Chairside Magazine Volume 2, Issue 1 - Glidewell Dental Labs

Chairside Magazine Volume 2, Issue 1 - Glidewell Dental Labs

APRIL 2007


A Publication of Glidewell Laboratories • Volume 2, Issue 1

No-Prep vs. Minimal-

Prep Veneers

On the Same Patient


With Dr. Michael DiTolla


Is the Wide Range in

Crown Fees Justifiable?

According to

Dr. Gordon Christensen

Lab Management Today’s

Crown Experiment 2007

Does Higher Lab Fee Guarantee Higher Quality?

Dr. Michael DiTolla’s Clinical Tips


7 Dr. DiTolla’s Clinical Tips

In this month’s Clinical Tips article, Dr. DiTolla

describes two topical anesthetics that he finds extremely

helpful for a number of clinical situations. He also looks

at two new burs that will greatly increase the efficiency

of your clinical dentistry.

11 No-Prep vs. Minimal-Prep Veneers on the

Same Patient

Meet a patient willing to have no-prep veneers placed,

removed with a laser, and then have minimal prep

veneers placed. This fascinating case highlights the

sometimes subtle differences between these two veneer


19 Photo Gallery: BioTemps Provisional


In this Photo Gallery, we show many examples of the

different clinical problems that can be solved with

BioTemps provisional restorations.


24 Is the Wide Range in Crown Fees


We are privileged to have Dr. Gordon Christensen

weigh in on the topic of crown fees. If you have ever

wondered why one doctor charges $1200 for a crown

and another charges $800 for a crown from the same

lab, you will enjoy this article.

29 Lab Management Today’s

Crown Experiment 2007

This is an experiment many of us always wanted to do

and thanks to LMT, its now been done. They were generous

enough to let us republish this fascinating look

into the relationship between crown fee and crown

quality. As you will see, you may not always get what

you pay for.


Cover photo by Kevin Keithley

Illustration by Wolfgang Friebauer, MDT

Editor’s Letter


Jim Glidewell, CDT


Is there anything we do on a daily basis in our offices that is as important to patient

satisfaction and comfort as our injections? Early in my career I learned first hand

how important a painless injection could be. When I graduated from dental school at

the age of 22, I still had all of my hair and looked too young to be a dentist. When

I came back to Southern California after graduation I practiced with my father for

the first 3 years of my career, still one of the most rewarding professional experiences

I have had.

I was surprised how many patients wanted to see my dad instead of me. Many times

I would do the examination and the patient would go to the front desk to schedule

the appointment, and would schedule the two crowns with dad rather than me.

I turned my focus to winning over those patients. Dad only had one chink in his

dental armor: his injections.

My dad hated topical and he could empty a carpule faster than I can load one. The

amount of fast twitch muscles in his thumb were mind-boggling and when he emptied

that carpule in less than 2 seconds, patients would levitate. I saw my chance to

win over the doubters, who were stuck having to have their broken tooth prepped

for a crown on Dad’s golf day. My interests in topical were both academic and

sophomoric: I found it worked as well on patients as it did on my dental school

roommates coffee cup rim. What other dental product opens the door to so many

practical jokes?

I began to brag to patients I could give them a practically painless injection, and it

worked! My crown preps took three times longer than my dad’s, but it would be a

levitation-free procedure. However, painless anesthesia technique does not necessarily

equal profound anesthesia technique, and I believe as dentists we owe it to the

profession and to our patients to continue to search for better techniques to make

dentistry more effective and compassionate.

I hope you enjoy this month’s interview with Dr. Alan Budenz where he makes a

compelling case for all of us to learn the Gow-Gates mandibular block. Just because

we have made it this far in our careers without it does not mean we should stop

striving to provide better dental techniques for our patients. And as I always say, if

you don’t have access to a prison population, you may want to perfect these techniques

on in-laws and staff members. Remember: there is always a price to pay,

especially for free dentistry!


Associate Publisher

Jim Shuck

Mike Cash, CDT

Creative Director

Rachel Pacillas

Clinical Editor

Michael DiTolla, DDS, FAGD


Lindsey Lauria


Jamie Austin

Eric Chou

Deb Evans

Phil Nguyen

Gary O’Connell

Rachel Pacillas

Ty Tran

Copy Editors

Lindsey Lauria

Al Lefcourt

Gary O’Connell

Photo Editors

Jamie Austin

Eric Chou

Deb Evans

Phil Nguyen

Rachel Pacillas

Ty Tran


Kevin Keithley

James Kwasniewski

Ed Pelissier


Wolfgang Friebauer, MDT

38 Laboratory Portrait: Mikhail Tkachev

Meet Mike Tkachev, an engineer in the Glidewell

Laboratories Research and Development department. He

shares with us his amazing story of how coming from

the former Soviet Union, he landed in Newport Beach,

California and how his previous experience in the

Soviet Army building top secret devices helps him in his

work today.

44 One-on-One with Dr. DiTolla

In this ongoing series, Dr. DiTolla tackles local anesthesia

issues with one of the country’s leading authorities,

Dr. Alan Budenz. Dr. Budenz sheds some light on a

new mandibular block technique that may convince you

to give up your standard inferior alveolar block.

52 Carpe Diem: Now Is the Time to Help

Patients Value the Importance of

Their Dental Office as Their Partner

for Great Health

Gary Takacs explains why now is the perfect time to

inform your patients on how oral heath is related to

overall heath. He provides us with a few examples of

how he thinks this doctor-patient communication can

be easily initiated during your patient’s appointment.

57 Planning the Shade Prescription

One of the country’s leading authorities on esthetic

fixed restorations, Dr. Gerard Chiche, shares with us his

method for shade determination and characterization.

62 Facial Correction without Injection:

Angellift ® Pricing and Technology Update.

The newest addition to the Angellift family of products,

Preview ® , is introduced in this article. This chairside

tool will help to demonstrate the effectiveness of the

Angellift device and to help patients decide if this

product is for them.




Dr. Michael DiTolla

Clinical Editor

Editor’s Letter



Gordon J. Christensen, DDS, MSD, PhD

Gordon J. Christensen is Founder and Director of Practical Clinical Courses (PCC) in Utah, and Dean of the

Scottsdale Center for Dentistry (SCD) in Arizona. Both groups are international continuing education organizations

providing courses and videos for all dental professionals. Dr. Christensen has presented over 45,000 hours of

continuing education throughout the world and has published many articles and books. Gordon and Dr. Rella

Christensen are co-founders of the non-profit CRA Foundation (CRA), which Rella directed for many years. Since

1976, CRA has conducted research in all areas of dentistry and published the findings to the profession in the wellknown

CRA Newsletter. Gordon is a practicing prosthodontist in Provo, Utah. Contact PCC at 800-223-6595, or e-mail For more information, visit Contact Scottsdale Center for Dentistry at or 866-921-7111.

Gary Takacs

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

dentists develop a more profitable and enjoyable practice. Gary frequently addresses dentists and team members at

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

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

practice management in professional publications. His articles have been published in leading journals including

Dentistry Today and Dental Economics. Gary is the founder of Ride and Learn, and Race and Learn. With Ride and

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

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

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


Michael DiTolla, DDS, FAGD

Dr. DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, California.

He performs clinical testing on new products in conjunction with the Research & Development department. Dental

technicians who work for Glidewell Laboratories have the privilege of rotating through Dr. DiTolla’s operatory and

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

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

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

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

e-mail him at or call 800-854-7256.

Gerard J. Chiche, DDS

Dr. Gerard J. Chiche is the Helmer Professor and Chairman of the Prosthodontics Department at Louisiana State

University School of Dentistry. He has given numerous programs nationally and internationally and holds memberships

in the American College of Dentists, the American Academy of Esthetic Dentistry, the American Academy of

Fixed Prosthodontics, the American Academy of Restorative Dentistry and the Omicron Kappa Upsilon Dental Honor

Society. He is a Past President of the American Academy of Esthetic Dentistry and is also, respectively with Alain

Pinault and Hitoshi Aoshima the author of the textbooks Esthetics of Anterior Fixed Restorations and Smile Design:

A Guide for Clinician, Ceramist, and Patient both published by Quintessence Publishing. He serves as adjunct faculty

at the Pankey Institute, he is the recipient of the 2003 LSUSD Alumnus of the Year Award and the recipient of the

2003 Educational Community Achievement Award of the Seattle Study Club for best dental educator of the year.

Alan W. Budenz, MS, DDS, MBA

Dr. Budenz is Professor in the Department of Anatomical Sciences and the Department of Diagnostic and Emergency

Services at the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, California. He also

lectures on Surgical Head & Neck Anatomy and orthognathic surgery to Oral & Maxillofacial Surgery Residents

at Highland General Hospital in Oakland, California and to Orthodontic Residents at Pacific. Dr. Budenz has extensive

experience in head and neck anatomy, dissection, and nerve tract identification, and has lectured nationally on

local anesthesia topics. He has more than twenty years of general practice experience in San Francisco, has served as

clinical Group Practice Administrator, as clinical department chair, and is a clinical floor instructor at Pacific.

Bradley Evans, MD, DDS, MS

Dr. Bradley Evans graduated from Rapid City Central and USD Medical School with highest honors. He became an

eye surgeon and practiced medicine in Hawaii prior to returning to school. He completed his dental and orthodontic

training at the University of the Pacific in San Francisco. Doctor Brad has the unique distinction of having been a

practicing ophthalmologist before entering the field of dentistry and becoming an orthodontic specialist. In his spare

time he enjoys skiing, hiking, biking, scuba diving, jazz music, and family time. He and his wife Brenna have a son

Rowan and a daughter Oona.





PRODUCT.............. Profound Lite

CATEGORY........... Topical Anesthetic

SOURCE................ Steven’s Pharmacy, Costa Mesa, CA


Since I switched to Profound Lite, I no longer see the tissue

dehydration I did before, and the patients still don’t feel

the penetration of the needle. It is an incredibly strong

topical anesthetic.

I have written before about how Profound has allowed me to

do lots of gingival recontouring and other soft tissue procedures

without the need for local anesthesia. Profound has also

allowed me to almost entirely eliminate lower blocks from my

day-to-day practice. I noticed that I could squirt it into the

furcation of a lower molar, wait 60 seconds and then slowly

inject one-half to two-thirds of a Septocaine carpule into the

furcation and achieve instant pulpal anesthesia without any

tongue or cheek numbness.

I became a hero to my patients for avoiding painful blocks and

not numbing half of their lower jaw for 3 hours!

Like many dentists, I began to use Profound for many more

clinical uses, as well as in my hygiene rooms. When I began

using it in the vestibule as a pre-injection topical, I noticed

that the patients felt no pain at all! My technique is to leave

the Profound on for 60 seconds, rinse it off, and then pierce

– ARTICLE by Michael DiTolla, DDS, FAGD

– PHOTOS by Kevin Keithley

– ILLUSTRATIONS by AXIS Dental Corporation

the mucosa with the 30-gauge needle as I pull the tissue taut.

They simply do not feel the needle anymore!

However, I also noticed that if I didn’t rinse it off completely,

some patients would experience a dehydration of the tissue

that would result in a white patch on the tissue. I called the

pharmacy to talk about this reaction and they were surprised

to hear that I was using it in the vestibule.

The strength of Profound had been based on doing laser surgery

without a local, not as a pre-injection topical. So with

dentists like me in mind, they formulated Profound Lite. For

those of us who use it more for pre-injections than for laser

surgery, it still has the same powerful combination of prilocaine,

lidocaine and tetracaine as Profound, but the ratios

have been adjusted to make it friendly to all oral tissues.

Since I switched to Profound Lite, I no longer see the tissue

dehydration that I did before, and the patients still don’t

feel the penetration of the needle. I keep a tube of original

Profound in each operatory for the gingival recontouring

touch-ups that seem to pop up in almost all of our esthetic

cases. My dental assistant also uses it on the lingual tissue

when the patient can feel the cord packing since we prefer not

to give palatal injections if we can avoid it.

Profound and Profound Lite are both available in 30 or 45

gram tubes. My staff then dispenses some of the topical into

Ultradent syringes with disposable 18-gauge tips for injecting

into molar furca and gingival sulci. The rest of the topical

stays in the original tube to be dispensed onto cotton-tipped

applicators for use as a pre-injection topical.

