A Publication of Glidewell Laboratories • Volume 8, Issue 1
Another Use for Anterior
BruxZir ® Restorations
Poor to Excellent Function in
Dr. Ara Nazarian
Embezzlement and the
An Interview with
Prosperident CEO David Harris
The Viability of Prosthetic
Dr. Robert Lowe
Dr. Michael DiTolla’s
Jennifer Folbigg, Customer Service Representative
Glidewell Laboratories, Newport Beach, Calif.
9 Dr. DiTolla’s Clinical Tips
Showcased in this issue are a cloud-based platform I
recently demoed from Smile Reminder that offers an
impressive suite of personalized patient communication
tools for growing your patient base, and an invaluable
oral hygiene product from Dental Herb Company to
aid in your practice’s fight against periodontal disease.
Also featured are two innovative products designed
to make your dentistry easier and more efficient: a
sectional matrix system from Triodent for performing
high-quality Class II restorations, and an LED curing
light from Ivoclar Vivadent that features a compact,
ergonomic shape to fit any dentist’s hands.
14 Poor to Excellent Function in One Day!
“Mini” or small-diameter implants offer many benefits
for patients seeking maxillary and mandibular overdenture
treatment. Dr. Ara Nazarian presents a case
report featuring Glidewell’s Inclusive ® Mini Implants
that demonstrates the protocol for the placement of
these small-diameter implants, and the subsequent
beneficial effects they have on the function and retention
of the patient’s new prostheses.
22 Photo Essay: Another Use for Anterior
BruxZir ® Solid Zirconia Restorations
In this photo essay, I address a difficult situation
restorative dentists face in clinical practice: treating a
patient with severe tetracycline staining. The patient
in this case presented the additional challenges of
severe bruxism and an edge-to-edge bite. I chose
BruxZir crowns because I knew these high-strength
restorations would not only withstand the destructive
forces generated in his mouth, but would also have a
better chance than a glass-ceramic material of completely
blocking out the dark stump shades.
Visit www.chairsidelive.com to view the latest episode of
our weekly Web series “Chairside Live.” Also available on
YouTube and iTunes.
38 Chairside Live Case of the Week:
Episode 32 — A Disastrous Double-Arch
This new column highlights a Case of the Week from
a recent episode of our weekly Web series “Chairside
Live.” The first case comes from Episode 32 and
addresses one of my dental pet peeves: when our lab
receives a bridge impression taken in a double-arch
tray. While double-arch impressions can be suitable for
a single-unit crown or two single-unit adjacent crowns,
they are best avoided for multi-unit restorations.
44 One-on-One with Dr. Michael DiTolla:
Interview of David Harris
According to Prosperident CEO and licensed private
investigator David Harris, embezzlement will strike
three in five dentists in their careers. While this statistic
may surprise you, it doesn’t need to discourage you. In
this issue’s featured interview, the man known in dental
circles as “the dental fraud guru” shares his expert
perspective on embezzlement in the dental office.
Chairside Magazine Digital Edition
Chairside magazine is now optimized for all popular
desktop, tablet and smartphone platforms! To try out
the new beta version of our digital magazine from
your desktop computer or favorite mobile device, visit
55 Prosthetic Tooth Repositioning: A Viable
Treatment Option for Select Cases
For a select group of patients with minor tooth
malposition, such as spacing, crowding, minor rotations
and facial-lingual arch form displacement, esthetic and
functional correction may be accomplished purely by
restorative means, claims Dr. Robert Lowe. Three case
reports demonstrate how prosthetic tooth repositioning
can be a viable treatment option for these types of
malocclusions when proper guidelines are followed.
64 Biologic Shaping from a Restorative
Dr. Daniel Melker focuses on the concept of biologic
shaping in this article, outlining the numerous
differences between this root-reshaping procedure
and traditional crown lengthening. A case example
illustrates how this periodontal corrective procedure
can provide the restorative dentist with a predictable
and successful method of restoring teeth.
Michael C. DiTolla, DDS, FAGD
Dr. Michael DiTolla is a graduate of the University of the Pacific Arthur A. Dugoni School of Dentistry. As director
of clinical education and research at Glidewell Laboratories, he performs clinical testing on new products
in conjunction with the company’s R&D department. Glidewell dental technicians have the privilege of rotating
through his operatory and experiencing his commitment to excellence through his prepping and placement of
their restorations. Dr. DiTolla is a CR evaluator and lectures nationwide on restorative and cosmetic dentistry.
His clinical programs are available on DVD and online through Glidewell Laboratories. For more info on his
articles or for a free copy of his clinical presentations, call 888-303-4221 or e-mail email@example.com.
David Harris, MBA, CMA
David Harris is a licensed private investigator, with a graduate business degree and a professional accounting
designation. He is CEO of Prosperident, the world’s largest dental embezzlement investigation firm. Prosperident
is consulted on hundreds of dental embezzlement matters annually, and David has frequently had the pleasure
of hearing cell doors slam shut on perpetrators. David has lectured at several universities in the faculties of
dentistry, business and law, and he has been interviewed on embezzlement by virtually every major North
American dental magazine. David is a member of the Academy of Dental Management Consultants (ADMC)
and the Speaking Consulting Network. Contact him at 888-398-2327 or www.dentalembezzlement.com.
Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE, FASDA
Dr. Robert Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982 and was
a clinical professor in restorative dentistry at the school until its closure in 1993. Since January 2000,
Dr. Lowe has maintained a private practice in Charlotte, N.C. He lectures internationally and his work
is frequently published in well-known dental journals on esthetic and restorative dentistry. Dr. Lowe has
earned Fellowship in the AGD, ICD, ADI, ACD and American Society for Dental Esthetics (ASDA), and
received the Gordon Christensen Outstanding Lecturers Award and Diplomat status on the American Board
of Esthetic Dentistry. Contact Dr. Lowe at 704-450-3321 or firstname.lastname@example.org.
Daniel J. Melker, DDS
Dr. Daniel Melker graduated from the Boston University School of Graduate Dentistry in 1975 with specialty
training in periodontics. Since then, he has maintained a private practice in periodontics in Clearwater,
Fla. Dr. Melker lectures at the University of Florida Periodontic and Prosthodontic graduate programs on
the periodontic-restorative relationship. He also presents at the University of Alabama at Birmingham,
University of Houston, Baylor University and Louisiana State University’s graduate periodontal programs.
Dr. Melker has published several articles in national dental magazines, and he has twice been honored with
the Florida Academy of Cosmetic Dentistry Gold Medal. Contact him at 727-725-0100.
Ara Nazarian, DDS, DICOI
Dr. Ara Nazarian maintains a private practice in Troy, Mich., with an emphasis on comprehensive and
restorative care. He is the director of the Reconstructive Dentistry Institute, a Diplomate of the ICOI, and has
conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the U.S.,
Europe, New Zealand and Australia. Dr. Nazarian is also the creator of the DemoDent ® patient education
model system. His articles have been published in many of today’s popular dental publications. Contact him
at 248-457-0500 or www.aranazariandds.com.
