A Publication of Glidewell Laboratories • Volume 4, Issue 2
Altered Passive Eruption:
Diagnosis and Treatment
An Interview with
Dr. Brock Rondeau
Dr. Michael DiTolla’s
9 Dr. DiTolla’s Clinical Tips
This month’s tips include my favorite curing light:
the ultra-portable Demi LED Curing Light. It has
taken me years to get comfortable with a five second
cure, having grown up in the 60-second era.
The COE® ADJUST-A-TRAY is about as good as
it gets for disposable impression trays. For the first
time ever, we can say that one tray size fits all. I love
when a great product gets more convenient to use,
and Exposé® is a simple way to place caries detector
on dentin. For single-unit crowns or two adjacent
single-unit crowns, there is nothing better than a
QUAD-TRAY Xtreme impression tray. It is now the
most popular double-arch tray that we see coming
into the laboratory.
14 Elective Cosmetic Dental Treatment:
One Dentist’s Philosophy Concerning
“When to Treat”
By now, you may have noticed that I feature a lot
of articles by Dr. Bob Lowe in the magazine. He has
been one of my clinical mentors for a long time. In
this article, Bob discusses his philosophy of conservatism
when doing smile makeovers, and shows
a case to demonstrate the dramatic effect a smile
makeover can have on a patient’s face.
23 Simple Bailout for Complex Periodontal
There have been many times over the years when
Bill Strupp’s out-of-the-box thinking has made me
shake my head in disbelief, and this is one of those
articles. This article marked my introduction to the
concept of biologic root reshaping. I always thought
that once a margin was prepped, it was irreversible.
In this piece, Dr. Strupp shows how crown margins
can be moved coronally and out of the way of the
Cover photo by Sharon Dowd
Cover illustration by Wolfgang Friebauer, MDT
A Master in the Art of Living draws no sharp distinction
between his work and his play; his labor and his leisure;
his mind and his body; his education and his recreation.
He hardly knows which is which. He simply pursues his
vision of excellence through whatever he is doing, and
leaves others to determine whether he is working or playing.
To himself, he always appears to be doing both.
--- François-René de Chateaubriand
I don’t know if Dr. Bill Strupp, Dr. Bob Lowe or Dr. Brock
Rondeau has ever seen this quote before, but having spent
time with all three of them, I am pretty sure they would
agree with it. These three clinical mentors of mine are
all excellent clinicians and, by Chateaubriand’s definition,
masters of living.
What does it take to be able to make the practice of dentistry
as much play as it is work? The answer is different
for everyone. For those three dentists that I’ve mentioned,
it is their pursuit of restorative excellence. For another
one of my friends, he knows exactly what he has to produce
per operatory-per hour-per day to achieve his financial
goals. It’s not a huge goal—it’s $277 per operatoryper
hour-per day, although he has more operatories than
the average dental practice. For him, the game is to be
organized enough to meet his goal on a daily basis.
Recently, I was surprised at how much fun I had surgically
placing my first implant. The placement will be
featured in a future issue of Chairside and will also be
featured in the appropriately titled DVD presentation, “My
First Implant.” As you will see, there is so much technology
behind the treatment planning of that case, that there
was virtually nothing that could have gone wrong. It was
shockingly easy to place, and overall, much easier than
even a single crown prep.
It was hard for me to see a distinction between work and
play with that implant. It was one of those times where
I thought, “Do I really get $1,000 for doing that?” Here’s
hoping your work can be your play as well.
Yours in quality dentistry,
Dr. Michael DiTolla
Editor in Chief, Clinical Editor
Jim Glidewell, CDT
Editor in Chief
Michael DiTolla, DDS, FAGD
Mike Cash, CDT
Michael DiTolla, DDS, FAGD
Jamie Austin, Deb Evans, Joel Guerra,
Phil Nguyen, Gary O’Connell, Rachel Pacillas
Wolfgang Friebauer, MDT
If you have questions, comments or complaints regarding
this issue, we want to hear from you. Please e-mail us at
firstname.lastname@example.org. Your comments may be
featured in an upcoming issue or on our Web site: www.
© 2009 Glidewell Laboratories
Neither Chairside Magazine nor any employees involved in its publication
(“publisher”), makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
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herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and materials
that are presented, you must make your own decisions about
specific treatment for patients and exercise personal professional judgment
regarding the need for further clinical testing or education and
your own clinical expertise before trying to implement new procedures.
Chairside ® Magazine is a registered trademark of Glidewell Laboratories.
34 One-on-One with Dr. DiTolla
Dr. Brock Rondeau forever changed the way I look at
patients after I took his Functional Orthopedics and
Orthodontics courses. Most of the smile makeover
cases I find myself doing are cases that should have
been treated with two-phase orthodontics years ago
in a much more conservative fashion. In this article,
Brock shares with me his philosophy and treatment
options for snoring and sleep apnea patients.
44 Photo Essay: Anterior Procera Zirconia
Crowns with No-Prep Vivaneers
In this photo essay, the patient presented with some
interproximal decay and failing composites on teeth
7-10. This case features the use of the Reverse Preparation
Technique to ensure adequate reduction for
the laboratory, as well as Procera ® Zirconia crowns
and no-prep Vivaneers for the restorations.
49 Altered Passive Eruption:
Diagnosis and Treatment
The more dentistry I do, the more I realize that the
gingival tissues are often the most difficult aspect
of an esthetic case, and it is the one that we are
solely responsible for. Dr. Danny Melkers is Dr. Bill
Strupp’s periodontist, and you will see some of his
work features in the Strupp article in this issue as
well. This article details the causes and treatment of
57 AlloDerm: An Effective Alternative
to Palatal Donor Tissue for Treatment
of Soft Tissue Alveolar Ridge Defects
My dental school professors had offered much insight
into my future profession, but nothing teaches
you more than actual experience. For me, I had the
unenviable task of performing a graft on a relative
during dental school. Though I learned a lot, the
experience was tough because of the physical pain
he had to endure from the palatal work. So I came
across this article by Dr. Edward Allen, who offers
great advice on the issue and provides a step-by-step
outline on how to perform a graft without having to
rely on donor tissue from the palate.
Letters to the Editor
“Dear Dr. DiTolla,
I have seen you lecture a few times and I
also have been using Glidewell for some of
my restorations. My question is concerning
IPS e.max full contour crowns. I was
using IPS e.max zirconia for my replacement
for PVCs. I have recently started
using the IPS e.max ® CAD product after
watching your video from Glidewell. The
idea seems to make sense, especially
since I have had some problems with my
overlay porcelain on my zirconia crowns
chipping or breaking. I know Christensen
had some concerns about these crowns
as well. So my question is, do you prefer
the IPS e.max full contour as your replacement
for PVC and have you had many
problems with them? Also, would you use
them anywhere in the mouth?”
- Dr. Jeffrey L. Schultz, Bellaire, TX
No, IPS e.max CAD has not totally
replaced PFMs for me, although I
suppose they could if you wanted
to avoid metal. I still like cast gold
for second molars, for example. In
areas of the mouth that aren’t esthetically
significant (such as molars), I
would rather go with a PFM for the
additional strength. If I were forced
to do an all-ceramic material, it
would probably be a zirconia-based
restoration, such as Lava or Prismatik
Clinical Zirconia . Zirconia is not
as strong as a PFM, but it is stronger
than IPS e.max CAD. IPS e.max
CAD is my “go to” all-ceramic crown
for bicuspids and anterior teeth. The
fact that IPS e.max CAD is the lowest
remake product of all of our permanent
crowns in the lab goes a long
way with me; it seems to work in everyone’s
- Dr. DiTolla
“Dear Dr. DiTolla,
Thanks for the reply. I have been using
zirconia for several years now just about
anywhere in the mouth. I have had a few
problems with the overlay porcelain chipping
and even breaking. I also have had
some failures with PFM, but more so with
zirconia crowns. The reason I thought IPS
e.max would be better than zirconia is that
the problem is not the zirconia itself, but it
is the overlay porcelain and since the IPS
e.max is stronger than the overlay porcelain,
wouldn’t the e.max be the strongest
in a way? I know everyone talks about how
strong zirconia is, but again, the problem
is not the zirconia breaking, it is the porcelain
on top of it that can fail. This is just a
thought because I haven’t done many IPS
e.max cases and do not know how they
hold up over time”
- Dr. Jeffrey L. Schultz
I completely agree. I have some insanely
long span zirconia bridges in
the mouth and though the framework
has never broken, they are prone to
chipping based on the overlying porcelain
that is used. Furthermore, if
they do chip, it is way harder to attempt
a repair than a PFM because
there is no metal to bond to. And cutting
off eight units of zirconia based
restorations? Total pain in the butt,
and potentially dangerous to the
teeth, as it is easy to inadvertently
cut into the tooth as the bur breaks
through the zirconia.
IPS e.max is as beautiful as you
would expect since it has no underlying
coping. However, we don’t have
enough long-term data to vouch for
its strength in all situations. The only
IPS e.max fracture I have had is one
that was placed with temporary cement;
suffice it to say, a PFM would
not have broken in that situation. At
approximately 300 MPa compressive
strength, IPS e.max is at the minimum
of what can be cemented conventionally.
If it were any weaker, it
would have to be bonded like Empress,
although I know of a few colleagues
who bond all of their e.max
into place. I know the average dentist
has no interest in bonding all of
their restorations into place.
I encourage you to place some e.max,
specifically the IPS e.max CAD. This
product is easily the lowest remake
product in our lab for permanent
crowns. Just keep in mind that it is
still an all-ceramic and should not be
placed in all clinical situations. In my
mind, PFMs and cast gold still can’t
be beat in those posterior regions
with high biting forces and limited
room for occlusal adjustment.
- Dr. DiTolla
“Dear Dr. DiTolla,
I have been reviewing my splint therapy.
I came across your DVD on the hard/soft
splint. I enjoyed your DVD and have seen
you speak in Asheville at one of Ross
Nash’s seminars at the Groove Park Inn. I
am a fan of yours and respect your ideas
and contribution. That being said, does
the soft part of the comfort splint increase
nighttime bruxism? I want to start using
these splints for protection, but I’ve read
about this concern.”
- Dr. Tommy Spears, Maryville, TN
I have heard that concern also, but
only anecdotally. Unfortunately, that
is the only way I can answer you as
well. My experience with the Comfort
H/S (hard/soft) splints in my
own mouth and with my patients is
that the inner soft layer is too thin to
be spongy enough to be chewed on
in that fashion. I also have a full soft
athletic mouthguard that I have worn
and that one is fun to chew on. It
is more important to me to have the
soft layer on the inner aspect of the
splint so that the splint will continue
to fit the patient even if their teeth
shift a little. I used to fabricate full
hard splints and have worn several
myself. I was always disappointed
how the splints would no longer fit at
some point due to the physiological
shifting of the teeth. I have a lot of
patients who report they don’t need
to wear their splints every night, and
I want to assure them that it will still
fit two months later if it has been sitting
in their drawer. For patients who
wear their splints every night, there
should be no problem making them
a full hard splint and having it continue
to fit for many years. If TMJ and
muscle symptoms decrease or disappear
with a hard/soft splint, it stands
to reason that nighttime bruxism has
- Dr. DiTolla
“Dear Dr. DiTolla,
I was placed on hold one time when I
heard you talk [in your “On-Hold Clinical
Tips”] about a bur that you use to remove
zirconia/e.max crowns. What is that bur?”
- Dr. Fred M. Rabinowitz, Plano, TX
burs on zirconia (such as typical
diamonds and carbides), but these
are the only ones that actually cut.
I cut through the porcelain on a zirconia
crown with the Razor carbide
from AXIS Dental, and then switch
to the ZIR-CUT Bur to get through
the zirconia coping itself. I use the
same Razor carbide to cut off e.max
crowns. Since e.max does not have
a substructure, there is no need to
change burs to cut these crowns off.
- Dr. DiTolla
“Dear Dr. DiTolla,
Hello, I am currently a dental resident and
I have a quick question for you. In the journal,
Dental Economics , you said that you
can reapply glaze to porcelain intraorally
by using a high-torque electric handpiece.
I would like to know, which polishing system
and pastes do you utilize for this procedure?
Thank you for your help.”
- Dr. Brandon G. Katz, Baldwin, NY
Thanks for the question! Well, I don’t
apply glaze to the crown intraorally,
per se; I return a glaze-like polish
back to the crown. Truth be told, if
you sent a crown back to the laboratory
to have it reglazed after it had
been in the mouth, nine out of 10 labs
would do the same thing. They use
handpiece, which you could do extraorally,
and this is one of the big
reasons I use electric handpieces
intraorally as well. I go through the
three steps of the CeraGlaze ® kit
from AXIS Dental (axisdental.com
or any dental dealer) on all teeth I
have adjusted intraorally. And then
for anterior teeth, especially on the
facial surface, I use a round 12 mm
soft bristle brush with some Diashine
(both from vhtechnologies.com)
to place a very high shine on these
esthetic restorations. The key for me
is the amazing amount of torque I
get from my KaVo ELECTROtorque
handpieces. It’s all about the torque!
- Dr. DiTolla
Chairside Magazine welcomes
letters to the editor, which
may be featured in an upcoming
issue or on our Web site.
Letter should include writer’s
full name, address and
daytime phone number.
To contact us: e-mail (email@example.com),
mail (Letters to the Editor,
Chairside Magazine, Glidewell
Laboratories, 4141 MacArthur
Blvd., Newport Beach, CA
92660) or call (888-303-4221).
There are actually two different burs
for zirconia and e.max. For zirconia,
I like the ZIR-CUT Bur from AXIS
Dental. I have tried to use other
Michael C. DiTolla, DDS, FAGD
Dr. Michael DiTolla is Director of Clinical Education & Research at Glidewell Laboratories in Newport
Beach, Calif. Here, he performs clinical testing on new products in conjunction with the company’s R&D
Department. Glidewell dental technicians have the privilege of rotating through Dr. DiTolla’s operatory
and experience his commitment to excellence through his prepping and placement of their restorations.
