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Chairside®

A Publication of Glidewell Laboratories • Volume 4, Issue 2

Elective Cosmetic

Dental Treatment

Simple Bailout

for Complex

Periodontal Dilemmas

Altered Passive Eruption:

Diagnosis and Treatment

One-on-One

An Interview with

Dr. Brock Rondeau

Dr. Michael DiTolla’s

Clinical Tips


Contents

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

Dilemmas

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

biologic width.

Cover photo by Sharon Dowd

Cover illustration by Wolfgang Friebauer, MDT

Contents 1


Editor’s Letter

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.

2

Yours in quality dentistry,

Dr. Michael DiTolla

Editor in Chief, Clinical Editor

mditolla@glidewelldental.com

www.chairsidemagazine.com

Publisher

Jim Glidewell, CDT

Editor in Chief

Michael DiTolla, DDS, FAGD

Managing Editors

Jim Shuck

Mike Cash, CDT

Creative Director

Rachel Pacillas

Clinical Editor

Michael DiTolla, DDS, FAGD

Copy Editor

Martin Yan

Magazine Coordinators

Sharon Dowd

Lindsey Lauria

Graphic Designers

Jamie Austin, Deb Evans, Joel Guerra,

Phil Nguyen, Gary O’Connell, Rachel Pacillas

Staff Photographers

Sharon Dowd

Kevin Keithley

Illustrators

Wolfgang Friebauer, MDT

Phil Nguyen

Ad Representative

Lindsey Lauria

(lindsey.lauria@glidewelldental.com)

If you have questions, comments or complaints regarding

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

chairside@glidewelldental.com. Your comments may be

featured in an upcoming issue or on our Web site: www.

chairsidemagazine.com.

© 2009 Glidewell Laboratories

Neither Chairside Magazine nor any employees involved in its publication

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

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

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

represents that its use would not infringe proprietary rights. Reference

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

trade name, trademark, manufacturer or otherwise does not necessarily

constitute or imply its endorsement, recommendation, or favoring

by the publisher. The views and opinions of authors expressed

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

shall not be used for advertising or product endorsement purposes.

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

that are presented, you must make your own decisions about

specific treatment for patients and exercise personal professional judgment

regarding the need for further clinical testing or education and

your own clinical expertise before trying to implement new procedures.

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.


Contents

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

gummy smiles.

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.

Contents 3


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

Dear Jeff,

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

4

www.chairsidemagazine.com

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

hands.

- 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

Dear Jeff,

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


Dear Tommy,

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

not increased.

- 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

Dear Brandon,

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

an electric

lab

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

WRITE US

Chairside Magazine welcomes

letters to the editor, which

may be featured in an upcoming

issue or on our Web site.

Letter should include writer’s

full name, address and

daytime phone number.

To contact us: e-mail (chairside@glidewelldental.com),

mail (Letters to the Editor,

Chairside Magazine, Glidewell

Laboratories, 4141 MacArthur

Blvd., Newport Beach, CA

92660) or call (888-303-4221).

Dear Fred,

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


Contributors

Michael C. DiTolla, DDS, FAGD

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

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

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

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

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

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

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

mditolla@glidewelldental.com.

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

e-mail center@epallendds.com.

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 boblowedds@aol.com.

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.

6

www.chairsidemagazine.com


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 brondeau@rondeauseminars.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.

Contributors 7


Dr. DiTolla’s

CLINICAL TIPS

– ARTICLE by Michael DiTolla, DDS, FAGD

– PHOTOS by Sharon Dowd

PRODUCT ....... Demi LED Curing Light

CATEGORY ...... Light Curing System

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

Orange, CA

800-537-7123

www.kerrdental.com

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

for light.

Dr. DiTolla’s Clinical Tips 9


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT ....... COE ® Adjust-A-Tray

CATEGORY ...... Impression Tray

SOURCE .......... GC America, Inc.

Alsip, IL

800-323-7063

www.gcamerica.com

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.

10 www.chairsidemagazine.com


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT ....... Exposé ®

CATEGORY ...... Caries Detector

SOURCE .......... Centrix Dental

Shelton, CT

800-235-5862

www.centrixdental.com

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


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT ....... QUAD-TRAY Xtreme

CATEGORY ...... Impression Tray

SOURCE .......... Clinician’s Choice

New Milford, CT

800-265-3444

www.quadtray.com

The QUAD-TRAY Xtreme is definitely on my list of

products 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

14 www.chairsidemagazine.com


■ 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 dilemma?

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

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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

fabrication.

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

be difficult.

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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

indeed empowering.

■ 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

two minutes.

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.

■ Epilogue

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).

