stable. 

Dr. Gordon Christensen 3 recommends the interocclusal 

record be trimmed so as to eliminate all material that touches 

soft tissue (Fig. 3), that extends to undercuts (Fig. 4) and that 

extends more than a tooth or two beyond the prepared teeth 

(Fig. 5). However, the advice of having a bite registration 

material between teeth on one side and not the other can 

cause an inaccurate mounting of the opposing models. 


OPPOSING CASTS 

As mentioned earlier, for crown & bridge cases, most dental 

practitioners take the impression of the opposing arch in 

alginate. Alginate impressions can contribute significantly to 

a fixed partial denture (bridge) being too high. 3 The quality 

of the alginate is compromised by a myriad of factors that 

include: the powder-to-liquid ratio is difficult to control, 

which affects flow, resultant accuracy and working time; 

the water temperature affects the speed of set and flow 

characteristics; syneresis (water leaving the gel) continues 

after the material is set, causing dimensional changes 15 ; 

distortion occurs after a short time if the alginate is not 

poured up immediately 16 ; the alginate can distort if disinfected 

17–21 ; if poured up in the office, the quality and dimensional 

stability of the resulting cast depends on the waterto-powder 

mix, as well as the method used for mixing of the 

dental stone 22 ; the stone used in the office is not as accurate 

as the die stones used in the laboratory; the impression is 

not stable, as it is affected by temperature and humidity 23–25 ; 

the type of tray used affects clinical accuracy 26,27 ; and the 

use (or nonuse) of adhesives affect the final outcome. 28,29 

No matter which highly accurate, good flow, stiff, dimensionally 

stable bite registration material the clinician uses, 

the untrimmed bite registration will never fit on models 

derived from alginate (Fig. 6). 30 This is due to the inherent 

mismatch in accuracy of the two materials, as the finely 

Figure 3: Bite registration was trimmed to remove all soft-tissue contacts 

and interferences. 

Figure 4: This bite registration does not seat on the model, due to undercuts 

and soft-tissue binding. 

Figure 5: “Donut” bite registration on prepared tooth, extending minimally 

to adjacent teeth 

Figure 6: The highly anatomically detailed VPS bite registration does not 

fit on a poorly detailed alginate-derived stone model. 


detailed occlusal anatomy picked up by high-flow VPS bite 

registration materials is not replicated by alginate, thus 

not allowing the bite registration to seat accurately on the 

alginate-derived stone model (Figs. 7, 8). If the clinician 

decides to continue using alginate impressions to generate 

opposing models, a lateral closed-bite registration is a better 

choice (Figs. 9, 10). 

ALGINATE SUBSTITUTES 

Alginate substitutes (Table) are essentially low-cost VPS 

materials that demonstrate all the favorable characteristics 

previously established for materials of the VPS category. 

Dr. Gordon Christensen 31 has described these alginate substitutes 

as accurate, clean to use, and with no unpleasant 

taste or odor (Fig. 11). Furthermore, the addition silicones 

(VPSs) have been shown to be very accurate and dimensionally 

stable; stable enough to pour after a delay of time or 

when making additional pours of the same impression. 2,32 

Additionally, VPSs have higher tear strength than alginates 

(an important feature when they are poured multiple times), 

and are minimally affected by disinfection techniques. 33,34 In 

using a VPS alginate substitute with a VPS bite registration 

and a working model derived from a VPS impression, mismatches 

that occur when using casts derived from alginate 

impressions can be eliminated (Fig. 12). This ensures the 

casts will be mounted by the dental technician in maximum 

intercuspation (Fig. 13), which reduces the incidence of 

Figure 7: Close-up view of an extremely detailed occlusal surface of a 

mandibular third molar, taken with a VPS bite registration material 

Figure 8: Same tooth as in Figure 7 as replicated from an alginate impression. 

Note that it does not capture the detailed deep occlusal anatomy. 

Figure 9: A lateral (closed) bite registration can be taken if the practitioner 

uses alginate for the opposing models. 

Figure 10: The lateral (closed) bite registration, once correctly trimmed, fits 

on an alginate-derived stone model. 


No matter which highly accurate, good flow, stiff, dimensionally 

stable bite registration material the clinician uses, the untrimmed 

bite registration will never fit on models derived from alginate. 