Do yourself (and your patients!) a favor by using Profound

Lite to drop the pain from your injection technique! Í

Dr. DiTolla’s Clinical Tips





PRODUCT.............. Cyclone/Cyclone DS

CATEGORY........... Topical Anesthetic

SOURCE................ Steven’s Pharmacy, Costa Mesa, CA



CATEGORY..............................Carbide Bur

SOURCE...................................AXIS Dental, Coppell,


Zir-Cut burs are absolutely necessary when replacing

zirconia-based restorations.

New from Axis Dental are Zir-Cut burs, filling a need just

recently created. It’s a huge time-saver, too. Zirconia-based

restorations entered the market a few years ago and are now

hitting their strides. Two of the newer systems (LAVA from

3M ESPE and Prismatik CZ from Glidewell Labs) are so strong

that nothing will cut efficiently through their zirconia substructures.

Enter the Zir-Cut burs, absolutely necessary when

replacing these all-ceramic, cementable restorations.

Even if you aren’t placing zirconia restorations (which I now

do routinely), one day you will have to take off a zirconia

crown placed by another dentist, and you’d better have some

Zir-Cut burs on hand!


CATEGORY..............................Carbide Bur

SOURCE...................................AXIS Dental, Coppell,


This amazing new bur will fly through both porcelain and

metal on any PFM with no problem.

The new Razor carbide bur from Axis Dental is a huge time

saver! This amazing bur will fly through porcelain and metal

on any PFM with no problem. I used to use an old diamond

to cut through the porcelain and then would switch to a 57 or

557 bur to cut through the coping. In addition to having these

burs snap far too often, the chatter they would make as they

cut through the metal was horrible!

In contrast, a new Razor will fly through the porcelain and

continue straight through the metal with no chatter at all. On

certain cases (usually those with semi-precious or high-noble

substructures), I have used the same Razor bur to remove 4 or

5 entire crowns. Just order a couple of them in the 57 size and

shape and you will see what I mean, especially if you have an

electric handpiece like I do.

We offer Cyclone DS to almost anyone having something

done who is not getting local anesthesia.

If you can remember about 10 years ago, there was a

product named Dyclone, which was a topical anesthetic in

liquid form that patients could swish with for one minute

to anesthetize gingival and palatal tissues. It was fantastic

for hygiene patients who need some anesthesia, but don’t

want local infiltrations or blocks. It also worked well for

needle-phobic sensitive hygiene patients, and for patients

who gag during impressions. I searched the FDA database

and found that the company decided to stop producing for

their own reasons. The FDA verified that it had nothing to

do with the safety or efficacy of the product.

Steven’s Pharmacy’s replacement product is called Cyclone

and it is available in the original strength that we used to

use, 0.5%, and also in a double-strength solution called

Cyclone DS that is a 1.0% solution. We have settled on

the Cyclone DS as our choice because we have noticed

no difference between the two solutions, except that the

Cyclone DS works better on most patients.

We use it on anyone who is worried about having impressions

taken, whether it is for Invisalign or bleaching trays

or even just study models. We use it on full arch crowns

and bridge impressions when we are worried about the

patient gagging while we try to capture the detail of multiple

preps. We will even use it prior to taking our digital

x-rays on patients who are worried about gagging.

On the hygiene side, we use it for periodontal probing for

patients with inflammation as well as for gross debridement

patients who are sensitive. We see a lot of patients

who are overdue for hygiene but do not need scaling and

root planing. Since we typically only use local anesthetic

for our root planing patients, Cyclone helps fill the gap by

being an easy-to-use topical that provides peace of mind

for the patients.

The bottom line is that we offer Cyclone to almost anyone

having something done who is not getting local anesthesia.

We do not charge for this service, although there are

dentists who have told me that they charge a small fee for

it (typically $5.00) and that patients are happy to pay it.

We don’t charge for local anesthetic, of course, and we feel

that this falls into the same category.

Dr. DiTolla’s Clinical Tips

Dr. DiTolla’s Clinical Tips

No-Prep vs. Minimal-Prep Veneers on the Same Patient

– ARTICLE by Michael DiTolla, DDS, FAGD

There seems to be a controversy today in the world of esthetic dentistry whether prepped or no-prep veneers are the better

restoration. Typically, this discussion takes place between dentists, from the dentist’s point of view and with little or no input

from the patient’s point of view. I doubt any article can ever settle that debate. My intent in this article is to simply compare

the esthetic results that can be achieved with both types of veneers.

In most articles comparing different restorations, one set is done on one patient and the other set is done on a different patient.

Unfortunately, when you compare the two techniques using two different patients, the comparison is not really significant. Each

patient will have his/her own hard and soft tissue features such as tooth alignment, dentin shade and gingival architecture. Many

times it is these factors that determine which set of restorations look better.

To accurately compare the esthetic potential of two sets of restorations, it is my opinion that both sets of restorations should be

fabricated by the same technician and placed on the same patient. We often do this by trying in both sets of restorations and

taking digital photographs. While this allows us to see the esthetic differences between the restorations, it does not allow us to

evaluate patient feedback about the difference on how the two different sets of restorations look, feel and function.

That’s why I jumped at the opportunity to see the difference between prep and no-prep veneers on the same patient. In this

study, we first placed no-prep veneers on the patient and left them on for six months. The patient loved these veneers from the

day they were placed and had no functional issues with them either. His wife however, who happens to be a dental technician,

thought that they looked too bulky. The patient did say that they initially felt “a little thick to his tongue,” but this feeling went

away within the first few weeks.

As part of our agreement for receiving the veneers for no charge, I removed the no-prep veneers with my Waterlase after

six months. After the veneers popped off, a thin layer of resin cement remained on the enamel surface. I removed the cement

with rubber wheels to get his teeth as close to their preoperative state as I could. This is not to say that I consider no-prep

veneers to be reversible, but if I did ever have to remove a set to return a patient to their pre-op state, I now know that I could

come close.

I then sent a study model to the laboratory in order to do minimal-prep veneers. While the term is somewhat unclear, I define

a minimal-prep case by two conditions: 1) the amount and location of the reduction is determined by the laboratory technician;

and 2) the preparation remains entirely within enamel. By allowing the dental technician to determine the amount and location

of reduction based on the diagnostic wax-up, we ensure we only remove enough tooth structure to achieve the esthetic result

shown by the diagnostic wax-up. By remaining in enamel, we nearly eliminate the potential for post-operative sensitivity while

taking advantage of the highest bond strength in dentistry.

Two weeks later the minimal-prep veneers were bonded into place and again the patient was very happy with them. This

time however, his wife, the dental technician, was also very pleased with the result. The patient did not see much difference

between this set of veneers and the no-prep veneers and commented that he “didn’t feel there was enough of a difference”

between the two sets of veneers to “justify the numbing and drilling.” Please keep in mind that this was not a dental phobic

patient. Had he been a dental phobic, the no-prep veneers would have been the only option and he would have been pleased

with that esthetic result.

I have presented his final pictures side by side so you can compare the results for yourself. While I expect that many dentists

will prefer the minimal-prep set of veneers, I urge you to keep the patient’s response in mind. Is there enough esthetic difference

in the final results to justify the anesthesia and preparation? Only you and your patient can decide. Í

No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient

Figure 1

Figure 2 Figure 3

Figure 5

Figure 6 Figure 7

Figure 4

Figure 1: Greg’s Pre-Operative Smile

You will notice when he smiles that he does not show the incisal edge of his maxillary anterior teeth. However, you will notice

after his teeth are restored, that his smile becomes more broad and more authentic and the incisal edges of the maxillary anterior

teeth become apparent.

Figure 2: Facial View of Pre-Operative Smile

A close-up view of the maxillary anterior teeth shows numerous esthetic issues, some more dramatic than others. A traumatic

fracture of the incisal edge of tooth #8 has left it 1mm shorter than tooth #9. The gingival levels on teeth #6, 8, 9 & 11 are

roughly in the correct position, but the gingival levels on tooth #7 and especially #10 are too far apical. Short of a gingival graft,

the only way to correct this problem would be to do a gingivectomy on #6, 8, 9 & 11 to match the levels of the lateral incisors,

but that would leave these other teeth with clinical crowns that were too long.

Figure 3: Right Lateral View of Pre-Operative Smile

In addition to the broken incisal edge on tooth #8, it is also apparent that tooth #7 is too short incisally. Teeth #6 & #7 also have

an excessively large incisal embrasure between them in addition to a small diastema.

Figure 4: Left Lateral View of Pre-Operative Smile

From this view, it is apparent that tooth #10 is angled to the facial making it too facially prominent. In a no-prep case like this,

I refer to this as a Facial Limiting Factor (FLF). Since this is a no-prep case by definition, all the teeth are going to get at least

0.3mm thicker on the facial. If the FLF is too noticeable, it will change a case from no-prep to minimal-prep.

Figure 8

Figure 5: Greg’s Smile After No-Prep Veneers

Notice how his smile is now a full smile with his lower lip paralleling the incisal edges of the maxillary anterior teeth. Like many

patients, being happy with their anterior teeth leads to more natural smiles.

Figure 6: Facial View of Post-Operative No-Prep Veneer Smile

I think we can all agree there has been a dramatic improvement from figure 2 to this picture. Essentially, all of the cosmetic

objections the patient originally had have been eliminated by the no-prep veneers. Interestingly, even our FLF has been somewhat

nullified by the no-prep veneer. Because tooth #10 was so short, the ceramist was able to increase its length while bringing

the incisal edge back toward the lingual. This has created an illusion that #10 is not as facially prominent as it actually is. The

only time I see this happen is when the FLF tooth is lengthened by the ceramist.

Figure 7: Right Lateral View of Post-Operative No-Prep Veneer Smile

Compare this picture with figure 3 and note the multiple esthetic improvements. For example, the incisal embrasure between

teeth #6 & #7 that was too far open in figure 3 has been closed in figure 7. The deficient distal-marginal ridge on tooth #6 has

been corrected in figure 7 giving tooth #6 a more pleasing overall shape and appearance. The broken incisal edge on tooth #8

has also been corrected.

Figure 8: Left Lateral View of Post-Operative No-Prep Veneer Smile

Compare this photo with figure 4 and note the multiple esthetic improvements. For example, the insufficient length of tooth

#10 has been corrected. Tooth #9 was a concern to me because the tooth was nearly ideal prior to treatment. Placing a no-prep

veneer on this tooth would not make it look any better, except that the shade will blend in with the adjacent teeth. In figure 8

however, tooth #9 does not appear to be too large. We also dodged a bullet on tooth #10, which was facially prominent prior

to treatment, as it blends in reasonably well. Í

No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient

Figure 9

Figure 10 Figure 11

Figure 9: Facial View of No-Prep Veneer Removal

I set the power on my Waterlase YSGG laser to its maximum (6.0 watts) and held it approximately 2mm away from the surface

of the veneers. Because these were no-prep veneers and extremely thin in most areas, the porcelain began to pop off quickly.

Through my loupes it appeared as though the ceramic fracture was taking place at the level of the silane. In other words, when

the porcelain came off, it left a thin layer of resin cement on the tooth. This was polished off with rubber wheels.

Figure 10: Close-Up View of No-Prep Veneer Removal

The reason I like removing these veneers with the laser is that it pops the porcelain off with much less potential for damaging

the underlying enamel. Because these veneers are so thin, it would be difficult to cut through them with a handpiece and bur

and not cut into the enamel. In areas where the veneers were slightly thicker, I found I could use a diamond bur to slightly thin

the porcelain if the laser was having no effect on it. Once the porcelain was thinned, the laser would pop it right off.

Figure 11: Facial View After Removal of No-Prep Veneers

This is a shot after the no-prep veneers were removed and initial rubber wheel polishing was done. Essentially, we have

taken the patient back to his pre-operative virgin teeth. While I would never tell patients that if they don’t like their no-prep

veneers we can always pop them off and go back to square one, it is nice to know that I do have a way of removing them if I

absolutely had to. Í

No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient

Figure 13 Figure 14

Figure 12

Figure 15

Figure 12: Greg’s Smile After Minimal-Prep Veneers

After the no-prep veneers were removed, a study model was made and sent to the technician. The technician identified the

FLFs he would like removed to enhance the esthetic results for this case. The minimal amount of preparation ensured that all

of the preparations remained entirely in enamel. The minimal-prep veneers were placed with the exact same steps as with the

no-prep veneers. Because the entire preparation is in enamel, we have no fear of post-operative sensitivity or potential loss of

tooth vitality.