He is a CR evaluator and lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has
several clinical programs available on DVD through Glidewell Laboratories. For more information on
his articles or to receive a free copy of Dr. DiTolla’s clinical presentations, call 888-303-4221 or e-mail
Edward Allen, DDS, PhD
Dr. Edward Allen is a full-time Professor of Periodontics and full-time private practitioner. A past President
of the American Academy of Esthetic Dentistry, the American Academy of Restorative Dentistry,
and the American Academy of Periodontology Foundation, Dr. Allen is presently the Periodontal Section
Editor for the Journal of Esthetic Dentistry and serves on the editorial boards of the Journal of Periodontology
and the International Journal of Periodontics and Restorative Dentistry. Dr. Allen is founder of
the Center for Advanced Dental Education in Dallas, an educational facility, where he teaches surgical
technique courses. He has published over 50 articles, has presented numerous lectures and surgical
demonstrations worldwide, and has a periodontal practice with an emphasis on periodontal plastic
surgery in Dallas, Texas. To contact Dr. Allen, call 877-696-1414, visit www.DrEdwardPAllen.com, or
Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD
Dr. Robert A. Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982 and
was a Clinical Professor in Restorative Dentistry until its closure in 1993. Since January of 2000, Dr.
Lowe has maintained a private practice in Charlotte, N.C. He lectures internationally and publishes
in well-known dental journals on esthetic and restorative dentistry. Dr. Lowe received fellowships in
the AGD, ICD, ADI, ACD, received the 2004 Gordon Christensen Outstanding Lecturers Award, and in
2005, Diplomat status on the American Board of Esthetic Dentistry. To contact Dr. Lowe at 704-364-
4711 or at firstname.lastname@example.org.
Daniel J. Melker, DDS
Dr. Daniel J. Melker graduated from Boston University School of Dentistry in 1975, with specialty training
in Periodontics. Since then, Dr. Melker has been maintaining a private practice in Periodontics in
Clearwater, Fla. He currently lectures at the University of Florida Periodontic and Prosthodontic graduate
programs on the Periodontic-Restorative relationship, as well as presenting at UAB, U. of Houston,
Baylor U. and LSU. He has published several articles in magazines as well as the International journal
of Periodontics and Restorative Dentistry. He is a two-time Gold Medal recipient from The Florida Academy
of Cosmetic Dentistry. To contact Dr. Melker, call 727-725-0100.
Robert Pulliam, DMD, MS, RPh
Dr. Robert Pulliam completed his undergraduate work at the University of Mississippi School of Pharmacy.
He worked as a hospital pharmacist in Tuscaloosa, Ala. before earning a DMD from the University
of Alabama at Birmingham, School of Dentistry. Dr. Pulliam earned a certificate and MS in Periodontics
at the University of Texas Health Science Center at San Antonio. As a diplomate of the American
Board of Periodontology and an active member of ADA, AAP, SAP, TDA, NDS, Dr. Pulliam has published
several articles and provides continuing education in periodontics and implant dentistry. Dr. Pulliam
maintains a private practice in Nashville, Tenn., with an emphasis on esthetic and implant dentistry,
and may be contacted by phone at 615-297-8973.
Brock Rondeau, DDS, IBO, DABCP
Dr. Brock Rondeau is a general dentist specializing in orthodontic, orthopedic and TMJ problems. A
1966 graduate of Dalhousie University Dental School in Halifax, Nova Scotia, Dr. Rondeau is recognized
as a leader in the orthodontic profession. In addition to being the first Canadian named the “American
Association of Functional Orthodontics Man of the Year” in 1988, Dr. Rondeau is also a Diplomat of
the International Board of Orthodontics, a past president and senior instructor for the International
Association for Orthodontics, and a member of the American Association of Functional Orthodontics,
International Association for Orthodontics, Academy of General Dentistry, London & District Dental
Society, the Academy of Dental Sleep Medicine, the Ontario and Canadian Dental Associations, and the
American Academy of Craniofacial Pain. For more information on Dr. Rondeau’s courses, visit www.
rondeauseminars.com, e-mail email@example.com, or call 877-372-7625.
Bill C. Strupp, DDS
Dr. Bill Strupp is a world-class dentist, best known for his vast knowledge on comprehensive cosmetic
and restorative dentistry. An admired clinician, he lectures both nationally and internationally to
thousands of dentists each year and has been published in many prominent dental publications. Dr.
Strupp also publishes the widely respected newsletter, Crown & Bridge UPDATE, aimed at educating
dentists in better dentistry. An Accredited Fellow of the American Academy of Cosmetic Dentistry, Dr.
Strupp continually evaluates and applies clinically relevant research to the day to day practice of crown
and bridge dentistry. Dr. Strupp’s teachings center on his nearly 40 years in private practice, from which
he’s been esteemed “the dentists’ dentist.” To contact Dr. Strupp, call 800-235-2515, visit www.strupp.
com, or e-mail Bill@Strupp.com.
– ARTICLE by Michael DiTolla, DDS, FAGD
– PHOTOS by Sharon Dowd
PRODUCT ....... Demi LED Curing Light
CATEGORY ...... Light Curing System
SOURCE .......... Kerr Corporation
Kerr has been at the forefront of light curing technology
going all the way back to their Demetron roots.
Their new LED curing light, the Demi, has been on
the market for just over a year and is already the #1
selling LED curing light in America. I got to test a unit
as a CRA evaluator and purchased one as soon as I
had to give the other one back. Other evaluators were
impressed too, and in the July 2008 Clinician’s Report,
the Demi was rated the best combination of performance
and handling of all the LED curing lights. The
Demi has a technology called “Periodic Level Shifting”
that gives you a true five-second cure time for composites
shade A3 and lighter. The Demi accommodates
all Demetron light tips in case you have a favorite tip
such as a 2 mm tip. It is half the size and weight of
previous Demetron LED curing lights which would be
reason enough for me to consider purchasing it, even
without the PLS technology. The charger will charge
two batteries as well, ensuring you are never at a loss
Dr. DiTolla’s Clinical Tips 9
PRODUCT ....... COE ® Adjust-A-Tray
CATEGORY ...... Impression Tray
SOURCE .......... GC America, Inc.
Every once in a while a product comes out that makes
me really angry that I did not think of it myself, and
the COE Adjust-A-Tray is one of those products. The
genius of the Adjust-A-Tray is its ability to be used in
four different widths: small, medium, large and extralarge.
The most common scenario for me is when I try
a medium tray into someone’s mouth and discover it
is too small. At this point, you simply remove the tray,
unsnap it from the medium setting and snap it into
the large size. Also, due to perforations at the rear
portion of the tray, you can adjust the tray to three different
lengths. There have been plenty of times when
the width of a tray is acceptable but the tray is too
long, and the Adjust-A-Tray easily solves that problem.
There are also two different sulcus heights so that
you can use the tray for partially edentulous arches
as well. I still use custom trays for all large crown and
bridge cases, but Adjust-A-Trays are great for all study
models, splints, and opposing models.
PRODUCT ....... Exposé ®
CATEGORY ...... Caries Detector
SOURCE .......... Centrix Dental
At times, I have loved the idea of caries indicators
more than I loved the caries indicators themselves.
Whether it was the time it took to set up the syringe
or place it in a dappen dish and grab a cotton pellet,
there were times when I would revert to using my
sight and tactile feel to diagnose caries. Somewhere
inside, I knew I could be fooled by caries and that
it would be more accurate to stain the teeth; I just
needed the right product to help me introduce it into
an efficient routine. Enter Exposé from Centrix. Leave
it to Centrix to figure out a way to impregnate caries
indicator onto the tip of one of their Benda Micro applicators.
Simply wet the tip of the brush (or if the
tooth is already wet, you can leave the brush dry).
Brush the prep with the tip of the brush and rinse.
The Exposé material remains on the affected dentin.
After removal, simply brush suspicious areas of the
prep again and rinse. It’s simple and accurate, and a
caries indicator is now part of my standard routine.
Dr. DiTolla’s Clinical Tips11
PRODUCT ....... QUAD-TRAY Xtreme
CATEGORY ...... Impression Tray
SOURCE .......... Clinician’s Choice
New Milford, CT
The QUAD-TRAY Xtreme is definitely on my list of
products I wouldn’t want to practice without. I’m not
sure what took it so long to get onto these pages, perhaps
I have just started to take it for granted. Maybe
it’s because it gets covered with impression material
pretty quickly and is not heard from again. From the
looks of the double-arch tray cases coming into the
laboratory, many of you like it as well, since almost
one-third of our incoming cases are taken with QUAD-
TRAYs. Clinician’s Choice improved the original
QUAD-TRAY by making the distal bar 25 percent thinner
to help make room for the retro molar pad, a big
problem area for plastic double-arch trays. A shorter
lingual wall keeps the tray free from the patient’s anterior
teeth, another common cause of plastic doublearch
tray distortion. The QUAD-TRAY Xtreme is now
the #1 selling aluminum double-arch impression tray
in the world, and has been my exclusive double-arch
tray for the last seven years. Try one and you won’t go
back to plastic!
Dr. DiTolla’s Clinical Tips13
Elective Cosmetic Dental Treatment
■ One Dentist’s Philosophy Concerning “When to Treat”
Conservatism as a philosophy of treatment
has also come ‘full circle.’ As Shavell once said,
‘Many teeth are sacrificed upon the alter of false conservatism.’
That statement was never more true than today. ”
– ARTICLE and PHOTOS by Robert Lowe, DDS, FAGD, FICD, FADI, FACD
■ A “Moral Dilemma?”
It is a wonderful time to be practicing dentistry! As advances in dental materials and techniques continue
to unfold, the benefits to the end user, the patient, are greater now than at any time in the history
of our profession. Dentistry is evolving from a “reactive profession” with the mindset “it can’t be fixed
until: 1 - the disease has progressed far enough, 2 - it breaks” to a “proactive profession” where prevention
and minimally invasive techniques are prevalent.
Conservatism as a philosophy of treatment has also come “full circle.” As Shavell 1 once said, “Many
teeth are sacrificed upon the alter of false conservatism.” That statement was never more true than
today. We no longer have to remove healthy tooth structure for the structural requirements of the restorative
material as we did for cast gold and dental amalgam. Adhesive technology has advanced so
far that we can micro-mechanically bond a “jig saw puzzle piece” of tooth colored restorative material
to tooth substrate that will wear favorably and support remaining natural tooth structure. So, where is
The ability to predictably bond very thin pieces of tooth colored restorative material to teeth and expect
excellent long term results has created a new area in the practice of dentistry -- that of elective cosmetic
treatment. Over the last 20 or so years, materials and technologies have continued to improve such that
today, many procedures whose longevity was felt by the “old school” to be a compromise, have proven
to be excellent, clinically viable, long term treatment options. Teeth can now be “resurfaced” with tooth
colored restorative materials requiring very little tooth preparation. The “lamination effect” 2 by virtue
of adhesive bonding technology allows the dentist to add a brittle restorative material of minimal thickness
to the surface of the tooth which will not break under normal masticatory function.
Hence, patients who are not happy with the smile “mother nature” provided can elect to have a “smile
makeover”, correcting esthetic problems associated with tooth shape, position, size and color. For many
years, patients had to live with esthetic problems that were tooth related. Orthodontics can straighten
teeth, but cannot alter malformation or problems associated with tooth color. The psychologic ramifications
to the patient of an unesthetic smile are only beginning to be understood and validated.
Some dentists still believe that it is a “violation of the Hippocratic Oath” to disturb “healthy” tooth
structure, even if the patient is unhappy with their esthetics, and that we should “talk them out of elective
treatment.” In this day and age, such backward thinking is unnecessary. Just ask the thousands
of happy patients who have “sacrificed” a few tenths of a millimeter of tooth structure whether the
dramatic esthetic changes achieved were worth the risk. And, that is exactly what it comes down to:
“risk versus benefit.” Is the risk associated with the minimal loss of tooth structure worth the benefit
of a long-term cosmetic change for the patient? For many patients, elective cosmetic dentistry can be a
life-altering experience altering those who were not fortunate enough to be born with “perfect teeth,”
the smile they have always wanted. The following is just such a case.
Figure 1: A full face view of a twenty-one year old female
with an unesthetic smile due to a congenital malformation
known as “microdontia.”
Figure 2: An unretracted view of the patient’s smile. She
rarely smiles in this fashion since she feels her teeth look
like “baby teeth.”
Elective Cosmetic Dental Treatment15
■ Patient History: The Anatomy of a Smile
The patient was a 21-year-old female who, for her entire life as she remembers it, was ashamed to
smile. She had a congenital condition called “microdontia” which caused much of her permanent dentition
to be malformed and so small that she had diastemata between most of her teeth from the molar
region forward. The buccal cusps of her canine and premolar teeth appeared to be very sharp and
pointed. Facially, this young woman appeared to have the teeth of a child (Figures 1-3). As far as her
occlusion was concerned, she had a Class I molar relationship and functioned in a very non-destructive
chewing pattern. She exhibited no muscle tenderness or temporo-mandibular joint dysfunction. Aside
from a few small direct dental restorations, her dental health history was unremarkable. Most dentists
would consider that she had “good teeth” from a disease perspective. However, to the patient, her teeth
were anything but “good.” The maxillary and mandibular arch form was good and the spacing was well
divided (Figures 4 & 5). It was almost as if the teeth had been orthodontically positioned to equalize
the spacing. The interarch distance was minimal, which meant the preparation for any full coverage
restorations would yield a stump with minimal axial height and retention after occlusal reduction. The
problem was to restore esthetic beauty with as little tooth reduction as possible and without altering
the occlusal vertical dimension. To complicate things further, the patient had to travel from Texas to
North Carolina for her treatment.
After a local dentist in Texas had taken a full mouth set of radiographs and preoperative study models,
it was determined that all teeth from the premolar region of both arches would require treatment.
The maxillary and mandibular molars would remain untreated and maintain the preoperative occlusal
vertical dimension. Due to the short cervicoincisal height of the clinical crowns, it was recommended
that the patient have surgical crown lengthening by a local periodontist to gain as much axial height
as possible. The tissues were allowed to heal for six months prior to the commencement of restorative
therapy. The operative plan was to prepare the anteriors and bicuspids on both maxillary and mandibular
arches, take master impressions, interocclusal records, a facebow transfer, and fabricate chairside
provisional restorations based on a preoperative laboratory wax-up (Figure 6). One month later, the
patient would return for delivery of the restorations, with a three-day follow up and necessary occlusal
adjustment prior to returning to Texas. A local dentist planned to follow the case and provide necessary
follow up care.
■ Smile Transformation: How Important Are Teeth?
The methodology of tooth preparation was to create 360° “minicrowns” for the six maxillary anterior
teeth. It was felt that in order to maximize the gingival esthetics and to create proper facial and lingual
embrasures, 360° preparation of these teeth would be necessary. However, the amount of tooth reduction
incisally and axially would be minimal, about five tenths of a millimeter. In actuality, one merely
needed to remove the heights of contour and create a finish line for the laboratory in a similar fashion
to preparing pedodontic teeth for stainless steel crowns. The mandibular anterior teeth, being more
closely spaced, would be prepared for three quarter “wrap around” porcelain veneers.