Table: Representative Alginate Substitutes 

Counter-FIT 

Algin•X 

Silgimix 

StatusBlue 

Freealgin ® 

Position Penta Quick 

AlgiNot 

CLINICIAN’S CHOICE 

DENTSPLY Caulk 

Sultan Healthcare 

Zenith Dental/DMG 

Zhermack 

3M ESPE 

SDS/Kerr 

Figure 11: Alginate substitute (Counter-FIT) shows good detail, even 

after multiple pour-ups 

Figure 12: Models derived from the alginate substitute accurately fit the 

bite registration material (Affinity Quick Bite). 

Figure 13: The registered acquired centric is correctly and accurately 

replicated in the mounted models. 


high occlusion in the final prosthesis and thus minimizes 

or eliminates the time required for occlusal adjustments. 

An added side benefit is that, rather than having to pour 

up the opposing alginate impression in the dental office, 

this alginate substitute VPS can be shipped along with the 

impression of the prepared teeth and bite registration to 

the dental laboratory. Thus, the time and cost incurred for 

pouring up the impression in the dental office is removed. 

This opposing cast fabrication becomes part of the laboratory 

fee, which more than compensates for the increased 

cost of taking the impression with an alginate substitute. 

DUAL-ARCH IMPRESSIONS 

It should now be abundantly clear why properly fabricated 

dual-arch impressions “produce mounted casts with significantly 

more accurate maximal intercuspal relationships 

than mounted casts from full-arch impressions.” 4 The dualarch 

impression, as an all-in-one technique, is faster, uses 

less impression material, and is easier for the clinician and 

the patient. 35 However, to be successful with the dual-arch 

impression tray, there are strict parameters for its use. The 

rear bar (connector) of the dual-arch tray must comfortably 

pass through the interocclusal retromolar area with no interference 

to proper closure. With the dual-arch technique, 

the prepared teeth should be bordered by intact teeth 

with centric stops (Fig. 14). 36 Single-tooth preparations that 

fit this criteria are indicated, but multiple tooth preparations 

may be problematic. 1,37 Because the articulators used 

for mounting dual-arch impressions are simple hinges 

(usually flexible plastic), the patient must have a cuspid rise 

(canine guidance) disclusion, not group function. Therefore, 

the canine tooth must be registered in the impression. 5 

This is facilitated by full-quadrant metal trays (such as the 

QUAD-TRAY ® XL [CLINICIAN’S CHOICE]) (Fig. 15). Plastic 

trays can flex, resulting in a distorted impression. Flexure 

occurs due to the hydraulic pressures of the impression 

material, tray side walls impinging on hard tissue (Figs. 

16, 17), axial roll or vertical flex of the plastic side walls, 

the action of swallowing by the patient during impression-taking, 

and elastic rebound upon removal of the 

impression. 38–40 The dual-arch tray must be rigid, 41 making 

metal trays the tray material of choice. In addition, a 

complementary rigid (stiff) impression material will 

increase the chance of overall success with this technique 

(Fig. 18). 36,38 The ADA, in its review of elastomeric impression 

materials, recommended an impression material with 

a strain in compression (stiffness) of less than 2 percent 42 

be used for the dual-arch impression technique. Nine of the 

10 heavy body impression materials tested in this review 

did not meet this criterion; only Correct Plus ® (Pentron 

Clinical Technologies) was found to have a strain in compression 

of 1.5 percent. Another VPS material on the 

market, AFFINITY Inflex, is also especially well suited for 

the dual-arch impression technique and has a strain in 

compression of 1.3 percent (Fig. 19). 

CONCLUSION 

For predictability in mounting or articulating models, it is 

prudent to use materials of matching accuracy so that the 

components work in harmony. To ensure clinical success, 

Figure 14: In following the correct dual-arch impression technique protocol, 

the prepared tooth should have teeth with centric stops on either side. 

Figure 15: A full-quadrant metal tray (such as QUAD-TRAY XL) picks up 

the cuspid in the impression so that the cuspid (canine) rise occlusion can 

be replicated in the laboratory. 


It should now be abundantly clear why properly fabricated 

dual-arch impressions “produce mounted casts with 

significantly more accurate maximal intercuspal 

relationships than mounted casts from full-arch impressions.” 

Figure 16: Preparation view of a dual-arch impression taken with a flexible 

plastic tray. This impression was distorted due to hard-tissue impingement. 