Figure 13: Facial View of Post-Operative Minimal-Prep Veneer Smile

Compare this with figure 6 and see which set of veneers you prefer. It should be apparent that the shape and contours of the

veneers in figure 13 are more pleasing and anatomically correct than those in figure 6. The teeth do not appear as bulbous and

the “negative space” in the various embrasures add a depth and vitality to these restorations.

Figure 14: Left Lateral View of Post-Operative Minimal-Prep Veneer Smile

Compare this to figure 8 and see which set of veneers you prefer. Again, the first thing I notice is the lateral incisor, tooth #10.

In the no-prep case in figure 8, the tooth looks bulbous, especially in the cervical third. Note how with the minimal-prep veneers

in figure 13 the cervical third appears much more natural, and the “negative space” surrounding the gingival embrasure makes

it appear more like a tooth and less like a restoration.

Figure 15: Right Lateral View of Post-Operative Minimal-Prep Veneer Smile

Compare this to figure 7 to see which set of veneers you prefer. The first thing that jumps out at me is how natural tooth #7

looks in the minimal-prep case versus the no-prep case. Teeth #6 & #8 also appear more natural, especially the way the incisal

third of tooth #8 is positioned more lingually in the minimal-prep case than in the no-prep case. Í

Figure 16 Figure 17 Figure 18

Figures 16, 17, 18 Retracted Left, Facial and Right Views of Post-operative Minimal-Prep Veneers

These close-up views of the completed minimal-prep veneers highlight the esthetic features that are not possible with no-prep

veneers. Every dentist who has looked at this case prefers the look of the minimal-prep veneers. However, every patient I have

shown this to, including the one the treatment was performed on, had no preference between the two sets of restorations. They

did have a preference for the no-prep procedure over any preparation.

No-prep veneers can solve a lot of esthetic issues in one appointment, without a drill and without anesthetic. For a lot of patients

that is a major benefit, even if the veneers don’t look as nice as if we did a minimal-prep or full-prep procedure. For them, the

main criteria are no drilling, no shots and no removal of tooth structure. These patients are much less concerned about the fact

that their veneers will be slightly bulbous, as they inevitably will be with the no-prep method.

For patients who are insisting on perfection in the shape of their veneers, we need to go to a minimal-prep or full-prep procedure.

It’s important to explain to the patient the advantages and disadvantages of the different kinds of veneers available to

them and then help them to make their own decision.

To watch the video of this entire procedure, visit the Glidewell Online Case Study website at:

educational/videos/index.html and click on Online Viewing — Case Studies: Comparative Study of No-prep, Laser Removal, and

Minimal-prep Veneers on the same patient.

No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep on the Same Patient

Correcting Esthetic and

Functional Problems with the U se of...

BioTemps Provisional Restorations

– ARTICLE by Michael DiTolla, DDS, FAGD

– PHOTOS by Ed Pelissier and Michael DiTolla, DDS, FAGD

In my opinion, BioTemps may be the most versatile restoration available in dentistry today.

This is surprising considering that it is a provisional restoration, but provisionals play such a

big role in managing clinical situations to ensure success with our final restorations. From tissue recontouring

to ovate pontic development, BioTemps are the ideal soft tissue template for shaping gingival

tissues to match your esthetic requirements. From restoring vertical dimension to withstanding months

of periodontal therapy, you won’t find a better long-term provisional on the market. This article looks

at some of the clinical applications I have found for BioTemps, and I welcome your input on any other

uses you may have found for these versatile provisional restorations . Í

Photo Gallery: BioTemps Provisional Restorations



This 59-year-old female patient presented with a collapsed vertical and anterior bridge that did not show teeth when she smiled. The lack of supporting bone

made implants unfeasible, so BioTemps were placed to overcome the resorbtion and restore a normal vertical dimension. Pink acrylic was used to mask the

resorbed area and permit a smile that would show her teeth.

This 21-year-old male patient would cover his smile with his hand to hide his teeth. This patient has suffered with GERD and has been treated by a physician.

Once under control, treatment could proceed and BioTemps were placed on the upper arch. The patient was visibly moved at seeing his new smile, and the

final restorations matched the size and shape of the BioTemps.



This 45-year-old male patient had a severe parafunctional habit for all of his adult life. Because of his edge-to-edge bite, he had lost several millimeters of vertical

dimension over the decades. Full upper and lower BioTemps were placed to restore vertical dimension and establish proper overjet and overbite.

This 34-year-old male patient did not like how his PFM bridge from #6-8 looked and the fact that food always got caught underneath. The patient decided to

restore his teeth from #5-12 at the same time. BioTemps were placed from #5-12 to successfully address the patient’s aesthetic and functional concerns.



This 41-year-old male patient had always smiled with his lips closed because he was embarrassed by the look of his smile. He did not like the spaces between

his teeth, the multiple discolorations or how short the teeth had become from parafunctional activity. BioTemps were used to improve his smile on the same

appointment and to act as a template for final restorations.

This 28-year-old male patient had multiple failing composites with recurrent decay and moderate periodontitis. He was also embarrassed to smile. After completing

his periodontal program, full-arch BioTemps were placed on the upper. The gingival embrasures were intentionally left open so the patient could easily


Photo Gallery: BioTemps Provisional Restorations

Photo Gallery: BioTemps Provisional Restorations



This 54-year-old male patient presented with unaesthetic PFMs with exposed metal margins. Upon further examination, it became apparent that teeth #8-

10 were periodontally involved and their prognosis was hopeless. Teeth #8-10 were atraumatically extracted with the use of periotomes. The patient did not

bite down on any 2x2s as this can cause collapse of interdental papilla. Since our goal was to create ovate pontic receptor sites, the BioTemps pontics were

extended into the extraction sites and were allowed to heal, creating a more esthetic result.

Clinical dentistry by Michael DiTolla, DDS, FAGD. BioTemps by Glidewell Laboratories.

This 31-year-old female patient was presented with a PFM bridge from #8-10 with open margins on both abutments. She complained that food constantly got

caught underneath the modified ridge lap pontic. It was decided to place a new PFM bridge with an ovate pontic. When the old bridge was removed, the faciolingual

width of the ridge was measured to see if there was enough space for the ovate pontic, and in this case there was. If the ridge has collapsed on the

facial due to a traumatic extraction, an ovate pontic is often not possible. A color transfer applicator was used to mark the tissue side of the BioTemps pontic,

and the bridge was tried into place, leaving a mark in the correct position for the ovate pontic receptor site. A Waterlase® YSGG laser was used to remove the

marked tissue. The BioTemps bridge was tried in again to continue marking the tissue. When the BioTemps bridge would seat completely, enough tissue had

been removed. The BioTemps were then cemented and the area was allowed to heal for 6-8 weeks.

Photo Gallery: BioTemps Provisional Restorations

Photo Gallery: BioTemps Provisional Restorations

LMT ® ’s Crown Experiment 2007:


Identical impressions were sent anonymously to nine different laboratories.

The resulting crowns were evaluated by a panel of

highly trained dentists and dental technologists. Every

one of them resoundingly said: “I wouldn’t want

any of these in my mouth.”

Reprinted with permission from LMT ®

Communications, Inc. Copyright © 2007.



he evaluators—as well

as LMT—were surprised by the

disappointing quality of the nine crowns in the experiment, which earned an average score of only 4.3

on a scale of 0 to 10. (See The Crowns: A Closer Look on page 32). “These are amateurish crowns with no

natural contours,” said evaluator Fred Hornedo, Jr., MDT, manager of Acqua-Dent Dental Laboratory, Jamesburg, New


The evaluators also criticized the shallow anatomy, gray or too-bright shades and the poor staining and glazing.

However, what concerned them most was that none of these crowns has an acceptable marginal fit

when evaluated on the die. “Every unit is rotating or rocking,” said Dr. Ira Zinner, who maintains a private

practice in New York City and is a clinical professor at New York University College of Dentistry. “None of them have

any bevels or closing angles to keep saliva out and prevent decay.”

The technicians on the panel were especially bothered by what appeared to be a

lack of pride in craftsmanship. “Why are we seeing such sloppy model work and presentations?

It seems as though some of these technicians were just going through the motions,” said

evaluator Gail Broderick, MDT, laboratory director for Jason J. Kim Dental Laboratory, Great Neck, New York.


LMT opted to use a Dentoform model as the “patient” so that there could be nine crowns in the

experiment without having to put a live patient through nine impressions. The dentist-consultant

modified the Dentoform so that it appeared more lifelike; he then prepared tooth #14 with a shoulder

preparation. He took nine full-arch impressions of the Dentoform and sent each one to a different

laboratory with a prescription for a low-gold PFM crown with a circumferential metal collar in shade A3.5. He requested

light fissure staining on the occlusal and hand-articulated casts. LMT chose to prescribe a PFM unit since that is still

the bread-and-butter work of most C&B departments and laboratories.

LMT chose six domestic labs (two small, two medium and two large) and three foreign labs. For the

domestic crowns, the goal was to get samples from each of three broad regions of the U.S. LMT also

wanted to cover a wide range of prices, so all of the crowns in the experiment are in the $60 to $190 range. The average

turnaround time was 12 days. Í

nce the crowns arrived at LMT, all the casts, dies and

crowns were marked with coordinating colors and

assigned a letter so that the identities of the laboratories (as well as their size and location) would not be known to


LMT then brought the crowns to two prestigious East Coast

LMT’s Crown Experiment 2007


Odental schools—New York University (NYU) and the University

of Connecticut (UCONN)—to have them evaluated by a

panel of technicians and dentists; one of the dentists is also

a master dental technician. (See Meet the Evaluators on

page 36.) They were asked to rate each crown in nine

categories: model and die prep, anatomy, contours, contacts/

embrasures, occlusion, shade/vitality/enamel blend, stain and

glaze, metal design/polish and the accuracy of fit on the die.

(Because LMT wanted to eliminate the variable of impressiontaking

and focus solely on laboratory techniques, the fit of

each crown on the Dentoform was not scored.) The scoring

system is based on a 0 to 10 scale, with 0 being “unacceptable”

and 10 being “excellent.”

“Why are we seeing such sloppy model work and

presentations? It seems as though some of these

technicians were just going through the motions.”

-Gail Broderick, MDT

LMT recognizes the limitations of this study and is not

portraying it as a scientific experiment or implying that the

work being evaluated here is necessarily representative of

the entire industry. Rather, the experiment is a rare opportunity

to get an inside look at the work being done in other

laboratories, and to juxtapose it with the fees these labs are

charging for their level of quality.


1. The lowest scores are for the accuracy of fit on the die. Even

the first-place crown received a 4.0 on the 0 to 10 scale in

that category; the average score for fit for all the crowns is

only 3.5.

Some evaluators commented that the type of shoulder prep

used by the dentist who helped with the experiment may

have inhibited a good fit, but others felt it is a real-world

prep, similar to those often done by general dentists and

that it has nice, clear margins. In the end, though, the real

concern is each laboratory’s inability to make a restoration

that doesn’t rock or rotate on the die. “No matter what the

prep is like, these crowns should fit better than they do,”

said evaluator Mario Zerrillo, MDT, owner of Zerillo Dental

Laboratory, Queens, NY.

2. The crowns that were fabricated outside of the United States

are on par with the ones fabricated inside the country (the

foreign crowns placed 5th, 6th and 7th among the nine restorations).

In fact, the average overall score of the foreign

crowns is 4.2 and the average for the domestic crowns is

4.4. While both of these scores reflect dissatisfaction among

the evaluators, they show that the quality of the foreign

crowns in the experiment is comparable to that of the

domestic ones.

3. What was most surprising about the individual crowns is

that the most expensive one in the group—in the $180

to $190 range—was rated to be the worst. Although the

geographic area in which the laboratory is located tends

to have higher prices, it was still shocking that—even on a

bad day—a crown in this price range would rate 2.8 on a

scale of 0 to 10.

What surprised LMT most about the individual crowns

is that the most expensive one in the group—in the

$180 to $190 range—was rated to be the worst.