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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 boblowedds@aol.com, or

visit www.destinationsmile.com.

■ References

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


Case Presentation:

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,

if possible.

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

possible.

Figure 1: The clinical appearance of the case before treatment.

Figure 2: Core buildups and surgical provisionals are required for the

protocol.

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.

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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

the restorations.

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

extraction.

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.

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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

fit properly.

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

plaque removal.

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

biologic width.

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

tubules.

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

teeth.

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.

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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

crest.

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

control it.

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

brushes.

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

concept.

30 www.chairsidemagazine.com


“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

restorations.

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.

Seminar

Title: Simplifying Complex Cosmetic & Restorative Dentistry

Date: June 12-13, 2009

Location: New York, NY USA

Seminar

Title: Simplifying Complex Cosmetic & Restorative Dentistry

Date: July 17-18, 2009

Location: Chicago, IL USA

Seminar

Title: Simplifying Complex Cosmetic & Restorative Dentistry

Date: January 29-30, 2010

Location: Clearwater, FL USA

Seminar

Title: Simplifying Complex Cosmetic & Restorative Dentistry

Date: June 25-26, 2010

Location: Santa Barbara, CA USA

32 www.chairsidemagazine.com


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.

34 www.chairsidemagazine.com


Interview

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

the patients.

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

36 www.chairsidemagazine.com


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

option.

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

38 www.chairsidemagazine.com


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

appliance working.

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

these appliances?

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

40 www.chairsidemagazine.com


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

themselves?

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

successfully stopped

the snoring and eliminated her

depression and her husband

came back to bed. She later

said, "Thanks for giving me my

life back."

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

daily basis.

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 brondeau@rondeauseminars.com.

42 www.chairsidemagazine.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

SITUATION

CHANCE OF DOZING

Sitting and reading.......................................................

Use rhinometer

to check for nasal

obstructions or other

blockages to nasal

airway.

The patient plugs his

nose to isolate airflow

to the pharynx, and

the pharyngometer

measures diameter of

the patient’s airway

with mandible in multiple

positions.

Watching television......................................................

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....................................................

The pharyngometer

and rhinometer are

part of the diagnostic

tools that some

sleep dentists use to

diagnose obstructions

and help predict if

oral appliances will be

successful.

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

the hospital.

Total Score...................................................................

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

attention.

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

medical community.

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


Photo Essay

Anterior

Procera Zirconia

Crowns with

No-Prep Vivaneers

– 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.

44 www.chairsidemagazine.com


Photo

Essay

Essay

Photo Essay: Anterior Procera Zirconia Crowns with No-Prep Vivaneers45


Photo

Essay

46 www.chairsidemagazine.com


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

as cementum.

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

recession.

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

treatment plan.

Clinicians now are

beginning to recognize

the importance of the

gingival complex in

the treatment of short

clinical crowns.

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

gingival health.

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.

CASE REPoRTS

– 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

was indicated.

During surgery, an inverse bevel incision following the CEJ was used. An effort

50 www.chairsidemagazine.com


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

immediately post-op.

DISCUSSIon

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

and laterals.

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

relationship.

Figure 4E: Alveolar crest is 1.5–2

mm from CEJ, clinical crown length is

10.5 mm.

Figure 4F: Postsurgery: Apically

repositioned flap exposes enamel

previously covered by gingival and

osseous tissues.

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

52 www.chairsidemagazine.com


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)

2. Ostectomy

3. Apically Positioned Flap

1. Apically Positioned Flap

1. Ostectomy

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

keratinized tissue.

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

relationships.

Altered Passive Eruption: Diagnosis and Treatment53


SUMMARy

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

procedures.

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.

Acknowledgment

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.

References

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

7(37):24-8, 1977.

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

9:197-206,1989.

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.

54 www.chairsidemagazine.com


AlloDerm:

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

is necessary.

“In spite of significant

refinements in surgical

technique, many patients

remain fearful of

palatal surgery and resist

recommendations

for treatment involving

soft tissue grafting.”

AlloDerm57


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

itself.

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.

58 www.chairsidemagazine.com


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.

AlloDerm59


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

weeks

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.

Discussion

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.

60 www.chairsidemagazine.com


Figure 10. AlloDerm positioned within pouch

over defect area and sutured to palatal wall

of pouch.

“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.

Conclusion

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

period.

To contact Dr. Edward Allen, call 877-696-1414, e-mail center@epallendds.com, or visit

www.DrEdwardPAllen.com.

AlloDerm61


References

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;

14(4):302-315.

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

Oct;19(5):471-479.

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;

76(2):178-186.

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;

72(8):998-1005.

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):

371-375.

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.

62 www.chairsidemagazine.com


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