Jim Glidewell, CDT
Editor-in-Chief and Clinical Editor
Michael C. DiTolla, DDS, FAGD
Jim Shuck; Mike Cash, CDT
Jennifer Holstein, David Frickman,
Chris Newcomb, Megan Strong
Digital Marketing Manager
Jamie Austin, Deb Evans,
Joel Guerra, Audrey Kame, Phil Nguyen,
Kelley Pelton, Makara You
Jamie Austin, Kevin Greene,
Allison Newell, Melanie Solis, Ty Tran
James Kwasniewski, Sam Lea
Wolfgang Friebauer, MDT
The crowns & bridges produced at Glidewell Laboratories
are now made using essentially 100 percent CAD/CAM
technology, and I really notice the difference in the
restorations I get back from the lab. The crowns just fit, and
if I give them enough reduction, I can always get contours
like a natural tooth. Before we started using CAD/CAM, the
most frequent complaint we used to hear from dentists was
about our consistency, so this technology really has been a
game changer for our lab and our customers.
More than a decade ago, new customers would tell me that
they would get three great crowns from us and then two soso
crowns, then another great one, then one ugly one, and so
on. We were doing everything we could to fix those issues,
but the underlying problem went deeper than our lab: there
simply weren’t enough trained dental technicians available.
There are currently only 18 accredited dental laboratory
programs in the U.S. If that number seems shockingly low
to you, it’s because it is. That number is down 62 percent
since 1992 — a drastic decrease for that 20-year period. In
fact, today these programs currently produce only about 300
graduates annually for the entire U.S. To meet our demand,
we had to hire people off the street and train them ourselves.
But it takes time to develop as a technician, just as it does
as a dentist.
In 2007, Ivoclar Vivadent’s IPS e.max ® was introduced
into our lab, and with this first high-strength, monolithic
restoration came the day where a machine did most of
the work. Ideal contours were found in CAD libraries, and
dentists just had to give CAD technicians enough room to
drop them in. Then in 2009, Glidewell launched BruxZir ®
Solid Zirconia, signaling the next wave of the monolithic
revolution. A year later, nearly all of our PFM crowns were
produced using CAD/CAM as well.
Coordinator and Ad Representative
Thanks to our president and CEO’s unwavering commitment
to technology, we are able to give you, our dentists, the
consistency and predictability you’ve always wanted. Dentists
often tell me that a BruxZir crown fits better than any
If you have questions, comments or complaints regarding
this issue, we want to hear from you. Please e-mail us at
other crown they have prescribed. It’s a good time to be a
email@example.com. Your comments may be
dentist, and it’s a great time to work with a lab that has fully
featured in an upcoming issue or on our website:
embraced the consistency of CAD/CAM dentistry.
Neither Chairside Magazine nor any employees involved in its publication
(“publisher”), © makes 2013 any Glidewell warranty, Laboratories
express implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
Chairside of any information, magazine apparatus, nor any employees product, involved or process in its disclosed, publication or
(“publisher”), represents makes that its any use would warranty, not express infringe proprietary or implied, rights. or assumes Reference any
liability herein or to responsibility any specific for commercial the accuracy, products, completeness, process, or or services usefulness by
Yours in quality dentistry,
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constitute that its or use imply would its endorsement, not infringe recommendation, proprietary rights. or Reference favoring
herein by the to publisher. any specific The commercial views and products, opinions of process, authors or expressed services
by herein trade do name, not necessarily trademark, state manufacturer or reflect those or otherwise of publisher does and not
necessarily shall not constitute be used for or advertising imply its endorsement, product endorsement recommendation, purposes. or
favoring CAUTION: by the When publisher. viewing The the views techniques, and opinions procedures, of authors theories expressed and materials
do that not are necessarily presented, state you or must reflect make those your of own the decisions publisher about and
specific treatment for patients and exercise personal professional judgment
regarding When viewing the need the for further techniques, clinical procedures, testing or education theories and
Editor-in-Chief, Clinical Editor
Dr. Michael C. DiTolla
shall not be used for advertising or product endorsement purposes.
materials your own that clinical are presented, expertise before you must trying make to implement your own new decisions procedures. about
specific treatment for patients and exercise personal professional
judgment Chairside regarding ® Magazine the is need a registered for further trademark clinical of testing Glidewell or education Laboratories. and
your own clinical expertise before trying to implement new procedures.
Chairside is a registered trademark of Glidewell Laboratories. Editor’s Letter
Letters to the Editor
Dear Dr. DiTolla,
Is BruxZir ® Solid Zirconia (Glidewell Laboratories)
indicated for inlays/onlays as well as
crowns? I only hear it mentioned for crowns.
For patients that insist on tooth-colored restorations
on second molars, what do you
place, if anything? I love IPS e.max ® (Ivoclar
Vivadent; Amherst, N.Y.), but I draw the line
at the first molars forward.
– Jeffrey L. Schultz, DDS, FAGD
BruxZir Solid Zirconia can be used for
inlays and onlays, as well as crowns.
We have dentists asking us for BruxZir
veneers as well, which we can do, but I
am waiting for some bond strength research
to conclude before we make any
recommendations. Veneers are essentially
non-retentive preps, so we need
to ensure that our cementation/bonding
protocol is sufficient to retain them.
For tooth-colored restorations on second
molars, BruxZir Solid Zirconia is
the only choice. However, you need
to have at least 0.5 mm of occlusal reduction.
I have a 0.6 mm depth-cutting
bur in my kit that I use for these restorations,
and by the time I finish the
reduction it will usually be at 0.7 mm.
At 0.5 mm, you must reduce the opposing
if the occlusion is high on the
restoration; otherwise, the BruxZir restoration
can fail. Cast gold still holds
the title as the best second molar restoration,
but you know as well as I do
that most patients will not accept it.
Hope that helps!
Dear Dr. DiTolla,
I’m totally blown away by “Chairside Live,”
which I was intrigued to watch for the first
time when you interviewed Gordon [Christensen]
— I believe it was Part 3. First, let
me congratulate you on the entire concept,
which I found entertaining, informative and
just plain fun to watch. You and Megan
remind me of the old Dan Aykroyd-Jane
Curtin SNL “Point/Counterpoint” parody. In
any event, great job! I loved your retching
skit at the end — hilarious!
But you know you and your guest can’t
spew out data without skeptical Michael
(that’s me) chiming in. As far as Gordon’s
claim that various drinks such as lemonade
are 10-times more damaging to the external
stain on BruxZir zirconia than Coca-Cola,
a quick search (Yahoo Answers, NEWTON
Ask-a-Scientist) found that the pH of Coke
is 2.5, while lemonade is 3.8. On the other
hand, another site (21st Century Dental) lists
Country Time Lemonade as having a pH of
2.5 and Coke Classic at 2.53. Gordon also
mentioned energy drinks being worse than
Coke, but this latter site found that Gatorade
has a pH of 2.95. Bottom line: It’s very
hard for me to believe that these drinks are
worse than Coke when it comes to dissolving
external ceramic stains, and 10-times
worse? Nah! Even if pH is not the be-all and
end-all factor, 10-times worse is still hard
You also stated that Multilink ® Automix
(Ivoclar Vivadent) was “self-etching,” but in
fact, it’s the primers in the kit that are selfetching,
not the cement itself. Minor point,
perhaps, but your viewers could possibly
have come away thinking that Multilink
Automix is similar to RelyX Unicem (3M
ESPE; St. Paul, Minn.), which, of course,
In any event, you again came up with a terrific
idea, which I have to admit I’m jealous I
didn’t think of first!