Preparation design for the premolar teeth needed a bit more “creativity.” The plan was to have functional
contacts on enamel and not to reduce the occlusal surfaces. Yet, some interproximal caries existed
in some areas and veneering only the facial surfaces would leave poorly contoured lingual embrasure
areas (shelves) with the potential to trap food. A modification of the onlay veneer preparation 3 was
planned that would restore lingual embrasure contours, remove decay and create resistance to facial
displacement, yet leave the occlusal enamel surface intact. This has been termed by the author the “Lebda
Modification” for the onlay veneer (named for the first patient on whom this design was used).
The distance (diastema) between the premolar teeth was equally divided and closed by the adjacent
proximal restored surfaces. The prepared teeth are shown in Figure 7. Following tooth preparation, a
periodontal probe was used to measure proximal sulcus depth of the maxillary anterior teeth. About
three millimeters of sulcus depth was measured on average. A diode laser (ezlaze , BIOLASE Technology,
Inc.) was used interproximally to create small triangular spaces in the soft tissue to give an
illusion of facial interdental papillary tissue (Figure 8). By creating this space and slightly lowering the
Figure 3: A retracted view of maxillary and mandibular arches. The
patient has a Class 1 malocclusion and is congenitally missing her
maxillary left permanent lateral incisor. The maxillary left permanent
cuspid has migrated into the lateral position and the patient
also has a limited interarch distance.
Figure 4: A view of the maxillary arch from the incisal/occlusal aspect.
Note the even distribution of spacing, lack of rotational problems
and the normal arch form that exists preoperatively.
Figure 5: A view of the mandibular arch from the incisal/occusal
aspect. Even spacing and ideal arch form exists in this arch also
allowing for minimal tooth preparation.
Figure 6: This is a view of the completed laboratory wax up for the
case creating proper tooth form and occlusal relationships for the
teeth to be treated. A duplicate of this model will be made in dental
stone so that a clear stent can be made for provisional restoration
Figure 7: This view shows the teeth in maximum intercuspation after
tooth preparation. Note that the molar teeth are in centric contact
and that a minimal amount of space has been created for the
addition of porcelain to the prepared tooth surfaces. The case will
be completed without any change in occlusal vertical dimension.
Figure 8: A diode laser (Twilight: BIOLASE) was used to create space
in the soft issues interproximally for the ceramist to create more
natural emergence angles when closing the spaces between the
preparations. This was done in free gingiva only so not to disturb
in the biologic width. The goal is to simulate papilla by “squeezing”
the tissue between adjacent porcelain surfaces.
Elective Cosmetic Dental Treatment17
Figure 9: Preparation margins were made at the gingival crest facially
and interproximally, while staying slightly above the gingival
crest lingually. A view of the maxillary final impression taken without
gingival retraction is shown.
Figure 10: The provisional restorations are shown in this full arch
retracted view after bonding them to place using filled adhesive
resin (Optibond 2 FL: Kerr Corporation). Note the maintenance of
occlusal vertical dimension in the molar region have proper esthetic
contour and occlusal interrelationships.
Figure 11: A full smile view of the patient with provisional restorations.
Compare to the preoperative smile in Figure 2.
Figure 12: The preoperative study models are shown in centric occlusion.
Figure 13: The laboratory models with the ceramic restorations are
shown in centric occlusion. Compare with Figure 12 preoperative
models to see the change in esthetics and function.
Figure 14: This is a view of the maxillary anterior preparations at
the delivery appointment after removal of the provisional restorations.
Notice the “papilla” that formed as a result of the provisional
emergence profiles. The marginal tissues are still immature and
the sulcular environment is such that bonding restorations could
interproximal margin, the ceramist could create an emergence profile that could push the interproximal
tissues together slightly and close the space. Also, this procedure would help the ceramist prevent
“ledging” of the ceramic material to eliminate “black triangles.” Aside from these interproximal areas, all
finish lines of tooth preparations were positioned at the crest of the gingival tissue, or slightly supragingival.
Master impressions (Figure 9) were made of both arches without the need for gingival retraction
or hemorrhage control.
A hard acrylic index (Luxabite: Zenith/DMG) was taken in the anterior region with the molar teeth in
proper centric position. A facebow transfer was also made relating the positions of the upper preparations
to the patient’s maxillary base. Bisacrylic provisional restorations were fabricated with temporary
material (Venus Provisional Material: Heraeus Kulzer) using a clear stent derived from the stone model
replica of the laboratory wax up. The provisional restorations were luted in place using flowable resin
(Venus Flow: Heraeus Kulzer) and the “spot etch” technique 4 excess resin was cleared away using a no.
2 Keystone brush (Paterson Dental) prior to light curing. The margins were finished with a high-speed
30-fluted composite finishing bur (Brasseler USA). Polishing of the bisacrylic provisional restorations
was performed using rubber abrasives followed by a polishing brush (Enhance Points: Dentsply/Caulk)
and Occlubrush: Kerr-Hawe. The final provisional restorations are shown in Figures 10 & 11. Note the
incredible transformation of this “little girl” into a grown woman. The esthetics of a beautiful smile is
■ Delivery of the Ceramic Restorations: The Moment of Truth
The patient had requested like so many other patients these days to have a “white and bright” smile.
The challenge with these cases is to create natural shape and contour that is brighter in value than
natural teeth, yet has the same optical properties, incisal translucency, and polychromacity as teeth in
the natural range of color. The ceramic restorations were fabricated from Venus Porcelain (Heraeus)
(Figures 12 & 13). The manufacturer reports that the patented synthetic quartz from which Venus Porcelain
is made creates dental restorations with the natural elegance of natural tooth structure.
The patient was scheduled for delivery of her restorations approximately four weeks after the preparation
appointment. Upon removal of the provisional restorations, the soft tissue environment was “less
than ideal” for bonding restorations. Generalized sulcular reddening of the epithelium was noted with
some tissue migration over marginal areas (Figure 14). Creating a suitable environment for bonding was
simply accomplished through the use of Expasyl (Kerr Corporation). Expasyl was syringed around each
preparation and gently packed apically with a moist cotton pledget (Figure 15). It was allowed to sit for
two minutes, and then rinsed away with an airwater spray (Figure 16). The combination of sulcular drying,
hemostasis, and tissue deflection now created a perfect environment to bond ceramics without the
risk of fluid contamination. The maxillary ceramic restorations were tried in individually for marginal
evaluation, then collectively for fit and contact verification. Next, they were all luted using a clear, dual
cured resin cement (NX3: Kerr Corporation).
The same regimen was performed for the mandibular restorations as well. After cementation centric
occlusion was adjusted, as needed, using articulation paper (Accufilm 2: Parkell) to identify occlusal
contacts. Next, lateral and protrusive excursions were checked and adjusted. All adjusted areas were
then polished using porcelain polishing points (Brasseler USA). The patient was restored with anterior
guidance and canine disclusion (Figures 17-21).
Some dentists still believe that it is a ‘violation of the
Hippocratic Oath’ to disturb ‘healthy’ tooth structure, even
if the patient is unhappy with their esthetics, and that we
should ‘talk them out of elective treatment’. ”
Elective Cosmetic Dental Treatment19
Figure 15: Expasyl (Kerr Corporation) is placed around
each preparation and is allowed to sit undisturbed for
Figure 16: After rinsing away the Expasyl with air-water
spray, notice the tissues have been deflated away from
the margins. Also, the hemostatic agent in Expasyl dries
up all sulcular fluids and creates a good environment for
bonding of the ceramic restorations.
Figure 17: The maxillary anterior ceramic restorations are
shown from the facial aspect three days after placement.
Although the patient requested “Hollywood white” restorations,
the natural tooth anatomy, cervicoincisal polychromatic
effect and incisal translucency create a bright,
but natural appearance.
Figure 18: This is a view of the mandibular incisor region
from the facial aspect. Note the natural mammelon development
and translucency created in only 0.5 millimeters
of ceramic materials. A high value restoration has been
created for the patient with little use of white modifiers,
which can create a “dead, opaque” appearance.
Conservative elective cosmetic dentistry and the right of the dental patient to seek and receive treatment
The case that has been presented is clearly one that has made a major life altering change for the patient.
The positive psychological ramifications of her new smile will be enjoyed for many years to come.
We all have the same potential to profoundly impact our patient’s lives by improving self-image and
self-esteem through the delivery of cosmetic dental procedures.
There are some in our profession, however, that view elective cosmetic dental procedures as “unethical”
and “unnecessary.” Who really should decide when such treatment is justified? How wide must the diastema
be, or how unesthetic the smile? In this modern era of dentistry, we now have the responsibility
to not only diagnose and treat dental disease, but to offer solutions for cosmetic dental problems as
well. Remember, it’s only a “good tooth” if the patient is happy. As a profession we must remember, we
treat not only teeth, but also the person to which they belong (Figures 22 & 23).
Figure 19: A full arch retracted view is shown at three days.
Figure 20: A maxillary arch view of the completed restoration from
the incisal/occlusal aspect. Note how the restorations on the premolar
teeth wrap around to the linguoproximal line angles to avoid
legding and the creation of poor interproximal contours.
Figure 21: A view of the completed mandibular arch from the incisal/occlusal
aspect. The premolar preparations incorporate the
“Lebda modification” to the facial veneer allowing for interproximal
decay removal without preparing the occlusal surface in the functional
centric contact areas.
Figure 22: A full smile three-day post delivery view is shown in this
photo. Refer to the preoperative smile in Figure 2 to see what a dramatic
morphogenesis this patient has gone through...from having
the smile of a child to that of a young lady in two visits via elective
dental esthetic reconstruction.
To contact Dr. Robert Lowe, call 704-364-4711, e-mail firstname.lastname@example.org, or
Figure 23: A three-day full-face postoperative photograph is shown
in this figure. Compare to Figure 1 and ask yourself if this elective
treatment was worth the risk for the patient. You know what her
answer would be.
1. Shavell HM, Lecture For Honors Day At Loyola University School Of Dentistry,
April, 1980. Nash RW, “Subtle Changes, Brighter Smiles With Porcelain Veneers”,
Compendium, 1994, 15(1): pp. 8-12.
2. Lowe RA, “The Contact Lens Inlay/Onlay Veneer: A Combination Of Structural
Strength And Esthetic Beauty”, Contemporary Esthetics And Restorative Practice,
Volume 5, Number 7, July 2001, pp. 50-55.
3. Lowe RA, “Tips For Successful Provisional Restorations -- Every Time For Every
Case”, Dental Products Reports, October 2002, pp. 68-72.
4. Lowe RA, “Matching Existing Natural Teeth With Ease And Predictability In The
Esthetic Zone”, Contemporary Esthetics And Restorative Practice, Vol. 6, No.
12, December 2003, pp. 54-59.
Reprinted with permission of Oral Health Journal (July 2008). Copyright ©2009
Oral Health Journal.
Elective Cosmetic Dental Treatment21
Simple Bailout for
Complex Periodontal Dilemmas
– ARTICLE and PHOTOS by Bill Strupp, DDS
Simple Bailout for Complex Periodontal Dilemmas23
Restorative dentistry, in particular full crown restorations,
often causes complex periodontal problems
for patients. Many restorative dentists select full
crowns to restore teeth that have lost significant tooth
structure caused by decay, fracture or resulting from previously
placed restorations that were large. Frequently,
full coverage restorations are the only way to manage
cases like these; unfortunately, they can trigger issues
that ultimately compromise the patient’s health. With
the ever-increasing body of scientific evidence correlating
periodontal infection to systemic disease, any treatment
protocol that promulgates infection should be avoided,
I prefer to use partial coverage restorations to restore teeth
because they enable the preservation of biology, which is
foremost in my mind as a preventive restorative dentist.
Unfortunately, many teeth just need full crowns and there
is no other option. Problems are created, however, with
full crowns when the margins of the crown extend into
the sulcus, which is somewhat of a paradox, because full
coverage is often mandated by pathology that extends
subgingivally. However, hundreds of published scientific
reports overwhelmingly conclude that subgingival margin
placement creates periodontal infection. One does not
need a lot of science to document these issues, as they are
readily evident upon mere clinical observation of almost
every crown with subgingival margins. Gingival bleeding
occurs easily upon probing or vigorous toothbrushing
around such restorations, thus providing a portal of entry
into the patient’s vascular system for the inflammatory
byproducts of infection that may prove fatal. A small percentage
of patients are immune to iatrogenic periodontal
infection, however, it is difficult to determine in advance
if the patient is susceptible to this undesirable side effect
of our treatment or not. Therefore, it is prudent to avoid
subgingival margins in crown and bridge dentistry whenever
Figure 1: The clinical appearance of the case before treatment.
Figure 2: Core buildups and surgical provisionals are required for the
Figure 3: Pulps protected by caries removal, core buildups, sealed dentin,
polycarboxylate cement and well fitting provisionals often heal within
two weeks. Likewise, soft tissue responds nicely to the absence of microbes
and their toxins.
Figure 4: Probings are often meaningless in determining the biologic issues
that exist around crowns in violation of the biologic width because
many of these restorations exhibit minimal probing depth.
Replacing old dentistry that has severely compromised
periodontal and pulp health presents one of the greatest
challenges in restorative dentistry. Certainly, the option of
removing the teeth and placing implants is often the easy
way out from a treatment perspective on many of these
cases. However, many patients simply do not want to lose
their teeth. The case presented here represents one such
case that my periodontist, Dr. Dan Melker, and I treated a
number of years ago.
Rita (Name changed to preserve the patient’s privacy)
presented to my office with three full porcelain to metal
crowns on the mandibular right quadrant, #29, 30 and
31. Significant bleeding occurred upon probing or vigorous
toothbrushing. The teeth had been treated historically
with full crowns and shortly thereafter the molars had
been treated endodontically. The soft tissue around the
crowns was swollen, red, sensitive when probed, and glistened
without stippling. The crown margins were open,
rough and subgingivally placed. Porcelain was worn and
fractured on the molars. Caries was obvious to the touch
with an explorer. The occlusal size of the teeth buccolingually
was enlarged. Lateral occlusal interferences existed
in both working and balancing excursions. Horizontal
bone loss in the furcations was significant, especially
on #30. The patient reported discomfort when chewing
on these teeth. The cosmetics of the case was fair
to poor. The patient was unable to clean plaque from
My diagnosis of the case was carious and periodontal infection
as well as occlusal trauma. The prognosis of the
case was good with proper perio-restorative treatment by
me and Dr. Melker, combined with the education of the
patient about preventive practices. I determined the etiology
of the pathology to be iatrogenic crown and bridge
dentistry, as well as possible cement sepsis.
