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Chairside Magazine Volume 2, Issue 1 - Glidewell Dental Labs

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APRIL 2007<br />

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

A Publication of <strong>Glidewell</strong> Laboratories • <strong>Volume</strong> 2, <strong>Issue</strong> 1<br />

No-Prep vs. Minimal-<br />

Prep Veneers<br />

On the Same Patient<br />

One-on-One<br />

With Dr. Michael DiTolla<br />

CHAIRSIDE VOL. 2 ISSUE 1<br />

Is the Wide Range in<br />

Crown Fees Justifiable?<br />

According to<br />

Dr. Gordon Christensen<br />

Lab Management Today’s<br />

Crown Experiment 2007<br />

Does Higher Lab Fee Guarantee Higher Quality?<br />

Dr. Michael DiTolla’s Clinical Tips


Contents<br />

7 Dr. DiTolla’s Clinical Tips<br />

In this month’s Clinical Tips article, Dr. DiTolla<br />

describes two topical anesthetics that he finds extremely<br />

helpful for a number of clinical situations. He also looks<br />

at two new burs that will greatly increase the efficiency<br />

of your clinical dentistry.<br />

11 No-Prep vs. Minimal-Prep Veneers on the<br />

Same Patient<br />

Meet a patient willing to have no-prep veneers placed,<br />

removed with a laser, and then have minimal prep<br />

veneers placed. This fascinating case highlights the<br />

sometimes subtle differences between these two veneer<br />

modalities.<br />

19 Photo Gallery: BioTemps Provisional<br />

Restorations<br />

In this Photo Gallery, we show many examples of the<br />

different clinical problems that can be solved with<br />

BioTemps provisional restorations.<br />

7<br />

24 Is the Wide Range in Crown Fees<br />

Justifiable?<br />

We are privileged to have Dr. Gordon Christensen<br />

weigh in on the topic of crown fees. If you have ever<br />

wondered why one doctor charges $1200 for a crown<br />

and another charges $800 for a crown from the same<br />

lab, you will enjoy this article.<br />

29 Lab Management Today’s<br />

Crown Experiment 2007<br />

This is an experiment many of us always wanted to do<br />

and thanks to LMT, its now been done. They were generous<br />

enough to let us republish this fascinating look<br />

into the relationship between crown fee and crown<br />

quality. As you will see, you may not always get what<br />

you pay for.<br />

11<br />

Cover photo by Kevin Keithley<br />

Illustration by Wolfgang Friebauer, MDT


Editor’s Letter<br />

Publisher<br />

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

Contents<br />

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

satisfaction and comfort as our injections? Early in my career I learned first hand<br />

how important a painless injection could be. When I graduated from dental school at<br />

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

I came back to Southern California after graduation I practiced with my father for<br />

the first 3 years of my career, still one of the most rewarding professional experiences<br />

I have had.<br />

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

I would do the examination and the patient would go to the front desk to schedule<br />

the appointment, and would schedule the two crowns with dad rather than me.<br />

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

dental armor: his injections.<br />

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

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

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

win over the doubters, who were stuck having to have their broken tooth prepped<br />

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

sophomoric: I found it worked as well on patients as it did on my dental school<br />

roommates coffee cup rim. What other dental product opens the door to so many<br />

practical jokes?<br />

I began to brag to patients I could give them a practically painless injection, and it<br />

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

levitation-free procedure. However, painless anesthesia technique does not necessarily<br />

equal profound anesthesia technique, and I believe as dentists we owe it to the<br />

profession and to our patients to continue to search for better techniques to make<br />

dentistry more effective and compassionate.<br />

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

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

we have made it this far in our careers without it does not mean we should stop<br />

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

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

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

especially for free dentistry!<br />

Sincerely,<br />

Associate Publisher<br />

Jim Shuck<br />

Mike Cash, CDT<br />

Creative Director<br />

Rachel Pacillas<br />

Clinical Editor<br />

Michael DiTolla, DDS, FAGD<br />

Coordinator<br />

Lindsey Lauria<br />

Designers<br />

Jamie Austin<br />

Eric Chou<br />

Deb Evans<br />

Phil Nguyen<br />

Gary O’Connell<br />

Rachel Pacillas<br />

Ty Tran<br />

Copy Editors<br />

Lindsey Lauria<br />

Al Lefcourt<br />

Gary O’Connell<br />

Photo Editors<br />

Jamie Austin<br />

Eric Chou<br />

Deb Evans<br />

Phil Nguyen<br />

Rachel Pacillas<br />

Ty Tran<br />

Photographers<br />

Kevin Keithley<br />

James Kwasniewski<br />

Ed Pelissier<br />

Illustrator<br />

Wolfgang Friebauer, MDT<br />

38 Laboratory Portrait: Mikhail Tkachev<br />

Meet Mike Tkachev, an engineer in the <strong>Glidewell</strong><br />

Laboratories Research and Development department. He<br />

shares with us his amazing story of how coming from<br />

the former Soviet Union, he landed in Newport Beach,<br />

California and how his previous experience in the<br />

Soviet Army building top secret devices helps him in his<br />

work today.<br />

44 One-on-One with Dr. DiTolla<br />

In this ongoing series, Dr. DiTolla tackles local anesthesia<br />

issues with one of the country’s leading authorities,<br />

Dr. Alan Budenz. Dr. Budenz sheds some light on a<br />

new mandibular block technique that may convince you<br />

to give up your standard inferior alveolar block.<br />

52 Carpe Diem: Now Is the Time to Help<br />

Patients Value the Importance of<br />

Their <strong>Dental</strong> Office as Their Partner<br />

for Great Health<br />

Gary Takacs explains why now is the perfect time to<br />

inform your patients on how oral heath is related to<br />

overall heath. He provides us with a few examples of<br />

how he thinks this doctor-patient communication can<br />

be easily initiated during your patient’s appointment.<br />

57 Planning the Shade Prescription<br />

One of the country’s leading authorities on esthetic<br />

fixed restorations, Dr. Gerard Chiche, shares with us his<br />

method for shade determination and characterization.<br />

62 Facial Correction without Injection:<br />

Angellift ® Pricing and Technology Update.<br />

The newest addition to the Angellift family of products,<br />

Preview ® , is introduced in this article. This chairside<br />

tool will help to demonstrate the effectiveness of the<br />

Angellift device and to help patients decide if this<br />

product is for them.<br />

38<br />

4<br />

44<br />

Dr. Michael DiTolla<br />

Clinical Editor<br />

chairside@glidewell-lab.com<br />

Editor’s Letter<br />

Contents


Contributors<br />

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

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

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

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

continuing education throughout the world and has published many articles and books. Gordon and Dr. Rella<br />

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

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

CRA Newsletter. Gordon is a practicing prosthodontist in Provo, Utah. Contact PCC at 800-223-6595, or e-mail<br />

info@pccdental.com. For more information, visit www.pccdental.com. Contact Scottsdale Center for Dentistry at<br />

scottsdale@pccdental.com or 866-921-7111.<br />

Gary Takacs<br />

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

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

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

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

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

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

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

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

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

com.<br />

Michael DiTolla, DDS, FAGD<br />

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

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

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

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

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

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

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

e-mail him at chairside@glidewell-lab.com or call 800-854-7256.<br />

Gerard J. Chiche, DDS<br />

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

University School of Dentistry. He has given numerous programs nationally and internationally and holds memberships<br />

in the American College of Dentists, the American Academy of Esthetic Dentistry, the American Academy of<br />

Fixed Prosthodontics, the American Academy of Restorative Dentistry and the Omicron Kappa Upsilon <strong>Dental</strong> Honor<br />

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

Pinault and Hitoshi Aoshima the author of the textbooks Esthetics of Anterior Fixed Restorations and Smile Design:<br />

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

at the Pankey Institute, he is the recipient of the 2003 LSUSD Alumnus of the Year Award and the recipient of the<br />

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

Alan W. Budenz, MS, DDS, MBA<br />

Dr. Budenz is Professor in the Department of Anatomical Sciences and the Department of Diagnostic and Emergency<br />

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

lectures on Surgical Head & Neck Anatomy and orthognathic surgery to Oral & Maxillofacial Surgery Residents<br />

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

experience in head and neck anatomy, dissection, and nerve tract identification, and has lectured nationally on<br />

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

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

Bradley Evans, MD, DDS, MS<br />

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

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

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

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

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

Rowan and a daughter Oona.<br />

Contributors<br />

Contributors


Dr.DiTolla’s<br />

CLINICAL TIPS<br />

PRODUCT.............. Profound Lite<br />

CATEGORY........... Topical Anesthetic<br />

SOURCE................ Steven’s Pharmacy, Costa Mesa, CA<br />

1-800-352-DRUG<br />

Since I switched to Profound Lite, I no longer see the tissue<br />

dehydration I did before, and the patients still don’t feel<br />

the penetration of the needle. It is an incredibly strong<br />

topical anesthetic.<br />

I have written before about how Profound has allowed me to<br />

do lots of gingival recontouring and other soft tissue procedures<br />

without the need for local anesthesia. Profound has also<br />

allowed me to almost entirely eliminate lower blocks from my<br />

day-to-day practice. I noticed that I could squirt it into the<br />

furcation of a lower molar, wait 60 seconds and then slowly<br />

inject one-half to two-thirds of a Septocaine carpule into the<br />

furcation and achieve instant pulpal anesthesia without any<br />

tongue or cheek numbness.<br />

I became a hero to my patients for avoiding painful blocks and<br />

not numbing half of their lower jaw for 3 hours!<br />

Like many dentists, I began to use Profound for many more<br />

clinical uses, as well as in my hygiene rooms. When I began<br />

using it in the vestibule as a pre-injection topical, I noticed<br />

that the patients felt no pain at all! My technique is to leave<br />

the Profound on for 60 seconds, rinse it off, and then pierce<br />

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

– PHOTOS by Kevin Keithley<br />

– ILLUSTRATIONS by AXIS <strong>Dental</strong> Corporation<br />

the mucosa with the 30-gauge needle as I pull the tissue taut.<br />

They simply do not feel the needle anymore!<br />

However, I also noticed that if I didn’t rinse it off completely,<br />

some patients would experience a dehydration of the tissue<br />

that would result in a white patch on the tissue. I called the<br />

pharmacy to talk about this reaction and they were surprised<br />

to hear that I was using it in the vestibule.<br />

The strength of Profound had been based on doing laser surgery<br />

without a local, not as a pre-injection topical. So with<br />

dentists like me in mind, they formulated Profound Lite. For<br />

those of us who use it more for pre-injections than for laser<br />

surgery, it still has the same powerful combination of prilocaine,<br />

lidocaine and tetracaine as Profound, but the ratios<br />

have been adjusted to make it friendly to all oral tissues.<br />

Since I switched to Profound Lite, I no longer see the tissue<br />

dehydration that I did before, and the patients still don’t<br />

feel the penetration of the needle. I keep a tube of original<br />

Profound in each operatory for the gingival recontouring<br />

touch-ups that seem to pop up in almost all of our esthetic<br />

cases. My dental assistant also uses it on the lingual tissue<br />

when the patient can feel the cord packing since we prefer not<br />

to give palatal injections if we can avoid it.<br />

Profound and Profound Lite are both available in 30 or 45<br />

gram tubes. My staff then dispenses some of the topical into<br />

Ultradent syringes with disposable 18-gauge tips for injecting<br />

into molar furca and gingival sulci. The rest of the topical<br />

stays in the original tube to be dispensed onto cotton-tipped<br />

applicators for use as a pre-injection topical.<br />

Do yourself (and your patients!) a favor by using Profound<br />

Lite to drop the pain from your injection technique! Í<br />

Dr. DiTolla’s Clinical Tips


Dr.DiTolla’s<br />

CLINICAL TIPS<br />

Dr.DiTolla’s<br />

CLINICAL TIPS<br />

PRODUCT.............. Cyclone/Cyclone DS<br />

CATEGORY........... Topical Anesthetic<br />

SOURCE................ Steven’s Pharmacy, Costa Mesa, CA<br />

1-800-352-DRUG<br />

PRODUCT.................................Zir-Cut<br />

CATEGORY..............................Carbide Bur<br />

SOURCE...................................AXIS <strong>Dental</strong>, Coppell,<br />