4. Overall, the technician-evaluators gave scores that are an

average of one point lower than the dentist-evaluators

(3.6 compared to the average dentist score of 4.5). It’s

LMT opted to use a Dentoform model (below) as the “patient” so that there could

be nine crowns in the experiment without having to put a live patient through

nine impressions. The dentist-consultant modified the Dentoform so that it

appeared more lifelike; he then prepared tooth #14 with a shoulder preparation,

took nine full-arch impressions of the Dentoform and sent each one to a

different laboratory with an identicalprescription.

What concerned the evaluators most was that none of the crowns in the experiment has an acceptable marginal fit when evaluated on the die.

Shown here are three crowns—(from l. to r.): Crown Z, Crown T and Crown R—that were among the worst of the lot.

logical that the technicians—being professionals in dental

prosthetics—would have a more technically critical

perspective. Still, it’s the dentist who is making the final

decision about whether a restoration is suitable to be placed

in a patient’s mouth.

Although all of the dentist-evaluators said they would

reject every crown if it was returned to them, some acknowledged

there are dentists who would consider at least a few

of these units to be clinically acceptable. And that’s the reality:

since quality is so subjective, what constitutes an acceptable

crown is going to differ from one individual to another.

That’s evident even in the context of the experiment: the

scores the evaluators gave Crown U in the stain and glaze

category, for example, range from 1 (from a technicianevaluator)

all the way to 9 (from a dentist-evaluator).

LMT believes that the laboratories involved in the experiment

would be genuinely surprised by the scores they received.

Of course, the evaluators didn’t know the identities of the

laboratories and, therefore, couldn’t be swayed by their

reputations or level of service. Instead, these crowns had to

speak for themselves.

Although in the real world, your marketing, positioning and

value-added service are part of the big picture, how would

your product fare if it was judged on technical merit alone? In

other words, if your work had to speak for itself, what would

it say? Í

LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007

The Crowns


Crown V Overall score: 6.0 Fabricator: A large, full service lab in the Western U.S. Price range: $170–$180

The “favorite” of both the dentist and technician evaluators,

the first-place crown comes from the largest laboratory in the

experiment and has more than a one-point lead over the

second-place “winner.” It received the highest marks in the stain

and glaze and metal design/polish categories. “This is the best

stain and glaze I’ve seen on any of the crowns so I’m giving it

a ‘9.’ This is a very sellable crown,” said Jason J. Kim Dental

Laboratory’s Gail Broderick, MDT. UCONN’s Dr. Dashti praised

the metal/porcelain margin and metal polish, but felt that the

embrasures were too open, especially on the mesial.

Crown S Overall score: 4.9 Fabricator: A small C&B laboratory in the Central U.S. Price range: $150–$160

This crown earned scores almost as high as the 1st place crown

for its metal design and polish, contacts and embrasures and

occlusion, but some of the evaluators gave it a “0” for

unacceptable model and die work, since the model was returned

to the dentist with chipped centrals. UCONN’s Dr. Squier also

pointed out that the die was overtrimmed, which probably accounts

for this crown’s poor marginal fit. There is also a stress fracture

on the lingual side of the crown, possibly due to metal/porcelain


Crown T Overall score: 4.8 Fabricator: A medium-sized full service lab in the Western U.S. Price range: $150–$160

Several of the evaluators commented on the impressive-looking

cusp of Carabelli on this crown. However, they were disappointed

with the occlusion. “There’s a ‘hit and slide’ on the occlusion and

it’s not designed in centric occlusion,” said Dr. Grayson of NYU.

UCONN’s Dr. Rungruanganunt agreed, “The crown is only occluding

on the lingual incline of the buccal cusp.” Other judges felt

that the contacts are too wide and too tight, and that the crown is


Crown WOverall score: 4.7 Fabricator: A large, full service lab in the Eastern U.S. Price range: $120–$130

This crown earned its highest scores in the model work and

occlusion categories, but didn’t do so well with its anatomy

evaluation. “This crown demonstrates a lack of knowledge

of occlusal anatomy,” said Dr. Grayson. Other evaluators

echoed that sentiment and also pointed out that the crown is

overcontoured, especially lingually, and that the contacts are too

wide. Dr. Raghavendra also felt that the crown has excessive external


Crown Y

Crown Z

Overall score: 4.4 Fabricator: A foreign laboratory Price range: $110–$120

The metal work on this crown concerned the evaluators. “If

you looked at this metal collar under a microscope, it would

look like the texture of concrete...a beautiful home for billions

of bacteria,” said Fred Hornedo, Jr., MDT, manager of Acqua-

Dent Dental Laboratory, Jamesburg, New Jersey. “There are a

lot of fine scratches that should have been polished out with

a red wheel.” The porcelain application is also disappointing.

“The color is uniform from the gingival on up—there’s no natural

coloring, no occlusal staining,” said Dr. Grayson.

Crown X Overall score: 4.3 Fabricator: A foreign laboratory Price range: $80–$90

“My first impression? It’s not good,” said Paul Federico, MDT,

owner of Federico Dental Lab, Staten Island, New York, when

he picked up this crown for evaluation. “It’s overcontoured, the

fit is terrible, the contacts are too tight and the shape is wrong

on the lingual and interproximal.” Other criticism offered by the

evaluators included shallow anatomy, tight contacts and poor

occlusion. UCONN’s Dr. Squier and Dr. Rungruanganunt also commented

that the dies looked worn or mishandled.

Overall score: 3.8 Fabricator: A foreign laboratory Price range: $60–$70

Though overall this crown falls into 7th place, the evaluators at

the University of Connecticut deemed this to be the worst crown

of them all, especially since it was not fabricated with a metal

collar as prescribed.“This is a terrible crown,” said Dr. Squier. “The

prescription wasn’t followed, there’s no contact on the models, no

metal margin on the buccal and the porcelain is overextended.” The

evaluators also pointed out that this crown is overcontoured and out

of occlusion and that the opaque shows through.

Crown U Overall score: 3.4 Fabricator: A medium-sized C&B laboratory in the Central U.S. Price range: $70–$80

This crown received the worst model and die scores of any of

the crowns in the experiment and nearly all of the evaluators

commented on the messy presentation. “Even if the model

work is accurate, it’s ugly. I gave it a ‘1’ for sloppiness,” said

Mario Zerrillo, MDT, owner of Zerrillo Dental Laboratory, Queens,

New York. It was also difficult to remove the die without pulling

off the other parts of the model. The porcelain application

was noted to be inconsistent—thick in some spots and thin in

others—and the crown exhibits bulky contours. “This crown is

unsellable and unacceptable,” said Broderick.

Crown R Overall score: 2.8 Fabricator: A small C&B laboratory in the Eastern U.S. Price range: $180–$190

“Crown ‘R’ is for reject. This is what you get with a $39 crown,”

said NYU’s Dr. Silberg, unaware that this was actually the most

expensive crown in the group. “This crown has no occlusion,

no retention, no contour.” In fact, overall, this crown received

the worst anatomy and occlusion scores of all of the crowns.

And the porcelain application and metal work didn’t fare much

better. “The shade is grayish and the stain doesn’t follow the

anatomy,” said Dr. Dashti. “Also, the metal polish is poor because

there are dark areas.” Í

LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007

LMT Technical Strategies Columnist Bill Mrazek, CDT, asks:


Crown S lost points during evaluation because it was returned

on a broken model (left photo) and because there are cracks in

the porcelain on the buccal and lingual surfaces (right photo).

When the fine folks at LMT asked if I would offer a

“real-world” perspective on the restorations in their

crown experiment, I agreed without hesitation. I felt I

had a pretty good grasp of the “levels” of restorations being

produced in our profession. I’ve been a dental technician

for 30 years and a CDT for almost 28 years. I’ve presented

numerous lectures and clinics and written articles for over

15 years. Many of us have looked to Willi Geller, Asami

Tanaka, Lee Culp and others for inspiration, guidance and

education—and continue to learn from them—in an attempt to

continually raise the level of our restorations.

As we know, there remains a range of acceptability in what

we produce. That is not to say that high quality restorations

are not being delivered on a daily basis; they certainly are.

There are also restorations being delivered that are not as

detailed; as accurately fitting; or as anatomically, functionally,

gnathologically or esthetically correct that still fall within that

range of acceptability. Then there are those that should not

be delivered at all. But, in most businesses, there is a market

for everything. Unfortunately, as evidenced from this study,

restorative dentistry is no exception.

First, let me say that my comments are not directed at

specific laboratories, since I do not know where the

restorations were fabricated. I evaluated each crown in the

same categories used by the other dentist- and technicianevaluators

(see Meet the Evaluators on page 36) and used

the same 0 to 10 scale. I looked at each crown three times,

on three different days, to make sure that I was being fair

and consistent. I’ve arranged my observations based on the

judging categories:

Model and die prep (my scores range from 0 to 7.5): Crown

S received a zero because the model was returned badly

broken, as if dropped from a second-floor window (see photo

on page 32). Crown T received the highest score because it

uses one-piece double pins and the model work is neat and

clean. Most of the cases use simple plastic articulators, which

are common, but they allow no protrusive movement and only

limited excursive movements.

In most businesses, there’s a market for everything.

Unfortunately, as evidenced from this study,

restorative dentistry is no exception.

Anatomy (my scores range from 2 to 8): Only Crown T

includes a Cusp of Carabelli, even though there clearly is one

on the 1st molar on the opposite side of the arch.

Contours (my scores range from 5 to 7.5): Almost all units

exhibit a square, boxy, overcontoured shape.

Contacts/embrasures (my scores range from 0 to 8): I gave

two crowns a zero—Crown W and Crown Z—because they

have both mesial and distal open contacts. Crown R and

Crown V have one open contact; the others have varying

degrees of contact, from point to concave design.

Occlusion (my scores range from 2 to 8): Crown R was

totally out of occlusion; the others exhibited good centric

contact, but most had lateral interferences.

Shade/vitality/enamel blend (my scores range from 0 to 9):

Most of the samples are too high in value, the chroma varies

from crown to crown and, the lower scoring units—such as

Crown S and Crown Z—don’t represent the requested A3.5

shade at all.

Stain and glaze (my scores range from 0 to 9): Most of the

restorations have a poor and unrealistic-appearing application

of occlusal stain, and some appear overglazed. I gave a

‘0’ to Crown S because it has cracks in the buccal and lingual

surfaces of the porcelain (see photo on opposite page). Crown

W earned a ‘9’ because it is the only one with surface texture.

Metal design/polish (my scores range from 0 to 9): Crown

Z earned the ‘0’ since it did not follow the Rx request for a

metal collar. The highest scores were given to those crowns

that exhibit the narrowest collar at the buccal margin (such as

Crown U).

Accuracy of fit on die (my scores range from 0 to 9): I gave

seven of the nine crowns scores of 2 or less; four of them

received a ‘0’! (The two that fit the best—Crown X and Crown

Y—earned a 9 and 7.5, respectively). To me, this is the most

amazing aspect of the experiment, as the prep is ideal and has

margins that could be read in the dark. Some of the crowns

fit very loosely on the die, others have open margins, short

margins, or over-extended margins that could be easily seen

without any form of magnification!

Final analysis: In my estimation, the clinical acceptability of

Crown X and Crown Y is questionable; the remaining crowns

are, without a doubt, undeliverable.

In all fairness, nine samples don’t constitute an accurate

representation of the work being done by the entire dental

laboratory profession. But doesn’t it seem reasonable to

expect that there would be at least some higher scores than

we see here? Obviously, the laboratories in this experiment

Nine samples don’t constitute an accurate

representation of the work being done by the entire

profession. But doesn’t it seem reasonable to expect

that there would be at least some higher scores?

sent back a product that they felt was an acceptable

restoration. If these restorations are accurate representations

of what they produce on a regular basis, it means their

products are being accepted and delivered on a regular


My greatest concern is not directed at those laboratories in

the experiment, but actually at the level of acceptance that

apparently exists in our profession—a level of acceptance

that is a shared responsibility between the dentist and the



Model &

Die Prep

Anatomy Contours Contacts/


I truly hope that restorative dentistry can remain a respectable

profession rather than becoming strictly a “business

arrangement” between the dentist and laboratory, primarily

based on price and turnaround time. Once we reach that point,

our restorations are nothing more than a manufactured commodity.