Figure 5: Pink tissue is often meaningless in diagnosing biologic issues
because inflammation of the inner lining of the pocket triggers the immune
response which will further periodontal destruction. Bone loss in
furcations frequently occurs after iatrogenic restorative dentistry.
Figure 6: After making a split thickness flap it is obvious that horizontal
bone loss in the furcation extends two millimeters. The margin placed in
the furcation fostered “protected” microbial growth, which caused the
severe pathology in this case.
Figure 7: Biologic Shaping, the approach Dr. Melker uses to surgically
resolve such complex periodontal conditions, can create an environment
where the microbes, which are the etiology of periodontal disease,
can be easily removed. The tooth surface has been reshaped 360° all
the way to the osseous crest.
Figure 8: Three millimeters is classically the dimension of the biologic
width. In this case, removing three millimeters of bone away from the
margin would open up the furcation so much that the tooth would require
Simple Bailout for Complex Periodontal Dilemmas25
“I prefer to use partial coverage
restorations to restore teeth because they
enable the preservation of biology, which is foremost
in my mind as a preventive restorative dentist.”
Figure 9: Biologic shaping can eliminate many zones where plaque can
accumulate such as: horizontal components of furcations, proximal concavities,
adherent calculus, root surface irregularities, CEJs, anatomical
defects and enamel.
Figure 10: The most critical element that Biologic Shaping removes is
the margin of the old restoration which was placed significantly deep
into the biologic width. When the old margin is removed a new margin
can be placed which is coronal to the old one and, therefore, out of the
biologic width. This aspect is the single greatest advantage over conventional
surgery. It is not necessary to remove bone. All that is required
for the final margin is a ferrule of 0.1 mm apical to the core buildup,
which frequently is 1.0-3.0 mm coronal to the old margin.
Figure 11: Biologic shaping is done by using progressively smoother flat
ended diamonds 360° around the tooth from the osseous crest to the
occlusal surface of the prepared tooth.
Figure 12: Finer grit diamonds leave an ultrasmooth surface on the root
to which new gingival fibers will attach.
When establishing a treatment plan (in this case, new
crowns after appropriate periodontal surgery) it is imperative
to establish the etiology of the pathology to assure
that the outcome of proposed treatment would be different
than the outcome of the previous treatment. Often, a
bit of forensics is required to glimpse into the reason for
clinical failures such as Rita’s case.
From the patient’s history, we learned her crowns were
five years old and were placed to address large fillings
and fractures of the teeth. It was easy to ascertain how the
current failure occurred after the old restorations were
removed. Gross microleakage caused significant decay,
cement dissolution, pulp pathology and tissue infection.
The suspected cause was cement sepsis, a clinical scenario
that plays out under all too many restorations with
subgingival margins. Frequently, such clinical management
results in missed impressions, poor marginal adaptation
of provisionals and inflamed tissue at cementation.
Cement contamination occurs when restorations are cemented
into a pool of blood. The result is cement sepsis; a
process where the compromised cement allows microbial
growth in the cement zone under the restoration causing
carious and periodontal pathology.
Caries result from acids produced under the crown by
microbial growth. Likewise, periodontal infection results
from the microbial growth under the crown that cannot
be controlled by preventive measures. Pulp pathology often
is immediate, as was the case with Rita. She advised
us that she had experienced extreme sensitivity after
the preparation of her previous crowns and suffered a
bad taste around the temporaries. This lead me to believe
that the pulp was insulted both during the provisional
phase and later when the crowns were cemented into the
pool of blood that accompanies provisionals that do not
Figure 13: When initial reshaping is finished osseous contouring is
done. The periosteum must be peeled back for access to the bone. A
bony parabolic architecture is necessary for success, because tissue
contours will always be parabolic and the bone must match that or a
pocket will be created.
Figure 14: When Biologic Shaping is completed the fine diamonds used
leave a “polished’ surface. The smoothness of the root will minimize
plaque accumulation around the final restoration. Final tooth contours
have been created to facilitate final restoration contours to allow easy
Figure 15: A subepithelial connective tissue graft was placed. The quantity
and quality of connective tissue that exists after surgery is the prime
determinant in the longevity of cases treated with this protocol termed
“Biologic Cosmetic Perio-Restorative Dentistry.”
Figure 16: The flap is closed by suturing to periosteum. Precise tissue
positioning can be achieved this way. The only reason the area of periosteum
was peeled back was to allow for osseous contouring.
Simple Bailout for Complex Periodontal Dilemmas27
Dr. Melker and I use an exacting protocol for approaching
these kinds of cases. It requires a team approach with
everyone paying attention to the smallest of details. Our
objectives are to create an environment that facilitates the
control and prevention of microbial infection so the restorative
dentistry is easier, more predictable and profitable.
It makes no sense to avoid sending a patient to the
periodontist when it makes the case easier, more predictable
and more profitable.
Provisionals are required, then removed at the time of
surgery to allow vertical access to the prepared tooth. The
old restorations and caries are removed and core buildups
are done so the extent of compromised tooth structure
in an apical direction can be assessed relative to the
Rita’s crowns were removed along with the gross caries,
stain and old filling material. Core buildups were done
using a specific bonding protocol for self-cure resin composite.
The provisionals were cemented with polycarboxylate
cement, which is antimicrobial and sticks to the
teeth when the provisionals are removed. The teeth were
sealed with SuperSeal before cementation to protect the
pulp in #29. Because the cement sticks to the tooth, when
microleakage occurs under the provisionals, microbial
growth is restricted between the cement and the intaglio
of the provisional, thus denying microbes access to dentinal
Surgical provisionals are easily removed, using mosquito
hemostats in a gently rocking motion several times from
the incisal/occlusal. Aggressive forces should be avoided
to prevent tooth fracture. Surgical provisionals must be
made of methylmethacrylate, not bis-acryl, because the
provisional must be able to flex for its removal. Bis-acryl
does not flex, it fractures and is, therefore, unacceptable
as a surgical provisional material.
Figure 17: Occlusal view of Biologic Shaping after grafting and flap closure.
The buccolingual dimension of the tooth has been dramatically
reduced, which will translate into less occlusal force after definitive restorative.
Figure 18: SuperSeal is used to seal the dentinal tubules of all vital
Figure 19: The periodontist must recontour the provisional, shorten the
margins, barrel in the furcal contours and cement it with polycarboxylate
to protect dentin that was cut. The cement must be removed before it is
set to keep it out of the wound and the sutures.
Figure 20: The provisional immediately after surgery. The wound must
be allowed to heal without interference from the provisional or cement.
Surgical provisionals and core buildups are done two
weeks before periodontal surgery. This two-week period
gives the soft tissue an opportunity to heal and to recover
from the microbial insult of the microleaking crown
and operative damage associated with caries removal and
core buildups. It also allows vital pulps to settle down.
Many times what seems to be an irreversible pulpitis goes
away when the etiology is removed. Sensitivity to hot,
cold and biting pressure often occurs in teeth exposed
to microbial assault from microleaking crowns. In many
cases, two weeks of protection from microbes is often all
that is required for pulps to become healthy again.
The primary objective of Biologic Shaping is to remove
the anatomical zones where plaque accumulates and cannot
be removed by simple brushing and flossing. In doing
so, the patient can practice appropriate preventive procedures
which can allow the teeth to survive. Without the
ability to totally remove plaque from the restorations the
case is destined to failure in 90% of patients.
Reshaping the tooth first minimizes the amount of bone
removal required. Conventional surgery relies on the position
of the old margin as a guideline for osseous contouring
requiring 3.0 mm from osseous crest to old margin.
Biologic shaping removes the old margin and the only
osseous removal necessary is for creation of the requisite
parabolic architecture and providing a distance of 3.0 mm
from the core buildup/sound tooth interface to the osseous
Excessive bone removal causes mobility and migration. It
can also open up a furcation to the point of making the
tooth hopeless. The objective of periodontal therapy is to
stop bone loss. If periodontal therapy requires bone loss
it is counterproductive therapy.
Vital teeth must be sealed because plaque acids will dis-
Figure 21: Enough healing has occurred at four weeks to allow simple
remake of the provisionals.
Figure 22: After four months the tissue has healed completely. There
is no place for plaque to hide where it cannot be easily removed with
routine preventive procedures.
Figure 23: The margin of the bicuspid that was buried to the bone no
longer exists. A new margin can now be created at the tissue level that
is significantly coronal to the old margin.
Figure 24: The final impression is easy to make, because the margins
are all placed at or above the tissue level.
Simple Bailout for Complex Periodontal Dilemmas29
solve the smear layer created by reshaping within 5 days,
opening tubules for ingress of microbes that cause pulp
pathology and patient discomfort.
The provisionals must be remade at four weeks using an
indirect technique to avoid resin contact with immature
tissue. The margins of the remade provisionals must be
left 1.0-2.0 mm supragingivally so that biologic healing
can take place without interference.
Post-operative sensitivity is a function of microbial invasion
into the tubules. SuperSeal, polycarboxylate cement,
fluoride varnish and PERFECT PLAQUE CONTROL will
The tissue must heal for four months from the time of
surgery before final preparations can be made. The final
restorative margins must be placed at or above the tissue
level or the iatrogenic process that destroyed the biology
of the previous case will be repeated.
The protocol demands that the restorative dentist NOT
disturb the connective tissue protecting the teeth. Preparation
and impression technique must be NONINVASIVE.
There is no room or no need for two retraction cords.
There is no need to cut the tissue either with electrosurge
or a laser. It is almost impossible to miss the impression
when tissue is healthy and it is left alone.
These contours must follow the barreled in furcations all
the way up to the occlusal surface to allow toothbrush
bristles access to remove the plaque. Dental floss will disturb
all plaque colonies interproximally without a great
deal of effort. The gingival embrasure spaces should be
left as open as possible to provide room for interproximal
Minimized buccolingual dimension, barreled in furcation
Figure 25: The contours of the final restorations allow the patient to
perform perfect plaque control.
Figure 26a: The buccolingual dimension of the original crowns was excessive.
Figure 26b: Forces generated from function and parafunction will be
much less with the smaller size of the new restorations.
Figure 27: The final restorations do not have a height of contour, especially
in the furcal areas. It is imperative the laboratory understand this
“Replacing old dentistry that has severely
compromised periodontal and pulp health presents
one of the greatest challenges in restorative dentistry.
Certainly, the option of removing the teeth and
placing implants is often the easy way out from a
treatment perspective on many of these cases.”
Figure 28: This is a different case with the same issues periodontally
that have compromised the patient’s health.
Figure 29: After Biologic Shaping has been done by Dr. Melker.
Figure 30: The quality of tissue health at impression time dictates long
term success. Margin design was thin chamfers for refractory porcelain
Figure 31: The final restorations have margins at or above the tissue
level that will not negatively affect tissue health.
Simple Bailout for Complex Periodontal Dilemmas31
contours, sharp occlusal contacts and diligent plaque removal will result in long term success. This statement is based
on my clinical experience for over 30 years with this perio-restorative protocol.
In summary, the natural dentition is subject to disease processes that compromise the longevity of that dentition as
well as the systemic health of the individual. Restorative dentistry is mandatory to replace missing and diseased tooth
structure, but the health of the investing tissues after the treatment should not be compromised by such treatment. Iatrogenic
dentistry is a disservice to the patient, potentially life-threatening and represents avenues for litigation that could
prove costly to the dentist. Perio-restorative protocols that offer predictability with respect to tissue health exist and
have been used successfully for over 30 years. These protocols are simple, easy to accomplish and provide enhanced
resistance to naturally occurring disease processes. All patients should be informed of the potential health complications
associated with the placement of subgingival margins. Restorative dentistry should use the measures available to
preserve and respect biology.
Dr. Bill Strupp is a full-time practicing clinician and an international speaker acclaimed for his practical, predictable results in crown and
bridge dentistry. He is a member of many prestigious organizations including the Academy of Operative Dentistry, the American Academy
of Fixed Prosthodontics, the American Prosthodontics Society, and the American Equilibration Society, as well as many others.
He is an Accredited Fellow and Founding Speaker of the American Academy of Cosmetic Dentistry. He was President and Founding
Speaker of the Florida Academy of Cosmetic Dentistry. He publishes “Crown and Bridge UPDATE Interactive”, a clinical newsletter
dedicated to excellence in restorative dentistry. He can be reached at www.strupp.com or 800-235-2515.
Title: Simplifying Complex Cosmetic & Restorative Dentistry
Date: June 12-13, 2009
Location: New York, NY USA
Title: Simplifying Complex Cosmetic & Restorative Dentistry
Date: July 17-18, 2009
Location: Chicago, IL USA
Title: Simplifying Complex Cosmetic & Restorative Dentistry
Date: January 29-30, 2010
Location: Clearwater, FL USA
Title: Simplifying Complex Cosmetic & Restorative Dentistry
Date: June 25-26, 2010
Location: Santa Barbara, CA USA
I have been looking forward to this interview with Dr. Brock Rondeau
for about three months now, since that was about the time I saw my
first advertisement for Pure Sleep on television. Since then, it seems
like I see the Pure Sleep commercial at least two or three times per
day. I think it’s pretty clear that they are selling many of these appliances
just from the frequency of the commercials. Pure Sleep is a
boil and bite snoring device that the patients use without the input of
a dentist or the custom fit of a lab-prescribed appliance. If you’ve always
wondered about patients’ interest in snoring appliances, let Pure
Sleep’s success be your answer. Read on to see how Brock wants you
to incorporate snoring and sleep apnea treatment into your practice.
with Dr.Brock Rondeau
– INTERVIEW of Brock Rondeau, DDS, IBO, DABCP
by Michael DiTolla, DDS, FAGD
– CLINICAL PHOTOS provided by Sleep Group Solutions
– PHOTOS by Sharon Dowd
Interview with Dr. Brock Rondeau35
Michael DiTolla: Brock, it is nice to have you here again today. The last time we
spoke, we had the opportunity to talk about two-phase orthodontics. Today, we’re
going to talk about snoring and sleep apnea, so as we get started on this, why don’t
you tell me a little bit about how you got involved with snoring and sleep apnea?
Brock Rondeau: Well, Mike, years ago I would take some small courses on
snoring and unfortunately with the courses I took, dentists were just learning
to make snoring appliances. The courses were mostly from dentists who
actually invented those snoring appliances and named them after themselves.