TX<br />

Zir-Cut burs are absolutely necessary when replacing<br />

zirconia-based restorations.<br />

New from Axis <strong>Dental</strong> are Zir-Cut burs, filling a need just<br />

recently created. It’s a huge time-saver, too. Zirconia-based<br />

restorations entered the market a few years ago and are now<br />

hitting their strides. Two of the newer systems (LAVA from<br />

3M ESPE and Prismatik CZ from <strong>Glidewell</strong> <strong>Labs</strong>) are so strong<br />

that nothing will cut efficiently through their zirconia substructures.<br />

Enter the Zir-Cut burs, absolutely necessary when<br />

replacing these all-ceramic, cementable restorations.<br />

Even if you aren’t placing zirconia restorations (which I now<br />

do routinely), one day you will have to take off a zirconia<br />

crown placed by another dentist, and you’d better have some<br />

Zir-Cut burs on hand!<br />

PRODUCT.................................Razor<br />

CATEGORY..............................Carbide Bur<br />

SOURCE...................................AXIS <strong>Dental</strong>, Coppell,<br />

TX<br />

This amazing new bur will fly through both porcelain and<br />

metal on any PFM with no problem.<br />

The new Razor carbide bur from Axis <strong>Dental</strong> is a huge time<br />

saver! This amazing bur will fly through porcelain and metal<br />

on any PFM with no problem. I used to use an old diamond<br />

to cut through the porcelain and then would switch to a 57 or<br />

557 bur to cut through the coping. In addition to having these<br />

burs snap far too often, the chatter they would make as they<br />

cut through the metal was horrible!<br />

In contrast, a new Razor will fly through the porcelain and<br />

continue straight through the metal with no chatter at all. On<br />

certain cases (usually those with semi-precious or high-noble<br />

substructures), I have used the same Razor bur to remove 4 or<br />

5 entire crowns. Just order a couple of them in the 57 size and<br />

shape and you will see what I mean, especially if you have an<br />

electric handpiece like I do.<br />

We offer Cyclone DS to almost anyone having something<br />

done who is not getting local anesthesia.<br />

If you can remember about 10 years ago, there was a<br />

product named Dyclone, which was a topical anesthetic in<br />

liquid form that patients could swish with for one minute<br />

to anesthetize gingival and palatal tissues. It was fantastic<br />

for hygiene patients who need some anesthesia, but don’t<br />

want local infiltrations or blocks. It also worked well for<br />

needle-phobic sensitive hygiene patients, and for patients<br />

who gag during impressions. I searched the FDA database<br />

and found that the company decided to stop producing for<br />

their own reasons. The FDA verified that it had nothing to<br />

do with the safety or efficacy of the product.<br />

Steven’s Pharmacy’s replacement product is called Cyclone<br />

and it is available in the original strength that we used to<br />

use, 0.5%, and also in a double-strength solution called<br />

Cyclone DS that is a 1.0% solution. We have settled on<br />

the Cyclone DS as our choice because we have noticed<br />

no difference between the two solutions, except that the<br />

Cyclone DS works better on most patients.<br />

We use it on anyone who is worried about having impressions<br />

taken, whether it is for Invisalign or bleaching trays<br />

or even just study models. We use it on full arch crowns<br />

and bridge impressions when we are worried about the<br />

patient gagging while we try to capture the detail of multiple<br />

preps. We will even use it prior to taking our digital<br />

x-rays on patients who are worried about gagging.<br />

On the hygiene side, we use it for periodontal probing for<br />

patients with inflammation as well as for gross debridement<br />

patients who are sensitive. We see a lot of patients<br />

who are overdue for hygiene but do not need scaling and<br />

root planing. Since we typically only use local anesthetic<br />

for our root planing patients, Cyclone helps fill the gap by<br />

being an easy-to-use topical that provides peace of mind<br />

for the patients.<br />

The bottom line is that we offer Cyclone to almost anyone<br />

having something done who is not getting local anesthesia.<br />

We do not charge for this service, although there are<br />

dentists who have told me that they charge a small fee for<br />

it (typically $5.00) and that patients are happy to pay it.<br />

We don’t charge for local anesthetic, of course, and we feel<br />

that this falls into the same category.<br />

Dr. DiTolla’s Clinical Tips<br />

Dr. DiTolla’s Clinical Tips


No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

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

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

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

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<br />

the esthetic results that can be achieved with both types of veneers.<br />

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

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

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

times it is these factors that determine which set of restorations look better.<br />

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

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

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

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

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

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

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

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

away within the first few weeks.<br />

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

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

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<br />

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<br />

come close.<br />

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

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

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

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

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

taking advantage of the highest bond strength in dentistry.<br />

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

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

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

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

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

with that esthetic result.<br />

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

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

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

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


No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

Figure 1<br />

Figure 2 Figure 3<br />

Figure 5<br />

Figure 6 Figure 7<br />

Figure 4<br />

Figure 1: Greg’s Pre-Operative Smile<br />

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

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

teeth become apparent.<br />

Figure 2: Facial View of Pre-Operative Smile<br />

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

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<br />

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

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,<br />

but that would leave these other teeth with clinical crowns that were too long.<br />

Figure 3: Right Lateral View of Pre-Operative Smile<br />

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<br />

an excessively large incisal embrasure between them in addition to a small diastema.<br />

Figure 4: Left Lateral View of Pre-Operative Smile<br />

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,<br />

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<br />

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

Figure 8<br />

Figure 5: Greg’s Smile After No-Prep Veneers<br />

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

patients, being happy with their anterior teeth leads to more natural smiles.<br />

Figure 6: Facial View of Post-Operative No-Prep Veneer Smile<br />

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

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

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

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

only time I see this happen is when the FLF tooth is lengthened by the ceramist.<br />

Figure 7: Right Lateral View of Post-Operative No-Prep Veneer Smile<br />

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

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<br />

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

has also been corrected.<br />

Figure 8: Left Lateral View of Post-Operative No-Prep Veneer Smile<br />

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

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

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<br />

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

to treatment, as it blends in reasonably well. Í<br />

No-Prep vs. Minimal-Prep on the Same Patient<br />

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


No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

Figure 9<br />

Figure 10 Figure 11<br />

Figure 9: Facial View of No-Prep Veneer Removal<br />

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

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

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

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

Figure 10: Close-Up View of No-Prep Veneer Removal<br />

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

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

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<br />

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

Figure 11: Facial View After Removal of No-Prep Veneers<br />

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

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<br />

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<br />

absolutely had to. Í<br />

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


No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

No-Prep vs. Minimal-Prep Veneers on the Same Patient<br />

Figure 13 Figure 14<br />

Figure 12<br />

Figure 15<br />

Figure 12: Greg’s Smile After Minimal-Prep Veneers<br />

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

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

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

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

tooth vitality.<br />

Figure 13: Facial View of Post-Operative Minimal-Prep Veneer Smile<br />

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

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

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

Figure 14: Left Lateral View of Post-Operative Minimal-Prep Veneer Smile<br />

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.<br />

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

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

it appear more like a tooth and less like a restoration.<br />

Figure 15: Right Lateral View of Post-Operative Minimal-Prep Veneer Smile<br />

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<br />

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

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

Figure 16 Figure 17 Figure 18<br />

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

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

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

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

did have a preference for the no-prep procedure over any preparation.<br />

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

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<br />

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

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

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.<br />

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

them and then help them to make their own decision.<br />

To watch the video of this entire procedure, visit the <strong>Glidewell</strong> Online Case Study website at: http://www.glidewell-lab.com/<br />

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

Minimal-prep Veneers on the same patient.<br />

No-Prep vs. Minimal-Prep on the Same Patient<br />

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


Correcting Esthetic and<br />

Functional Problems with the U se of...<br />

BioTemps Provisional Restorations<br />

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

– PHOTOS by Ed Pelissier and Michael DiTolla, DDS, FAGD<br />

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

This is surprising considering that it is a provisional restoration, but provisionals play such a<br />

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

to ovate pontic development, BioTemps are the ideal soft tissue template for shaping gingival<br />

tissues to match your esthetic requirements. From restoring vertical dimension to withstanding months<br />

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

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

uses you may have found for these versatile provisional restorations . Í<br />

Photo Gallery: BioTemps Provisional Restorations


CASE A<br />

CASE D<br />

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<br />

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

resorbed area and permit a smile that would show her teeth.<br />

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.<br />

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<br />

final restorations matched the size and shape of the BioTemps.<br />

CASE B<br />

CASE E<br />

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<br />

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

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<br />

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.<br />

CASE C<br />

CASE F<br />

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<br />

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<br />

appointment and to act as a template for final restorations.<br />

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

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

floss.<br />

Photo Gallery: BioTemps Provisional Restorations<br />

Photo Gallery: BioTemps Provisional Restorations


CASE G<br />

CASE H<br />

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

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

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<br />

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

Clinical dentistry by Michael DiTolla, DDS, FAGD. BioTemps by <strong>Glidewell</strong> Laboratories.<br />

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<br />

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<br />

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<br />

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,<br />

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<br />

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

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

Photo Gallery: BioTemps Provisional Restorations<br />

Photo Gallery: BioTemps Provisional Restorations


LMT ® ’s Crown Experiment 2007: <br />

“NOT IN MY MOUTH!”<br />

Identical impressions were sent anonymously to nine different laboratories.<br />

The resulting crowns were evaluated by a panel of<br />

highly trained dentists and dental technologists. Every<br />

one of them resoundingly said: “I wouldn’t want<br />

any of these in my mouth.”<br />

Reprinted with permission from LMT ®<br />

Communications, Inc. Copyright © 2007.<br />

Visit www.lmtcommunications.com<br />

T<br />

he evaluators—as well<br />

as LMT—were surprised by the<br />

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

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

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

Jersey.<br />

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

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

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

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

any bevels or closing angles to keep saliva out and prevent decay.”<br />

The technicians on the panel were especially bothered by what appeared to be a<br />

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

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

evaluator Gail Broderick, MDT, laboratory director for Jason J. Kim <strong>Dental</strong> Laboratory, Great Neck, New York.<br />