Ultimately, it is up to each of us to determine where

we are headed. In what direction do you want to go? Í




Bill Mrazek, CDT, is the owner of Mrazek

Prosthodontics, Ltd. and Mrazek Consulting

Services in Naperville, Illinois. LMT is grateful

to Bill for lending his creative input during

brainstorming for this experiment, as well as

for his technical expertise during its planning

and execution.


Stain &






of Fit

on Die

CROWN R 3.9 1.5 2.9 2.0 1.8 2.8 3.6 4.5 1.5

CROWN S 3.5 4.9 4.5 6.0 5.7 5.1 5.6 6.6 2.6

CROWN T 4.5 5.1 5.0 4.6 4.7 5.4 6.2 6.3 1.5

CROWN U 2.3 2.7 3.0 4.7 3.9 3.6 5.1 3.6 1.9

CROWN V 5.9 5.7 6.0 6.4 5.8 7.0 6.6 6.7 4.0

CROWN W 5.9 4.6 4.5 4.3 5.2 4.4 4.4 5.0 4.3

CROWN X 5.2 3.5 3.1 3.9 3.6 4.0 4.1 5.0 6.7

CROWN Y 4.6 4.5 3.6 3.7 3.2 4.3 4.6 5.0 6.2

CROWN Z 3.4 4.2 4.1 2.7 4.2 4.8 5.6 2.5 3.2

LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007


Dr. Allan Grayson

Dr. Sangeetha Raghavendra

Fred Hornedo, MDT, ATACP,

Dr. Steven Silberg

New York University

LMT went to two prestigious East Coast dental

schools to have the crowns evaluated: New

York University (NYU) and the University of

Connecticut (UCONN). The panel includes

laboratory owners and managers, practicing

dentists and educators:

Gail Broderick, MDT, is the Laboratory Director of

Jason J. Kim Dental Lab, Great Neck, New York. She

is on the board of the Dental Laboratory Association

of New York, and is affiliated with the American

Society of Master Dental Technicians, International

Congress of Oral Implantologists, Alpha Omega

International Dental Fraternity, Northeastern

Gnathological Society, Dawson Center, Occlusal

Concepts Study Club and Six Sigma Greenbelt.

Dr. Buthaina Dashti is an Assistant Clinical

Professor in the Department of Oral Rehabilitation

at UCONN Dental School, where she teaches dental

students and prosthodontic residents. She received

her dental degree in the U.K. and her prosthodontic

degree from the University of Southern California.

Paul Federico, AAS, BS, MDT, owns Federico

Dental Lab, Staten Island, New York, a full service

lab specializing in full mouth rehabilitation. He

is on the faculty of NYU College of Dentistry and

president of the American Society of Master Dental

Technologists. Federico is also the director of

Predictable Restorative Dentistry Seminars and

a member of the Dr. Richard Tucker cast gold

study club.

Dr. Allan Grayson is Clinical Professor of fixed

and removable prosthodontics at NYU College of

Dentistry and maintains a private practice in New

York City. He’s been an educator for 28 years

and this summer will complete the Master Dental

Technologist program.

Fred Hornedo, MDT, ATACP, AAOP, has 28 years’

experience in all phases of laboratory work and is

the manager of Acqua-Dent Dental Laboratory,

Jamesburg, New Jersey. He is an alliance technician

for the American College of Prosthodontists, and

a member of American Society of Master Dental

Technicians and the American Academy of Oral

Facial Pain.

Dr. Sangeetha Raghavendra is an Assistant Clinical

Professor in the Department of Oral Rehabilitation,

Biomaterials and Skeletal Development at

LMT’s Crown Experiment 2007

UCONN School of Dental

Medicine. She also practices

in Chicopee, Massachusetts and is

a Diplomate of the American Board

of Prosthodontics and a Fellow of the

American College of Prosthodontists.

Dr. Patchanee Rungruanganunt is a faculty

member at UCONN Health Center and course director

for the fixed prosthodontics program. She practices

in University Dentists, the dental school’s multidisciplinary

faculty group practice.

Dr. Buthaina Dashti

Dr. Steven Silberg is a Clinical Associate Professor at

NYU College of Dentistry and practices in East Rockaway,

New York. Also a Master Dental Technologist, Dr. Silberg is a

member of the American Dental Association, American

Academy of Fixed Prosthodontics, American Society of Master

Dental Technologists, Academy of General Dentistry (Fellow),

Northeastern Gnathological Society and the Consensus for

Dental Excellence.

Dr. Rachel Squier is an Assistant Professor in the Department

of Oral Rehabilitation, Biomaterials and Skeletal Development at

the UCONN School of Dental Medicine. She practices in University

Dentists, the dental school’s multi-disciplinary faculty group

practice. She is a Diplomate of the American Board of Prosthodontics,

a Fellow of the American College of Prosthodontists and a member

of the International Team for Implantology and the Academy of


Mario Zerillo, CDT, MDT, is the owner of Zerillo Dental Laboratory,

a one-person ceramic lab in Queens, New York and a member of the

American Society of Master Dental Technologists. He got his start in

the industry 20 years ago when studying dental technology at the

George Westinghouse High School in New York and the New York

City Technical College.

Dr. Ira Zinner is a clinical professor at NYU College of Dentistry

and director of its Full Mouth Rehabilitation Program and Masters

of Dental Technology Program. He has a prosthodontics practice

in New York City and is a Diplomate of the American Board of

Prosthodontists; a Fellow of the American College of Prosthodontists,

Greater New York Academy of Prosthodontists and Academy of

Osseointegration; and an honorary Fellow of the New York Academy

of Oral Rehabilitation.

Dr. Rachel Squier

University of Connecticut

Dr. Ira Zinner

Paul Federico, AAS, BS, MDT

Dr. Patchanne Rungruanganunt

Gail Broderick, MDT

Mario Zerillo, CDT, MDT

Title of Article



Mikhail Tkachev

Engineer, Research and Development

Glidewell Laboratories

It must have been something about that visit from the Soviet secret police. Even his top-secret military

clearance couldn’t keep Mikhail Tkachev from coming under suspicion for the simple act of request

ing permission to visit his friend in Poland, and when the men in black suits came to interrogate him

at his Vladikovkas apartment, he knew it was time to take leave of his Mother Russia.

It was a country Mikhail knew well, perhaps too well, having been the second of eight children born to a

father who moved 13 times, by Mikhail’s count, before he was old enough to join the army. There he was

first assigned to a tank unit, but his aptitude with electronics recommended him to special duty building

top-secret devices in a Soviet weapons lab. He soon learned to reverse engineer, repair and improve any

electronic device in the world, a skill that would ironically be put to a positive use, at last, years later at

Glidewell Laboratories.

That journey, from a small town just 15 miles from the now war-torn Chechnya to Orange County,

California, is truly the stuff of Hollywood films.

It took two years from that fateful visit from the secret police, and two major upheavals in the Russian

government, for Mikhail’s desire to emigrate to the U.S. to come to fruition. Now, in 1991, a married man

with a three-year-old daughter and a six-year-old son, he jumped at the opportunity offered by Mikhail

Gorbachev’s bold open-border policy. Mikhail Tkachev (pronounced T’Kah-chow) brought his family to

the U.S. with no money and no English, bearing only the phone number of a friend in Sacramento whose

simple promise of assistance was enough hope for someone seeking a new start in a land of freedom.

But something went awry the moment he and his family set foot in the promised land. A clerical error at

the immigration office in the airport in New York rerouted them to St. Louis, Mo., instead of to Sacramento

where their friend awaited. There they were placed in a boarding house in a rough section of St, Louis,

a town where they knew no one and, indeed, weren’t even quite sure where they were. But a couple of

noisy nights marked by the sounds of nearby fights and robberies quickly told them it was a place they

didn’t want to be.

Amazingly, Mikhail found someone who spoke enough Russian to help him get in touch with his

Sacramento friend, Victor. Victor had driven to the Los Angeles airport

to pick up the Tkachev family only to be left there helplessly

wondering what had happened to them when their plane landed

and they weren’t on it. On receiving the call from his stranded

Russian friends, Victor was stunned by what had happened Í

– ARTICLE by Al Lefcourt

– PHOTOS by Ed Pelissier and Kevin Keithley

Mikhail Tkachev, far left on both photos, the early years (personal collection).

Title of Article

Laboratory Portrait

to them, but having preceded the Tkachevs to America by only three months, he hadn’t enough money

to fly them to California.

Mikhail, ever resourceful, went through his little black book of phone numbers he’d been collecting all

though his immigration process, and called a friend of his brother’s, also from the Russian military and

now in the U.S., and he immediately agreed to loan them some travel money. But the money was just

enough to get them to Los Angeles; someone would still have to drive down to pick them up.

But again fate had other plans. Mikhail’s son, Sergei, got ill on the flight to LA, causing the plane to land in

Phoenix. There the airport medical emergency team flew into a panic; they spoke no Russian, the Tkachevs

spoke no English, and they had on their hands a little boy turning bluer every minute. They called over

the airport PA system for anyone who spoke Russian, and only one person stepped forward: another boy,

a brave little fourth grader who was just beginning to study Russian.

Language turned out to be just one barrier they faced. Mikhail had no knowledge of the American systems

of health care, insurance and credit, and the fourth-grader’s language skills were clearly not up to the task

of explaining it all. Thinking he would have to pay cash for the hospital cash he didn’t have, Mikhail made

a difficult decision. He waited a bit for his son to feel better and asked to resume the flight.

At this point, of course, the airline was concerned about liability for the sick child and made the Tkachevs

sign a medical release form they really didn’t understand. But for them, it was California or bust, so they

were happy just to finally arrive at LAX.

Where yet another disappointment awaited. Their friend Victor’s car had broken down on the way

from Sacramento to Los Angeles, and this time it was the Tkachevs who were left alone and wondering

at the airport.

Mikhail again pulled out his little black book and found a phone number with a Russian name but no

record of who it was or where the number had come from. But, it was a local number and he called it. It

turned out to be a generous and helpful fellow named Peter who’d lived in the U.S. since the age of three

but who spoke fluent Russian. They asked Peter only for help in contacting Victor, but ties to Russia and

the Tkachev’s absurd predicament opened Peter’s heart to house them for two weeks, then bring them to

a place they could rent, and even to loan them enough money to get them started in their new home.

And as unlikely a series of events as this might be, it turned out to be nothing short of miraculous for

Glidewell Laboratories. If Mikhail had managed to get to Sacramento on either of his attempts, he may not

have settled in Los Angeles and may have never brought his considerable talents to the company. And that

would certainly have been a loss not just for Glidewell, but for the dental industry at large.

Mikhail’s first job in America was one of the few things one could do where the boss had only to point

and motion for you to understand what was expected of you: breaking rocks with a sledgehammer at

construction sites. Not the place one would normally expect to find a man with a degree in electrical

engineering. Unwilling to accept a long-term career in rock breakage, Mikhail enrolled in English classes

so he could better his lot.

The teacher was demanding, but hardly as demanding as Mikhail was of himself. He worked and he

schooled, both full-time, determined to get ahead in America. But he wasn’t earning enough to support

his family and his debts, so he started dental technician classes at Pasadena City College (7 a.m. to 5 p.m.,

Mon.-Fri.!) and, on the side, taking in auto transmissions for repair. It was something he could do, and do

well, for much less than a repair shop would charge, because he didn’t have the overhead of a garage.

Which also meant…he didn’t have a garage overhead.

So Mikhail rented workspace when he could, but often he actually had to carry transmission up the stairs

to his apartment to tear them apart and rebuild them. A grueling task he did for five years while he continued

to perfect his English and his dental tech skills, and he now bears the back pain to prove it.

As with everything Mikhail undertakes, he was so good at it, his customers nearly prevented him from

quitting when he was offered a job as an R&D dental technician at Glidewell Laboratories. But he eventually

was able to devote himself full-time to Glidewell, where his new English skills and his old Russian Í

Custom Plastic Injection Mold

This plastic injection mold was needed to make stump sticks inhouse,

rather than purchase them at high cost from dental dealers.

Technicians place an all-ceramic restoration onto the top of the stump

stick, which is colored to imitate the shade of the preparation in

the mouth.

Jar Rolling Mill

This simple Jar Rolling Mill is used during the zirconium oxide ball

milling process. The device can be utilized when the particle size of

zirconium oxide powder needs to be reduced.