So I would take a course from one dentist and learn about his appliance, and
I would take a course from another dentist and learn about his appliance,
and then I would try the various appliances. I have also used the Silent Nite
appliance, which is one of the most popular appliances made by Glidewell.
I like it very much as it's a very simple appliance and very comfortable for
MD: So, in the beginning, it wasn’t really a unified field per se, and a dentist would
come up with an appliance and the only way to tell a dentist about it was to teach
your course. So it was not like you could go take a comprehensive class; every class
that you took was centered around one appliance?
BR: Yes. When I joined the American Academy of Dental Sleep Medicine, they
also talked about sleep apnea and snoring synonymously, and how sleep apnea
is a medical disorder. And since we really need to treat the snoring as well
as the apnea, a medical doctor, and not a dentist, must make the diagnosis.
The oral appliance is the number one treatment, the key to treating all mild
and moderate cases.
Today, we do sleep studies in our office that determine whether or not the
patient has mild, moderate, or severe problems. If the patient has a mild or
moderate problem, we make the oral appliance and confirm the results with
another sleep study to make sure the oral appliance has stopped the snoring
as well as the sleep apnea. So now we’re treating the whole patient and I think
if the profession embraces this philosophy, then oral appliances would be better
accepted by the medical community.
There are really only three ways to treat sleep apnea: CPAP, oral appliances
and surgery. CPAP—which is that device that goes over the nose with an
air compressor that blows air up your nose all night, works very well
for obese patients; they swear by it, their life improves so dramatically
that they can’t live without it. It does prolong their life and I heartily
recommend CPAP for any severe case. On the other hand, if
a patient is just snoring and doesn’t have sleep apnea, or if the
patient can’t wear the CPAP device, or for the mild to moderate
cases, the oral appliance is the number one option. The
thing that turned it around for me is when I read in the
January 2006 issue of the medical journal, Sleep from the
American Academy of Sleep Medicine, in which they
stated that for mild to moderate obstructive sleep
apnea, the oral appliance is the first treatment option.
MD: That must have been a big change for them.
We might like to think that medicine doesn’t
have any politics in it or doesn’t have any
factions, but you can imagine medical doctors and their associations looking for
medical cures for this medical condition. Was it somewhat controversial when they
came out with a dental recommendation for this medical condition?
BR: That’s right. It was actually Dr. Rob Vies who first enlightened me several
years ago when he stressed the fact that if you treat snoring, you must also
treat sleep apnea. I think it was a bit controversial and I think a lot of sleep
specialists still don’t go along with it because I’m getting more patients coming
to me that can’t wear their CPAP device. And that’s probably the number one
way patients find me. I have a radio ad and I put the word out that if you’ve
been diagnosed with sleep apnea or you snore, and you’ve been given a CPAP
device and you cannot wear it, then give me a call and we’ll see whether or not
an oral appliance is the answer for you. So, we get at least three new patients
a week coming in seeking alternative treatment.
MD: If 100 average people are given a CPAP, what percent would you say do fine
with it, what percent are so-so, and what percent are unable to wear the CPAP?
BR: I think you have to break it down to mild, moderate, severe. And I think
that’s where I’m having the problem, when they give the CPAP machine to
the mild and moderate patients. Those patients really don’t take to it too well.
First of all, their problem is not so serious that they are having severe daytime
sleepiness and symptoms, and they find it cumbersome. So I think if you look
at the severe cases, they are really in bad shape, really overweight and so
tired that they can’t function normally. Daytime sleepiness is the number one
symptom of obstructive sleep apnea; this constant daytime sleepiness, waking
up unrefreshed and being tired all the time makes the patient susceptible
to falling asleep when driving. Many car accidents, even the Exxon Valdez accident
and the Chernobyl accident, were due to excessive daytime sleepiness because
of sleep apnea. Frequently, you pick up the paper and there are reports
that some highway truck driver has fallen asleep and caused an accident. It’s
a very serious problem. In fact, they’re saying obstructive sleep apnea causes
more accidents than alcohol related incidents. It’s a big deal. So the patients
with severe sleep apnea adapt very well to the CPAP.
MD: Because it’s kind of like a matter of life and death for them almost, literally,
to wear this unit.
BR: Yes, and to be honest, the oral appliance is not as effective at preventing
obstructive sleep apnea if the truck driver has an extremely large neck, is
grossly overweight, or has a severely retrognathic lower jaw. The oral appliance
is not as effective in the severe sleep apnea cases, so I really think we
have to work with the medical profession and say, “Look, you take the severe
ones, give us the ones that are mild to moderate or just snoring, and let us
treat those.” But I’m finding that even some patients who go to the hospital
for a sleep test, if they come out and they’re snoring, the doctors don’t even
treat them. They just tell these patients that they have to lose weight. They are
ideal candidates for oral appliances and dentists should identify these patients
in their practice who need and want oral appliance therapy. Failure to treat
patients who snore is also unacceptable to spouses who do not enjoy being
kept awake all night with loud snoring as well as apneic events.
The thing that turned it around
for me is when I read in the
January 2006 issue of the
medical journal, Sleep from the
American Academy of Sleep
Medicine, in which they stated
that for mild to moderate obstructive
sleep apnea, the oral
appliance is the first treatment
MD: The CPAP machine is undoubtedly the most effective way to treat sleep apnea,
but it also has the highest amount of side effects and objections?
Interview with Dr. Brock Rondeau37
BR: Yes, and to finally answer your question, for the mild to moderate cases
who are given CPAP, I’m finding a tremendous failure rate–I’m thinking that it
could be as high as 70 percent, and that’s where I’m getting a lot of patients.
Now, the other interesting thing is that Medicare has just been looking into
this and they’re going to start paying for the treatment of patients with obstructive
sleep apnea. Medicare wants to prove compliance because they don’t
want to pay anybody to have these machines sit in their closet, they want the
patient to wear them. So there’s actually a new CPAP device where you attach
it to a dedicated telephone line just like a fax machine, and they’ll read directly
from that CPAP device and it’ll tell you exactly how many hours per night the
patient has been wearing it or if they haven’t been wearing it at all. If the patient
is not wearing the machine, then the CPAP company is not going to get
paid from Medicare.
Daytime sleepiness is the
number one symptom of obstructive
sleep apnea; this
constant daytime sleepiness,
waking up unrefreshed and
being tired all the time makes
the patient susceptible to falling
asleep when driving. Many
car accidents, even the Exxon
Valdez accident and the Chernobyl
accident were due to
excessive daytime sleepiness
because of sleep apnea.
I think this is an ideal opportunity for the dental profession to get involved
and help these patients. It is important for dentists who are interested in
oral appliance therapy to approach the medical profession and especially the
pulmonologists in the sleep centers and hospitals, to refer the patients who
cannot tolerate their CPAP devices to dentists who are knowledgeable in fabricating
oral appliances. I have done that in my city and now have medical
doctors and sleep specialists referring me patients. The system is not presently
working for patients with sleep apnea. Once the diagnosis is made, the patients
are referred to a company that sells them the CPAP device. If they cannot
tolerate this device then no further treatment is offered to the majority of these
patients. Most patients who come to my office state that neither their medical
doctor, the sleep specialist, nor the company that sells the CPAP machine ever
mentioned to them that oral appliance therapy is a viable alternative to their
treatment. I think there is something wrong with the system because I believe
these patients’ treatment should be more closely monitored. By not treating
these patients they are subject to cardiovascular complications, Type 2 Diabetes
and GERD (Gastroesophageal Reflux Disease).
MD: I sleep on my stomach for example, so I don’t think I could ever wear a CPAP
unit. Sometimes, I even have a hard time falling asleep with my night guard in my
mouth, let alone putting something like a CPAP on. There has to be some realization
that CPAP is a great way to go, but there are a large percentage of people who
can’t wear it. So your radio advertisements, what do they actually say?
BR: It’s a 30 second ad that says, “If you snore, or if you have sleep apnea and
you can’t wear your CPAP device overnight, give me a call because oral appliances
are often very effective at treating that condition.” It gives my phone
number and the phone starts ringing. It’s interesting when the husbands come
in and I ask them who referred them. Often they say that their wives forced
them to come in. And then it’s really interesting when you send them for a
sleep study, and they come back and you go over the sleep study and you say,
“Well, you realize you’ve got a pretty severe condition here.” I ask them for
their family history of heart attack, strokes, or diabetes and frequently they’ll
say that their father had diabetes, heart disease, or a heart attack. I tell them
that’s the road they’re heading down unless we do something to intercede.
The cardiologists are starting to get on board now and they’re writing articles
about the relationships between sleep apnea, heart attacks, stroke, and cardiac
arrhythmias. And the thing I found interesting at the sleep meeting was that
many professionals believed that plaque builds up in the arteries mainly due
to cholesterol and saturated fats in the diet. Well, it turns out that it’s the lack
of oxygen that stimulates the saturated fats to go into the vessels. So, really, the cause of a lot of
these problems is not just the diet but it’s the sleep apnea and lack of oxygen, and having all these
apneic events during the night. When you understand that, you can see why perhaps Medicare is
getting involved with sleep apnea: it’s a lot cheaper treating the sleep apnea rather than treating
people for heart attacks and strokes.
MD: Let’s say somebody hears your advertisement, a patient who has tried to wear a CPAP and just could
not do it. Walk me through how you are going to treat that patient.
BR: Well, I think the key to every success is diagnosis, and I have a couple of devices in my office,
which are unique to a sleep practice. One device is called a rhinometer, which evaluates any
obstruction in the nose, and so we just put it up to one nostril and the patient doesn’t breathe and
the sound waves go up the nose and any obstructions are recorded on the computer screen. I had
a patient the other day who broke his nose and of course he’s got a blockage, but it’s not too far
back in the turbinate area so it should be relatively easy to rectify the problem. The rhinometer
tells us that if there’s any blockage due to enlarged turbinates, deviated septum, polyps, or any
allergies which cause swollen nasal mucosa. Now, the key is that if there is any blockage in the
nose and if you see the patient mouth-breathing, then I think you should send the patient to an
ENT specialist. Once the nasal airway is clear, then you’ve got a much better chance of the oral
The second device is called the pharyngometer. We have the patient blow all the air out of their
lungs, and then we measure to determine the size of the airway. We get a measurement, and then
we put some wax between the back teeth and move the jaw to a position similar to a construction
bite. For example, we might open the vertical in the anterior 5 mm and move the jaw forward 4
mm. We use the pharyngometer again to see if the airway measurement increases, sometimes it
is 50 or 100 percent increase. When the airway significantly increases when the mandible is held
forward, we are confident that the oral appliance will be effective. The oral appliance effectively
protects the airway at night, even when the patient is lying on their back, by moving the mandible
and the tongue forward.
MD: I think the idea of sending patients out for sleep studies seems confusing to dentists. You mentioned
that you often have the patients do them at home with a take-home unit provided by your office?
BR: That’s right. I’m using a device called Embletta now which is more recognized by the medical
profession because it has a nasal cannula. The device I was using before wasn’t as recognized by
the medical profession so I’m sticking to devices that the physicians recommend. I just met someone
today who told me that many sleep specialists have adapted these overnight sleep studies—
home sleep studies—in their sleep centers because some patients come in and they say, “I don’t
want to sleep in a strange bed all night, I don’t want all of those things hooked up to me, I can’t
do it, I’m claustrophobic,” so they give them the home sleep study. In Europe, most of the studies
are home sleep studies because the Europeans have figured out that it’s a lot less expensive to do
the home studies than it is to do the hospital studies. Here in Canada, like in Vancouver, B.C., it’s a
year and a half to get a sleep study, and in Nova Scotia, it’s a six-month wait. In the U.S., you’ve got
a better system, but still, if everybody that needed it went in for a hospital sleep study, you couldn’t
possibly handle the volume. I talked to a pulmonologist in Reno, Nev. and he told me he thinks that
obstructive sleep apnea affects 15-30 percent of the adult population, even though the published
number in the literature is much lower. That is a large number of patients who need treatment,
which means this is an excellent opportunity for dentists to get involved to help these patients.
MD: For general dentists who aren’t currently making these appliances in their office and want to
get started, what’s the best way to identify which of their patients might make a good candidate for
BR: You need the Epworth Sleepiness Scale, because it basically asks patients how likely they are
Interview with Dr. Brock Rondeau39
to fall asleep during routine situations. A zero means you would never doze
off, one means a slight chance of dozing, two is a moderate chance of dozing,
three is a high chance of dozing. You will be amazed at the amount of daytime
sleepiness in your patient population. I had a dentist take my sleep course in
Toronto and he went back to his office and he gave the Epworth Sleepiness
Scale to all the patients who said they snored that came into his office during
the next three weeks. Now he’s got a big practice—in three weeks, he’s got 50
people lined up for snoring appliances! This includes the hygienists giving the
test to anyone who knows or has been told that they snore. So if dentists don’t
know whether it’s going to be worth doing in their practice, they need to have
some patients take the Epworth test and I think they might be surprised.
MD: Is that doctor now going to do home sleep studies on all those patients?
... he gave the Epworth Sleepiness
Scale to all the patients
who said they snored that
came into his office during the
next three weeks. Now he’s got
a big practice—but in three
weeks he’s got 50 people lined
up for snoring appliances!
BR: Yes. He bought the Embletta, and he’s going to do the home sleep studies
on those patients. I recommend that the home sleep study device, the
Embletta, be used as a screening device to determine the seriousness of the
problem. If the patient is severe, they should go to the hospital for an overnight
sleep study which is known as a polysomnogram. The diagnosis must be
made by a sleep specialist. If the diagnosis is mild to moderate sleep apnea,
then the dentist can proceed with the oral appliance therapy. It is important to
mention that following oral appliance therapy, patients must either repeat the
home sleep study or go to the sleep center for a polysomnogram to confirm
that the oral appliance effectively treated the sleep apnea. The Embletta home
test is very good–obviously, if the medical doctors are buying it and using it in
their sleep centers. It’s also the one that is reputed to be the number one home
sleep study used in Europe for the past eight years. It’s been well-researched
and it corresponds very accurately with the polysomnogram at the hospital.
Now, if a dentist wants to get into this and doesn’t want to buy
any equipment and says, “Look, I don’t want a rhinometer,
I don’t want a pharyngometer, I don’t want to buy an Embletta,
I don’t want to spend a nickel,” he can just hand out
the Epworth sleepiness scale to his patients. He can
just contact a sleep center and tell them “I want to send you some patients.”