Figure 17: The opposing side must also be visually checked. Tissue contact 

seen here can cause flex or axial roll. 

Figure 18: A rigid metal tray with a complementary rigid techniquedesigned 

impression material will yield the most accurate models and 

final prosthesis. 

Figure 19: A dual-arch impression using a technique-designed stiff VPS 

impression material (AFFINITY Inflex) 


use a high-flow, stiff (no bounce) bite registration material; remove soft-tissue interferences; use an alginate substitute for 

a high-quality opposing model resulting in better interdigitation of all of the components; or use an all-in-one dual-arch 

impression using a metal tray and technique-specific impression material. 

The recommendations presented in this article will help the clinician in reducing occlusal adjustments on final crown & 

bridge prostheses, thus saving time and reducing stress at the delivery appointment. CM 

Dr. Boksman is director of clinical affairs for Clinical Research Dental/CLINICIAN’S CHOICE. He is also an adjunct clinical professor at the Schulich School of Medicine and 

Dentistry and maintains a private practice in London, Ontario, Canada. Contact him at lboksman@clinicalresearchdental.com. 

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techniques. Dent Clin North Am. 2004;48:445–70. 

2. Boksman L. Eliminating the variables in impression taking. Ont Dent. 

2005;34:22–25. 

3. Christensen GJ. Making fixed prostheses that are not too high. J Am Dent 

Assoc. 2006;137:96–98. 

4. Parker MH, Cameron SM, Hughbanks JC, et al. Comparison of occlusal 

contacts in maximum intercuspation for two impression techniques. J Prosthet 

Dent. 1997;78:255–59. 

5. Christensen GJ. Ensuring accuracy and predictability with double-arch 

impressions. J Am Dent Assoc. 2008;139:1123–25. 

6. Millstein PL, Clark RE. Determination of the accuracy of laminated wax 

interocclusal wafers. J Prosthet Dent. 1983;50:327–31. 

7. Lassila V. Comparison of five interocclusal recording materials. J Prosthet Dent. 

1986;55:215–18. 

8. Anselm Wiskott HW, Nicholls JI. Fixed prosthodontics centric relation registration 

technique using resin copings. Int J Prosthodont. 1989;2:447–52. 

9. Urstein M, Fitzig S, Moskona D, et al. A clinical evaluation of materials used in 

registering interjaw relationships. J Prosthet Dent. 1991;65:372–77. 

10. Tripodakis AP, Vergos VK, Tsoutsos AG. Evaluation of the accuracy of interocclusal 

records in relation to two recording techniques. J Prosthet Dent. 

1997;77:141–46. 

11. Lassila V, McCabe JF. Properties of interocclusal registration materials. 

J Prosthet Dent. 1985;53:100–04. 

12. Breeding LC, Dixon DL. Compression resistance of four interocclusal recording 

materials. J Prosthet Dent. 1992;68:876–78. 

13. Chun JH, Pae A, Kim SH. Polymerization shrinkage strain of interocclusal 

recording materials. Dent Mater. 2009;25:115–20. 

14. Millstein PL, Hsu CC. Differential accuracy of elastomeric recording materials 

and associated weight change. J Prosthet Dent. 1994;71:400–03. 

15. Boksman L, Tousignant G. Alginate substitutes: rationale for their use. Dent 

Today. 2009;28:104–05. 

16. Nichols PV. An investigation of the dimensional stability of dental alginates 

[dissertation]. Sydney, Australia: Faculty of Dentistry, University of Sydney; 2006. 

Available at: http://hdl.handle.net/2123/1270. Accessed Oct. 22, 2010. 

17. Taylor RL, Wright PS, Maryan C. Disinfection procedures: their effect on the 

dimensional accuracy and surface quality of irreversible hydrocolloid impression 

materials and gypsum casts. Dent Mater. 2002;18:103–10. 

18. Jagger DC, Al Jabra O, Harrison A, et al. The effect of a range of disinfectants 

on the dimensional accuracy of some impression materials. Eur J Prosthodont 

Restor Dent. 2004;12:154–60. 

19. Machado C, Johnston W, Coste A, et al. Simulated clinical compatibility of disinfectant 

solutions with alginate impression materials. Presented at: IADR General 

Session & Exhibition; July 1, 2006; Brisbane, Australia. Abstract 2467. 