Laboratory Portrait

Laboratory Portrait

Pressure Vessel

This is a Pressure Vessel for silicone material injection. Using the

vessel, we create rubber molds, which are then used in the fabrication

of pressable ceramics. This device uses air pressure to force the

otherwise viscous silicone material into a chamber to create the mold.

Today, 40% of the ceramic restorations we fabricate in the laboratory

are pressables, and that number is expected to eventually double.

X, Y Table

This adjustable X,Y Table has a spindle mounted on the top for zirconium

oxide sample preparation.

military engineering training combined to make him an integral part of one of the dental lab industry’s

most advanced commercial R&D departments.

One of the first episodes that brought Mikhail’s talents to Jim Glidewell’s personal attention was the failure

of a critical $30,000 piece of intricate equipment from Germany that would have slowed production of

restorations to a crawl, something that would have been unacceptable to Glidewell, its customers and to

countless patients around the country.

The problem was that the machine’s manufacturer in Germany would take two weeks to get a technician

to California with the proper replacement parts. Not good. Enter Mr. Tkachev with an offer to take

the thing apart, figure out what makes it tick and do whatever it takes to get it back online. Needless

to say, there were those who questioned the advisability of such a course of action, but Mike knew he

could do it-all those years of military training weren’t wasted on him and Jim Glidewell opted to give him

the chance.

Mike worked into the night, eventually isolating the problem to a certain sector of the main motherboard,

which he took home to test with his own special electronic diagnostic equipment. (Best not to ask.) By 4

a.m. he’d tracked the problem to a single chip that he was sure was the culprit.

When businesses opened later that morning, he rushed to an electrical supply shop to get a replacement

chip. “No such thing” he was told by the man behind the counter. “Not in this country.” Turns out he was

right. There was no U.S. equivalent for the German chip used in the machine.

Not to be deterred, Mikhail asked for the catalog to leaf through himself to find something, anything, that

he could use to replace the faulty chip. Finally he found an item that was close enough in function and

size to the original that with some ingenuity and a hot soldering iron he could make it work, whether it

wanted to or not.

Sure enough, before noon that very day, just as Glidewell managers were filing into a meeting where

they’d decide what to do about the calamitous equipment failure, Mikhail was able to send the message

up to the brass: ”The machine is put back together, and it works. It works!”

Mikhail has gone on to devise dozens of ingenious solutions to problems, and new ways to accomplish

old tasks in smarter, more efficient and more economical ways. He’s an important reason Glidewell is the

competitive powerhouse it is, constantly offering its customers new products and better prices.

One such example is the magnetic articulator system marketed by Glidewell Direct. It’s an elegantly simple

solution for dental technicians’ desire to hold impressions securely in place and then remove them quickly,

without having to make a huge investment in a competing system. Yes, it was Jim Glidewell’s idea to

develop such a tool, but it’s Mikhail’s creation, right down to the details of tooling and die-casting.

Of course, being the gentleman he is, Mikhail breaks into his typical bright-eyed, boyish grin when

he discusses the articulator and credits his co-workers and especially Wolfgang Friebauer, the head of

Glidewell’s R&D department, for bringing it into being. He even asked that Chairside deflect credit to his

machinist, Viktor Khivrenko.

Need proof of the Tkachevs’ success in America? Both of their children graduated college at the age of

18. Daughter Alona is now studying nursing at Long Beach State, and son Sergei, who earned a BA from

UCLA at age 21, works at KPMG and is halfway though his CPA exams.

Meanwhile, Vladikavkas remains a small but technically advanced town in the Caucasus Mountains, now

home to the Polymer Research Institute of Electronic Materials, a place Mikhail may have found employment

had he stayed. And had the secret police approved.

Laboratory Portrait

Laboratory Portrait

– INTERVIEW of Alan Budenz, MS, DDS, MBA

by Michael DiTolla, DDS, FAGD

– PHOTOS by Kevin Keithley

After missing a mandibular block a few weeks back, I decided it was time to interview one of my

instructors from dental school who has gone on to become one of the country’s leading authorities

on local anesthesia. Dr. Alan Budenz is an Associate Professor in the Department of Anatomic

Sciences and Chair of the Department of Diagnosis and Management at the University of the Pacific

in San Francisco, CA. By the end of the interview, Dr. Budenz had inspired me to learn at least one

new injection that I wasn’t taught in dental school: the Gow-Gates. As you read the interview you

may find yourself wondering, just as I was, why you are not using this injection on a daily basis. I am

taking a hands-on anesthesia class with cadavers next month with Dr. Budenz and I look forward to

giving my first Gow-Gates on a cadaver and then moving on to live patients the next morning.

20 Questions with Dr. Alan Budenz

Question 1: What’s the most exciting thing to happen in local

anesthesia in the last 5-10 years?

Alan Budenz: There’s been a lot certainly with the advent

of the CompuDent Wand and the Dentsply Comfort Control

syringe. Both are computer controlled devices and more than

ten years old, but still relatively new to the field. I have both

of these devices and they don’t necessarily allow me to do

anything I couldn’t do with a traditional syringe, but what

they do is make the process less taxing, and they let me

administer the anesthetic more consistently, time

after time.

The more slowly it gives the injection

-- particularly if it’s an anes-

t h e t i c

with a vasoconstrictor, because

those are more

acidic and would tend to cause the patient a little more

burning sensation -- and with consistent control, the patient

feels virtually nothing. It’s all about making it more comfortable

for the patient, and it doesn’t hurt that it makes it more

comfortable for yourself as well.

Another exciting development recently is the VibraJect. At first

I doubted it was worth $230 for a little vibrator so I don’t have

to shake the cheek anymore to distract the patient. I thought

there had to be more to it, and I discovered that it’s actually

a very clever device. It gives you a very low level of stimulation

going down to the tip of the needle, and if the needle

is in close proximity to the nerve tissue it will stimulate that

nerve at a low level, which will open up more of the sodium

channels. And it’s the sodium channel opening that allows

the anesthetic to flow in and bind to the receptor sites in the

sodium channels.

Q2: So it’s really more than a comfort and distraction device, it

actually improves the quality of the injection?

AB: Yeah, it’s really not a distraction device at all. It’s not

vibrating where it’s going to distract the patient from the

penetration, particularly. Really, what it is all about is getting

that stimulation to open up the sodium channels. It’ll tend to

give you a more profound anesthesia and potentially less of

that problem where you start to drill on a mandibular molar

and the patient feels it even though when you check with an

explorer, everything appears to be numb. But the patient still

feels it when you root plane or drill because you don’t have

enough of those sodium channels blocked. This device will

reduce the incidence of that. I bring this up not because it’s

the greatest thing in anesthetics, but because it’s a very simple

device with a very brilliant idea behind it – and it works!

But bottom line, the best thing that’s happened in local anesthesia

in the last 5–10 years is Septocaine coming on the U.S.

market in 2000. It’s a really good anesthetic but there are

drawbacks to it. The simple fact that there’s so much controversy

about it has stimulated people to ask so many more

questions about anesthetics and how they give them, that

overall, I think it’s beneficial because people aren’t just taking

everything for granted anymore. Typically people would say “I

use lidocaine for everything except when I can’t use epi, then

I use mepivocaine plain and for long-acting, I use Marcaine.”

It’s made people think about what’s out there, what’s appropriate

to use, what’s safe to use and what technique should

be used with it.

Q3: As a 4% anesthetic, do you avoid giving blocks with it? There’s

some literature about a possible increase rate of parasthesia with


AB: All of the reports I’ve seen are anecdotal. There’s no real

scientific study that shows that absolutely the 4% anesthetics

are the cause of paresthesia, but there’s enough anecdotal

material out there to make me think there is a greater risk of

parasthesia using the 4% solutions, both articaine and prilocaine.

I’m not hesitant to use Septocaine for blocks, when it’s

indicated, except for the inferior alveolar block. I’m extremely

hesitant about Septocaine for that one because we’ve seen

numerous reports that the greatest incidence of paresthesia is

with that injection technique and the 4% anesthetics.

But personally, I don’t choose to give inferior alveolar nerve

blocks the conventional way. I prefer the Gow-Gates technique,

which from all the evidence I can gather is a safer injection

with any solution. I use it on a regular basis.

Q4: Say someone’s been practicing for 15–20 years and has been

giving lower blocks and knows there’s something better but is just

a little nervous about shooting that high with the Gow-Gates versus

the typical target point, what do you think is the best way for a

GP to learn how to do the Gow-Gates technique comfortably?

AB: The ideal way is to go to a hands-on course. Mostly you’ll

find this in a dental school setting, occasionally at a larger

meeting, but that’s pretty rare. Another alterative is to find a

practitioner in your area who knows the technique. A lot of

oral surgeons are familiar with the technique. More recent

dental school grads are more likely to have been taught the

technique. Watch them do it and have them observe you

doing it to give you feedback as you do it. A “study club” setting

like that is the ideal way to do it outside of a dental school

course/CE course. Í

20 Questions with Dr. Alan Budenz

Q 5 : I have seen numbers published on the

mandibular block stating that up to 20% of

blocks are missed on the first attempt. Do you agree

with that?

AB: Yes, but it always seems to go in spurts.

Practitioners tell me, “I can’t miss a block for weeks

and all of a sudden I’m missing every one.” I published

a literature review paper some time ago and the range

I saw was 63% to 86%, with some studies reporting it

into the 90% range. Now that’s with the first injection. But

most of us get it with the second attempt. I think the true

incidence of failed anesthesia is well below 1%. But on the first

attempt, I’d say 15%, plus or minus 5%, is about average.

Q6: One of the most frustrating experiences most of us GP’s have

are with “hot teeth”. Any tips you can give us on accessory innervation

and how to anesthetize these patients?

AB: On a mandible, of course, the number one nerve to anesthetize

is the inferior alveolar nerve, number two is the long

buccal nerve. The long buccal has been shown to have a lot

of accessory innervation to the teeth, particularly the molars.

When you look at the retromolar pad area, there are a lot of

accessory foramina there. You may wonder are they there for

blood vessels, are they for nerves, or are they just air holes?

You cannot tell just by looking at the bone. But there are a

lot of holes there. By doing micro-dissection, the long buccal

nerve is seen to send little branches into the bone. It’s not

just the main pathway like we instructors have always taught.

There are a lot of accessory nerve branches coming off all

along the long buccal pathway.

The number three nerve to anesthetize is the mylohyoid

nerve. In anatomy, we teach that this is a motor nerve to

the mylohyoid muscle at the floor of the mouth and also

out to the anterior belly of the digastric under the chin. What

is not taught from the anatomy literature, is that there are

also pain and temperature fibers in that nerve. And those

pain fibers have been tracked through micro-dissection into

teeth. So yes, it is an accessory nerve pathway. All along

the pathway to the mylohyoid, it is giving off little branches

into the bone and many of those branches are accessory

innervation to teeth.

Q7: I recall being taught that the long buccal just innervated

buccal tissue and for crown preps it was necessary, but only

for soft tissue anesthesia. With all these nerves branching off, it

sounds like nature is not as simple and straightforward as we

want it to be.

AB: Exactly. That is a great summary. We teach the basic nerve

pathways, but we probably don’t do a decent enough job of

teaching that any nerve that exists in the neighborhood of a

tooth is likely to be carrying some accessory innervation to

that tooth. No nerve is purely sensory or purely motor. They

all have a mixture. Some of those fibers are proprioceptive,

but some of those are also primary pain fibers and going to

tooth structures. Unfortunately for us, as dentists and dental

hygienists, we have to be aware of all of the possible nerve

pathways in the oral cavity.

Q8: Say I come to your office and I need crowns on #18, #19 and

#20. Walk us through exactly what you’re going to do in terms of

local anesthesia.

AB: I would start with a Gow-Gates injection. It has the best

likelihood of anesthetizing the inferior alveolar, the lingual,

the long buccal and the mylohyoid nerves all with one injection.

I’ll use a 27-gauge long needle and I’m going to drop

a full cartridge of lidocaine. I could use Prilocaine or

Septocaine if I felt that you were a person who expressed

to me that you were very hard to get numb or you had a

history of getting numb but not staying numb very long, or

had a history of drug abuse. Then I might use one of the

“big boys,” the 4% solutions. Ideally, I’d just use lidocaine

because it’s pretty safe. I find that with the Gow-Gates

technique, I have a good success rate using one cartridge of

lidocaine, in the upper 80s to mid-90% range. Occasionally, I

will need to chase it with a full second cartridge in the same

location. The one nerve that is hardest to get consistently is

the long buccal. So I may sometimes have to inject that separately.