EXPERIMENT DETAILS<br />

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

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

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

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

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

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

the bread-and-butter work of most C&B departments and laboratories.<br />

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

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

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<br />

turnaround time was 12 days. Í<br />

nce the crowns arrived at LMT, all the casts, dies and<br />

crowns were marked with coordinating colors and<br />

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

evaluators.<br />

LMT then brought the crowns to two prestigious East Coast<br />

LMT’s Crown Experiment 2007


“NOT IN MY MOUTH!”<br />

Odental schools—New York University (NYU) and the University<br />

of Connecticut (UCONN)—to have them evaluated by a<br />

panel of technicians and dentists; one of the dentists is also<br />

a master dental technician. (See Meet the Evaluators on<br />

page 36.) They were asked to rate each crown in nine<br />

categories: model and die prep, anatomy, contours, contacts/<br />

embrasures, occlusion, shade/vitality/enamel blend, stain and<br />

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

(Because LMT wanted to eliminate the variable of impressiontaking<br />

and focus solely on laboratory techniques, the fit of<br />

each crown on the Dentoform was not scored.) The scoring<br />

system is based on a 0 to 10 scale, with 0 being “unacceptable”<br />

and 10 being “excellent.”<br />

“Why are we seeing such sloppy model work and<br />

presentations? It seems as though some of these<br />

technicians were just going through the motions.”<br />

-Gail Broderick, MDT<br />

LMT recognizes the limitations of this study and is not<br />

portraying it as a scientific experiment or implying that the<br />

work being evaluated here is necessarily representative of<br />

the entire industry. Rather, the experiment is a rare opportunity<br />

to get an inside look at the work being done in other<br />

laboratories, and to juxtapose it with the fees these labs are<br />

charging for their level of quality.<br />

OBSERVATIONS<br />

1. The lowest scores are for the accuracy of fit on the die. Even<br />

the first-place crown received a 4.0 on the 0 to 10 scale in<br />

that category; the average score for fit for all the crowns is<br />

only 3.5.<br />

Some evaluators commented that the type of shoulder prep<br />

used by the dentist who helped with the experiment may<br />

have inhibited a good fit, but others felt it is a real-world<br />

prep, similar to those often done by general dentists and<br />

that it has nice, clear margins. In the end, though, the real<br />

concern is each laboratory’s inability to make a restoration<br />

that doesn’t rock or rotate on the die. “No matter what the<br />

prep is like, these crowns should fit better than they do,”<br />

said evaluator Mario Zerrillo, MDT, owner of Zerillo <strong>Dental</strong><br />

Laboratory, Queens, NY.<br />

2. The crowns that were fabricated outside of the United States<br />

are on par with the ones fabricated inside the country (the<br />

foreign crowns placed 5th, 6th and 7th among the nine restorations).<br />

In fact, the average overall score of the foreign<br />

crowns is 4.2 and the average for the domestic crowns is<br />

4.4. While both of these scores reflect dissatisfaction among<br />

the evaluators, they show that the quality of the foreign<br />

crowns in the experiment is comparable to that of the<br />

domestic ones.<br />

3. What was most surprising about the individual crowns is<br />

that the most expensive one in the group—in the $180<br />

to $190 range—was rated to be the worst. Although the<br />

geographic area in which the laboratory is located tends<br />

to have higher prices, it was still shocking that—even on a<br />

bad day—a crown in this price range would rate 2.8 on a<br />

scale of 0 to 10.<br />

What surprised LMT most about the individual crowns<br />

is that the most expensive one in the group—in the<br />

$180 to $190 range—was rated to be the worst.<br />

4. Overall, the technician-evaluators gave scores that are an<br />

average of one point lower than the dentist-evaluators<br />

(3.6 compared to the average dentist score of 4.5). It’s<br />

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

be nine crowns in the experiment without having to put a live patient through<br />

nine impressions. The dentist-consultant modified the Dentoform so that it<br />

appeared more lifelike; he then prepared tooth #14 with a shoulder preparation,<br />

took nine full-arch impressions of the Dentoform and sent each one to a<br />

different laboratory with an identicalprescription.<br />

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

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

logical that the technicians—being professionals in dental<br />

prosthetics—would have a more technically critical<br />

perspective. Still, it’s the dentist who is making the final<br />

decision about whether a restoration is suitable to be placed<br />

in a patient’s mouth.<br />

Although all of the dentist-evaluators said they would<br />

reject every crown if it was returned to them, some acknowledged<br />

there are dentists who would consider at least a few<br />

of these units to be clinically acceptable. And that’s the reality:<br />

since quality is so subjective, what constitutes an acceptable<br />

crown is going to differ from one individual to another.<br />

That’s evident even in the context of the experiment: the<br />

scores the evaluators gave Crown U in the stain and glaze<br />

category, for example, range from 1 (from a technicianevaluator)<br />

all the way to 9 (from a dentist-evaluator).<br />

LMT believes that the laboratories involved in the experiment<br />

would be genuinely surprised by the scores they received.<br />

Of course, the evaluators didn’t know the identities of the<br />

laboratories and, therefore, couldn’t be swayed by their<br />

reputations or level of service. Instead, these crowns had to<br />

speak for themselves.<br />

Although in the real world, your marketing, positioning and<br />

value-added service are part of the big picture, how would<br />

your product fare if it was judged on technical merit alone? In<br />

other words, if your work had to speak for itself, what would<br />

it say? Í<br />

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


The Crowns<br />

A CLOSER LOOK<br />

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

The “favorite” of both the dentist and technician evaluators,<br />

the first-place crown comes from the largest laboratory in the<br />

experiment and has more than a one-point lead over the<br />

second-place “winner.” It received the highest marks in the stain<br />

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

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

a ‘9.’ This is a very sellable crown,” said Jason J. Kim <strong>Dental</strong><br />

Laboratory’s Gail Broderick, MDT. UCONN’s Dr. Dashti praised<br />

the metal/porcelain margin and metal polish, but felt that the<br />

embrasures were too open, especially on the mesial.<br />

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

This crown earned scores almost as high as the 1st place crown<br />

for its metal design and polish, contacts and embrasures and<br />

occlusion, but some of the evaluators gave it a “0” for<br />

unacceptable model and die work, since the model was returned<br />

to the dentist with chipped centrals. UCONN’s Dr. Squier also<br />

pointed out that the die was overtrimmed, which probably accounts<br />

for this crown’s poor marginal fit. There is also a stress fracture<br />

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

incompatibility.<br />

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

Several of the evaluators commented on the impressive-looking<br />

cusp of Carabelli on this crown. However, they were disappointed<br />

with the occlusion. “There’s a ‘hit and slide’ on the occlusion and<br />

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

UCONN’s Dr. Rungruanganunt agreed, “The crown is only occluding<br />

on the lingual incline of the buccal cusp.” Other judges felt<br />

that the contacts are too wide and too tight, and that the crown is<br />

overcontoured.<br />

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

This crown earned its highest scores in the model work and<br />

occlusion categories, but didn’t do so well with its anatomy<br />

evaluation. “This crown demonstrates a lack of knowledge<br />

of occlusal anatomy,” said Dr. Grayson. Other evaluators<br />

echoed that sentiment and also pointed out that the crown is<br />

overcontoured, especially lingually, and that the contacts are too<br />

wide. Dr. Raghavendra also felt that the crown has excessive external<br />

staining.<br />

Crown Y<br />

Crown Z<br />

Overall score: 4.4 Fabricator: A foreign laboratory Price range: $110–$120<br />

The metal work on this crown concerned the evaluators. “If<br />

you looked at this metal collar under a microscope, it would<br />

look like the texture of concrete...a beautiful home for billions<br />

of bacteria,” said Fred Hornedo, Jr., MDT, manager of Acqua-<br />

Dent <strong>Dental</strong> Laboratory, Jamesburg, New Jersey. “There are a<br />

lot of fine scratches that should have been polished out with<br />

a red wheel.” The porcelain application is also disappointing.<br />

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

coloring, no occlusal staining,” said Dr. Grayson.<br />

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

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

owner of Federico <strong>Dental</strong> Lab, Staten Island, New York, when<br />

he picked up this crown for evaluation. “It’s overcontoured, the<br />

fit is terrible, the contacts are too tight and the shape is wrong<br />

on the lingual and interproximal.” Other criticism offered by the<br />

evaluators included shallow anatomy, tight contacts and poor<br />

occlusion. UCONN’s Dr. Squier and Dr. Rungruanganunt also commented<br />

that the dies looked worn or mishandled.<br />

Overall score: 3.8 Fabricator: A foreign laboratory Price range: $60–$70<br />

Though overall this crown falls into 7th place, the evaluators at<br />

the University of Connecticut deemed this to be the worst crown<br />

of them all, especially since it was not fabricated with a metal<br />

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

prescription wasn’t followed, there’s no contact on the models, no<br />

metal margin on the buccal and the porcelain is overextended.” The<br />

evaluators also pointed out that this crown is overcontoured and out<br />

of occlusion and that the opaque shows through.<br />

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

This crown received the worst model and die scores of any of<br />

the crowns in the experiment and nearly all of the evaluators<br />

commented on the messy presentation. “Even if the model<br />

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

Mario Zerrillo, MDT, owner of Zerrillo <strong>Dental</strong> Laboratory, Queens,<br />