20. Muller-Bolla M, Lupi-Pégurier L, Velly AM, et al. A survey of disinfection of 

irreversible hydrocolloid and silicone impressions in European Union dental 

schools: epidemiologic study. Int J Prosthodont. 2004;17:165–71. 

21. Lu JX, Zhang FM, Chen YM, et al. The effect of disinfection on dimension stability 

of impressions [in Chinese]. Shanghai Kou Qiang Yi Xue. 2004;13:290–92. 

22. Frey G, Lu H, Powers J. Effect of mixing methods on mechanical properties of 

alginate impression materials. J Prosthodont. 2005;14:221–25. 

23. Perry R. Using polyvinyl impressions for study models: a case report. Dent 

Today. 2004;23:106–07. 

24. Chen SY, Liang WM, Chen FN. Factors affecting the accuracy of elastomeric 

impression materials. J Dent. 2004;32:603–09. 

25. Bayindir F, Yaniko lu N, Duymu Z. Thermal and pH changes, and dimensional 

stability in irreversible hydrocolloid impression material during setting. Dent 

Mater J. 2002;21:200–09. 

26. Mendez AJ. The influence of impression trays on the accuracy of stone 

casts poured from irreversible hydrocolloid impressions. J Prosthet Dent. 

1985;54:383–88. 

27. Gordon GE, Johnson GH, Drennon DG. The effect of tray selection on the 

accuracy of elastomeric impression materials. J Prosthet Dent. 1990;63:12–15. 

28. Leung KC, Chow TW, Woo EC, et al. Effect of adhesive drying time on the 

bond strength of irreversible hydrocolloid to stainless steel. J Prosthet Dent. 

1999;81:586–90. 

29. Smith SJ, McCord JF, Macfarlane TV. Factors that affect the adhesion of two 

irreversible hydrocolloid materials to two custom tray materials. J Prosthet Dent. 

2002;88:423–30. 

30. Boksman L. Point of care: how do I minimize the amount of occlusal adjustment 

necessary for a crown? J Can Dent Assoc. 2005;71:494–95. 

31. Christensen GJ. Ask Dr. Christensen. Dental Economics. 2008;98:66. 

32. Karthikeyan K, Annapurni H. Comparative evaluation of dimensional stability 

of three types of interocclusal recording materials: an in vitro study. J Indian 

Prosthodont Soc. 2007;7:24–27. 

33. Waranowicz MT, O’Keefe KL. Alginates and alginate substitutes. The Dental 

Advisor. 2007;24 (special issue). 

34. Christensen G. Impression material disinfection: is it necessary? Clinician’s 

Report. Feb 2010:3,4. 

35. Lane DA, Randall RC, Lane NS, et al. A clinical trial to compare double-arch and 

complete-arch impression techniques in the provision of indirect restorations. 

J Prosthet Dent. 2003;89:141–45. 

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1996;127:234–40. 

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Am J Dent. 1991;4:89–92. 

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not the answer. Dentaltown. 2009;10:18–21. 

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pilot study. J Prosthet Dent. 2002;87:625–27. 

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accuracy of double-arch and complete-arch impressions. J Prosthet Dent. 

2002;87:510–15. 

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dentistry. J Prosthet Dent. 1983;49:198–202. 

42. Elastomeric impression materials. ADA Product Review. 2007;2:9–14 

Reprinted by permission of Dentistry Today, ©2011 Dentistry Today. 


The 

Wynne 

Hybrid 

Introduction 

Advancements in material technology provide us with many 

opportunities to improve a patient’s smile. There are a number 

of new substrate-supported systems, as well as all-porcelain 

systems, to meet our demands as clinicians. These improved 

materials reflect, refract, absorb and transmit light in unique 

ways (Fig. 1). The selection of a material system now depends 

upon the patient’s clinical needs, assistance from the dental 

laboratory and the clinician’s personal material philosophy. 