With a Gow-Gates injection, I’ve never had to give a

separate mylohyoid.

If you have a hot tooth, a tooth you’re going to extract or

that you need to do a root canal procedure on because it’s

abcessed, that’s a lot harder to get numb. I’m still going to do

the Gow-Gates and then I might use an intraosseous around

the tooth, or PDL injections to get it. But the Gow-Gates works

well because you’re so high up on the innervation pathway.

You target the anterior-medial aspect of the neck of the condyle.

With the mouth wide open, the condyle translates out

just immediately lateral to the foramen ovale. So you’re right

next to where this whole big nerve trunk is coming in to the

infratemporal fossa. If you drop your anesthetic bolus there

and keep the patient’s mouth wide open – Dr. Gow-Gates recommended

for a full 90 seconds after you finish the injection

— you keep that bolus right there next to the nerve. If there

are any accessory branches coming off of anywhere along the

trigeminal nerve pathways, you’re still catching them right at

the source.

Q9: How long do you wait after a Gow-Gates injection to test

for anesthesia?

AB: Gow-Gates has a slower onset because you’re approaching

such a large nerve trunk. The most peripheral fibers are

going to the back of the mouth. The fibers at the center of

that big nerve bundle are coming out to the tip of the tongue

and the lip, and so you must wait at least five minutes. The

study I like to quote, shows that it’s at ten minutes when the

Gow-Gates injection is really going to give you the absolute

best result. Within the five minute window I should be getting

some signs that the anesthesia has taken effect, and if so

I’m going to wait a little longer and double-check it for signs

of full anesthesia. If I’m not getting signs after 5 minutes,

I may conclude that I’ve missed it and give a second Gow-

Gates injection.

Q10: Some esthetic clinicians are advocating the use of the

Anterior Middle Superior Alveolar injection, the AMSA, because it

numbs all the maxillary anterior teeth. Do you use this injection

if you are working on 8 anterior teeth rather than going around

and giving numerous infiltrations? It seems counter-intuitive,

being a palatal injection. Tell us a little about it.

AB: There are actually two AMSA techniques, a facial approach

and a palatal approach. The palatal injection technique is

actually one that was first described in the 1920s. When

the Wand first came out they really pushed this palatal AMSA

technique but it has never really caught on. The whole principle

of this technique is that rather than doing the standard

facial approach AMSA injection, which is properly called the

infraorbital block injection given on the face just below the

eye, which is a true block, when you do the palatal approach

you’re further down on the pathway of the anterior and middle

superior alveolar nerves, at the junction where the vertical

process of the maxilla meets the horizontal hard palate.

If you take a line perpendicular to the midline palatal raphe

and extend it out to where it meets the two bicuspids halfway

along that line, you’ll be at that junction. Drop your anesthetic

there, a small amount, very slow injection, and you’ll

get anterior and middle superior alveolar anesthesia. Now the

beauty of this injection is that you don’t get lip anesthesia

like you do with the infraorbital, but you do get buccal soft

tissue anesthesia around the teeth. You get palatal, pulpal

and buccal anesthesia so you can do work from the second

bicuspid forward. It might be a little fuzzy at the second

bicuspid because you’re getting a little innervation coming in

from the posterior, the PSA, so I always give a little infiltration

behind there as well. By the way, infiltrations on the maxilla,

pretty much the only thing I’m giving these days is Septocaine.

Lots of times it gives me palatal anesthesia as well buccal.

Not on everybody, but most of the time.

Q11: You’re absolutely right about the Septocaine. It seems as

though I can pack cord on the lingual on nearly everybody without

any problems. Maybe once or twice every couple of months I

am not able to and need to give a little palatal soft tissue anesthesia.

So you like the AMSA injection?

AB: Well, with the palatal AMSA, you’ve got maxillary anterior

anesthesia without having the lip numb, which is helpful

for esthetic dentistry. But there are two drawbacks with it.

One, it’s a palatal injection, so you have to give it real slow

and #2 it doesn’t have as good duration because it’s not a true

block. It’s in between a block and an infiltration. For veneer

cases, where you want to keep the smile line and you’re not

going to be in there very long, it’s a real efficient way to do it.

But if you’re going to be doing crown preps from bicuspid Í

to bicuspid, in my opinion, I’d rather use the infraorbital and

the nasopalatine.

20 Questions with Dr. Alan Budenz

Q12: So you’re going to be giving an infraorbital and a nasopalatine

if you are doing crowns from second bicuspid to second

bicuspid? As opposed to giving 8 infiltrations over those teeth?

AB: Yes. I want blocks. As a rule of thumb a block will give

you twice as long a duration of anesthesia as an infiltration.

That’ll depend a little bit on your anesthetic and other

variables. But if you want hemostasis, if you’re gong to be

doing root planing or surgery or subgingival preps, anything

where you know you’ll be getting some bleeding, I will do

local infiltration using ideally Lidocaine with 1 to 50,000

epinephrine. That one little infiltration will give me a great

deal of hemostasis in a localized site. If I use 1 to 50,000, for

an I.A. block, my anesthesia will be about the same duration

as 1 to 100,000 but it won’t give me good hemostasis. So for

blocks, I want to use as low a concentration of vasoconstrictor

as I can. For example, Septocaine now has the 1 to 200,000

epi solution available and there are a number of studies

now, which are all quite similar, that there is no significant

difference in duration. It’s a little bit shorter duration with

1 to 200,000 than 1 to 100,000, but clinically it’s not really

significant. So why not use the safest one with the lowest

concentration? But if I am going to use it for hemostasis as a

local infiltration, I am going to use the highest one I can get

my hands on.

Q13: I have to tell you that I don’t know any of my friends who

are giving infraorbital injections with a nasopalatine for anterior

crowns like that, I think most of them are still giving 8 infiltrations.

Do you think there are a lot of GP’s using your technique?

AB: No

14: Can you explain to me how exactly you do it? Or do you even

recommend that the average GP does this?

AB: Absolutely, I have no hesitation. So what you do is feel

the lower rim of the orbit. You feel for the lowest part of the

rim, but it’s not right in the center. It is actually more towards

the base of the nose. Drop your finger down 1cm below that

rim and your finger is right over the foramen. And with many

people, if they’re a little bit thin there, you can press and they

can feel a little bit of nerve tingling. So you are right over

the foramen. Keep one fingertip there and I take my other

fingertip, usually my thumb and slide it up into the top of the

maxillary vestibule in the area of the cuspid to bicuspid. That

distance between those two fingertips is going to be the depth

of my penetration of the needle.

Q15: I am doing it on myself as you talk, and it doesn’t feel very

deep. It feels like a quarter inch or a half-inch to me.

AB: Yeah, for most people it’s less than 10mm, less than a

centimeter. So it’s not a big deal. So then I’m going to insert

a needle up into the top of the vestibule paralleling the slope

of the maxillary bone there until I feel that needle right up

underneath my fingertip that’s outside over the foramen.

Q16: So where’s the puncture point in relation to the crowns on

the teeth?

AB: I’m coming in really more over the bicuspids. I use a little

more posterior approach because it’s more comfortable, you

know, away from the midline. The technique I was taught in

school you came in over the lateral to cuspids and that brought

you in close to the base of the nose and patients always feel

that, so you go further posterior and it’s not as sensitive. I’m

coming into the vestibule over the bicuspids and paralleling

the bone until my needle is in about a centimeter so it’s right

up underneath my fingertip. I stop, aspirate, drop my bolus of

anesthetic and then with that same finger that’s been outside

the mouth the whole time, I just massage the bolus into the

foramen. I give the injection with the patient lying down and

I keep the patient lying down. Then that anesthetic is either

going to dissipate into the soft tissue or it’s going to flow

down into that foramen.

Q17: How often do you get a positive aspiration on that infraorbital


AB: Not very often. There are little blood vessels there but

they’re small enough to be of little consequence. And I give it

slowly. I give all my injections very slowly. To me it’s all about

patient comfort, but it’s also about safety. If I see any blanching

there, I’m giving it too fast. I shouldn’t see that.

Q18: So when you successfully give the infraorbital block, what

gets anesthetized?

AB: It’ll anesthetize the lip, the buccal soft tissue, and the

pulps of the anterior teeth cuspid to central. It won’t get

palatal soft tissues and it may or may not get the pulps of the

bicuspids. So I may have to infiltrate over the bicuspids in

some cases, maybe 25% of the time.

Q19: Do you think it’s safe to say that in dental school fifty years

from now or in general practices fifty years from now that the

Gow-Gates might be the routine and the IA blocks kind of the

thing of the past?

AB: It could be, but I honestly don’t think of it in those

terms, Mike, because to me, I want to know as many tricks

as possible, if “tricks” is the right word. No two people are

put together the same and there are always these oddball

situations where it helps to know different techniques. The

conventional IA technique has been around since the 1880’s,

it’s got a good track record. You know, I started using the

Gow-Gates initially because when my regular lower block

didn’t work I wanted a back up technique. And the Gow-Gates

technique usually worked. Then I started reading about it and

I was seeing the higher success rates in the literature and I

thought, if this is so successful, then why don’t I do this all

the time and use the other one, the conventional technique,

just when I need to for an alternative. And so now I almost

exclusively use the Gow-Gates. But I think it’s good to know

all the techniques. That’s my opinion.

And another troubleshooting tip is that, I advocate caution

giving additional inferior alveolar injections if the first one

doesn’t work. If I give an inferior alveolar nerve block conventional

technique, I was taught if you didn’t get it the first time,

to go a little higher and little deeper the second time, and, you

know, it usually worked.

Q20: By higher, by deeper, do you mean to the hub or do you

mean medially versus laterally? What do you mean by deeper?

AB: Well, that’s a great question because you are never quite

sure what people are referring to when they say that’s what

they do. By going a little bit higher I’m talking about a quarter

of an inch at the most higher up on my thumbnail at the

anterior border of the mandible. As far as deeper, what I’m

referring to is a slightly more posterior injection site, not necessarily

going in deeper with the needle because the bone

should still be in the same place, so it’s just that my injection

site is slightly more posterior than my initial one.

But what I’ve found reading the literature is that that higher

and deeper technique also led to increased incidents of positive

aspirations. I don’t really want to be more successful with

anesthesia at the risk of causing more bleeding. And that again

is what led me to look more closely at the Gow-Gates.

I didn’t start out using the Gow-Gates, I started out using

it only for back up and the more I used it the more I got

comfortable with it. Everything points to it being safer, being

more effective, being more efficient, and that’s why I’m a big

believer in it now.

Michael DiTolla: I’ve learned some great stuff today and if we

just inspire one or two people to take a look at their local anesthetic

procedures, and they can add a new technique that will

keep a patient comfortable while they are having dentistry done,

I think we’ve done our job. I look forward to taking

your cadaver course at the CDA meeting,

and thank you so much

for your time today.

AB: My pleasure


I enjoyed talking

with you.

20 Questions with Dr. Alan Budenz

Carpe Diem!


is the time to help patients value the importance of their dental office as their partner for great health

– ARTICLE by Gary Takacs

– PHOTO by Ed Pelissier

Perhaps the biggest challenge we have in the dental

profession is creating value in our patients’ minds for the

services we provide. In the most simplistic sense, patients

accept treatment recommendations and keep their appointments

because they value the care we provide. In the not-sodistant

past, many patients seemed to disconnect their dental

health from their overall body health. That situation is changing


Today, good health is a valued commodity and the great news

is that there is a growing body of evidence that links good

dental health to good overall body health. While this link is

hardy new, what is new is that the general public is beginning

to understand how oral health has a dramatic impact on general

health. As a result, we have a wonderful window of opportunity

to help our patients place greater value on the care we


Let me present some proof of how the public is being educated

about the link between daily. Some of this information is from

the scientific community and some comes from the media.