New York. It was also difficult to remove the die without pulling<br />

off the other parts of the model. The porcelain application<br />

was noted to be inconsistent—thick in some spots and thin in<br />

others—and the crown exhibits bulky contours. “This crown is<br />

unsellable and unacceptable,” said Broderick.<br />

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

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

said NYU’s Dr. Silberg, unaware that this was actually the most<br />

expensive crown in the group. “This crown has no occlusion,<br />

no retention, no contour.” In fact, overall, this crown received<br />

the worst anatomy and occlusion scores of all of the crowns.<br />

And the porcelain application and metal work didn’t fare much<br />

better. “The shade is grayish and the stain doesn’t follow the<br />

anatomy,” said Dr. Dashti. “Also, the metal polish is poor because<br />

there are dark areas.” Í<br />

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


LMT Technical Strategies Columnist Bill Mrazek, CDT, asks:<br />

WHERE ARE WE HEADED?<br />

Crown S lost points during evaluation because it was returned<br />

on a broken model (left photo) and because there are cracks in<br />

the porcelain on the buccal and lingual surfaces (right photo).<br />

When the fine folks at LMT asked if I would offer a<br />

“real-world” perspective on the restorations in their<br />

crown experiment, I agreed without hesitation. I felt I<br />

had a pretty good grasp of the “levels” of restorations being<br />

produced in our profession. I’ve been a dental technician<br />

for 30 years and a CDT for almost 28 years. I’ve presented<br />

numerous lectures and clinics and written articles for over<br />

15 years. Many of us have looked to Willi Geller, Asami<br />

Tanaka, Lee Culp and others for inspiration, guidance and<br />

education—and continue to learn from them—in an attempt to<br />

continually raise the level of our restorations.<br />

As we know, there remains a range of acceptability in what<br />

we produce. That is not to say that high quality restorations<br />

are not being delivered on a daily basis; they certainly are.<br />

There are also restorations being delivered that are not as<br />

detailed; as accurately fitting; or as anatomically, functionally,<br />

gnathologically or esthetically correct that still fall within that<br />

range of acceptability. Then there are those that should not<br />

be delivered at all. But, in most businesses, there is a market<br />

for everything. Unfortunately, as evidenced from this study,<br />

restorative dentistry is no exception.<br />

First, let me say that my comments are not directed at<br />

specific laboratories, since I do not know where the<br />

restorations were fabricated. I evaluated each crown in the<br />

same categories used by the other dentist- and technicianevaluators<br />

(see Meet the Evaluators on page 36) and used<br />

the same 0 to 10 scale. I looked at each crown three times,<br />

on three different days, to make sure that I was being fair<br />

and consistent. I’ve arranged my observations based on the<br />

judging categories:<br />

Model and die prep (my scores range from 0 to 7.5): Crown<br />

S received a zero because the model was returned badly<br />

broken, as if dropped from a second-floor window (see photo<br />

on page 32). Crown T received the highest score because it<br />

uses one-piece double pins and the model work is neat and<br />

clean. Most of the cases use simple plastic articulators, which<br />

are common, but they allow no protrusive movement and only<br />

limited excursive movements.<br />

In most businesses, there’s a market for everything.<br />

Unfortunately, as evidenced from this study,<br />

restorative dentistry is no exception.<br />

Anatomy (my scores range from 2 to 8): Only Crown T<br />

includes a Cusp of Carabelli, even though there clearly is one<br />

on the 1st molar on the opposite side of the arch.<br />

Contours (my scores range from 5 to 7.5): Almost all units<br />

exhibit a square, boxy, overcontoured shape.<br />

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

two crowns a zero—Crown W and Crown Z—because they<br />

have both mesial and distal open contacts. Crown R and<br />

Crown V have one open contact; the others have varying<br />

degrees of contact, from point to concave design.<br />

Occlusion (my scores range from 2 to 8): Crown R was<br />

totally out of occlusion; the others exhibited good centric<br />

contact, but most had lateral interferences.<br />

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

Most of the samples are too high in value, the chroma varies<br />

from crown to crown and, the lower scoring units—such as<br />

Crown S and Crown Z—don’t represent the requested A3.5<br />

shade at all.<br />

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

restorations have a poor and unrealistic-appearing application<br />

of occlusal stain, and some appear overglazed. I gave a<br />

‘0’ to Crown S because it has cracks in the buccal and lingual<br />

surfaces of the porcelain (see photo on opposite page). Crown<br />

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

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

Z earned the ‘0’ since it did not follow the Rx request for a<br />

metal collar. The highest scores were given to those crowns<br />

that exhibit the narrowest collar at the buccal margin (such as<br />

Crown U).<br />

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

seven of the nine crowns scores of 2 or less; four of them<br />

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

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

amazing aspect of the experiment, as the prep is ideal and has<br />

margins that could be read in the dark. Some of the crowns<br />

fit very loosely on the die, others have open margins, short<br />

margins, or over-extended margins that could be easily seen<br />

without any form of magnification!<br />

Final analysis: In my estimation, the clinical acceptability of<br />

Crown X and Crown Y is questionable; the remaining crowns<br />

are, without a doubt, undeliverable.<br />

In all fairness, nine samples don’t constitute an accurate<br />

representation of the work being done by the entire dental<br />

laboratory profession. But doesn’t it seem reasonable to<br />

expect that there would be at least some higher scores than<br />

we see here? Obviously, the laboratories in this experiment<br />

Nine samples don’t constitute an accurate<br />

representation of the work being done by the entire<br />

profession. But doesn’t it seem reasonable to expect<br />

that there would be at least some higher scores?<br />

sent back a product that they felt was an acceptable<br />

restoration. If these restorations are accurate representations<br />

of what they produce on a regular basis, it means their<br />

products are being accepted and delivered on a regular<br />

basis.<br />

My greatest concern is not directed at those laboratories in<br />

the experiment, but actually at the level of acceptance that<br />

apparently exists in our profession—a level of acceptance<br />

that is a shared responsibility between the dentist and the<br />

laboratory.<br />

Crown<br />

Model &<br />

Die Prep<br />

Anatomy Contours Contacts/<br />

Embrasures<br />

I truly hope that restorative dentistry can remain a respectable<br />

profession rather than becoming strictly a “business<br />

arrangement” between the dentist and laboratory, primarily<br />

based on price and turnaround time. Once we reach that point,<br />

our restorations are nothing more than a manufactured commodity.<br />

Ultimately, it is up to each of us to determine where<br />

we are headed. In what direction do you want to go? Í<br />

Occlusion<br />

Shade/<br />

Vitality<br />

Bill Mrazek, CDT, is the owner of Mrazek<br />

Prosthodontics, Ltd. and Mrazek Consulting<br />

Services in Naperville, Illinois. LMT is grateful<br />

to Bill for lending his creative input during<br />

brainstorming for this experiment, as well as<br />

for his technical expertise during its planning<br />

and execution.<br />

AVERAGE SCORES RECEIVED BY EACH CROWN IN ALL CATEGORIES<br />

Stain &<br />

Glaze<br />

Metal<br />

Design/<br />

Polish<br />

Accuracy<br />

of Fit<br />

on Die<br />

CROWN R 3.9 1.5 2.9 2.0 1.8 2.8 3.6 4.5 1.5<br />

CROWN S 3.5 4.9 4.5 6.0 5.7 5.1 5.6 6.6 2.6<br />

CROWN T 4.5 5.1 5.0 4.6 4.7 5.4 6.2 6.3 1.5<br />

CROWN U 2.3 2.7 3.0 4.7 3.9 3.6 5.1 3.6 1.9<br />

CROWN V 5.9 5.7 6.0 6.4 5.8 7.0 6.6 6.7 4.0<br />

CROWN W 5.9 4.6 4.5 4.3 5.2 4.4 4.4 5.0 4.3<br />

CROWN X 5.2 3.5 3.1 3.9 3.6 4.0 4.1 5.0 6.7<br />

CROWN Y 4.6 4.5 3.6 3.7 3.2 4.3 4.6 5.0 6.2<br />

CROWN Z 3.4 4.2 4.1 2.7 4.2 4.8 5.6 2.5 3.2<br />

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


MEET THE EVALUATORS<br />

Dr. Allan Grayson<br />

Dr. Sangeetha Raghavendra<br />

Fred Hornedo, MDT, ATACP,<br />

Dr. Steven Silberg<br />

New York University<br />

LMT went to two prestigious East Coast dental<br />

schools to have the crowns evaluated: New<br />

York University (NYU) and the University of<br />

Connecticut (UCONN). The panel includes<br />

laboratory owners and managers, practicing<br />

dentists and educators:<br />

Gail Broderick, MDT, is the Laboratory Director of<br />

Jason J. Kim <strong>Dental</strong> Lab, Great Neck, New York. She<br />

is on the board of the <strong>Dental</strong> Laboratory Association<br />

of New York, and is affiliated with the American<br />

Society of Master <strong>Dental</strong> Technicians, International<br />

Congress of Oral Implantologists, Alpha Omega<br />

International <strong>Dental</strong> Fraternity, Northeastern<br />

Gnathological Society, Dawson Center, Occlusal<br />

Concepts Study Club and Six Sigma Greenbelt.<br />

Dr. Buthaina Dashti is an Assistant Clinical<br />

Professor in the Department of Oral Rehabilitation<br />

at UCONN <strong>Dental</strong> School, where she teaches dental<br />

students and prosthodontic residents. She received<br />

her dental degree in the U.K. and her prosthodontic<br />

degree from the University of Southern California.<br />

Paul Federico, AAS, BS, MDT, owns Federico<br />

<strong>Dental</strong> Lab, Staten Island, New York, a full service<br />

lab specializing in full mouth rehabilitation. He<br />

is on the faculty of NYU College of Dentistry and<br />

president of the American Society of Master <strong>Dental</strong><br />

Technologists. Federico is also the director of<br />

Predictable Restorative Dentistry Seminars and<br />

a member of the Dr. Richard Tucker cast gold<br />

study club.<br />

Dr. Allan Grayson is Clinical Professor of fixed<br />

and removable prosthodontics at NYU College of<br />

Dentistry and maintains a private practice in New<br />

York City. He’s been an educator for 28 years<br />

and this summer will complete the Master <strong>Dental</strong><br />

Technologist program.<br />

Fred Hornedo, MDT, ATACP, AAOP, has 28 years’<br />

experience in all phases of laboratory work and is<br />

the manager of Acqua-Dent <strong>Dental</strong> Laboratory,<br />

Jamesburg, New Jersey. He is an alliance technician<br />

for the American College of Prosthodontists, and<br />

a member of American Society of Master <strong>Dental</strong><br />

Technicians and the American Academy of Oral<br />

Facial Pain.<br />

Dr. Sangeetha Raghavendra is an Assistant Clinical<br />

Professor in the Department of Oral Rehabilitation,<br />

Biomaterials and Skeletal Development at<br />

LMT’s Crown Experiment 2007<br />

UCONN School of <strong>Dental</strong><br />

Medicine. She also practices<br />

in Chicopee, Massachusetts and is<br />

a Diplomate of the American Board<br />

of Prosthodontics and a Fellow of the<br />

American College of Prosthodontists.<br />

Dr. Patchanee Rungruanganunt is a faculty<br />

member at UCONN Health Center and course director<br />

for the fixed prosthodontics program. She practices<br />

in University Dentists, the dental school’s multidisciplinary<br />

faculty group practice.<br />

Dr. Buthaina Dashti<br />

Dr. Steven Silberg is a Clinical Associate Professor at<br />

NYU College of Dentistry and practices in East Rockaway,<br />

New York. Also a Master <strong>Dental</strong> Technologist, Dr. Silberg is a<br />

member of the American <strong>Dental</strong> Association, American<br />

Academy of Fixed Prosthodontics, American Society of Master<br />

<strong>Dental</strong> Technologists, Academy of General Dentistry (Fellow),<br />

Northeastern Gnathological Society and the Consensus for<br />

<strong>Dental</strong> Excellence.<br />

Dr. Rachel Squier is an Assistant Professor in the Department<br />

of Oral Rehabilitation, Biomaterials and Skeletal Development at<br />

the UCONN School of <strong>Dental</strong> Medicine. She practices in University<br />