Now, what sleep center would not want a dentist to send them some patients?
So all the patients who score higher than a 7 on the Epworth scale are sent
to the sleep center. If they are diagnosed with severe sleep apnea, then the
patient stays with the sleep center and gets a CPAP. I urge the dentists to have
an agreement with the pulmonologist or sleep specialist. “If the patient I sent
you is mild to moderate, send them back to me for an oral appliance, and
then I’ll send the patient back to you to see if the oral appliance is effective
in reducing the sleep apnea.” The sleep specialist is getting numerous patients
referred for sleep studies so naturally he’ll want to deal with the dentist, and
then gradually the dentist builds up a good rapport with the sleep specialist.
The objective is to get the sleep specialists sending you patients who won’t
wear CPAP. The patient must receive the most ideal treatment, CPAP for severe
sleep apnea and oral appliances for the mild to moderate sleep apnea. The
good news for the dental profession is that the majority of patients who snore
have mild to moderate cases, and are therefore ideal candidates for oral appliance
therapy. The medical and dental profession must work together in the
best interests of the patients.
MD: What would you say to our dentists about the profitability of treating sleep
patients? Can it be a profitability center in the typical general dental practice? Are
you comfortable talking about how much you would normally charge for the appliances
BR: Well, I think it’s very profitable because the records are all done by the
staff. They explain the home sleep study and show the patient how to put the
device on at night and how to record it, and when they come back the staff
puts the Embletta chip into the computer and prints the report out for me.
My staff does the initial consult and spends half to three quarters of an hour
with each new sleep patient to educate them about what’s going on. Then they
do the rhinometer test, the pharyngometer test, and give them the Epworth
Sleepiness Scale and a few other forms that we have them fill out. I review all
of this and go in to discuss the problem with the patient. I charge a total of
$3,000; some dentists charge less but I include two or three home sleep studies
for each patient with that fee. Thankfully, with the Embletta, the
disposables only cost me seven dollars. The last system I used, the
cost of each home sleep study was $85 and it wasn’t as good as the
Embletta. I’m doing two sleep studies, sometimes three, and I’ve
got the pharyngometer, rhinometer, I’m testing their nose, testing
their airway. I put the appliance in, I test the airway again to make
sure it opened up. To be honest, most of the members of the American
Academy of Dental Sleep Medicine don’t have a pharyngometer,
or rhinometer, or a home sleep study device. They send all their
patients for hospital sleep studies (polysomnograms) before
and after oral appliance therapy. Personally, I find these
three diagnostic devices extremely useful in any sleep
practice to improve my success rate.
MD: If they are interested in taking one of your
courses, where’s the best place for somebody to find
you on the Internet?
A 40 year old female patient
was snoring and depressed,
because her husband would
not sleep with her. The oral appliance
the snoring and eliminated her
depression and her husband
came back to bed. She later
said, "Thanks for giving me my
BR: www.RondeauSeminars.com. The American Academy of Dental Sleep
Medicine also has many courses, and their website is: www.aadsm.org.
Interview with Dr. Brock Rondeau41
MD: I can personally vouch for your courses, they are all extremely practical, so I personally recommend
your courses as a great jumping off point for most dentists. But you said the Academy has some as well?
BR: Yes, the Academy has them as well. You should join the Academy and get to work towards your
certification and practice within the guidelines of the Academy. But I honestly think that if dentists
really embrace this and start talking to pulmonologists or sleep center specialists in their area and
work with the medical profession, that they’re going to have a very successful practice, and it’s going
to impact the bottom line very positively. It’s a great service and it’s great knowing that you’re
helping people live longer and you’re improving their quality of life. Although snoring and sleep
apnea is more prevalent among males, I also have some female patients with these sleep disorders.
One particular female patient was excessively tired and extremely depressed because her husband
would not sleep with her due to her snoring problems. When I fabricated an oral appliance for
her, it literally changed her life. She stopped snoring, her daytime sleepiness disappeared, and she
went off her depression medication. Her husband came back to the bedroom and she felt loved
again. The first month after inserting the oral appliance she jumped out of the dental chair, gave
me a big hug and said, “Thanks for giving me my life back.” It’s nice to make money and it’s nice
to have a successful practice, but it’s extremely rewarding to do it by helping people. And your lab
does that by fabricating oral appliances for our patients. Your lab also provides education to dentists
through your Chairside Magazine and I think it’s a valuable service that you’re providing.
MD: It’s funny you mention that because I think every dentist has had some experience with a crown
and bridge case or veneer case where the patient was so happy she cried and she gave the dentist a hug.
But I’ll tell you just what I’ve seen from doing all types of dentistry, there’s a lot more hugs and a lot
more gratitude on the part of the sleep apnea patients, the patient who has felt like crud and run down
and is falling asleep during the day and worried they’re going to kill somebody else when driving. And
now, all of a sudden, they feel good again and they remember what it felt like to actually feel good on a
BR: Well, particularly if it’s 15 to 30 percent of the adult population that has the problem. I think if
you just get all of your snoring patients to fill out the Epworth Sleepiness Scale you will see this is
true. The other thing is that it’s a good idea to get his wife to fill it out too, because sometimes men
will underestimate how sleepy they are, and the wives will always score higher. At the consultation
appointment the women will frequently say to their husbands, “What do you mean you don’t
fall asleep in front of the TV? You fall asleep every night in front of the TV!” The cardiologists are
starting to get involved now, and they’re seeing a significant increase in cardiovascular diseases. It
appears there’s a definite correlation between CVD and sleep apnea, so we need to get in there and
get these people screened faster and treated faster. That’s why I think these overnight sleep studies
are going to go over well and be much more cost-effective than going for the overnight sleep study
at the hospital for mild to moderate cases.
MD: Well, you know, these sleep apnea patients are kind of the lost segment of the population that are
different from some of the high visibility diseases like hypertension, diabetes and cancer, for example.
Those get a lot of dollars and tons of ad space. Sleep apnea is relatively quiet, but unfortunately, it kills
its fair share of people, so I think you’re absolutely right: It’s a great thing for your practice but more importantly,
it’s a great thing for your patients. It’s been a pleasure Brock, thanks for your time!
To contact Dr. Brock Rondeau, call 877-372-7625, visit www.rondeauseminars.com, or e-mail email@example.com.
EPWORTH SLEEPINESS SCALE The Epworth Sleepiness
Scale (ESS) was developed and validated by Dr. Murray Johns of
Melbourne, Australia. It is a simple, self-administered questionnaire
and widely used by sleep professionals in quantifying the level of
daytime sleepiness. (Johns, M.W. “A new method for measuring daytime
sleepiness: The Epworth Sleepiness Scale.” Sleep 14 (1991): 540-545.)
How likely are you to doze off or fall asleep in the following
situations, in contrast to feeling ‘just tired’? This refers
to your usual way of life at present and in the recent past. Even if
you have not done some of these things recently, try to work out how
they would have affected you.
Choose the most appropriate number for each situation: 0=
Would never doze; 1= Slight chance of dozing; 2= Moderate
chance of dozing; 3= High chance of dozing
CHANCE OF DOZING
Sitting and reading.......................................................
to check for nasal
obstructions or other
blockages to nasal
The patient plugs his
nose to isolate airflow
to the pharynx, and
measures diameter of
the patient’s airway
with mandible in multiple
Sitting, inactive in a public place
(e.g. theater, meeting)..................................................
As a passenger in a car for an hour
without a break............................................................
Lying down to rest in the afternoon
when circumstances permit.........................................
Sitting and talking to someone....................................
Sitting quietly after lunch without alcohol....................
In a car while stopped for a
few minutes in traffic....................................................
and rhinometer are
part of the diagnostic
tools that some
sleep dentists use to
and help predict if
oral appliances will be
The Embletta is a
device that allows patients
to perform sleep
studies at home rather
than at the hospital.
Many feel that patients
get a more typical
night of sleep at home
as opposed to sleeping
in a strange bed at
Epworth Scale Values: Interpretation of the Data
0-7 It is unlikely that you are abnormally sleepy.
8-9 You have an average amount of daytime sleepiness.
10-15 You may be excessively sleepy, depending on the
situation, and may want to consider seeking medical
16-24 You are excessively sleepy and should consider
seeking medical attention.
The Embletta features
a much more comfortable
set-up than the
typical hospital sleep
study. The use of the
nasal cannula, as seen
here, has led to wider
acceptance by the
Clinical photos provided by Sleep Group Solutions, 16840 NE 19th Avenue,
North Miami Beach, FL, 33162. 866-353-3936. www.sleepgs.com.
Interview with Dr. Brock Rondeau43
– Clinical Photos by Michael DiTolla, DDS, FAGD
his patient presented with some interproxi-
mal decay and some failing composites on
teeth 7-10. The teeth were prepared according to the
Reverse Preparation Technique to ensure adequate
reduction for the laboratory. The caries was stained,
removed, and the deficient areas were built-up with
a self-etching flowable composite. Procera ® Zirconia
crowns were placed on teeth 7-10, and to finish the
smile, no-prep Vivaneers were placed on the cuspids
and bicuspids, resulting in an esthetic smile.
Photo Essay: Anterior Procera Zirconia Crowns with No-Prep Vivaneers45
Altered Passive Eruption:
– ARTICLE by Robert P. Pulliam, DMD, MS, RPh
Daniel Melker, DDS
– CLINICAL PHOTOS by Bill Strupp, DDS
The esthetic arena of dentistry has become an increasing portion of any clinician’s practice. An understanding of the
gingival complex is a vital aspect of any restorative treatment plan. Often the patient’s initial chief complaints are short
teeth or a gummy smile. In the past, these concerns were often overlooked, or the crowns were lengthened prosthodontically.
1 Patients and dentists alike are becoming aware of an increasing demand for comprehensive facial evaluations.
Currently, the gingival complex is a vital aspect of any restorative treatment plan. Clinicians now are beginning to recognize
the importance of the gingival complex in the treatment of short clinical crowns. The etiology of short clinical
crowns can usually be subdivided into two categories: coronal destruction resulting from traumatic injury, caries, or
incisal attrition, and a coronally situated gingival complex resulting from tissue hypertrophy or a phenomenon known
as altered passive eruption (APE). 1
APE, also known as delayed passive or retarded passive eruption, occurs when the marginal gingiva is malpositioned
incisally in adulthood on the anatomic crown and does not approximate the cemento-enamel junction (CEJ). 2-4 Goldman
and Cohen 5 described altered passive eruption as a condition in which the free gingival margin fails to recede during
Figure 1: Passive Eruption stages (Gottlieb and Orban)
Stage I – dentogingival junction is located on enamel.
Stage II – dentogingival junction is located on enamel, as well
Stage III – dentogingival junction is located entirely on cementum,
extending coronally to the CEJ.
Stage IV – dentogingival junction is located entirely on cementum
and the root surface is exposed, resulting in gingival
Figure 2: Four types of altered passive eruption (Coslet)
(All types present with the free gingival margin located occlusal to the CEJ)
Type 1A – wider band of dekeratinized tissue, alveolar crest
– CEJ normal (~1.5 mm)
Type 1B – wider band of dekeratinized tissue, alveolar crest
– CEJ (~0 mm)
Type 2A – normal band of dekeratinized tissue, alveolar crest
– CEJ normal (~1.5 mm)
Type 2B – normal band of dekeratinized tissue, alveolar crest
– CEJ (~0 mm)
Altered Passive Eruption: Diagnosis and Treatment49
Currently, the gingival
complex is a vital
aspect of any restorative
Clinicians now are
beginning to recognize
the importance of the
gingival complex in
the treatment of short
tooth eruption to a level apical to the cervical convexity of the clinical crown.
By contrast, passive eruption is a biologic process whereby tooth eruption occurs
normally. During this normal tooth eruption the dentogingival junction
shifts apically. 6 This process occurs when active eruption is complete and may
continue until the early or mid-20s of adulthood. 7 At this time, the free gingival
margin approximates the CEJ. Gottlieb and Orban classified passive eruption
into four stages, believing this was a continuous physiologic process of tooth
eruption (Figure 1). Although some debate currently exists when passive eruption
becomes pathologic, it is generally accepted that cementum exposure or
gingival recession (Stage 4) is a pathologic process.
APE is one of the most commonly overlooked causes of short clinical crowns.
Although literature provides limited information regarding the incidence of
APE, Volchansky and Cleaton-Jones 7 found that 12 percent of patients studied
had signs of APE. 8 Excessive gingival display has been estimated at 7 percent
of men and 14 percent of women. 2 Thus any clinician must be cognizant of the
dentogingival complex and be comfortable with the differential diagnoses of
a gummy smile when striving for long-term optimal restorative esthetics and
Gargioulo and Ainomo 9,10 described the typical dentogingival relationship with
the free gingival margin being located in close proximity to the CEJ. However,
if APE exists, the gingival complex is situated in a more coronal position, making
the CEJ difficult to detect clinically and thus displaying the pathognomonic
signs of short clinical crowns and excessive gingival display.
Figure 3A: Initial presentation: Teeth
6-11 appear short and boxy.
Coslet and others 11 classified APE into two case types, based on the gingival
and osseous relationships. Type 1 presents with a noticeably wider band of
keratinized tissue and Type 2 exhibits a smaller band of keratinized tissue falling
within normal limits (Figure 2). Types 1 and 2 each have subcategories, A
and B. In the A subgroup, the osseous crest is located 1.5 mm to 2 mm below
the CEJ 9 (normal), while in the B subgroup, the osseous crest is found directly
adjacent the CEJ.
This article presents treatment for two common types of APE found clinically.
To date, no scientific literature has investigated the incidence of Coslet’s four
classifications of APE. However, it is believed that Type 1B is more prevalent. 1
This article presents and discusses the more common case types and the treatments
employed to achieve long-term esthetic results.
– Coslet Type 1A –
A 26-year-old woman presented with a chief complaint of “short teeth” (Figure
3A). After a comprehensive clinical facial and dentogingival examination, both
centrals were found to have little or no incisal wear and were approximately
8.5 mm in length (Figure 3B). The CEJ was undetectable clinically and the patient
was diagnosed with APE.
Figure 3B: Initial presentation: Short
clinical crowns, teeth 8 & 9 measure
8.5 mm in length.
Local anesthesia (AstraZenca Pharmaceuticals LP) was used before further examination.