– Michael Miller, DDS
Wow, coming from you that is quite
an honor! I have such respect for
what you do at REALITY (www.
realityesthetics.com), and it means
a lot when one of my mentors takes
the time to write a letter like this. You
might even see your letter read on
“Chairside Live,” which would earn
you a signed picture of Megan and
me. I’ll be sure to mark it with a dotted
line so you can cut me out of the
picture. Plus, addressing your letter on
the show will give me the chance to
prove I know the difference between
self-etching resin cements and selfadhesive
Gordon was referring to an AGD study
in their journal, General Dentistry (von
Fraunhofer JA, Rogers MM. Effects of
sports drinks and other beverages on
dental enamel. Gen Dent. 2005 Jan-Feb;
After that episode aired, a viewer sent
me this link, http://fit4maui.com/water/
pu/bottled_ph.html, which purports to
measure the pH of different brands
of bottled water. Could Aquafina and
Dasani really have a pH of 4?
Thanks again for the kind words,
Michael! They mean the world to me.
Dear Dr. DiTolla,
I have followed some of your CE courses online.
I see that you are a fan of SpeedCEM
(Ivoclar Vivadent). Do you use SpeedCEM
to cement feldspathic porcelain veneers?
Would you etch with hydrofluoric acid if the
lab has already done so?
– Marea White, DDS
Nice to hear from you! I am a fan of
SpeedCEM, which is a self-adhesive
resin cement similar to RelyX Unicem
or Maxcem Elite (Kerr Corp.; Orange,
Calif.). While these cements are strong
enough for inlays, retentive onlays and
retentive crown preps, they are not
strong enough to bond low-retention
restorations such as veneers.
Every veneer manufacturer I have
spoken with still recommends the
total-etch (now called etch and rinse)
technique for luting veneers, including
higher strength veneers like IPS e.max.
There is one lecturer I know of, Dr. Jose
Luis-Ruiz, who mentioned to me in an
interview for Chairside magazine that
he is using self-etch to place veneers.
However, he is doing it using a cement
with a separate self-etch solution.
PANAVIA F2.0 (Kuraray America; New
York, N.Y.) and Multilink Automix are
two good examples of self-etching
resin cements with separate self-etch
The standard of care today is to use
the total-etch (etch and rinse) technique
with a light-cured resin cement
to place veneers.
The research I have seen does not
show any improvement in bond
strength if you re-etch the veneers
with hydrofluoric acid in your office
after try-in, although it is acceptable
to clean the veneer with phosphoric
Dear Dr. DiTolla,
I practice general dentistry in Petaluma,
Calif. A few months ago, I attended one
of your CE courses through our local
dental society, Redwood Empire Dental
Society (REDS). I enjoyed your lecture and
your sense of humor. Most importantly, I
really liked all of your practical tips and
information. I have been practicing since
2000, and have taken many CE classes, but
your lecture has made the biggest impact
on my practice so far. Your preparation and
impression techniques have helped me
achieve perfect impressions and my crown
cement appointments are so enjoyable now.
My dental lab technician had always told me
that my preps and impressions were very
good, but the small changes I made since
attending your course have helped me
achieve excellent and consistent results. I
wanted to thank you and let you know how
useful your tips have been to my practice
and to me. I hope you return to this area to
– Nadia Navid, DDS
Thank you so much for your kind letter.
I love hearing stories like yours,
and I know your lab techs will be
thrilled with your preps and impressions
as well. They will love you even
more if you send a digital photograph
with all anterior cases! I keep playing
with new products and techniques,
looking for ways to help dentists get
better results in a simple, predictable
fashion. I will be sure to pass any of
those your way, and I hope I get a
chance to make it back to your neck
of the (red)woods soon!
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Letters to the Editor 7
Total number of BruxZir ® crowns placed
Source: Glidewell Laboratories internal data
Number of countries where
BruxZir ® Solid Zirconia is sold
Source: Glidewell Laboratories internal data
Dentistry personnel per 10,000 people in the U.S. Dentistry
Source: Wolfram|Alpha, www.wolframalpha.com
personnel per 10,000 people in China
Source: Infodent International magazine
Number of Glidewell
in 2012 that had
were fabricated for
Source: Glidewell Laboratories
Unemployment rate of U.S.
dentists (one of the lowest
of all U.S. professions)
Source: U.S. Bureau of Labor Statistics
Percentage of anterior
restorations fabricated at
Glidewell Laboratories from
BruxZir ® Solid Zirconia
Source: Glidewell Laboratories internal data
#8 & #9
BruxZir ® Solid Zirconia is the second most
requested restorative material at Glidewell
Laboratories for these upper front teeth
Source: Glidewell Laboratories internal data
PRODUCT........ Bluephase ® Style
SOURCE........... Ivoclar Vivadent Inc. (Amherst, N.Y.)
Design matters. Apple has taught me over the last
few years that, regardless of how well an object
does something, the look and feel of an item play
an important role in the user’s personal connection
to it. The original curing lights were gun-shaped, on
the clunky side and struggled to reach the molars.
The Bluephase Style LED curing light from Ivoclar
Vivadent has won multiple design awards, and it
is easy to see why. We just hired our first female
dentist, and her hands are tiny compared to mine.
Considering that more than 50 percent of dental
school graduates are women, ergonomics is an
important issue when we are sharing instruments
such as electric handpieces and curing lights.
Bluephase Style’s Polywave ® LED technology provides
a broadband spectrum of 385–515 nm, and it
will cure every dental material on the market today.
The 10 mm light probe tip allows you to cure even
the largest restorations because it can provide
continuous curing for more than 10 minutes.
Dr. DiTolla’s Clinical Tips 9
PRODUCT........ Tooth & Gums Tonic ®
SOURCE........... Dental Herb Company ® Inc.
I started using Tooth & Gums Tonic more than 10 years
ago when I started practicing at Glidewell Laboratories.
Once we began filming all of my dentistry, I realized
how bad bleeding tissue looked when we were making
impressions or placing restorations. For some reason,
I had been willing to tolerate this bleeding for the first
13 years of my career, but now that I could see it onscreen,
I was disgusted. While the potent and effective
formulas of Dental Herb Company products remain unchanged,
the impact of the company’s new ownership
is evident. In addition to a fresh, new look, the company
has vastly improved its customer service, updated its
packaging and informational materials, and provided a
more user-friendly Web presence with a “Find a Dentist”
locator tool that patients can use to search for the nearest
dental office carrying its products. So while the new
owners continue to sell Tooth & Gums products through
dental professionals, the company expects to have online
ordering ready to go by this summer. It’s clear that
Dental Herb Company wants to be a valued partner in
your practice’s fight against periodontal disease, and
in our lab’s fight against bloody impressions!