Dental material development seems to be moving in the 

direction of restorative material strength. However, Pascal 

and Urs state, “New restorative approaches should aim to 

create not the strongest restorations, but rather a restoration 

that is compatible with the mechanical, biologic and optical 

properties of underlying dental tissues.” 1 If clinicians accept 

that notion, then the concept of “esthetic demands and functional 

risk” calls for restorations that have a high degree of 

versatility (Fig. 2). One such restoration design is the Wynne 

Hybrid. This unique restoration utilizes the antimicrobial 

benefits of Captek Nano (Argen Corporation; San Diego, 

Calif.) substructures (Fig. 3) to seal out and reduce harmful 

bacterial plaque with conservative preparations interproximally; 

maximizes abutment strength; and esthetically blends 

supragingival margins on the lingual and buccal. 2 

The Wynne Hybrid technique focuses on the lingual esthetics 

of maxillary teeth, in addition to facial esthetics. The lingual 

dark line around maxillary teeth has been referred to as the 

– ARTICLE and PHOTOS by William P.D. Wynne, DDS, PA 

Figure 1: Having a wide range of restorative options, each 

with a varying degree of transparency, helps clinicians achieve 

maximum esthetics. Understanding the manner in which light 

reflects, refracts, absorbs and transmits in and through materials 

will help match the clinical challenge with the appropriate 

material and coping design. 

Figure 2: For each tooth being restored, the margin design 

and the underlying prep color will, in many cases, dictate the 

optimal coping material and coping design at the margin edge. 

Reducing a core material from the margin edge, extending the 

core material to the margin, or developing a metal collar are all 

important options to consider. 

The Wynne Hybrid57 

d

most overlooked esthetic zone 3,4 (Fig. 4). As a result, many 

patients with small children or grandchildren have been 

asked, “Mom, Dad, Grandma or Grandpa, what is that dark 

thing in your mouth?” 

The article that follows shares a rationale, as well as the clinical 

and laboratory processes of the Wynne Hybrid restoration. 

Restorative Materials 

Four groups of restorative materials are available for patient 

restorative needs. 5 These groups are: 

1. Powder/liquid feldspathic porcelains 

2. Pressed or machined glass ceramic 

Figure 3: The Wynne Hybrid Captek Nano crown design matches 

the versatility of a metal-ceramic system, with the benefits of 

pressed ceramic porcelains: Transparent margins with conservative 

proximal preparation design. Note the interproximal collar 

and pressed ceramic margins on each facial and lingual. The 

restorations shown will be air abraded with 50 µ aluminum oxide 

in preparation for cementation. 

3. High-strength crystalline ceramics 

4. Metal ceramics 

These restorative materials are listed in order of increasing 

strength and the amount of necessary tooth reduction. Captek, 

however, is a more conservative metal-ceramic preparation 

design. This relationship of material selection, strength factors 

and preparation requirements needs to be understood 

if the primary goal of the restoring clinician involves selecting 

the least invasive, longest-lasting restoration. According to 

Spear, “All teeth should be restored with the most conservative 

restoration that satisfies the patient’s esthetic and functional 

requirements.” 6 Understanding material options allows the 

clinician to select materials on a tooth-by-tooth basis, as determined 

by the esthetic, functional and clinical circumstances of 

each tooth to be restored (Figs. 5–8). 

Figure 4: For many patients, it is important to consider the lingual 

esthetics of maxillary teeth as well as the facial esthetics. 

Dark lines or visible margins can distract the eye, creating an 

unpleasant overall esthetic result. 

Parameters of Material Selection 

When choosing the optimal restorative material for each 

tooth, four criteria should be considered 5 : 

1. Substrate condition (amount and type of dentin and enamel) 

2. Flexure risk assessment 

Figure 5: Tooth #8 and #9 had been endodontically treated. They 

were restored unsuccessfully with transparent restorations that 

were designed to absorb and transmit light. 

3. Tensile and shear risk assessment 

4. Bond/seal maintenance risk assessment 

These factors will dictate the strength requirements, the position 

of the final margin, tooth reduction and degree of transparency 

of the substrate. 

Managing the Margin to Maximize Esthetics 

All-porcelain systems help clinicians mimic the light transmission 

of enamel and dentin. 7–9 Teeth in the esthetic zone can 

Figure 6: When the transparent restorations are removed, 

the preparations reveal dark underlying structure. Dark stump 

shade is a contraindication for fully transparent restorations with 

supragingival margins. 