Dentists, the dental school’s multi-disciplinary faculty group<br />

practice. She is a Diplomate of the American Board of Prosthodontics,<br />

a Fellow of the American College of Prosthodontists and a member<br />

of the International Team for Implantology and the Academy of<br />

Osseointegration.<br />

Mario Zerillo, CDT, MDT, is the owner of Zerillo <strong>Dental</strong> Laboratory,<br />

a one-person ceramic lab in Queens, New York and a member of the<br />

American Society of Master <strong>Dental</strong> Technologists. He got his start in<br />

the industry 20 years ago when studying dental technology at the<br />

George Westinghouse High School in New York and the New York<br />

City Technical College.<br />

Dr. Ira Zinner is a clinical professor at NYU College of Dentistry<br />

and director of its Full Mouth Rehabilitation Program and Masters<br />

of <strong>Dental</strong> Technology Program. He has a prosthodontics practice<br />

in New York City and is a Diplomate of the American Board of<br />

Prosthodontists; a Fellow of the American College of Prosthodontists,<br />

Greater New York Academy of Prosthodontists and Academy of<br />

Osseointegration; and an honorary Fellow of the New York Academy<br />

of Oral Rehabilitation.<br />

Dr. Rachel Squier<br />

University of Connecticut<br />

Dr. Ira Zinner<br />

Paul Federico, AAS, BS, MDT<br />

Dr. Patchanne Rungruanganunt<br />

Gail Broderick, MDT<br />

Mario Zerillo, CDT, MDT<br />

Title of Article


Laboratory<br />

PORTRAIT<br />

Mikhail Tkachev<br />

Engineer, Research and Development<br />

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

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

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

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

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

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

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

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

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

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

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

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

California, is truly the stuff of Hollywood films.<br />

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

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

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

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

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

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

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

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

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

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

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

didn’t want to be.<br />

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

Sacramento friend, Victor. Victor had driven to the Los Angeles airport<br />

to pick up the Tkachev family only to be left there helplessly<br />

wondering what had happened to them when their plane landed<br />

and they weren’t on it. On receiving the call from his stranded<br />

Russian friends, Victor was stunned by what had happened Í<br />

– ARTICLE by Al Lefcourt<br />

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

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

Title of Article<br />

Laboratory Portrait


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

to fly them to California.<br />

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

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

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

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

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

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

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

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

a brave little fourth grader who was just beginning to study Russian.<br />

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

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

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

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

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

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

were happy just to finally arrive at LAX.<br />

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

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

at the airport.<br />

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

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

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

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

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

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

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

<strong>Glidewell</strong> Laboratories. If Mikhail had managed to get to Sacramento on either of his attempts, he may not<br />

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

would certainly have been a loss not just for <strong>Glidewell</strong>, but for the dental industry at large.<br />

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

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

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

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

so he could better his lot.<br />

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

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

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

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

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

Which also meant…he didn’t have a garage overhead.<br />

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

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

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

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

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

was able to devote himself full-time to <strong>Glidewell</strong>, where his new English skills and his old Russian Í<br />

Custom Plastic Injection Mold<br />

This plastic injection mold was needed to make stump sticks inhouse,<br />

rather than purchase them at high cost from dental dealers.<br />

Technicians place an all-ceramic restoration onto the top of the stump<br />

stick, which is colored to imitate the shade of the preparation in<br />

the mouth.<br />

Jar Rolling Mill<br />

This simple Jar Rolling Mill is used during the zirconium oxide ball<br />

milling process. The device can be utilized when the particle size of<br />

zirconium oxide powder needs to be reduced.<br />

Laboratory Portrait<br />

Laboratory Portrait


Pressure Vessel<br />

This is a Pressure Vessel for silicone material injection. Using the<br />

vessel, we create rubber molds, which are then used in the fabrication<br />

of pressable ceramics. This device uses air pressure to force the<br />

otherwise viscous silicone material into a chamber to create the mold.<br />

Today, 40% of the ceramic restorations we fabricate in the laboratory<br />

are pressables, and that number is expected to eventually double.<br />

X, Y Table<br />

This adjustable X,Y Table has a spindle mounted on the top for zirconium<br />

oxide sample preparation.<br />

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

most advanced commercial R&D departments.<br />

One of the first episodes that brought Mikhail’s talents to Jim <strong>Glidewell</strong>’s personal attention was the failure<br />

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

restorations to a crawl, something that would have been unacceptable to <strong>Glidewell</strong>, its customers and to<br />

countless patients around the country.<br />

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

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

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

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

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

the chance.<br />

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

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

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

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

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

right. There was no U.S. equivalent for the German chip used in the machine.<br />

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

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

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

wanted to or not.<br />

Sure enough, before noon that very day, just as <strong>Glidewell</strong> managers were filing into a meeting where<br />

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

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

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

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

competitive powerhouse it is, constantly offering its customers new products and better prices.<br />

One such example is the magnetic articulator system marketed by <strong>Glidewell</strong> Direct. It’s an elegantly simple<br />

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

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

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

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

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

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

machinist, Viktor Khivrenko.<br />

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

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

UCLA at age 21, works at KPMG and is halfway though his CPA exams.<br />

Meanwhile, Vladikavkas remains a small but technically advanced town in the Caucasus Mountains, now<br />

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

had he stayed. And had the secret police approved.<br />

Laboratory Portrait<br />

Laboratory Portrait


– INTERVIEW of Alan Budenz, MS, DDS, MBA<br />

by Michael DiTolla, DDS, FAGD<br />

– PHOTOS by Kevin Keithley<br />

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

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

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

Sciences and Chair of the Department of Diagnosis and Management at the University of the Pacific<br />