PRODUCT........ Triodent V3 Sectional Matrix System
SOURCE........... Ultradent Products Inc. (South Jordan, Utah)
Because I practice inside of a dental laboratory, I
typically only do direct restorations when they are
adjacent to other indirect restorations I am placing.
I was introduced to this sectional matrix system while
I was testing BruxZir ® inlays and found myself doing
only inlay preps for a month. While I was able to
rationalize that it was OK when I nicked an adjacent
tooth while dropping the proximal box and extending
it buccolingually, a fellow dentist told me about the
WedgeGuard interproximal tooth shield, which is an
integral part of the V3 Matrix. WedgeGuard is the
standard Wave-Wedge interproximal wedge with a
metal protector attached to it. Place the WedgeGuard
between the teeth and prep the tooth safely with the
metal protector in place. After you finish the prep,
you simply grab the metal protector and pull it out
with the wedge still in place. Then you place your
matrix, place the V3 Ring, and place and cure the
composite. Genius! Go to exclusive U.S. distributor
Ultradent’s YouTube page to view an animation of
the system in action.
Dr. DiTolla’s Clinical Tips11
PRODUCT........ Smile Reminder
SOURCE........... Solutionreach (Lehi, Utah)
FREE $10 STARBUCKS GIFT CARD! Yep, that is all
it took to get me to take the online demo of Smile
Reminder. Once a month I am asked to fill out an
online survey for which the soliciting company will
send me a $5 check. Don’t bother; I don’t want to walk
it over to the bank. But a $10 Starbucks gift card?
One of my staff members goes to one of their drivethru
locations every day on her way to work — well
played, Smile Reminder! What started off as a demo
turned into a purchase just 10 minutes later when I
saw the platform’s mind-boggling suite of features,
which address everything from reducing no-shows
with messaging and filling late cancellations, to
sending targeted e-mail campaigns based on patient
surveys and giving dentists and staff the ability to
record custom video birthday greetings that get sent
to patients. You can even track your online reputation
by finding positive and negative reviews, as well as
invite patients to write reviews and post them to the
sites where your online reputation needs a boost.
The electronic “recare” feature alone pays for the
service because it automatically contacts patients
who don’t have an appointment and are past their
recall frequency, pulling the data from your practice
management software. We use Henry Schein’s
Dentrix ® , and the front office loves that it shows a live
update of each patient’s pre-approved CareCredit
amount. The Smile Reminder fixed price guarantee
is also a refreshing approach I wish others would
take. The dentists who signed up for Smile Reminder
years ago are still paying the same price today. I like
knowing what my monthly flat fee will always be and
that there will not be any surprises down the road. I
left out about 50 other functions where this powerful
software also shines. Yes, you have my permission
to put down the magazine and go get your Starbucks
gift card. Go to http://tinyurl.com/smilereminder.
Poor to Excellent
Function in One Day!
– ARTICLE by Ara Nazarian, DDS, DICOI
Minimally invasive devices and procedures are fast becoming the largest growth
segment of the medical and dental device industry. When compared to traditional
approaches, they require less anesthesia, shorten surgical and recovery times,
reduce patient risk, and can offer significant cost savings. Over time, we have
witnessed the research and development of smaller and smaller components.
Mini dental implants dramatically improve the quality of the outcomes for patients
seeking maxillary and mandibular overdenture treatment.
Small-diameter implants (1.8 mm to 3.0 mm) also differ from their full-sized
counterparts in several ways. Their configuration allows for a more conservative
placement protocol without involving tissue flaps or tapping procedures,
resulting in minimal trauma for the bone and the gingival tissues. Mini dental
implants’ size also allows the clinician to place them in ridges that might not
otherwise be suitable for full-sized implants. Once these mini dental implants
are firmly seated in place in intimate contact with bone, they can be immediately
loaded with no lengthy waiting period or second-stage surgery.
The following case report will demonstrate the protocol for the placement of
small-diameter implants, and the subsequent effects on the new prostheses.
Poor to Excellent Function in One Day!15
Diagnosis and Treatment Planning
A male in his late 70s presented to our office; he was
frustrated with the look and fit of his upper and lower
dentures (Fig. 1). Most importantly, he complained that his
lower denture was nonretentive and nonfunctional, always
falling out when speaking or while eating. He had been a
denture wearer for the last 25 years, resulting in excessive
resorption of the mandible. The patient also suffered from
hypertension, which was controlled with medication.
The first phase of treatment would consist of having a new
set of upper and lower dentures (Simply Natural Dentures
[Glidewell Laboratories]) that would fit properly and occlude
functionally. Utilizing recorded bases with corresponding
wax rims, we analyzed the positioning of the teeth and
proper proportions for an ideal smile. The patient desired
to have his new set of teeth with shade B1 (VITA Classical
Shade Guide [Vident; Brea, Calif.]). When the patient viewed
the wax try-in, he quickly approved them for processing
Palpation and radiographic examination revealed a
moderately narrowed mandibular ridge (Fig. 3). Crestal bone
and ridge height were sufficient to receive four 3 mm x 13 mm
Inclusive ® Mini Implants (Glidewell Direct) (Fig. 4). The thread
pattern and pitch of this implant are purposely designed
to immediately maximize bone-to-implant thread contact.
Others like it include: I-Mini (OCO Biomedical; Albuquerque,
N.M.), I6B (AB Dental USA; Los Angeles, Calif.), HM Implant
(Hiossen; Fairless Hills, Pa.), MILO ® (Intra-Lock; Boca Raton,
Fla.), Midi ® (Basic Dental Implants; Albuquerque, N.M.),
Intermezzo (MegaGen USA; Englewood Cliffs, N.J.) and
miniMARK (ACE Surgical; Brockton, Mass.).
After reviewing the patient’s panoramic radiograph, the
mental foramina were also located, and it was confirmed
that the four mini dental implants could be safely placed
within the cuspid-to-cuspid area.
Figure 1: Existing dentures were approximately 17 years old.
Figure 2: New upper and lower dentures.
Figure 3: Lower edentulous ridge, in preparation for mini dental
Outline of Clinical Treatment
Before starting treatment, all the risks, benefits and
alternatives were reviewed with the patient. A clean
operating environment was established, the patient was
draped and local anesthetic was administered. Then, an
indelible marker was used to designate landmarks and
areas of insertion.