Figure 7: Captek Nano full-coverage restorations with metal to 

the edge and subgingival margins will be placed on tooth #8 

and #9, next to IPS e.max veneers on tooth #7 and #10. 

benefit from the esthetics provided by all-porcelain materials, 

but there are situations where strength is an issue. Bruxers 

or occlusally involved patients need additional restorative 

strength. Patients with flexure, as well as excessive shear and 

tensile stress risk, are included in this group as well. 2 According 

to McLaren and Whitman: “If a high-stress field is anticipated, 

stronger and tougher ceramics are needed. The restoration 

design should be engineered with such support that it will 

redirect shear and tensile stress patterns to compression. The 

substructure should reinforce the veneering porcelain by using 

the reinforced porcelain system, which is generally accepted 

in literature as a metal-ceramic concept.” 5 

The Wynne Hybrid 

Figure 8: The final result reveals an esthetic blend of restorations: 

Esthetic transparent restorations matched to restorations 

that fully block out discoloration yet artificially refract and reflect 

light to match natural tooth structure. 

Figure 9: A visible dark line surrounds the existing lateral PFM 

that had been treated with a root canal. 

Figure 10: Removal of the PFM restoration reveals dark 

underlying tooth structure. Radiographic examination exposes 

a screw-type post. It is decided to replace the crowns and 

leave the post, for fear of fracturing the tooth. 

The Wynne Hybrid, as the name suggests, involves two margin 

designs: the facial and lingual pressed porcelain butt margins 

on definitive shoulder or chamfer margins. Interproximally, a 

knife-edge design developed to the edge with Captek Nano 

material is conservative but also bacteriostatic. 2 In the author’s 

opinion, this interproximal design is also the easiest for the 

clinician to finish, especially in the often hard-to-reach molar 

interproximal area. 

When underlying tooth colors are heavily stained, as is often 

the case when retreating old restorations, preparation blockout 

techniques that require more tooth reduction are often 

difficult to control (Fig. 9). Old metal posts in anterior endodontically 

treated teeth pose another challenge 6 (Fig. 10). 

When we attempt to remove and replace these post systems, 

we run the risk of fracturing the tooth. The Wynne Hybrid 

can be utilized in such situations to resolve this issue in a 

conservative yet esthetic manner (Figs. 11, 12). 

Another advantage of this design is the increase of the ferrule 

effect. 10,11 This is due to the interproximal margin placement 

that engages more of the diameter of the tooth. The reasoning 

behind this is that crowns with metal copings are less likely to 

snap off with the tooth still inside should they receive a blow. 

Biological Width Considerations 

When restoring teeth, biologic width issues can often be a 

concern. The gold knife-edge margin is the most controllable 

of all margins in the posterior interproximal areas. Some clinicians 

advocate a 360-degree porcelain butt margin around all 

teeth. The key to predictable margins is the ability to control 

the finishing of all 360 degrees of tooth margin. Anterior teeth 

have interproximal margins that can be reached and highly 

polished. However, as we move from premolars to molars, 

the facial-lingual dimension of the contact space increases. 

This diminishes the ability of the clinician to control the interproximal 

margins. Concave root surfaces eliminate or greatly 

diminish the chance of properly finishing the margin. This 

knife-edge margin is more easily cleaned with an explorer 

The Wynne Hybrid59

and floss. The facial and lingual porcelain butt margins are 

entirely accessible and can be finished with the clinician’s 

preferred technique. 

Wynne Hybrid Prep 

Preparing a tooth for the Wynne Hybrid requires only four 

burs: the 701 bur (SS White 9990935); a gold margination diamond 

(Brasseler 686231-012); a flat-topped polishing diamond 

(Brasseler 8837-012); and a pear-shaped diamond (Brasseler 

7408). The Wynne Hybrid crown technique is detailed below. 

1. The Wynne Hybrid is a classic porcelain-fused-to-metal 

preparation. Therefore, 1.5 mm to 2 mm of occlusal reduction 

is necessary. The 701 bur is 0.5 mm in diameter at the 

tip and 1 mm in diameter at the shank. Try to visualize the 

clearance with the opposite arch closed. This is the initial 

occlusal reduction. 

Figure 11: Note the Wynne Hybrid coping design: a facial and 

lingual porcelain margin and small proximal collars. Depending 

on where the light needs to be absorbed or blocked, a hybrid 

coping design can be fabricated to blend transparency and 

control light. 

2. At this point, old restorative material and decay can be removed. 

The tooth can now be based out and built up and 

readied for continued prepping. 