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

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

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

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

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

20 Questions with Dr. Alan Budenz


Question 1: What’s the most exciting thing to happen in local<br />

anesthesia in the last 5-10 years?<br />

Alan Budenz: There’s been a lot certainly with the advent<br />

of the CompuDent Wand and the Dentsply Comfort Control<br />

syringe. Both are computer controlled devices and more than<br />

ten years old, but still relatively new to the field. I have both<br />

of these devices and they don’t necessarily allow me to do<br />

anything I couldn’t do with a traditional syringe, but what<br />

they do is make the process less taxing, and they let me<br />

administer the anesthetic more consistently, time<br />

after time.<br />

The more slowly it gives the injection<br />

-- particularly if it’s an anes-<br />

t h e t i c<br />

with a vasoconstrictor, because<br />

those are more<br />

acidic and would tend to cause the patient a little more<br />

burning sensation -- and with consistent control, the patient<br />

feels virtually nothing. It’s all about making it more comfortable<br />

for the patient, and it doesn’t hurt that it makes it more<br />

comfortable for yourself as well.<br />

Another exciting development recently is the VibraJect. At first<br />

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

to shake the cheek anymore to distract the patient. I thought<br />

there had to be more to it, and I discovered that it’s actually<br />

a very clever device. It gives you a very low level of stimulation<br />

going down to the tip of the needle, and if the needle<br />

is in close proximity to the nerve tissue it will stimulate that<br />

nerve at a low level, which will open up more of the sodium<br />

channels. And it’s the sodium channel opening that allows<br />

the anesthetic to flow in and bind to the receptor sites in the<br />

sodium channels.<br />

Q2: So it’s really more than a comfort and distraction device, it<br />

actually improves the quality of the injection?<br />

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

vibrating where it’s going to distract the patient from the<br />

penetration, particularly. Really, what it is all about is getting<br />

that stimulation to open up the sodium channels. It’ll tend to<br />

give you a more profound anesthesia and potentially less of<br />

that problem where you start to drill on a mandibular molar<br />

and the patient feels it even though when you check with an<br />

explorer, everything appears to be numb. But the patient still<br />

feels it when you root plane or drill because you don’t have<br />

enough of those sodium channels blocked. This device will<br />

reduce the incidence of that. I bring this up not because it’s<br />

the greatest thing in anesthetics, but because it’s a very simple<br />

device with a very brilliant idea behind it – and it works!<br />

But bottom line, the best thing that’s happened in local anesthesia<br />

in the last 5–10 years is Septocaine coming on the U.S.<br />

market in 2000. It’s a really good anesthetic but there are<br />

drawbacks to it. The simple fact that there’s so much controversy<br />

about it has stimulated people to ask so many more<br />

questions about anesthetics and how they give them, that<br />

overall, I think it’s beneficial because people aren’t just taking<br />

everything for granted anymore. Typically people would say “I<br />

use lidocaine for everything except when I can’t use epi, then<br />

I use mepivocaine plain and for long-acting, I use Marcaine.”<br />

It’s made people think about what’s out there, what’s appropriate<br />

to use, what’s safe to use and what technique should<br />

be used with it.<br />

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

some literature about a possible increase rate of parasthesia with<br />

Septocaine.<br />

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

scientific study that shows that absolutely the 4% anesthetics<br />

are the cause of paresthesia, but there’s enough anecdotal<br />

material out there to make me think there is a greater risk of<br />

parasthesia using the 4% solutions, both articaine and prilocaine.<br />

I’m not hesitant to use Septocaine for blocks, when it’s<br />

indicated, except for the inferior alveolar block. I’m extremely<br />

hesitant about Septocaine for that one because we’ve seen<br />

numerous reports that the greatest incidence of paresthesia is<br />

with that injection technique and the 4% anesthetics.<br />

But personally, I don’t choose to give inferior alveolar nerve<br />

blocks the conventional way. I prefer the Gow-Gates technique,<br />

which from all the evidence I can gather is a safer injection<br />

with any solution. I use it on a regular basis.<br />

Q4: Say someone’s been practicing for 15–20 years and has been<br />

giving lower blocks and knows there’s something better but is just<br />

a little nervous about shooting that high with the Gow-Gates versus<br />

the typical target point, what do you think is the best way for a<br />

GP to learn how to do the Gow-Gates technique comfortably?<br />

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

find this in a dental school setting, occasionally at a larger<br />

meeting, but that’s pretty rare. Another alterative is to find a<br />

practitioner in your area who knows the technique. A lot of<br />

oral surgeons are familiar with the technique. More recent<br />

dental school grads are more likely to have been taught the<br />

technique. Watch them do it and have them observe you<br />

doing it to give you feedback as you do it. A “study club” setting<br />

like that is the ideal way to do it outside of a dental school<br />

course/CE course. Í<br />

20 Questions with Dr. Alan Budenz


Q 5 : I have seen numbers published on the<br />

mandibular block stating that up to 20% of<br />

blocks are missed on the first attempt. Do you agree<br />

with that?<br />

AB: Yes, but it always seems to go in spurts.<br />

Practitioners tell me, “I can’t miss a block for weeks<br />

and all of a sudden I’m missing every one.” I published<br />

a literature review paper some time ago and the range<br />

I saw was 63% to 86%, with some studies reporting it<br />

into the 90% range. Now that’s with the first injection. But<br />

most of us get it with the second attempt. I think the true<br />

incidence of failed anesthesia is well below 1%. But on the first<br />

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

Q6: One of the most frustrating experiences most of us GP’s have<br />

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

and how to anesthetize these patients?<br />

AB: On a mandible, of course, the number one nerve to anesthetize<br />

is the inferior alveolar nerve, number two is the long<br />

buccal nerve. The long buccal has been shown to have a lot<br />

of accessory innervation to the teeth, particularly the molars.<br />

When you look at the retromolar pad area, there are a lot of<br />

accessory foramina there. You may wonder are they there for<br />

blood vessels, are they for nerves, or are they just air holes?<br />

You cannot tell just by looking at the bone. But there are a<br />

lot of holes there. By doing micro-dissection, the long buccal<br />

nerve is seen to send little branches into the bone. It’s not<br />

just the main pathway like we instructors have always taught.<br />

There are a lot of accessory nerve branches coming off all<br />

along the long buccal pathway.<br />

The number three nerve to anesthetize is the mylohyoid<br />

nerve. In anatomy, we teach that this is a motor nerve to<br />

the mylohyoid muscle at the floor of the mouth and also<br />

out to the anterior belly of the digastric under the chin. What<br />

is not taught from the anatomy literature, is that there are<br />

also pain and temperature fibers in that nerve. And those<br />

pain fibers have been tracked through micro-dissection into<br />

teeth. So yes, it is an accessory nerve pathway. All along<br />

the pathway to the mylohyoid, it is giving off little branches<br />

into the bone and many of those branches are accessory<br />

innervation to teeth.<br />

Q7: I recall being taught that the long buccal just innervated<br />

buccal tissue and for crown preps it was necessary, but only<br />

for soft tissue anesthesia. With all these nerves branching off, it<br />

sounds like nature is not as simple and straightforward as we<br />

want it to be.<br />

AB: Exactly. That is a great summary. We teach the basic nerve<br />

pathways, but we probably don’t do a decent enough job of<br />

teaching that any nerve that exists in the neighborhood of a<br />

tooth is likely to be carrying some accessory innervation to<br />

that tooth. No nerve is purely sensory or purely motor. They<br />

all have a mixture. Some of those fibers are proprioceptive,<br />

but some of those are also primary pain fibers and going to<br />

tooth structures. Unfortunately for us, as dentists and dental<br />

hygienists, we have to be aware of all of the possible nerve<br />

pathways in the oral cavity.<br />

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

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

local anesthesia.<br />

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

likelihood of anesthetizing the inferior alveolar, the lingual,<br />

the long buccal and the mylohyoid nerves all with one injection.<br />

I’ll use a 27-gauge long needle and I’m going to drop<br />

a full cartridge of lidocaine. I could use Prilocaine or<br />

Septocaine if I felt that you were a person who expressed<br />

to me that you were very hard to get numb or you had a<br />

history of getting numb but not staying numb very long, or<br />

had a history of drug abuse. Then I might use one of the<br />

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

because it’s pretty safe. I find that with the Gow-Gates<br />

technique, I have a good success rate using one cartridge of<br />

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

will need to chase it with a full second cartridge in the same<br />

location. The one nerve that is hardest to get consistently is<br />

the long buccal. So I may sometimes have to inject that separately.<br />

With a Gow-Gates injection, I’ve never had to give a<br />

separate mylohyoid.<br />

If you have a hot tooth, a tooth you’re going to extract or<br />

that you need to do a root canal procedure on because it’s<br />

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

the Gow-Gates and then I might use an intraosseous around<br />

the tooth, or PDL injections to get it. But the Gow-Gates works<br />

well because you’re so high up on the innervation pathway.<br />

You target the anterior-medial aspect of the neck of the condyle.<br />

With the mouth wide open, the condyle translates out<br />

just immediately lateral to the foramen ovale. So you’re right<br />

next to where this whole big nerve trunk is coming in to the<br />

infratemporal fossa. If you drop your anesthetic bolus there<br />

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

for a full 90 seconds after you finish the injection<br />

— you keep that bolus right there next to the nerve. If there<br />

are any accessory branches coming off of anywhere along the<br />

trigeminal nerve pathways, you’re still catching them right at<br />

the source.<br />

Q9: How long do you wait after a Gow-Gates injection to test<br />

for anesthesia?<br />

AB: Gow-Gates has a slower onset because you’re approaching<br />

such a large nerve trunk. The most peripheral fibers are<br />

going to the back of the mouth. The fibers at the center of<br />

that big nerve bundle are coming out to the tip of the tongue<br />

and the lip, and so you must wait at least five minutes. The<br />

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

Gow-Gates injection is really going to give you the absolute<br />

best result. Within the five minute window I should be getting<br />

some signs that the anesthesia has taken effect, and if so<br />

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

of full anesthesia. If I’m not getting signs after 5 minutes,<br />

I may conclude that I’ve missed it and give a second Gow-<br />

Gates injection.<br />

Q10: Some esthetic clinicians are advocating the use of the<br />

Anterior Middle Superior Alveolar injection, the AMSA, because it<br />

numbs all the maxillary anterior teeth. Do you use this injection<br />

if you are working on 8 anterior teeth rather than going around<br />

and giving numerous infiltrations? It seems counter-intuitive,<br />

being a palatal injection. Tell us a little about it.<br />

AB: There are actually two AMSA techniques, a facial approach<br />

and a palatal approach. The palatal injection technique is<br />

actually one that was first described in the 1920s. When<br />

the Wand first came out they really pushed this palatal AMSA<br />

technique but it has never really caught on. The whole principle<br />

of this technique is that rather than doing the standard<br />

facial approach AMSA injection, which is properly called the<br />

infraorbital block injection given on the face just below the<br />

eye, which is a true block, when you do the palatal approach<br />

you’re further down on the pathway of the anterior and middle<br />

superior alveolar nerves, at the junction where the vertical<br />

process of the maxilla meets the horizontal hard palate.<br />

If you take a line perpendicular to the midline palatal raphe<br />

and extend it out to where it meets the two bicuspids halfway<br />

along that line, you’ll be at that junction. Drop your anesthetic<br />

there, a small amount, very slow injection, and you’ll<br />

get anterior and middle superior alveolar anesthesia. Now the<br />

beauty of this injection is that you don’t get lip anesthesia<br />

like you do with the infraorbital, but you do get buccal soft<br />

tissue anesthesia around the teeth. You get palatal, pulpal<br />

and buccal anesthesia so you can do work from the second<br />

bicuspid forward. It might be a little fuzzy at the second<br />

bicuspid because you’re getting a little innervation coming in<br />

from the posterior, the PSA, so I always give a little infiltration<br />

behind there as well. By the way, infiltrations on the maxilla,<br />

pretty much the only thing I’m giving these days is Septocaine.<br />

Lots of times it gives me palatal anesthesia as well buccal.<br />

Not on everybody, but most of the time.<br />

Q11: You’re absolutely right about the Septocaine. It seems as<br />

though I can pack cord on the lingual on nearly everybody without<br />

any problems. Maybe once or twice every couple of months I<br />

am not able to and need to give a little palatal soft tissue anesthesia.<br />

So you like the AMSA injection?<br />

AB: Well, with the palatal AMSA, you’ve got maxillary anterior<br />

anesthesia without having the lip numb, which is helpful<br />

for esthetic dentistry. But there are two drawbacks with it.<br />

One, it’s a palatal injection, so you have to give it real slow<br />

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

block. It’s in between a block and an infiltration. For veneer<br />

cases, where you want to keep the smile line and you’re not<br />

going to be in there very long, it’s a real efficient way to do it.<br />

But if you’re going to be doing crown preps from bicuspid Í<br />

to bicuspid, in my opinion, I’d rather use the infraorbital and<br />

the nasopalatine.<br />

20 Questions with Dr. Alan Budenz


Q12: So you’re going to be giving an infraorbital and a nasopalatine<br />

if you are doing crowns from second bicuspid to second<br />

bicuspid? As opposed to giving 8 infiltrations over those teeth?<br />

AB: Yes. I want blocks. As a rule of thumb a block will give<br />

you twice as long a duration of anesthesia as an infiltration.<br />

That’ll depend a little bit on your anesthetic and other<br />

variables. But if you want hemostasis, if you’re gong to be<br />

doing root planing or surgery or subgingival preps, anything<br />

where you know you’ll be getting some bleeding, I will do<br />

local infiltration using ideally Lidocaine with 1 to 50,000<br />

epinephrine. That one little infiltration will give me a great<br />

deal of hemostasis in a localized site. If I use 1 to 50,000, for<br />

an I.A. block, my anesthesia will be about the same duration<br />

as 1 to 100,000 but it won’t give me good hemostasis. So for<br />

blocks, I want to use as low a concentration of vasoconstrictor<br />

as I can. For example, Septocaine now has the 1 to 200,000<br />

epi solution available and there are a number of studies<br />

now, which are all quite similar, that there is no significant<br />