Keeping correct alignment, a 1.5 mm pilot drill from the
Inclusive ® Surgical Kit (Glidewell Direct) was placed into
the sites and advanced to a depth of 15 mm, measuring
from the tissue surface using a surgical motor (AEU-7000E
[Aseptico; Woodinville, Wash.]) with generous amounts of
Figure 4: Inclusive Mini Implants (Glidewell Direct) in packages and
ready for placement.
sterile water. This additional 2 mm was the same depth
of the tissue height to bone. In other words, 13 mm for
the osteotomy in bone and 2 mm for tissue thickness was
created to place a 13 mm long implant. Paralleling pins
(Salvin Dental; Charlotte, N.C.) were placed in the sites
of the osteotomies and an X-ray was taken to check the
angulations to ensure proper orientation among the implant
sites. Using a rotary tissue punch, a 3.0 mm outline was
created over the initial osteotomies and the tissue plugs
removed with a serrated curette (Zoll Dental; Niles, Ill.). The
osteotomies were completed with the final drill (2.4 mm)
included in the Inclusive Surgical Kit. Once the osteotomies
were completed, four 3 mm x 13 mm Inclusive Mini Implants
were placed in the osteotomies, using an implant finger
driver (Fig. 5) until increased torque became necessary. The
ratchet wrench was then connected to the adapter and the
implants were torqued to final depth, reaching a torque
level of 65 Ncm (Fig. 6). A postoperative radiograph was
taken of the implants before initiating the prosthetic phase
At that point, the location of each implant was transferred
to the denture using bite registration material (Take 1 ®
Advance [Kerr Corp.; Orange, Calif.]). These areas were
relieved to a diameter of 5.0 mm, and the denture was then
reseated passively, confirming adequate relief had been
A covering silicone (Fit Test C&B [VOCO America; Briarcliff
Manor, N.Y.]) was used to cover any undercuts or interface
of the implants, allowing only the O-ball of the implant
to be exposed. This step prevented problems of the pickup
material locking around the implants. A female O-ring
keeper cap (Inclusive) was then fitted over each implant.
Retentive fit and mobility were again verified. Each O-ring
would create a retentiveness of approximately 5 lbs. Since
there were four implants with corresponding housings,
the total amount of force needed to remove the prosthesis
would be about 20 lbs.
The cleaned and dried recesses in the lower denture were
filled with cold-cure acrylic (Quick Up [VOCO America])
(Fig. 7) and seated onto the implants, allowing it to
polymerize. Upon setting, the lower denture was relieved of
any excess flash, and the flange areas were relieved (Fig. 8).
Finally, postoperative instructions were reviewed with the
patient regarding denture placement, removal and oral
hygiene. The patient was extremely excited and pleased that
his new dentures were now very retentive and functional.
Figure 5: The mini dental implant on the plastic insertion driver.
Figure 6: Four mini dental implants in place in the mandible.
Figure 7: Quick Up (VOCO America) was placed in recesses for
Figure 8: Retentive housings, as picked up in the lower denture.
Poor to Excellent Function in One Day!17
Implants Are Easy to Code: The Question Is the Final Appliance!
Tom M. Limoli, Jr.
Gaining in rapid popularity are these so-called “mini
implants.” They are sometimes referred to as “small” or
“narrow diameter” depending on the precise dimensions as
well as the specific manufacturer. From the coding, billing
and reimbursement perspective, let’s separate the global
procedure into its two major subcomponents. They are the
implant and the existing denture that is now being modified
to become an overdenture.
Procedure code D6010 identifies the surgical placement
of the implant body. In reviewing thousands of claims for
multiple implant placements during the same surgical
series, it is not uncommon to find documentation and
billing based upon the premise of the “single incision
rule.” This type of billing generally results in the first
implant being billed at 100 percent of the fee, while each
additional at the same surgical visit being billed at some
variation of 80 percent, 60 percent, all the way down to
40 percent of the fee for the first surgically placed implant.
Implant Codes and Fees
When the technique involved is the modification of an
existing removable denture to one becoming an implantretained
overdenture, they are globally identified with
procedure code D5875. This code would only be applicable
if we were simply going to be using the patient’s existing
appliance with modifications. A weakness in the existing
coding sequence is that code D5875 does not specify if
the original removable appliance replaces either a partial
or completely edentulous arch. Also the fact that this code,
by ADA definition, does not require a “by report” clinical
narrative makes the claim delay the inevitable. That is why
I recommend that the code always be submitted with a
description of the prosthetic modification along with the
original date of placement and anticipated longevity.
As concerns Dr. Nazarian’s specific technique and
treatment plan for this individual patient code, D5875 would
not apply since the completed “global” procedure is in fact
an implant-retained overdenture identified by code D6053.
Code Description Low Medium High
Modification of removable
prosthesis following implant surgery
$250 $324 $577 $334 6.68
D6010 Surgical placement of implant body $1,532 $1,745 $2,398 $2,012 40.24
$2,117 $2,514 $3,500 $2,650 53.00
CDT-2011/2012 copyright American Dental Association. All rights reserved. Fee data copyright Limoli and Associates/Atlanta Dental Consultants. This data
represents 100 percent of the 90 th percentile. The relative value is based upon the national average and not the individual columns of broad-based data.
The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office
is available for a charge from Limoli and Associates/Atlanta Dental Consultants at 800-344-2633 or www.limoli.com.
The advent of the mini dental implant has given general
dentists an efficient and more affordable way of solving
many of the challenges associated with complete dentures.
In providing mini dental implants that immediately improve
denture function and retention, the clinician can rapidly
restore a patient’s confidence and also yield positive economic
benefits for the practice. In addition, the simplified protocols,
conservative procedures and elimination of gingival surgery
make mini dental implants ideal for medically, anatomically
and financially compromised patients.
It has been estimated that more than 36 million patients in
the United States have lost their teeth; however, 0.5 percent
have received implant therapy. This striking disparity signifies
a huge untapped market for implants and dentures! CM
Dr. Nazarian maintains a private practice in Troy, Mich., with an emphasis on
comprehensive and restorative care. He can be reached at 248-457-0500 or at
Disclosure: Dr. Nazarian reports no disclosures.
Reprinted by permission of Dentistry Today, © 2012 Dentistry Today.
Another Use for ANTERIOR
BruxZir ® Solid Zirconia Restorations
– ARTICLE by Michael C. DiTolla, DDS, FAGD
One of the most difficult clinical situations restorative dentists face in
clinical practice is treating a patient with severe tetracycline staining.
I treated one of these patients a few years ago with a set of veneers
that were conservative but an esthetic compromise. The tetracycline stains
showing through the veneers were still visible enough to bother the patient.
When we removed the veneers six months later, I prepped 0.6 mm deeper to
make the veneers thicker. But at the try-in appointment, it was clear that the
esthetics hadn’t improved much from the first set. We ended up using lithium
disilicate crowns, which provided an improved result, but there was still some
minor show-through in the gingival third.
Not long ago, the patient’s brother came to see me. He was already prepared
to do crowns, so I wanted to see if BruxZir ® Solid Zirconia crowns (Glidewell
Laboratories) could block out the prep shade. While not as esthetic as lithium
disilicate crowns, I hoped to get a more esthetic overall result by entirely
blocking out the stump shade. Unlike his sister, this patient had fractured nearly
every PFM in his mouth, and the wear in his mouth and his edge-to-edge
bite clearly revealed a severe bruxing habit. Taking this into consideration,
I knew BruxZir Solid Zirconia was the only ceramic material that would stand
a chance of surviving in this hostile oral environment.
Another Use for Anterior BruxZir Solid Zirconia Restorations23
Figure 2: With retractors, we get a much better picture of the challenge
we are up against. When a young patient takes tetracycline
while their primary or permanent teeth are forming, the tetracycline
chelates, or binds, to calcium ions present on the hydroxyapatite
crystals in the dentin and, to a lesser degree, in the enamel.