3. Next, clear out the contacts to increase access to the interproximal 

areas. 

4. Scribe a line completely around the crown, simulating the 

location of the final margin. This is typically performed at 

the height of the gingival. 

5. Now, place the interproximal margins with the Brasseler 

686231-012 diamond (Fig. 13). 

Figure 12: Conservative yet esthetic outcome 

6. Place the facial and lingual butt margins with the 701 bur 

and polish with the Brasseler 8837-012 polishing diamond 

(Fig. 14). The depth of this butt is from 0.8 mm to 1.5 mm, 

depending on what is trying to be accomplished. The shallow 

margin obviously removes less tooth structure, but 

more reduction may be needed to cover up dark tooth 

structure. 

7. Finally, use the Brasseler 7408 pear-shaped diamond to 

polish the occlusal surface. 

The Wynne Hybrid design gives you three basic options: 

1. Facial porcelain butt with mesial, distal and lingual gold 

collar 

2. Facial and lingual porcelain butt with mesial and distal 

gold collar 

3. Lingual porcelain butt with mesial, distal and facial gold 

collar 

Figure 13: Wynne Hybrid crown preparation. Contacts are 

cleared to increase access to the interproximal areas, and then 

a Brasseler 686231-012 gold margination diamond is used to 

design a conservative flame-shaped margin. 


Case Study 

This case involved six posterior teeth on the patient’s right side, 

which had previously been treated with full crowns (Fig. 15). 

Over the years, recession had begun and progressed until 

a significant amount of tooth structure was exposed. It was 

decided that teeth #2–4 and #29–31 would be restored with 

Captek Nano material. 

Figure 14: The facial and lingual butt margins are then refined to 

necessary depth with a Brasseler 8837-012 flat-topped polishing 

diamond. 

Figure 15: Preoperative view 

Captek Nano internally reinforced gold copings were fabricated 

at Glidewell Laboratories, a Captek Advanced Certified 

lab. Notice the cut-back on the facial as well as the lingual 

margins (Figs. 16–20). The patient was extremely happy with 

the esthetics of the Captek Nano restorations (Fig. 21). 

In focusing our concerns on the esthetic nature of contemporary 

restorations, we often limit our focus to the facial 

aspect of teeth. If we can comprehend all the visual possibilities, 

new areas of focus will appear. The lingual aspect of 

most maxillary teeth falls into this new focus. Incorporating 

the facial and lingual zones as esthetic areas will generate a 

higher level of esthetics for the patients we treat. With the 

Wynne Hybrid, esthetics can be balanced with a conservative 

and supportive preparation design, high porcelain fracture 

resistance and biological health. 

Benefits of the Wynne Hybrid Design 

1. Block out color 

2. Compatible with bleach shades 

3. Increase ferrule effects 

4. Control biologic width 

5. Eliminate painful palatal injections 

Figure 16: Captek Nano copings seated on solid model with 

porcelain bonder applied. Note that the facial is cut back to the 

accepted pressed porcelain margins and metal is to the edge 

in the proximal. 

6. Bacteriostatic interproximals 

7. No periodontal encroachment on facial or lingual 

8. Use in esthetic zone 

9. Easy cement clean up 

10. Color compatible with most restorations 

Summary 

Figure 17: After pressed porcelain application, final QC of the 

maxillary restorations is done on the solid model. 

Opinions on material selection abound. And, for now, there is 

no perfect dental restoration or material combination. Many 

times a single system can be utilized for all of the patient’s 

restorative work. However, the patient may best be served 

with a combination of systems. It is clear that stronger systems, 

such as the time-tested PFM, may serve better in the 

functional zone, while all-porcelain systems — or modified 

The Wynne Hybrid61

metal designs like the Wynne Hybrid design — may be better 

indicated in the esthetic zone. Strong, healthy and esthetic 

restorations are the result of deciding what is best for the 

individual tooth. Today, with clinicians having access to so 

many restorative material options, no patient should have to 

settle for anything less than ideal. CM 

Dr. William Wynne maintains a private practice focused on esthetic and restorative dentistry 

in Raleigh, N.C. Contact him at www.raleighareadentist.com or 919-851-3716. 