Periodontal probing revealed a gingival sulcus of 3 mm, while bone
sounding revealed a probing depth of 5 mm from the free gingival margin to
the osseous crest, indicating a diagnosis of APE Type 1A. To achieve an ideal
central incisor length of 10.5 mm, 12 an esthetic crown lengthening procedure
During surgery, an inverse bevel incision following the CEJ was used. An effort
was made to preserve the interproximal papillary tissues. A full-thickness flap
was subsequently reflected to the mucogingival junction (MGJ). A split-thickness
flap was employed beyond the MGJ. This technique allows for atraumatic
mucoperiosteal flap management and mobility. As anticipated, the osseous
crest levels were found to be approximately 1.5 mm to 2 mm from the CEJ (Figure
3C), confirming the diagnosis of APE Type 1A. No osseous resection was
required before flap closure. A vertical mattress technique using a 5-0 plain
gut suture (Ethicon, Inc.) was used to apically reposition the gingival tissues
(Figure 3D). After six months, gingival health was optimal and an ideal clinical
crown length of approximately 10.5 mm had been established (Figure 3E).
– Coslet Type 1B –
A 33-year-old woman presented with a chief complaint of “I don’t like how
my front teeth look” (Figure 4A). An examination was performed and the patient
was found to have excessive gingival display and short clinical crowns
with a boxy appearance. Both central incisors measured approximately 8.5
mm in length (Figure 4B). Periodontal probing revealed a gingival sulcus of 1
mm, while bone sounding revealed a probing depth of 3 mm from the free
gingival margin to the osseous crest, indicating a diagnosis of APE Type 1B.
An esthetic crown lengthening procedure was indicated using ostectomy and
apically repositioned flap.
During surgery, an inverse bevel incision following the CEJ was used to establish
ideal gingival symmetry. Subsequently a full-thickness flap was reflected
to the MGJ, while a split-thickness flap was employed beyond the MGJ. Osseous
crest levels were found directly adjacent the CEJ (Figure 4C). Defective
composite restorations were present on teeth 8 and 9. Approximately 1.5 mm
to 2 mm of ostectomy/osteoplasty was carefully performed using rotary instruments
to establish a normal osseous crest to CEJ relationship (Figures 4D & 4E).
A vertical mattress suturing technique with 5-0 plain gut sutures was used for
flap adaptation (Figure 4F). The incisors were restored with feldspathic porcelain
laminate veneers. At one year, gingival tissues were healthy and an ideal
clinical crown length for the central incisors was achieved at approximately
10.5 mm (Figure 4G).
Figure 3C: After mucoperiosteal flap
reflection, the osseous crest is 1.5–2
mm below the CEJ. Diagnosis: Coslet’s
type 1A, ostectomy is contraindicated.
Figure 3D: Apically repositioned flap
This article presents the diagnosis and treatment of the more commonly encountered
examples of APE, Types 1A and 1B. The diagnosis and treatment
of APE has begun to receive the necessary attention in the dental literature. 1,8
However, APE has been referred to as the “undiagnosed entity,” 4 and still remains
an esoteric underdiagnosed condition. In addition to limited recognition,
APE may also present perio-restorative challenges. APE presents with
a coronally positioned dentogingival complex. If crown lengthening is not
performed before restorative therapy, subgingival margins may often lead to
greater plaque accumulation, gingival inflammation, and subsequent periodontal
breakdown. 2,13 Optimal restorative margin placement presents a functional
and esthetic challenge for any dentist.
In the past, clinicians have treated APE through conventional gingivectomy
procedures; recently, laser therapy 14,15 has become a popular modality. Although
these procedures have distinct indications, 16 the more common APE
examples (Type 1B) will require some ostectomy to provide a stable gingival
complex and prevent gingival rebound to the preoperative levels. Employing
gingival recontouring procedures as the only method of clinical crown
lengthening is the result of not fully understanding the dimensions of biologic
Figure 3E: One-year follow-up. Teeth
8 & 9 have an ideal clinical crown
length of 10.5 mm & 11 mm, revealing
the natural teeth shapes and contours.
Optimal gingival symmetry and
tissue health are noted.
Altered Passive Eruption: Diagnosis and Treatment51
Figure 4A: Preoperative photograph.
Note the box appearance of the centrals
Figure 4B: Preoperative photograph.
Note the gingival asymmetry and
composite restorations with defective
margins on teeth 8 & 9.
Figure 4C: Osseous crest is located
at the CEJ. Ostectomy is indicated.
Figure 4D: Ostecomy and osteoplasty
provides correct oveolar-dental
Figure 4E: Alveolar crest is 1.5–2
mm from CEJ, clinical crown length is
Figure 4F: Postsurgery: Apically
repositioned flap exposes enamel
previously covered by gingival and
Figure 4G: One-year follow-up. Feldspathic
porcelain laminate veneers.
Tissue health is optimal and incisor
length is 10.5–11 mm.
width, 9 which in turn results in misdiagnosis or simply overlooking the possible
diagnosis of APE. Ingber and others 17 coined the term “biologic width”
to describe the distance from the alveolar crest to the base to the sulcus. Commonly
this distance is approximately 2 mm: 1 mm of epithelial attachment and
1 mm of connective tissue attachment. When bone sounding, a 1 mm gingival
sulcus depth must be added to this dimension. When bone sounding on the facial
of an incisor (i.e., tooth 8), a probing depth measurement of ≤ 3 mm must
employ ostectomy and an apically repositioned flap to achieve crown lengthening,
while a gingivectomy procedure is contraindicated. However, if bone
sounding is >3 mm, a gingivectomy procedure can be used with success. For
example, bone sounding of 5 mm may employ a 2 mm gingivectomy without
gingival rebound to the preoperative levels. However, without following these
specific fundamental guidelines, properly diagnosing APE and maintaining an
ideal biologic width 9 may be difficult to achieve. Each of these principles is
important to follow when striving for optimal long-term esthetics.
The first case presented, Type 1A, demonstrates a good example of a normal
osseous crest relationship requiring only an alteration of the gingival complex or an apically repositioned flap to
achieve ideal gingival health and esthetics (Figure 3A). The patient presented with a chief complaint of “short front teeth”
and thus APE was included in the differential diagnosis. Bone sounding to 5 mm indicated APE and surgery ultimately
confirmed the diagnosis. Restorations were not indicated and the normal dentogingival relationship was established
with an apically-positioned flap (Figure 3E). By contrast, the second case, Type 1B, required both a gingival alteration
APE Treatment Options
APE Type 1A
APE Type 1B
APE Type 1C
APE Type 1D
1. Gingivectomy (optional)
2. Apically Positioned Flap
1. Gingivectomy (optional)
3. Apically Positioned Flap
1. Apically Positioned Flap
2. Apically Positioned Flap
Diagram 1: Altered passive eruption treatment options.
and osseous recontouring to establish an ideal alveolar-dental relationship (Figure 4B). Short clinical crowns, defective
restorations, biologic width invasion, and gingival asymmetry were present. Bone sounding to 3 mm indicated APE,
and was confirmed during surgery. The surgical objectives were to reestablish biologic width by placing osseous crest
levels 3 mm from crown margins while simultaneously providing a normal clinical crown length of approximately 10.5
mm. Following these objectives will promote functional and esthetic dentogingival relationships while simultaneously
facilitating placement of supragingiva l2 or intracrevicular 18 restorative margins (Figure 4G).
Each type of APE has specific surgical options to consider (Diagram 1). Type 1A has a greater than normal amount of
keratinized tissue with a normal osseous crest-CEJ relationship. This may be treated by gingival recontouring alone
and/or by an apically repositioned flap. Type 1B, however, presents with an osseous crest located at the CEJ, and
usually requires gingival recontouring combined with ostectomy and an apically repositioned flap. Type 2A presents
with a normal amount of keratinized tissue and has a normal osseous crest-CEJ relationship. This requires an apically
repositioned flap rather than a gingivectomy to preserve adequate keratinized tissue. Type 2B, on the other hand, has
an excessive osseous crest and requires ostectomy combined with an apically repositioned flap to preserve adequate
Although each classification of APE requires specific surgical guidelines to establish an ideal dentogingival relationship,
any surgeon is faced with two basic options:
1. To alter the gingival complex alone, or
2. To alter the gingival complex and/or remove bone.
Thus, any surgeon must ultimately decide to either include ostectomy or not. Although the osseous architecture and
correct choice of surgical procedure is difficult to establish without reflecting a mucoperiosteal flap, bone sounding has
proven to be a valuable adjunct when indirectly locating osseous crest levels. Bone sounding includes administering
local anesthesia, inserting a periodontal probe positioned within the sulcus, and then pressing the probe through the
junctional epithelium and connective tissue to the crest of bone. This procedure provides a method of bone mapping
and will supplement diagnostic information. However, bone-sounding data only represents specific points of the osseous
crest and thus is limited in providing a precise replica of osseous architecture. Dento-alveolar anomalies and root
concavities may also go undetected. To reduce touch-up procedures and gingival recontouring, surgically reflecting a
mucoperiosteal flap is the most predictable method of determining osseous architecture to achieve optimal dentogingival
Altered Passive Eruption: Diagnosis and Treatment53
It is important to consider APE in the differential diagnosis any time the chief complaint resembles a “gummy
smile” or “short front teeth.” Short clinical crowns may often be a result of APE, a condition that is commonly overlooked.
Fundamental knowledge of the dental and soft tissue relationships must be employed when diagnosing and
treating APE. Establishing proper crown length and maintaining biologic width are critical for gingival health and restorative
If APE is suspected, bone sounding is a
valuable diagnostic tool, although surgical intervention
may provide the most reliable method to establish
a harmonious perio-restorative interface.
If APE is suspected, bone sounding is a valuable diagnostic tool, although surgical intervention may provide the most
reliable method to establish a harmonious perio-restorative interface. Considering the esthetic emphasis in dentistry
today, it is important to properly recognize APE during any dentofacial examination and strive for optimal gingival
health and esthetics.
Robert P. Pulliam, DMD, MS, RPh, is in private practice and may be contacted by phone at 615-297-8973. Daniel J. Melker, DDS, is also in private practice and may be
reached by calling 727-725-0100.
The restorations presented in this article were performed by Bill Strupp, DDS, Clearwater, Florida.
Reprinted from Contemporary Esthetics and Restorative Practice: Pulliam RP, Melker D. “Altered Passive Eruption: Diagnosis and Treatment.” 2002; 8(4): 20-30. Copyright
2002, with permission from AEGIS Publications, LLC.
1. Dolt A, Robbins W: Altered passive eruption: An etiology of short clinical crowns. Quintessence Int 28(6):363-72, 1997.
2. Dello Russo NM: Placement of crown margins in patients with altered passive eruption. Int J Periodontics Restorative Dent 4(1):59-65, 1984.
3. Wolffe GN, van der Weijden FA, Spanauf AJ, et al: Lengthening clinical crowns—A solution for specific periodontal, restorative, and esthetic problems.
Quintessence Int 25(2):81-8, 1984.
4. Evian CI, Cutler SA, Rosenberg ES, Shah RK: Altered passive eruption: The undiagnosed entity. J Am Dent Assoc 124(10):107-110, 1993.
5. Goldman HM, Cohen DW: Periodontal Therapy, ed 4. St. Louis: Mosby, 1968.
6. Gottlieb B, Orban B: Active and continuous passive eruptions of teeth. J Dent Res 13:214, 1933.
7. Volchansky A, Cleaton-Jones P, Retief DH: Delayed passive eruption—a predisposing factor to Vincent’s Infection. J Dent Asso S. Africa 29:291-4,1974.
8. Weinberg MA, Eskow RN: An overview of delayed passive eruption. Compend Contin Educ Dent 21(6):511-514, 516, 518 passim; quiz 522, 2000
9. Gargiulo AW, Wentz FM, Orban B: Dimensions and relations of the dentogingival junction in humans. J Periodontol 32:261-7, 1961.
10. Ainamo J, Loe H: Anatomical characteristics of gingiva. A clinical and microscopic study of the free and attached gingiva. J Periodontol 37(1):5-13, 1966.
11. Coslet JG, Vanarsdal R, Weisgold A: Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan
12. Ash M: Wheelers’s Dental Anatomy, Physiology and Occlusion, ed 6. Philadelphia: Saunders, p 120, 1984.
13. Flore-de-Jacoby L, Zafiropoulos GG, Ciancio S: The effect of crown margin location on plaque and periodontal health. Int J Perio Rest Dent
14. Cortex M: Nd:YAG laser-assisted gingivectomy, bleaching, and porcelain laminates, Part 2. Dent Today 18(4):52-55, 1999.
15. Russo J: Periodontal laser surgery. Dent Today 16(11):80-81, 1997.
16. AAP position paper: Lasers in Periodontics. J Periodontol 67:826-830, 1996.
17. Ingber JS, Rose LF, Coslet JG: The “biologic width” area concept in periodontics and restorative dentistry. Alpha Omegan 70(3):62-5, 1977.
18. Maynard JB, Wilson RDK: Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 50:170-174, 1979.
An Effective Alternative to Palatal
Donor Tissue for Treatment of Soft
Tissue Alveolar Ridge Defects
– Article and Clinical Photos by Edward P. Allen, DDS, PhD
– Introduction by Michael DiTolla, DDS, FAGD
When I was in dental school, I did a graft on my cousin and fellow dental student, David, with the help of
one of our instructors. David was getting ortho done at the school and had minimal attached gingival on
the facial of an upper bicuspid. Since the archwire was going to slightly expand his upper arch, the graft was
necessary prior to starting the orthodontics. Cutting into your cousin’s palate with a Bard-Parker in the first
year of clinical dentistry was a little scary for me. Anesthetizing the entire left hand side of his palate was a
little out of my comfort zone as well. However, both of those paled in comparison to watching him try to eat
and drink in the days afterwards since we were roommates. He had a lot of pain in that next week, especially
when the perio pack fell off about five minutes after the surgery. Dr. Edward Allen shows an elegant method
of avoiding using donor tissue from the palate when performing a graft. I can think of many patients who
have refused this type of esthetic periodontal surgery because of the palatal surgery, and the option Dr. Allen
demonstrates allows patients to have the graft done without the palatal procedure.
oft tissue grafting using palatal donor tissue, primarily
to increase the zone of attached gingiva, was introduced
more than 40 years ago. 1 Subsequently, there
have been numerous reports describing use of palatal
connective tissue grafts for treatment of gingival recession
defects and soft tissue alveolar ridge defects. 2-14 Surgical applications
of soft tissue grafting have been improved by the introduction of
microsurgery with more precise incisions, closer wound apposition,
reduced hemorrhage, and reduced trauma at the surgical site. 15 Microsurgery
uses smaller instruments and smaller suture providing less
invasive surgery and less complicated postoperative sequellae.