Figure 1: My experience with tetracycline patients is that they have
spent most of their lives trying not to smile. Even though smiling is
an involuntary reaction to something that strikes us as funny, the
majority of these patients become adept at smiling with stiff lips to
cover as much of their teeth as possible.
Figure 3: This view of the maxillary arch reveals the abuse that
goes on in this patient’s mouth. The effect of his edge-to-edge
bite is clear from the wear on the unrestored teeth. The strength
of this patient’s musculature is also clear from the broken PFMs.
Kudos to the dentist who put the cast metal crown on tooth #15;
it’s doing fine!
Figure 4: This view of the mandibular arch shows the same type of
destruction evident in the maxillary arch. The patient said no dentist
had ever told him that he needed a nightguard, which surprised
me. (Keep in mind, I’ve found patients to be wrong more than they
are right when relaying clinical facts.) Again, the cast metal crown
on the lower right is the only tooth — natural or restored — that is
doing well in this oral environment.
Figure 5: Just for fun, I take out my VITA Easyshade ® Compact
(Vident; Brea, Calif.) and attempt to get a reading on the current
shade of the patient’s teeth. I have to admit that I half expected
smoke to come pouring out of the device as it attempted to match
this shade. The device is programmed to give the closest shade
as opposed to the exact shade, so it indicated a C4 as you might
Figure 6: When I place the C4 tab next to the teeth, it’s clear that
the hue and the chroma are more intense, and the value is much
lower. As the tetracycline staining is technically in the dentin, what
we are seeing is the stains showing through the enamel. You know
as well as I do that when we prep into the enamel, this discoloration
will only intensify.
Figure 7: A SeeMORE 4-way retractor (Discus Dental; Los Angeles,
Calif.) is placed. I used to use these retractors only when filming,
but then I realized they freed up a hand each for my assistant and
me. The company stopped making them for a while, but rumor has
it they are starting to again. Here I am placing PFG Light topical
anesthetic (Steven’s Pharmacy; Costa Mesa, Calif.) onto moist
mucosal tissue. (NOTE: Don’t dry the tissue beforehand.) We leave
it in place for 45–60 seconds before rinsing. I love this topical gel
because it is the only one I have found that keeps the patient from
feeling the needle insertion.
Another Use for Anterior BruxZir Solid Zirconia Restorations25
Figure 8: Next, I use my Wand ® STA ® device (Aseptico; Woodinville,
Wash.) to give anesthetic. This anesthesia system has removed so
much stress from my time spent in the operatory, especially when
it comes to giving anterior infiltrations — a simple injection to give
in a very sensitive area of the patient’s mouth. It never occurred to
me that I was tensing up during these injections and concentrating
on giving the anesthetic as slowly as possible. With the STA, I can
set it to the slow speed and tell my assistant jokes, creating a lowstress
environment for the patient.
Figure 9: The first step in the Reverse Preparation Technique is to
break the proximal contacts. We will be prepping all of the patient’s
anterior teeth, so we start by simultaneously breaking the contact
between tooth #8 & #9. Usually we use a #56 bur for this; however,
by using an 856-025 bur (Axis Dental; Coppell, Texas), we not only
break the contact, but we also begin to form our interproximal margins
at the same time.
Figure 10: Here we are starting to break through the contact,
pushing the bur toward the palatal. With my KaVo ELECTROtorque
handpiece (KaVo Dental; Charlotte, N.C.) spinning at 40,000 rpm,
this big bur easily makes its way through the contact. The one thing
to watch out for is nicking the gingival papilla. We also go to great
lengths not to go subgingival, unless the existing crown has subgingival
Figure 11: I then move on to the rest of the interproximal contacts
using the 856-025 bur to create separation and begin the formation
of the interproximal margins. When I reach the most distal tooth I
am going to prepare, I can still use the 856-025 bur on the mesial,
but I must switch to the 856-016 bur (Axis Dental) on the distal
to avoid over-preparing the tooth or damaging the adjacent tooth.
Figure 12: This is the Razor ® Carbide bur from Axis Dental, my
favorite bur for cutting through PFM crowns. The Razor even cuts
well on those metal substructures we see on patients who went
to Mexico to have their dentistry done. It feels like you are cutting
through a 1950’s Chevy bumper when replacing those types of restorations.
The Razor cuts through porcelain as well, so it’s the only
bur I ever need to get through a PFM.
Figure 13: What’s not to love about the 90-degree angle of the
Christensen Crown Remover (Hu-Friedy; Chicago, Ill.)? I’ve owned
this one for at least 15 years and it still looks like it did the first time
I used it. It’s a good thing Hu-Friedy’s scalers and explorers need to
be replaced, otherwise they might put themselves out of business!
Figure 14: This is a better shot of the Razor Carbide bur going
though the porcelain of a PFM we are replacing. I used to use a
diamond bur to cut through the porcelain and would then switch to
a carbide to cut through the metal coping. But with the Razor, it’s
one and done. It even has a reinforced shank to prevent breakage.
Figure 15: Sometimes when I use the Christensen Crown Remover
to open a crown, it still won’t come off because of the contacts.
Rather than cutting through the lingual portion, I try to grab the
coping with my hemostats and do my best to wiggle it off. Having
cut off many high-strength, all-ceramic crowns, I will never again
complain about cutting off a PFM.
Another Use for Anterior BruxZir Solid Zirconia Restorations27
Figure 16: The next step of the Reverse Preparation Technique is
to prepare the gingival margin. Unlike in dental school where I was
taught to prep the margin as the last step of the preparation, I now
do it as the second step. In my experience, doing it at the end feels
10 times harder than doing it at this point. In fact, most dentists
who try this never go back to placing the margin at the end of
Figure 17: The 801-021 bur (Axis Dental) is a round diamond, and
when used parallel to the tooth, it cuts a half-circle into the gingival
third. This ensures we have enough reduction in the gingival third
for an esthetic restoration that won’t have an over-contoured
emergence profile. An ugly gingival third is almost always the cause
of ugly anterior crowns.
Figure 18: With the gingival margin prepped on all teeth, we are
now going to place incisal edge depth cuts. The three rings that
are visible on the shank indicate that this is a 1.5 mm depth cutter,
which will provide an adequate amount of reduction for the dental
technician to build the desired incisal edge. This is especially true
when working with IPS e.max ® crowns (Ivoclar Vivadent; Amherst,
N.Y.), because they can be cut-back and layered for the best
Figure 19: The benefit of using a self-limiting depth cutter is not
having to guess like you do when using a #330 bur as a depth cutter.
The shank is much wider than the cutting surface of the bur,
making it impossible to go too deep. Once the shoulder of this bur
is on the incisal edge, I can move the bur to the lingual to complete
the depth cut.
Figure 20: On posterior teeth, this depth cutter is also used to
establish reduction, which is typically 2 mm for bilayered restorations
such as PFMs or Lava crowns (3M ESPE; St. Paul, Minn.).
For lithium disilicate crowns, I prefer 1.5 mm of occlusal reduction.