difference in duration. It’s a little bit shorter duration with<br />

1 to 200,000 than 1 to 100,000, but clinically it’s not really<br />

significant. So why not use the safest one with the lowest<br />

concentration? But if I am going to use it for hemostasis as a<br />

local infiltration, I am going to use the highest one I can get<br />

my hands on.<br />

Q13: I have to tell you that I don’t know any of my friends who<br />

are giving infraorbital injections with a nasopalatine for anterior<br />

crowns like that, I think most of them are still giving 8 infiltrations.<br />

Do you think there are a lot of GP’s using your technique?<br />

AB: No<br />

14: Can you explain to me how exactly you do it? Or do you even<br />

recommend that the average GP does this?<br />

AB: Absolutely, I have no hesitation. So what you do is feel<br />

the lower rim of the orbit. You feel for the lowest part of the<br />

rim, but it’s not right in the center. It is actually more towards<br />

the base of the nose. Drop your finger down 1cm below that<br />

rim and your finger is right over the foramen. And with many<br />

people, if they’re a little bit thin there, you can press and they<br />

can feel a little bit of nerve tingling. So you are right over<br />

the foramen. Keep one fingertip there and I take my other<br />

fingertip, usually my thumb and slide it up into the top of the<br />

maxillary vestibule in the area of the cuspid to bicuspid. That<br />

distance between those two fingertips is going to be the depth<br />

of my penetration of the needle.<br />

Q15: I am doing it on myself as you talk, and it doesn’t feel very<br />

deep. It feels like a quarter inch or a half-inch to me.<br />

AB: Yeah, for most people it’s less than 10mm, less than a<br />

centimeter. So it’s not a big deal. So then I’m going to insert<br />

a needle up into the top of the vestibule paralleling the slope<br />

of the maxillary bone there until I feel that needle right up<br />

underneath my fingertip that’s outside over the foramen.<br />

Q16: So where’s the puncture point in relation to the crowns on<br />

the teeth?<br />

AB: I’m coming in really more over the bicuspids. I use a little<br />

more posterior approach because it’s more comfortable, you<br />

know, away from the midline. The technique I was taught in<br />

school you came in over the lateral to cuspids and that brought<br />

you in close to the base of the nose and patients always feel<br />

that, so you go further posterior and it’s not as sensitive. I’m<br />

coming into the vestibule over the bicuspids and paralleling<br />

the bone until my needle is in about a centimeter so it’s right<br />

up underneath my fingertip. I stop, aspirate, drop my bolus of<br />

anesthetic and then with that same finger that’s been outside<br />

the mouth the whole time, I just massage the bolus into the<br />

foramen. I give the injection with the patient lying down and<br />

I keep the patient lying down. Then that anesthetic is either<br />

going to dissipate into the soft tissue or it’s going to flow<br />

down into that foramen.<br />

Q17: How often do you get a positive aspiration on that infraorbital<br />

injection?<br />

AB: Not very often. There are little blood vessels there but<br />

they’re small enough to be of little consequence. And I give it<br />

slowly. I give all my injections very slowly. To me it’s all about<br />

patient comfort, but it’s also about safety. If I see any blanching<br />

there, I’m giving it too fast. I shouldn’t see that.<br />

Q18: So when you successfully give the infraorbital block, what<br />

gets anesthetized?<br />

AB: It’ll anesthetize the lip, the buccal soft tissue, and the<br />

pulps of the anterior teeth cuspid to central. It won’t get<br />

palatal soft tissues and it may or may not get the pulps of the<br />

bicuspids. So I may have to infiltrate over the bicuspids in<br />

some cases, maybe 25% of the time.<br />

Q19: Do you think it’s safe to say that in dental school fifty years<br />

from now or in general practices fifty years from now that the<br />

Gow-Gates might be the routine and the IA blocks kind of the<br />

thing of the past?<br />

AB: It could be, but I honestly don’t think of it in those<br />

terms, Mike, because to me, I want to know as many tricks<br />

as possible, if “tricks” is the right word. No two people are<br />

put together the same and there are always these oddball<br />

situations where it helps to know different techniques. The<br />

conventional IA technique has been around since the 1880’s,<br />

it’s got a good track record. You know, I started using the<br />

Gow-Gates initially because when my regular lower block<br />

didn’t work I wanted a back up technique. And the Gow-Gates<br />

technique usually worked. Then I started reading about it and<br />

I was seeing the higher success rates in the literature and I<br />

thought, if this is so successful, then why don’t I do this all<br />

the time and use the other one, the conventional technique,<br />

just when I need to for an alternative. And so now I almost<br />

exclusively use the Gow-Gates. But I think it’s good to know<br />

all the techniques. That’s my opinion.<br />

And another troubleshooting tip is that, I advocate caution<br />

giving additional inferior alveolar injections if the first one<br />

doesn’t work. If I give an inferior alveolar nerve block conventional<br />

technique, I was taught if you didn’t get it the first time,<br />

to go a little higher and little deeper the second time, and, you<br />

know, it usually worked.<br />

Q20: By higher, by deeper, do you mean to the hub or do you<br />

mean medially versus laterally? What do you mean by deeper?<br />

AB: Well, that’s a great question because you are never quite<br />

sure what people are referring to when they say that’s what<br />

they do. By going a little bit higher I’m talking about a quarter<br />

of an inch at the most higher up on my thumbnail at the<br />

anterior border of the mandible. As far as deeper, what I’m<br />

referring to is a slightly more posterior injection site, not necessarily<br />

going in deeper with the needle because the bone<br />

should still be in the same place, so it’s just that my injection<br />

site is slightly more posterior than my initial one.<br />

But what I’ve found reading the literature is that that higher<br />

and deeper technique also led to increased incidents of positive<br />

aspirations. I don’t really want to be more successful with<br />

anesthesia at the risk of causing more bleeding. And that again<br />

is what led me to look more closely at the Gow-Gates.<br />

I didn’t start out using the Gow-Gates, I started out using<br />

it only for back up and the more I used it the more I got<br />

comfortable with it. Everything points to it being safer, being<br />

more effective, being more efficient, and that’s why I’m a big<br />

believer in it now.<br />

Michael DiTolla: I’ve learned some great stuff today and if we<br />

just inspire one or two people to take a look at their local anesthetic<br />

procedures, and they can add a new technique that will<br />

keep a patient comfortable while they are having dentistry done,<br />

I think we’ve done our job. I look forward to taking<br />

your cadaver course at the CDA meeting,<br />

and thank you so much<br />

for your time today.<br />

AB: My pleasure<br />

Mike,<br />

I enjoyed talking<br />

with you.<br />

20 Questions with Dr. Alan Budenz


Carpe Diem!<br />

NOW<br />

is the time to help patients value the importance of their dental office as their partner for great health<br />

– ARTICLE by Gary Takacs<br />

– PHOTO by Ed Pelissier<br />

Perhaps the biggest challenge we have in the dental<br />

profession is creating value in our patients’ minds for the<br />

services we provide. In the most simplistic sense, patients<br />

accept treatment recommendations and keep their appointments<br />

because they value the care we provide. In the not-sodistant<br />

past, many patients seemed to disconnect their dental<br />

health from their overall body health. That situation is changing<br />

dramatically.<br />

Today, good health is a valued commodity and the great news<br />

is that there is a growing body of evidence that links good<br />

dental health to good overall body health. While this link is<br />

hardy new, what is new is that the general public is beginning<br />

to understand how oral health has a dramatic impact on general<br />

health. As a result, we have a wonderful window of opportunity<br />

to help our patients place greater value on the care we<br />

provide.<br />

Let me present some proof of how the public is being educated<br />

about the link between daily. Some of this information is from<br />

the scientific community and some comes from the media.<br />

Recently, I saw a segment on the ABC television show Good<br />

Morning America discussing the link between periodontal<br />

disease and pancreatic cancer. In this segment, Diane Sawyer<br />

and Dr. Timothy Johnson discussed some recent research that<br />

demonstrated a possible connection between perio disease<br />

and pancreatic cancer. At the end of the segment, Dr. Johnson<br />

looked directly into the camera as if he was talking to a<br />

particular person in the audience and said, “So, what does this<br />

mean to you as a viewer. Well, what it means is that if you are<br />

not going to the dentist you need to be under the care of<br />

a dentist because today going to the dentist is not just about<br />

your teeth, it’s about oral health and general health. New<br />

information on the oral-systemic link emerges almost your<br />

total body health.”<br />

I wanted to stand up and cheer!! What a great message for<br />

the public and it was right there on the screen stated by a<br />

respected authority.<br />

Here’s more proof of how this message is spreading to the<br />

public. Colgate-Palmolive is currently running an advertising<br />

campaign with Christie Brinkley as spokesperson, focusing<br />

on educating the public about the link between perio disease<br />

and systemic health. In the ads, she talks about how perio<br />

disease has been linked to heart disease, diabetes, pancreatic<br />

cancer, pre-term low birth weight and other systemic concerns.<br />

On the Colgate website, Brooke Shields is also featured in a<br />

segment discussing the link between dental health and overall<br />

body health.<br />

As another example, the magazine Scientific American recently<br />

published an entire special issue entitled “Oral and Whole<br />

Body Health” with an absolute wealth of information designed<br />

for health care professionals and patients alike.<br />

In the spirit of Dr. Timothy Johnson from Good Morning<br />

America, I’ll ask the question, “So, what does all this mean<br />

to you?” In my opinion, it can be nothing but good news<br />

when we have Diane Sawyer, Christie Brinkley, Dr. Timothy<br />

Johnson, Brooke Shields, at least one major magazine, and<br />

countless other media channels educating the public that<br />

indeed, good oral health may be connected to overall health!<br />

All of this exposure presents a wonderful opportunity to build<br />

value for our role in helping patients become as healthy as<br />

possible.<br />

However, I would not suggest sitting passively by and hoping<br />

your patients become educated about the link between oral<br />

health and systemic health. Rather, I’d recommend a proactive<br />

approach where you take the lead in helping your patients make<br />

this connection. Following are three specific recommendations<br />

that will help your office take this proactive approach.<br />

The first recommendation is a very simple one<br />

to initiate, namely, take a blood pressure reading at the beginning<br />

of all exams in your practice. In addition to the value of<br />

the information that you and your patient receive by taking<br />

a blood pressure measurement, this simple step has the<br />

wonderful effect of symbolically connecting the dental visit<br />

with overall health. This simple step will create lasting benefits<br />

in your practice.<br />

The second recommendation is to create a system<br />

for oral cancer screening in your practice. Each year, more<br />

than 30,000 Americans are diagnosed with oral cancer and<br />

Practice Management


some 9,000 people die of this dreaded disease. Early detection<br />

and treatment of oral cancer can reduce the mortality<br />

rate Í dramatically and the dental office should be the first<br />

line of defense in early detection. Most hygienists and dentists<br />

conduct an oral cancer exam as part of the patient visit, yet<br />

many patients have absolutely no idea that they have received<br />

an oral cancer exam.<br />

I have routinely conducted exit interviews with patients and<br />

asked them for their feedback so we can improve the practice.<br />

Among other questions, I ask if they received an oral cancer<br />

screening exam today, knowing full well that one was done.<br />

Many patients respond with an outright, “no” or “I really don’t<br />

know.” If you did the screening and the patient is not aware<br />

of it then you have lost an important opportunity to create<br />

value. Tell your patients you are doing an oral cancer exam;<br />

they will appreciate it and it will reinforce the dental/systemic<br />

health connection.<br />

You should also review the manner in which you do this exam<br />

to be certain it is as thorough as possible. In addition to your<br />

visual and palpitative exam, I would also recommend installing<br />

a system such as the VisiLite process to further enhance<br />

the oral cancer screening system in your practice. Also, let’s<br />

not forget that initiating a system for oral cancer screening in<br />

your office may well result in saving lives.<br />

The third recommendation I have is to revisit<br />

your system for conservative perio therapy and update it to<br />

21st century standards. If you do not have a state-of-the-art<br />

system in your practice for perio diagnosis and treatment,<br />

now is the time to develop one. There have been significant<br />

advances in the science of the diagnosis and treatment of<br />

perio disease in the last few years and most offices could<br />

benefit significantly by reviewing protocols here.<br />

For example, science now provides us with the capability of<br />

conducting a very simple DNA test resulting in the identification<br />

of the specific bacteria causing that patient’s perio disease.<br />

With the identification of the specific bacteria, a proven treatment<br />

regimen can be provided targeting those bacteria. (Visit<br />

www.addx.us for more information about this DNA testing<br />

process). This science provides a level of exactness that will<br />

result in improved clinical results in the treatment of perio<br />

disease. As part of your improved system for perio diagnosis<br />

and treatment, set up very specific probing and exam protocols<br />

for all patients and educate the entire team on great verbal<br />

skills to use to educate your patients about perio disease and<br />

how modern treatment can help them become as healthy as<br />

possible. With all the news and coverage about the link<br />

between perio disease and overall body health, you will find<br />

that your patients are more receptive than ever to your education<br />

and treatment recommendations.<br />

Now is an absolutely incredible time to be in the dental<br />

profession! There has never been a better time to educate your<br />

patients and the general public about the importance of how<br />

good oral health is connected to good general health. You are<br />

getting a huge “assist” from the media today about this link<br />

and it is important that you leverage this opportunity to full<br />

advantage. Consider the three recommendations in this article<br />

as a way to take a proactive approach that demonstrates your<br />

interest and commitment to helping your patients become as<br />

healthy as possible. The end result will be that your patients<br />

will place increased value on the importance of their dental<br />

office as a partner in achieving great health.<br />

Author Credit: Gary’s life work and passion is helping dentists and their team members<br />

develop a more profitable and enjoyable practice. He is a sought-after speaker at national<br />

and international dental meetings where his informational courses are often recognized<br />

as the most fun and entertaining courses that attendees have ever experienced.<br />

Gary is also the founder of Ride and Learn, and Race and Learn, perhaps the most<br />

unique continuing education programs in dentistry today. Ride and Learn combines a<br />

Harley Davidson motorcycle tour with dental CE and Race and Learn combines high<br />