Acknowledgments 

1. Illustration by Arturo Lima (Fig. 1). 

2. Dentistry and clinical photography by Dr. Hedstrom (Figs. 5, 6, 8). 

3. Laboratory fabrication and photography by Alvin Fillastre, III, CDT (Fig. 7). 

4. Laboratory fabrication by Glidewell Laboratories with photography by Chris 

Lowthorp, CDT (Figs. 16-19). 

5. Annie Chu, RDH, for her editing and computer skills. 

References 

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approach. Chicago, Ill: Quintessence Publishing Co. 2002:59. 

2. Goodson J, Shoher I, Imber S, Nathanson D. Reduced dental plaque accumulations 

on composite gold alloy margins. J Perio Res. 2001;36(4):252–59. 

3. Dudney T. Achieving an ideal restorative material. Inside Dent. 2011;7(2):58–63. 

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indirect esthetic restorations. Adv Esthet Interdisciplinary Dent. 2005;1(4):4–13. 

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materials: a case report. Pract Proced Aesthet Dent. 2004;16(7):495–502. 

9. Little DA. Illustrating predictable anterior and posterior esthetics results: two case 

studies. Compend Contin Educ Dent. 2002 Mar;23(3 Suppl 1):17–23. 

10. Shoher I, Whitman A. Reinforced porcelain system: a new concept in ceramometal 

restorations. J Prosthet Dent. 1983;50(4):489–96. 

11. Jotkowitz A, Samet N. Rethinking ferrule — a new approach to an old dilemma. 

Br. Dental J. 2010;209(1):25–33. 

Figure 18: The mandibular Captek Nano restorations from an 

internal perspective. 

Figure 19: The restorations are seated on the solid model to 

check for complete marginal seal and contacts. 

Figure 20: The mandibular restorations will be treated prior to 

cementation. For posterior restorations and restorations with 

low retention form, it is recommended to abrade the internal 

surface of the metal composite with 50 µ aluminum oxide at 

between 20 and 40 lbs. of pressure. Acid etching is used to 

prepare the ceramic margins. 

Figure 21: Six Wynne Hybrid restorations. Teeth #2–4 were restored 

first. The patient was so pleased with the result that she 

committed to treating #29–31. Photo was taken after seating of 

the mandibular restorations. 

62 www.chairsidemagazine.com 

d

Congratulations, Chairside ® PHOT 

Hunt Winners! 

You guys really outdid 

yourself last issue! We did 

not anticipate that so many 

of you would search for differences 

between the two 

images. We could tell from 

the envelopes that some of 

you might even have taken 

the photo hunt home, perhaps 

to enlist the help of 

your kids. 

The main difference between 

first and second place on 

nearly every entry was the 

second molar on the model: 

If you found that, you probably 

found them all. Here is the 

final tally: 

Original 

• 50 dentists 

found all 21 differences 

and will receive $500 

in lab credit each 


found 20 differences 




found 19 differences 



If you are not sure what to 

use your credit for, I suggest 

prescribing a BruxZir ® crown 

or an aveoTSD ® for the 

snorer in your family. Thanks 

for playing! 

Answers 

Chairside Photo Hunt Contest entries 

were individually scored after being sent 

to the lab via e-mail, fax and standard 

mail. Prize winners were notified by 

phone and standard mail. In total, 166 

prizes were awarded.

The Chairside® PHOT Hunt 

Eleven years ago I got my first pair of loupes. It gave me the opportunity to improve the quality of my restorative dentistry, and I have been 

recommending them ever since. Well, I hope you took my recommendation because you are going to need them for this month’s Photo 

Hunt! Clean off the shards of enamel and salivary splatter and get searching. Our company logo is a “G” and an “L” next to each other: GL. 

We have hidden a lot of GLs in this aerial shot of our Newport Beach, Calif., headquarters. Circle them and send this page back to us via: 

MAIL 


ATTN: Chairside magazine 

4141 MacArthur Blvd. 

Newport Beach, CA 92660 

E-MAIL 

chairside@glidewelldental.com 

FAX 

800-599-9564 

Limit one entry per office. The winners of the Chairside Photo Hunt will receive: 1 st place – $500 in Glidewell credit/$500 credit toward his 

or her account; 2 nd /3 rd place – $100 in Glidewell credit/$100 credit toward their accounts. 

Name:______________________________________ City/State of Practice:________________________________________________________ 

Phone:_______________________________________ Total found:____________ 

Entries must be received 

by June 30, 2011.

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