I prefer 1 mm for BruxZir crowns, but this material can be prepped
as thin as 0.6 mm. On this cuspid, we are reducing the incisal edge
1.5 mm, like we did for the other anterior teeth.
Figure 21: I am now placing a 1 mm depth cut on the facial surface
of the teeth to be prepped. I prefer to do this at the height
of contour, or incisal to the height of contour, to ensure that I reduce
enough in that area. One of the most frequent mistakes I used
to make was under-reducing in this area, which leads to bulky,
opaque, ugly crowns.
Figure 22: This image shows the payoff of spending a little extra
time up front to make these depth cuts. Now we can grab our 856-
025 bur again and go to town, secure in the knowledge that we
know exactly where we are going. These depth cuts are a road map
that keeps us from under-prepping or over-prepping these teeth,
allowing us to fly through this part of the prep sequence.
Figure 23: Typically, I start this part of the prep sequence by reducing
the incisal edges. I intentionally use the middle third of the bur
to do this reduction because I want to save the tip of the bur for
finishing the gingival margin. There is little chance that the tip will
be dulled by then, but I’m prepping multiple teeth and I want it as
new and as sharp as possible.
Another Use for Anterior BruxZir Solid Zirconia Restorations29
Figure 24: Here I am using the 856-016 bur to do the occlusal
reduction on the bicuspid. I use the bigger 856-025 bur on molars,
but it is a little too big to use on bicuspids without accidentally
nicking the adjacent teeth. You could also use a football bur to
do this reduction (the convex shape of the bur will give you some
Figure 25: The 856-025 bur does a great job on the facial surface of
anterior teeth as well. You can see that I already finished the facial
reduction on tooth #10 as I reduce tooth #9 here. Notice how dark
the staining is on tooth #10 compared to tooth #8. Tooth #9 is right
in the middle in terms of shade because we have removed about
half of the enamel. You can already see that the margin looks good
on tooth #10 — that’s the beauty of the round bur.
Figure 26: I use the 379-023 football bur (Axis Dental) to reduce
the lingual surfaces of the anterior teeth. The convex shape of
the bur helps to prepare a concave shape that will allow room
for the incisal edges of the lower anteriors. Unlike other allceramic
materials that require at least 1 mm of reduction, we
can reduce just 0.6 mm on the lingual for a BruxZir crown.
I have a 0.6 mm depth cutter in my bur kit to measure this precisely.
Figure 27: Toward the end of the prep sequence, I like to start
rounding things over, especially the junctions of the facial surfaces
and the incisal edges. I also try to avoid leaving sharp corners on
the mesial and distal corners of the incisal edges. While BruxZir
crowns are strong enough to be placed on these sharp angles,
CAD/CAM mills are not able to replicate those sharp angles with
their round burs.
Figure 28: Even though we know we reduced the proper amount
on the incisal, facial and gingival surfaces, there are interproximal
areas where it is impossible to place depth cuts. This makes it
prudent at this point to try on the BioTemps ® prep stent (Glidewell
Laboratories) for the BioTemps Provisionals we will be placing
to make sure we have reduced enough in all dimensions. The
BioTemps are prepped as thin as possible, so there should be
plenty of clearance, except maybe interproximally.
Figure 29: You can also try on the stent that was made with the
BioTemps on the model. While the first prep stent serves to check
interproximal reduction, this one shows your preps in relation to
the BioTemps, which act as the proposed final restorations. Just
as important, this stent can save you if something goes wrong
with the BioTemps; simply fill this stent with Luxatemp ® Ultra
(DMG America; Englewood, N.J.) and place it on the teeth for a
Figure 30: The rubber really meets the road when you try in the
BioTemps for the first time. If you have followed every step detailed
so far, 9 times out of 10 the BioTemps will drop into place passively.
This is our objective. If you skip the first stent that was made on
the BioTemps prep model, the BioTemps may not passively seat.
(For BioTemps techniques and troubleshooting tips, view the video
“BioTemps Techniques for Indirect Temporization,” available in the
Video Gallery at www.glidewelldental.com.)
Figure 31: Here we have placed the Luxatemp Ultra into the
BioTemps and are seating them on the preps. I insist on Luxatemp
Ultra because it is the only bis-acryl temporary material that goes
through a doughy stage, which allows me to pump the BioTemps up
and down in it as though it were methyl methacrylate — other bisacryl
materials go from soft to hard too quickly for this technique,
potentially locking the BioTemps into place too soon.
Another Use for Anterior BruxZir Solid Zirconia Restorations31
Figure 32: My assistant has trimmed the BioTemps with a thin,
perforated diamond disc, taking extra care to make sure she
opens the gingival embrasures. If anything, she will intentionally
create black triangles on the temps so the patient can swish Tooth
& Gums Tonic ® (Dental Herb Company; Lancaster, N.H.) through
the spaces. This also avoids blunting the papilla with the temps,
which can lead to real black triangles when we try in the permanent
crowns. I have made that mistake too many times in the past and
have had to drop the prep margins and re-impress.
Figure 33: The BioTemps are now cemented with TempBond ®
(Kerr Corp.; Orange, Calif.) and the temporary cement is cleaned
up with an explorer and Thornton 3-in-1 Floss (Thornton International;
Norwalk, Conn.). The proper overjet and overbite relationship
has been re-established with the BioTemps, and the next two
weeks will give us a good chance to see if the patient has any
issues with this change. My assistant did a good job with the embrasures,
but she over-trimmed the gingival margin on tooth #9. If
I were concerned about gingival overgrowth on the margin, I could
place some flowable composite, but I feel confident it will stay put.
Figure 34: Two weeks later the patient returns, reporting no functional
or phonetic issues with the BioTemps, so we can ask the
dental technician assigned to the case to fabricate the final BruxZir
crowns based on the digital scan of the BioTemps. Thanks to digital
technology, we can now duplicate BioTemps in the contours of
the final restorations by scanning them, storing the digital information
and then using the stored digital file to mill the final crowns to
match. (To request this “scan & save” service, simply note this preference
on your BioTemps prescription.) Things look pretty good
when we remove the BioTemps, and there are just a few spots of
minor gingival irritation. It’s now time to take the final impression.
Figure 35: Not taking the impression during the prep appointment
for large anterior cases was a difficult lesson to learn, but now I
won’t do it any other way. I have had too many cases of crowns
having to be remade because the temps blunted the papilla. The
first thing my assistant does is place a #00 Ultrapak ® cord (Ultradent;
South Jordan, Utah). This cord does not have any hemostatic
agent or epinephrine on it. Its purpose is to create vertical retraction
of the tissue and sit against the inflamed base of the sulcus to
prevent bleeding when I pull the top cord.
Figure 36: I prefer to use straight, non-serrated cord packers when
placing the #00 cord. In this shot, you can see that this cord is
braided and hollow. Its hollowness makes it easier to pack into the
sulcus; however, even #00 solid cords are fairly easy to pack. Because
it is braided, the #00 cord starts to expand once it is placed
in the sulcus, absorbing any crevicular fluids. Trying to pack a #00
cord when it is wet is frustrating, so we try to dry the sulcus as
much as possible first, especially at the gingival margin.