Recently, I saw a segment on the ABC television show Good

Morning America discussing the link between periodontal

disease and pancreatic cancer. In this segment, Diane Sawyer

and Dr. Timothy Johnson discussed some recent research that

demonstrated a possible connection between perio disease

and pancreatic cancer. At the end of the segment, Dr. Johnson

looked directly into the camera as if he was talking to a

particular person in the audience and said, “So, what does this

mean to you as a viewer. Well, what it means is that if you are

not going to the dentist you need to be under the care of

a dentist because today going to the dentist is not just about

your teeth, it’s about oral health and general health. New

information on the oral-systemic link emerges almost your

total body health.”

I wanted to stand up and cheer!! What a great message for

the public and it was right there on the screen stated by a

respected authority.

Here’s more proof of how this message is spreading to the

public. Colgate-Palmolive is currently running an advertising

campaign with Christie Brinkley as spokesperson, focusing

on educating the public about the link between perio disease

and systemic health. In the ads, she talks about how perio

disease has been linked to heart disease, diabetes, pancreatic

cancer, pre-term low birth weight and other systemic concerns.

On the Colgate website, Brooke Shields is also featured in a

segment discussing the link between dental health and overall

body health.

As another example, the magazine Scientific American recently

published an entire special issue entitled “Oral and Whole

Body Health” with an absolute wealth of information designed

for health care professionals and patients alike.

In the spirit of Dr. Timothy Johnson from Good Morning

America, I’ll ask the question, “So, what does all this mean

to you?” In my opinion, it can be nothing but good news

when we have Diane Sawyer, Christie Brinkley, Dr. Timothy

Johnson, Brooke Shields, at least one major magazine, and

countless other media channels educating the public that

indeed, good oral health may be connected to overall health!

All of this exposure presents a wonderful opportunity to build

value for our role in helping patients become as healthy as


However, I would not suggest sitting passively by and hoping

your patients become educated about the link between oral

health and systemic health. Rather, I’d recommend a proactive

approach where you take the lead in helping your patients make

this connection. Following are three specific recommendations

that will help your office take this proactive approach.

The first recommendation is a very simple one

to initiate, namely, take a blood pressure reading at the beginning

of all exams in your practice. In addition to the value of

the information that you and your patient receive by taking

a blood pressure measurement, this simple step has the

wonderful effect of symbolically connecting the dental visit

with overall health. This simple step will create lasting benefits

in your practice.

The second recommendation is to create a system

for oral cancer screening in your practice. Each year, more

than 30,000 Americans are diagnosed with oral cancer and

Practice Management

some 9,000 people die of this dreaded disease. Early detection

and treatment of oral cancer can reduce the mortality

rate Í dramatically and the dental office should be the first

line of defense in early detection. Most hygienists and dentists

conduct an oral cancer exam as part of the patient visit, yet

many patients have absolutely no idea that they have received

an oral cancer exam.

I have routinely conducted exit interviews with patients and

asked them for their feedback so we can improve the practice.

Among other questions, I ask if they received an oral cancer

screening exam today, knowing full well that one was done.

Many patients respond with an outright, “no” or “I really don’t

know.” If you did the screening and the patient is not aware

of it then you have lost an important opportunity to create

value. Tell your patients you are doing an oral cancer exam;

they will appreciate it and it will reinforce the dental/systemic

health connection.

You should also review the manner in which you do this exam

to be certain it is as thorough as possible. In addition to your

visual and palpitative exam, I would also recommend installing

a system such as the VisiLite process to further enhance

the oral cancer screening system in your practice. Also, let’s

not forget that initiating a system for oral cancer screening in

your office may well result in saving lives.

The third recommendation I have is to revisit

your system for conservative perio therapy and update it to

21st century standards. If you do not have a state-of-the-art

system in your practice for perio diagnosis and treatment,

now is the time to develop one. There have been significant

advances in the science of the diagnosis and treatment of

perio disease in the last few years and most offices could

benefit significantly by reviewing protocols here.

For example, science now provides us with the capability of

conducting a very simple DNA test resulting in the identification

of the specific bacteria causing that patient’s perio disease.

With the identification of the specific bacteria, a proven treatment

regimen can be provided targeting those bacteria. (Visit for more information about this DNA testing

process). This science provides a level of exactness that will

result in improved clinical results in the treatment of perio

disease. As part of your improved system for perio diagnosis

and treatment, set up very specific probing and exam protocols

for all patients and educate the entire team on great verbal

skills to use to educate your patients about perio disease and

how modern treatment can help them become as healthy as

possible. With all the news and coverage about the link

between perio disease and overall body health, you will find

that your patients are more receptive than ever to your education

and treatment recommendations.

Now is an absolutely incredible time to be in the dental

profession! There has never been a better time to educate your

patients and the general public about the importance of how

good oral health is connected to good general health. You are

getting a huge “assist” from the media today about this link

and it is important that you leverage this opportunity to full

advantage. Consider the three recommendations in this article

as a way to take a proactive approach that demonstrates your

interest and commitment to helping your patients become as

healthy as possible. The end result will be that your patients

will place increased value on the importance of their dental

office as a partner in achieving great health.

Author Credit: Gary’s life work and passion is helping dentists and their team members

develop a more profitable and enjoyable practice. He is a sought-after speaker at national

and international dental meetings where his informational courses are often recognized

as the most fun and entertaining courses that attendees have ever experienced.

Gary is also the founder of Ride and Learn, and Race and Learn, perhaps the most

unique continuing education programs in dentistry today. Ride and Learn combines a

Harley Davidson motorcycle tour with dental CE and Race and Learn combines high

Practice Management

Planning the


– ARTICLE by Gerard J. Chiche, DDS

– COVER PHOTO by Kevin Keithley

When the a patient comes to consult for Esthetic Treatment, the consultation

appointment is divided into 1) a conventional evaluation with charting, periodontal,

occlusal and radiographic surveys; 2) diagnostic models and photographs; 3) an

esthetic evaluation involving an esthetic analysis and a focus on the patient’s esthetic


The media image displayed in many advertisements has a very strong influence

in contemporary dental treatment. Increasingly, today’s smile is part of a youthful

dynamic appearance characterized by whiter teeth which often fall beyond the

range of traditional shade guides. To that extent it is possible to identify two types

of patients: “perfect-minded,” and “natural-minded.” Í

Planning the Shade Prescription

Figure 1: Right lateral view of an ideal smile for a

“perfect minded” patient.

Figure 2: Right lateral view of an ideal smile for

a“natural-minded” patient. (In collaboration with

Dr. Basil Mizrahi).

Figure 3: Left lateral view of an ideal smile for a

“natural-minded” patient. (In collaboration with

Dr. Basil Mizrahi).


Patients in the first category will typically

expect maximum regularity and

alignment along with maximum brightness

and a “generally sparkling effect.”.

It will be critical to provide for these

patients a straight dental midline, a

regular smile line, often flatter than the

curvature of the lower lip, symmetric

central incisors, lateral incisors and

canines, along with symmetric gingival

margins. (Fig. 1, right lateral view of an

ideal smile for a “perfect minded” patient).


Natural-minded patients will typically

expect a general sense of regularity and

alignment along with definite brightness,

but do not wish their teeth to be

noticed at every turn. In any pleasant

smile, pleasing tooth symmetry is found

close to the midline, therefore the central

incisors must be mostly symmetric

with only minor irregularities (a central

incisor may be more mesially inclined

than the other, and the distal incisal

angle of the central incisors may be

bilaterally asymmetric). The main asymmetry

will be provided between the lateral

incisors. The canines will also provide

minor asymmetry as their gingival

margins and their cusp tips do not need

to be leveled horizontally. The depth

of the incisal embrasures should be of

a natural depth in addition to providing

a natural progression (Figs. 2 and 3).

These pictures also illustrate the need to

provide these patients with subtle polychromatic

effects: incisal halo, streaks

and increased cervical saturation.

When planning the shade prescription, one must bear in mind that the most frequent

shade variation from the basic shade of an anterior tooth is observed in nature at

the incisal third. The next most frequent category observed is when the shade distribution

is nearly uniform, resulting in a monochromatic appearance. In the third

category, the color deviation from the basic shade is observed at the cervical third

mostly, and finally in the fourth group, the shade variation involves the middle

aspect of the tooth.

In order to give the patient an idea of what incisal effects are possible, the incisal

aspect of the shade tab is discussed with the patient after the basic shade is selected.

The patients’ reaction usually is to prefer incisal effects similar to the shade tab if

they are natural- driven, and to attenuate the effects to the maximum if they are


There are three typical scenarios that may be transmitted to the dental ceramist:


Lightly Monochromatic

Figure 4

Shade Design

Figure 5

It is very common to find patients who are so displeased by the dark appearance

of their teeth that they end up requesting very monochromatic and high brightness

restorations (Fig. 4, 5). The shade prescription is accordingly straightforward and

uncomplicated and the dental ceramist will assume that the incisal effects are very

tenuous and hardly noticed. Í

Planning the Shade Prescription

Planning the Shade Prescription


Lightly Polychromatic

Shade Design

Figure 6

Figure 7


Lightly Monochromatic

Shade Design with


Figure 8

Figure 9

There are situations where several shades and various degrees of discolorations

coexist in the same mouth. Also, there are situations where different ceramic systems

are present and do not perfectly match with one another.

In such situations, the rule is to assure for maximum patient’s acceptance of the

restorations that by keeping the central incisors at a slightly higher value than the

other anterior teeth. If the value of the central incisors ends up a slightly lower

value due to some excessive translucency for example, then it is very likely that the

patient will reject the final result, even with the best designed proportions, display

and length. Therefore, in situations where the patient desires a natural appearance

or when several different colors or ceramic systems are expected in the final outcome,

a lightly polychromatic system should be considered.

Typically, a mild transition in shades will be produced whereas the central incisors

have the highest value, followed by the lateral incisors and finally the canines.

Whenever possible, this effect should be very soft. However, it allows for an easy

transitions from a light central incisor to a dark canine which was not bleached (Figs.

6 and 7). It is very important in such transitions to keep the value of the lateral incisor

closest to the central incisor even if the canine is of a much lower value.

The typical incisal effects found on unworn incisors include: 1. Halo effect;

2. Transparent incisal Border; 3. Dentin Streaks or mamelons; and 4. Proximal

translucency (Figs. 8 & 9). These are the typical shading effects young unworn

incisors have, imparting a very pleasing effect to the tooth shade overall. The

incorporation of these effects for the natural-driven patients yields the above shade

prescription. It is recommended that the clinician provides in such situations the

same template each time so that nuances and variations recorded from patient to

patient may be more easily interpreted.

Fig. 2, 3, 6, 7, 8, and 9 are reproduced from the textbook by Chiche G., Aoshima H.: Smile Design. Quintessence Pub.

Co. Inc. Chicago 2005.


1. Mc Lean, JW.: The Science and Art of Dental Ceramics. Louisiana State University School of Dentistry, Monographs

I and II, (1974) III and IV (1976)

2. McLean JW.: The science and art of dental ceramics. Quintessence Pub. Co. Inc. Chicago 1980.

3. Sproull R.C.: Color matching in dentistry. Practical applications of the organization of color. J. Prosthet. Dent.


4. Jinoian V.: The importance of proper light source in metal Ceramics. In: Preston J.D.: Perspectives in Dental ceramics.

Proceedings of the Fourth International Symposium on Ceramics. pp 229. Quintessence Pub. Co. Inc. 1988,


5. Hegenbarth E.A.: The Creative Color System. Quintessence Pub. Co. Inc. 1989, Chicago.

6. Miller L.L.: Scientific approach to shade matching. In: Preston J.D.: Perspectives in Dental ceramics. Proceedings

of the Fourth International Symposium on Ceramics. pp 193. Quintessence Pub. Co. Inc. 1988, Chicago.

7. Nakagawa Y. at al.: Analysis of natural tooth color. Shikai Tenbo 46;527;1975

8. Sekine M. et al.: Translucent effects of porcelain jacket crowns. 1. Study of translucent patterns in the natural teeth.

Shika Giko 3:49;1975.

9. Chiche G., Pinault A.: Esthetics of Anterior Fixed Restorations. Quintessence Pub. Co. Inc. Chicago 1994.

10. Chiche G., Aoshima H..: Smile Design. Quintessence Pub. Co. Inc. Chicago 2005. Consultant Noritake co.

Planning the Shade Prescription

Planning the Shade Prescription

Lip Lines and

Spider Lines

– ARTICLE by Bradley Evans, MD, DDS, MS

– Images courtesy of Medical Matrix, LLC

Facial Correction without Injection:

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