Practice Management


Planning the<br />

PRESCRIPTION<br />

– ARTICLE by Gerard J. Chiche, DDS<br />

– COVER PHOTO by Kevin Keithley<br />

When the a patient comes to consult for Esthetic Treatment, the consultation<br />

appointment is divided into 1) a conventional evaluation with charting, periodontal,<br />

occlusal and radiographic surveys; 2) diagnostic models and photographs; 3) an<br />

esthetic evaluation involving an esthetic analysis and a focus on the patient’s esthetic<br />

requests.<br />

The media image displayed in many advertisements has a very strong influence<br />

in contemporary dental treatment. Increasingly, today’s smile is part of a youthful<br />

dynamic appearance characterized by whiter teeth which often fall beyond the<br />

range of traditional shade guides. To that extent it is possible to identify two types<br />

of patients: “perfect-minded,” and “natural-minded.” Í<br />

Planning the Shade Prescription


Figure 1: Right lateral view of an ideal smile for a<br />

“perfect minded” patient.<br />

Figure 2: Right lateral view of an ideal smile for<br />

a“natural-minded” patient. (In collaboration with<br />

Dr. Basil Mizrahi).<br />

Figure 3: Left lateral view of an ideal smile for a<br />

“natural-minded” patient. (In collaboration with<br />

Dr. Basil Mizrahi).<br />

CATEGORY 1<br />

Patients in the first category will typically<br />

expect maximum regularity and<br />

alignment along with maximum brightness<br />

and a “generally sparkling effect.”.<br />

It will be critical to provide for these<br />

patients a straight dental midline, a<br />

regular smile line, often flatter than the<br />

curvature of the lower lip, symmetric<br />

central incisors, lateral incisors and<br />

canines, along with symmetric gingival<br />

margins. (Fig. 1, right lateral view of an<br />

ideal smile for a “perfect minded” patient).<br />

CATEGORY 2<br />

Natural-minded patients will typically<br />

expect a general sense of regularity and<br />

alignment along with definite brightness,<br />

but do not wish their teeth to be<br />

noticed at every turn. In any pleasant<br />

smile, pleasing tooth symmetry is found<br />

close to the midline, therefore the central<br />

incisors must be mostly symmetric<br />

with only minor irregularities (a central<br />

incisor may be more mesially inclined<br />

than the other, and the distal incisal<br />

angle of the central incisors may be<br />

bilaterally asymmetric). The main asymmetry<br />

will be provided between the lateral<br />

incisors. The canines will also provide<br />

minor asymmetry as their gingival<br />

margins and their cusp tips do not need<br />

to be leveled horizontally. The depth<br />

of the incisal embrasures should be of<br />

a natural depth in addition to providing<br />

a natural progression (Figs. 2 and 3).<br />

These pictures also illustrate the need to<br />

provide these patients with subtle polychromatic<br />

effects: incisal halo, streaks<br />

and increased cervical saturation.<br />

When planning the shade prescription, one must bear in mind that the most frequent<br />

shade variation from the basic shade of an anterior tooth is observed in nature at<br />

the incisal third. The next most frequent category observed is when the shade distribution<br />

is nearly uniform, resulting in a monochromatic appearance. In the third<br />

category, the color deviation from the basic shade is observed at the cervical third<br />

mostly, and finally in the fourth group, the shade variation involves the middle<br />

aspect of the tooth.<br />

In order to give the patient an idea of what incisal effects are possible, the incisal<br />

aspect of the shade tab is discussed with the patient after the basic shade is selected.<br />

The patients’ reaction usually is to prefer incisal effects similar to the shade tab if<br />

they are natural- driven, and to attenuate the effects to the maximum if they are<br />

perfect-driven.<br />

There are three typical scenarios that may be transmitted to the dental ceramist:<br />

SCENARIO 1<br />

Lightly Monochromatic<br />

Figure 4<br />

Shade Design<br />

Figure 5<br />

It is very common to find patients who are so displeased by the dark appearance<br />

of their teeth that they end up requesting very monochromatic and high brightness<br />

restorations (Fig. 4, 5). The shade prescription is accordingly straightforward and<br />

uncomplicated and the dental ceramist will assume that the incisal effects are very<br />

tenuous and hardly noticed. Í<br />

Planning the Shade Prescription<br />

Planning the Shade Prescription


2SCENARIO 2<br />

Lightly Polychromatic<br />

Shade Design<br />

Figure 6<br />

Figure 7<br />

SCENARIO 3<br />

Lightly Monochromatic<br />

Shade Design with<br />

Effects<br />

Figure 8<br />

Figure 9<br />

There are situations where several shades and various degrees of discolorations<br />

coexist in the same mouth. Also, there are situations where different ceramic systems<br />

are present and do not perfectly match with one another.<br />

In such situations, the rule is to assure for maximum patient’s acceptance of the<br />

restorations that by keeping the central incisors at a slightly higher value than the<br />

other anterior teeth. If the value of the central incisors ends up a slightly lower<br />

value due to some excessive translucency for example, then it is very likely that the<br />

patient will reject the final result, even with the best designed proportions, display<br />

and length. Therefore, in situations where the patient desires a natural appearance<br />

or when several different colors or ceramic systems are expected in the final outcome,<br />

a lightly polychromatic system should be considered.<br />

Typically, a mild transition in shades will be produced whereas the central incisors<br />

have the highest value, followed by the lateral incisors and finally the canines.<br />

Whenever possible, this effect should be very soft. However, it allows for an easy<br />

transitions from a light central incisor to a dark canine which was not bleached (Figs.<br />

6 and 7). It is very important in such transitions to keep the value of the lateral incisor<br />

closest to the central incisor even if the canine is of a much lower value.<br />

The typical incisal effects found on unworn incisors include: 1. Halo effect;<br />

2. Transparent incisal Border; 3. Dentin Streaks or mamelons; and 4. Proximal<br />

translucency (Figs. 8 & 9). These are the typical shading effects young unworn<br />

incisors have, imparting a very pleasing effect to the tooth shade overall. The<br />

incorporation of these effects for the natural-driven patients yields the above shade<br />

prescription. It is recommended that the clinician provides in such situations the<br />

same template each time so that nuances and variations recorded from patient to<br />

patient may be more easily interpreted.<br />

Fig. 2, 3, 6, 7, 8, and 9 are reproduced from the textbook by Chiche G., Aoshima H.: Smile Design. Quintessence Pub.<br />

Co. Inc. Chicago 2005.<br />

REFERENCES<br />

1. Mc Lean, JW.: The Science and Art of <strong>Dental</strong> Ceramics. Louisiana State University School of Dentistry, Monographs<br />

I and II, (1974) III and IV (1976)<br />

2. McLean JW.: The science and art of dental ceramics. Quintessence Pub. Co. Inc. Chicago 1980.<br />

3. Sproull R.C.: Color matching in dentistry. Practical applications of the organization of color. J. Prosthet. Dent.<br />

29:556;1973.<br />

4. Jinoian V.: The importance of proper light source in metal Ceramics. In: Preston J.D.: Perspectives in <strong>Dental</strong> ceramics.<br />

Proceedings of the Fourth International Symposium on Ceramics. pp 229. Quintessence Pub. Co. Inc. 1988,<br />

Chicago.<br />

5. Hegenbarth E.A.: The Creative Color System. Quintessence Pub. Co. Inc. 1989, Chicago.<br />

6. Miller L.L.: Scientific approach to shade matching. In: Preston J.D.: Perspectives in <strong>Dental</strong> ceramics. Proceedings<br />

of the Fourth International Symposium on Ceramics. pp 193. Quintessence Pub. Co. Inc. 1988, Chicago.<br />

7. Nakagawa Y. at al.: Analysis of natural tooth color. Shikai Tenbo 46;527;1975<br />

8. Sekine M. et al.: Translucent effects of porcelain jacket crowns. 1. Study of translucent patterns in the natural teeth.<br />

Shika Giko 3:49;1975.<br />

9. Chiche G., Pinault A.: Esthetics of Anterior Fixed Restorations. Quintessence Pub. Co. Inc. Chicago 1994.<br />

10. Chiche G., Aoshima H..: Smile Design. Quintessence Pub. Co. Inc. Chicago 2005. Consultant Noritake co.<br />

Planning the Shade Prescription<br />

Planning the Shade Prescription


Lip Lines and<br />

Spider Lines<br />

– ARTICLE by Bradley Evans, MD, DDS, MS<br />

– Images courtesy of Medical Matrix, LLC<br />

Facial Correction without Injection:<br />

Angellift ® Pricing and Technology Update<br />

Lower Lip<br />

Recession<br />

Deep Nasolabial<br />

Folds<br />

Laugh Lines<br />

Smoker Lines and<br />

Chin Depression<br />

In June of 2006, Angellift was introduced to the dental industry as a technique and device to remove lower facial wrinkles.<br />

Within 6 months Angellift was featured on NBC, FOX, CBS, CW and appeared throughout the Canadian press. Consumer<br />

response to our media coverage has been extraordinarily enthusiastic and deeply gratifying. Clearly the dental industry now<br />

has an effective, comprehensive tool in the competition for the consumers’ anti-aging dollar.<br />

Last year, Americans spent 2.2 billion dollars fighting facial wrinkles with injectable materials. Until the introduction of Angellift,<br />

most dentists could not offer comparable alternative anti-aging services to this booming industry as it was considered to be<br />

practicing beyond the legal scope of general dentistry.<br />

Extraordinary consumer demand for the Angellift device throughout North America, has enabled us to REMOVE THE PRICING<br />

CEILING in order to charge an appropriate fee for their professional services. The new pricing structure enables additional profits<br />

where demand is highest without negatively impacting sales in areas where Angellift consumer awareness is relatively new.<br />

In addition to the new retail pricing flexibility, Angellift is introducing the Preview ® , a soft, flexible strip which allows you to<br />

promote and evaluate a patient for Angellift within seconds. The Preview is a patented, flexible, surgical silicone based strip<br />

with an imbedded titanium wire that allows you or your staff too safely, comfortably and quickly demonstrate to a patient the<br />

effectiveness of the Angellift without the need for an impression or<br />

timely consultation. The<br />

Previw can be placed in the mouth for a quick cosmetic pre-<br />

view, during a<br />

routine exam, cleaning or even front desk consultation. This<br />

could never be done with Botox ® or dermal fillers.<br />

Women spend more money on skin care and cosmetic products<br />

and services than the combined total spent on porcelain veneers,<br />

teeth whitening and orthodontics. The combination of our new<br />

pricing flexibility and ease of the Preview puts your practice<br />

in the sweet spot of this extraordinarily profitable market.<br />

Unlike any shot or injectable dermal filler, Angellift is hypoal- l e r -<br />

genic, removable and doesn’t pose any of the inherent dangers related to<br />

injections, chemical peels, fillers or surgery. Combining these benefits<br />

with the new<br />

Preview and our revised retail pricing policy, Angellift can bring you new<br />

patients, expand<br />

the scope of your practice and make your practice even more profitable.<br />

Upper Lip<br />

Depression<br />

Angellift and Preview are registered trademarks of Medical Matrix, LLC, San Diego, CA.<br />

Botox is a registered trademark of Allergan, Inc. Irvine, CA.<br />

Angellift: Facial Correction without Injection<br />

Angellift: Facial Correction without Injection


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