Additionally, in patients who seek treatment, anatomical or medical
concerns may be present that rule out use of the palate as a donor
source. For these reasons, an effective substitute for palatal donor tissue
“In spite of significant
refinements in surgical
technique, many patients
remain fearful of
palatal surgery and resist
for treatment involving
soft tissue grafting.”
AlloDerm Regenerative Tissue Matrix
AlloDerm (LifeCell Corporation, Branchburg, NJ), widely used in both
medical and dental surgery over the past twelve years, is an acellular
dermal matrix derived from donated human skin tissue supplied
by tissue banks in the United States, utilizing the standards of the
American Association of Tissue Banks and Food and Drug Administration
(FDA) guidelines. Human skin consists of both epidermis
and dermis. In nature, the dermis contains a framework of cells and
structural components that allow it to regenerate and replace itself
continually throughout life.
After determining that donated skin tissue is eligible for transplantation,
LifeCell processes the tissue. When AlloDerm is prepared, the
human donor tissue undergoes a multi-step proprietary process that
removes both the epidermis and the cells in the dermis that can lead
to a recipient response, tissue rejection, and graft failure, without
altering the structural and biochemical components of the matrix.
The resulting extracellular matrix is freeze-dried by a proprietary
method to preserve the tissue without the formation of damaging
ice crystals. This entire process is performed under stringent documented
quality-controlled systems that have been demonstrated to
reduce HIV-l and the surrogate for hepatitis C virus to non-detectable
levels (>99.9 percent). Histology testing is completed on each lot of
final product to verify cell removal. Cell removal ensures against viral
replication and renders free particles more susceptible to detergent
inactivation. In addition to viral safety, both incoming tissue and final
products are screened for bacterial and fungal growth and deemed
negative. The remaining fibrous framework of biologically active
components and vascular channels stimulates the recipient to initiate
the intrinsic tissue regeneration process, integrating and replacing
the graft tissue with newly formed dense, collagenous connective
tissue. 16-18 Thus, AlloDerm provides a viable biologic substitute for
palatal donor tissue.
Figure 1. Semilunar crestal incision avoiding
sulci of adjacent teeth.
Figure 2. Folding AlloDerm graft in half longitudinally,
basement membrane surface approximating
Use of AlloDerm in Periodontics
AlloDerm is used as a substitute for palatal connective tissue in the
treatment of gingival recession and soft tissue alveolar ridge defects.
Randomized controlled clinical trials have demonstrated that root
coverage with AlloDerm is equivalent to that obtained with palatal
donor tissue in the treatment of gingival recession. 18-22 An increase
in marginal tissue thickness equivalent to palatal tissue grafts has
been demonstrated at six and 12 months postoperatively, by both
clinical and histometric analysis. 18, 21 Equivalent attachment to the
root surface has been found by histologic evaluation of human bock
sections at six months postoperatively. 18 Case reports have demonstrated
effective restoration of buccal alveolar ridge defects with AlloDerm
grafts. 23, 24 A recent case series described the successful re-
Figure 3. Inserting AlloDerm graft into the
pouch with an Allen Micro-elevator.
pair of oronasal fistulae with AlloDerm grafts. 25 This report describes
techniques for using AlloDerm in the treatment of one and two-tooth
buccal alveolar ridge defects.
Ridge Augmentation Surgical Technique
Figure 4. Passing the suture through the two
ends of the folded AlloDerm graft.
Figure 5. Suture tied to palatal wall of pouch.
For a single missing tooth site, place a semilunar incision with a #15
blade beginning at the deficient ridge crest, curving facially; do not
cross over the papillae into sulci of the adjacent teeth (Figure 1). This
incision should extend to the bone surface. Create a facial pouch in
the defect area by sharp supraperiosteal dissection, extending approximately
6-10 mm apical to the ridge crest. Place incisions in the
proximal sulcus of each adjacent tooth to mobilize the papillae. Measure
the width and depth of the pouch, approximately 6-10 mm horizontally
and 8-10 mm vertically. Following two successive washes in
normal saline, the AlloDerm is trimmed to create a graft of proper
width and a length two times the depth of the pouch.
Fold the graft in half longitudinally, approximating the basement
membrane surface (Figure 2), and while grasping the approximated
ends with Microsurgical Corn Suture Pliers (Hu-Friedy, Chicago, IL),
introduce the folded end of the AlloDerm graft into the recipient
pouch with an Allen Micro-elevator (Figure 3). Place an interrupted
suture through the two exposed ends of the AlloDerm graft coronally
(Figure 4), recapture the needle, then push the graft ends just under
the lip of the pouch. Pass the needle through the palatal wall of the
pouch to secure the coronal aspect of the graft (Figure 5). Replace the
provisional fixed partial denture (FPD) with the ovate pontic lightly
contacting the graft.
For two adjacent missing teeth (Figure 6), place a semilunar incision
at the ridge crest as described above at the location of each missing
tooth, leaving the papillary area between the missing teeth intact
(Figure 7). Create a supraperiosteal pouch by sharp dissection facial
to both missing teeth, tunneling under the papillary area. Measure
the width and depth of the pouch and trim an AlloDerm graft with a
width equal to the span of the two-tooth site and a length twice the
pouch depth. Fold the AlloDerm graft in half longitudinally and secure
the margins with 6-0 resorbable suture (Figure 8). Introduce the
graft into the pouch through one of the semilunar incisions (Figure
9), align horizontally within the pouch, and secure the coronal graft
border to the palatal pouch wall with 6-0 suture (Figure 10). Replace
the provisional FPD with the ovate pontics lightly contacting the
graft (Figure 11).
Figure 6. Moderate to severe buccal alveolar
ridge defect at the site of the missing left lateral
incisor and canine.
Postoperative care includes the following:
1. Systemic antibiotics for 10 days
2. Chlorhexidine mouthrinse for two to three weeks
3. Pain medication, as needed
4. Ice applied to face for 24 hours, intermittently, at 10 minute intervals
5. Cold liquids for the first three meals
6. No mastication or toothbrushing at surgical site for two to three
Figure 7. Semilunar crestal incisions approximating
each missing tooth.
7. Remove surface sutures at two to four weeks
Initial postoperative swelling peaks approximately three days after
surgery and gradually subsides over a two-week period. By six to
eight weeks postoperatively, the gain of ridge contour will approximate
the thickness of the layers of AlloDerm placed (Figure 12).
If additional contour is needed in larger buccal defects, a second
augmentation may be performed at eight weeks following the initial
procedure. The soft tissue form gained will be maintained long-term
provided ovate pontics remain in contact with the restored ridge.
Developed more than 10 years ago, AlloDerm is a safe and effective
biomaterial for use as a substitute for palatal connective tissue
in root coverage grafting and soft tissue ridge augmentation procedures.
There have been no reports of disease transmission as a
result of AlloDerm use in medical or dental applications. AlloDerm
has proven equivalence to palatal connective tissue for root coverage
procedures in randomized controlled clinical trials. 19-22 AlloDerm
provides distinct advantages over palatal connective tissue in that
it does not require a second surgical site to obtain donor tissue,
and provides an unlimited amount of tissue to treat multiple sites at
one appointment. Patient acceptance of recommended treatment is
increased due to elimination of the fear associated with use of the
palate for harvesting donor tissue. When compared to the use of
palatal donor tissue, the postoperative experience with AlloDerm is
less complicated, without the sequellae associated with palatal donor
surgery. Further, patients are not as reluctant to return for additional
AlloDerm grafting procedures when required.
AlloDerm grafting is effective for restoring buccal ridge form at sites
of ridge deformities due to developmental defects, trauma, or natural
ridge resorption. Complete restoration of form is related to the
anatomy of the site and the number of contiguous missing teeth. Results
are best at sites without loss of proximal bone or soft tissue on
Figure 8. AlloDerm folded and sutured.
Figure 9. Inserting AlloDerm into the pouch
through the crestal opening.
Figure 10. AlloDerm positioned within pouch
over defect area and sutured to palatal wall
“A successful surgical outcome is
dependent on proper pontic
and abutment form beginning
the day of surgery and continuing
through the healing phase.
The same is true for the final
restorations in order to ensure longterm
maintenance of ridge form.”
the teeth adjacent to the edentulous ridge and at one and two-tooth
sites. A gain in tissue thickness of approximately 3 mm can be expected
from a single surgery using a folded AlloDerm graft. At sites
with greater than 3 mm of buccal deficiency, a second surgery may
be necessary. Minimal increase in vertical dimension can be achieved
with the technique described.
Figure 11. Provisional FPD placed following
conversion of ridge-lap pontics to ovate form.
Long-term maintenance of the soft tissue form achieved is dependent
on the support of the adjacent bony walls proximally and the
ovate pontic form crestally. Without the support of the ovate pontic
during the healing phase, there will be loss of the coronal portion
of the augmented site. Shrinkage of the ridge will occur without the
support from the convex form of the pontic maintaining the concave
pontic site in the ridge. Such shrinkage is commonly seen where
modified ridge-lap pontics are used. A successful surgical outcome is
dependent on proper pontic and abutment form beginning the day
of surgery and continuing through the healing phase. The same is
true for the final restorations in order to ensure long-term maintenance
of ridge form.
Figure 12. Improved ridge form three months
after surgery. A second graft at the lateral incisor
site would result in complete restoration of
ridge contour. Esthetic crown lengthening was
performed on the right side at the same time
as the ridge augmentation.
The surgical techniques outlined represent a refinement in the approach
to soft tissue ridge augmentation. The procedures are minimally
invasive microsurgical techniques that enhance wound stability
while reducing morbidity due to the use of AlloDerm. Reduced
discomfort and improved patient satisfaction characterize the postoperative
To contact Dr. Edward Allen, call 877-696-1414, e-mail firstname.lastname@example.org, or visit
1. Björn H. Free transplantation of gingival propria. Sveriges Tandlakar forbunds Tidning 1963; 22:684-689.
2. Miller PD. Root coverage using a free soft tissue autogenous graft following citric acid application. I. Technique. Int J Periodontics Restorative Dent 1982; 2: 216-229.
3. Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol 1985; 56:397-402.
4. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985; 56:715-720.
5. Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987; 58:95-102.
6. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent 1994;
7. Azzi R, Etienne D. Recouvrement radiculaire et reconstruction papillaire par greffon conjonctif enfoui sous un lambeau vestibulaire tunnellisé et tracté coronairement.
J Parodontol Implant Orale 1998; 17(1):71-77.
8. Blanes R, Allen EP. The bilateral pedicle flap-tunnel technique: a new approach to cover connective tissue grafts. Int J Periodontics Restorative Dent 1999
9. Abrams L. Augmentation of the deformed residual ridge for fixed prosthesis. Compend Contin Educ Dent 1980; 1(3): 205-213.
10. Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent 1981; 2(4): 212-223.
11. Langer B, Calagna L. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent
1982; 2(2): 22-33.
12. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part 1. Technique and wound healing. Compend Contin Educ
Dent 1983; 4(5): 437-453.
13. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part 2. Prosthetic/periodontal relationships. Compend Contin
Educ Dent 1983; 4(6): 549-562.
14. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985; 56(4): 195-199.
15. Shanelec DA. Periodontal microsurgery. J Esthet Restor Dent 2003; 15(7):402-407.
16. Silverman RP, Li EN, Holton lll LH, Sawan KT, Goldberg NH. Ventral hernia repair using allogenic acellular dermal matrix in a swine model. Hernia 2004; 8: 336-342.
17. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): A new alternative for abdominal hernia repair. Ann Plast Surg 2004; 52: 188-194.
18. Cummings LC, Kaldahl WB, Allen EP. Histologic evaluation of autogenous connective tissue and acellular dermal matrix grafts in humans. J Periodontol 2005;
19. Aichelmann-Reidy ME, Yukna RA, Evans GH, et al. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 2001;
20. Novaes AB, Grisi DC, Molina GO. Comparative 6-month clinical study of a subepithelial connective tissuegraft and acellular dermal matrix graft for the treatment of
gingival recession. J Periodontol 2001; 72(11):1477-1484.
21. Paolantonio M, Dolci M, Esposito P, et al. Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recession: A
comparative 1-year study. J Periodontol 2002; 73(11):1299-1307.
22. Tal H, Moses O, Zohar R, et al. Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective
tissue grafts. J Periodontol 2002; 73(12):1405-1411.
23. Fowler EB, Breault LG. Ridge augmentation with a folded acellular dermal matrix allograft: a case report. J Contemp Dent Prac 2001; 2(3): 31-40.
24. Lorson ME, Gapski R. Aesthetic crown lengthening in combination with an acellular dermal matrix for ridge development. Pract Proced Aesthet Dent 2006; 18(6):
25. Kirschner RE, Cabiling DS, Slemp AE, et al. Repair of oronasal fistulae with acellular dermal matrices. Plast Reconstr Surg. 2006 Nov;118:1431-1440.
“You’ve got to be better
than the jackass who
was my last dentist.”
Jeff Hibbard, DDS
1st place winner of a $500 lab credit
“I still find it hard to
believe that UCLA means
‘University of California
License for Apes’.”
Lester Rodriguez, DDS
2nd place winner of a $100 lab credit
“You have a very busy
practice, Dr. Simian. I bet you
swing from room to room all day.”
Patrick Fleming, DDS
3rd place winner of a $100 lab credit
“So, is this that new four-handed dentistry I have heard about?”
Robert R. Harmen, DDS
Grand Junction, CO
“From ‘Monkey see…Monkey do U’, and I’m your first patient?”
Mr. Barrett Haynes, Crown Jewel Dental
Pacific Beach, CA
Caption Contest Winners!
Congratulations to the winners of the Vol. 4, Issue 1 Chairside Caption Contest. These captions were chosen among thousands of entries
submitted to Chairside Magazine when asked to add a caption to the picture shown above. Winning entries and honorable mention callouts
were judged on humor and ingenuity.
“Look Ma, no gloves!”
Send your captions for the above photo, including your name and city of practice, to: email@example.com. By submitting
a caption, you are authorizing Chairside Magazine to print your name in a future issue or on our Web site. You may also submit your
entries online at www.chairsidemagazine.com.
The winner will receive $500 in Glidewell credit or a $500 credit towards their account. The 2nd and 3rd place winners will receive
$100 in Glidewell credit or a $100 credit towards their account. Entries must be received by May 1, 2009. The winners will be announced
in the Summer issue of Chairside Magazine.
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