Figure 37: Now that the #00 cords are all in place, we can inspect
the margins and see if any of them need to be dropped subgingivally.
Our goal is to have slightly subgingival margins without taking
a bur subgingival. We are able to achieve this because the #00 cord
has vertically retracted the tissue approximately 0.5 mm. I typically
drop the margins with the 856-025 bur, and most times I turn the
water off and my electric handpiece down to 3,000 rpm. This way,
I can clearly see what I’m doing.
Figure 38: Even though I am a huge fan of the two-cord impression
technique, I continue to try every non-cord retraction technique
that comes on the market, hoping that one day I can stop packing
cord. So far I haven’t found anything that works as well as cord,
but the search continues. My common complaint about the paste
retraction systems has been the difficulty in getting retraction
material into the sulcus, so I ordered the 3M ESPE Retraction
Capsule after seeing an ad about its narrow tip that the company
claims fits directly in the sulcus. You can see us trying it out here.
Figure 39: The retraction paste is left in place for a minimum
of two minutes, but typically closer to eight minutes. Just
like we do with the two-cord technique, we place ROEKO
Comprecap Anatomic compression caps (Coltène/Whaledent;
Cuyahoga Falls, Ohio) over the preps to help keep the retraction
paste in place and the patient’s tongue away. The pressure
also drives blood out of the capillaries, providing us with additional
Another Use for Anterior BruxZir Solid Zirconia Restorations33
Figure 40: I find that the 3M ESPE retraction paste rinses
out more easily than other retraction pastes — another common
complaint I have with them. As I examine the final impression,
I am impressed with how good it looks. I still think I would
have had more retraction with a second cord on top of the #00
cord, but it might be the best cord-free impression I have taken.
I’m not switching from retraction cord just yet, but this new
product is a step in the right direction.
Figure 41: Having practiced around dental technicians for the last
12 years, I always hear them talking about what they want to see
in a bite registration. They want the bite registration material to be
only on the hard tissue. They also want the material to be between
only the prepped and the opposing teeth; they don’t want any
material between the unprepared teeth. It simply needs to capture
the incisal thirds of the prepped teeth and the incisal thirds of the
opposing teeth. After taking the bite registration, we put the temps
back on and schedule the patient to come back one week later.
Figure 42: Seven days later we remove the temps. To clean up the
preps, I know no better way than with my KaVo SONICflex ® scaler
(KaVo Dental). This scaler will blast any temporary cement — even
Durelon ® (3M ESPE) — off the preps, leaving behind no trace of
cement that could interfere with seating. The scaler doesn’t spin,
so even if you accidently bump the tissue, it won’t cause bleeding.
Figure 43: After trying in the crowns and getting the patient’s
approval, we place two one-minute coats of G5 All-Purpose
Desensitizer (CLINICIAN’S CHOICE; New Milford, Conn.) on the
preps. We are going to use Ceramir ® Crown & Bridge cement
(Doxa Dental; Newport Beach, Calif.) to place the BruxZir crowns,
so we don’t need to use the Ivoclean ® solution (Ivoclar Vivadent)
or Z-PRIME Plus (Bisco Inc.; Schaumburg, Ill.). Because Ceramir
doesn’t rely on phosphates to bond to the zirconia, the salivary
phosphates do not affect it, so there is no need to use a zirconia
primer. As always, we place tooth #8 & #9 first to ensure proper
seating, applying pressure apically with pinewood sticks.
Figure 44: Retracted facial view of the cemented BruxZir crowns. In
addition to being the only permanent cement that bonds to BruxZir
restorations without the use of a zirconia primer, Ceramir is also
a breeze to clean up due to its gel state during set-up that allows
for any excess cement to be peeled off in one piece. While these
crowns likely won’t be mistaken for IPS Empress ® (Ivoclar Vivadent)
or IPS e.max in terms of esthetics, these glass-ceramic materials
would have resulted in show-through due to the dark stump shade
color. This is definitely one case where the lower translucency of
BruxZir Solid Zirconia is advantageous.
Figure 45: Retracted left lateral view of the cemented BruxZir
crowns. An interesting thing to note is the visible broken PFM in the
lower left quadrant. We prescribed BruxZir Solid Zirconia for this
case because we wanted to use a material that would completely
mask the dark underlying stump shade. It’s just a coincidence that
we can see a broken PFM, but broken restorations typically are
my primary reason for prescribing BruxZir crowns. I don’t give a
patient more than one chance to break restorations.
Figure 46: Retracted right lateral view of the cemented BruxZir
crowns. Here we see another broken PFM in lower right quadrant.
My point in noting these broken PFMs is that, even if this patient
didn’t have tetracycline staining and instead required replacement
of all of these anterior crowns due to old, leaky composites and
recurrent decay, BruxZir Solid Zirconia still would have been my
restorative material of choice. PFMs have a pretty good track
record over the last 50 years, but when I see a patient who breaks
them, their two choices in my mind are cast gold and BruxZir
Figure 47: Occlusal view of the cemented BruxZir crowns. How are
these restorations going to hold up against this patient’s difficult
occlusal situation? There are no guarantees in dentistry, but singleunit
BruxZir crowns have the lowest fracture rate of any restoration
in our lab, with the exception of cast gold, but that material really
wasn’t an option in this case. Because BruxZir Solid Zirconia is a
monolithic material (solid zirconia with no porcelain overlay), I have
a high degree of confidence that these crowns will be intact for
years to come.
Another Use for Anterior BruxZir Solid Zirconia Restorations35
• Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to
zirconia: clinical and experimental considerations. Dent Mater. 2011
• Holt LR, Boksman L. Monolithic zirconia: minimizing adjustments.
Dent Today. 2012 Dec;31(12):78, 80-1.
• Janyavula S, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO.
The wear of polished and glazed zirconia against enamel. J Prosthet
Dent. 2013 Jan;109(1):22-9.
• Rinke S, Schäfer S, Lange K, Gersdorff N, Roediger M. Practicebased
clinical evaluation of metal-ceramic and zirconia molar
crowns: 3-year results. J Oral Rehabil. 2013 Mar;40(3):228-37.
• Shahin R, Kern M. Effect of air-abrasion on the retention of zirconia
ceramic crowns luted with different cements before and after artificial
aging. Dent Mater. 2010 Sep;26(9):922-8.
• Kern M, Swift EJ Jr. Bonding to zirconia. J Esthet Restor Dent. 2011
• Sasse M, Eschbach S, Kern M. Randomized clinical trial on single
retainer all-ceramic resin-bonded fixed partial dentures: Influence
of the bonding system after up to 55 months. J Dent. 2012 Sep;
Figure 48: The final result — not a bad smile for a guy who told
me he hasn’t smiled for the last 30 years. This type of patient really
does need some coaching to learn to smile again, and I encourage
them to practice in front of the mirror, as silly as that sounds. To me,
it’s not that different from physical therapy, where a patient needs
to re-learn a physical skill that they haven’t been able to do for an
extended period of time. With this patient, I am already wondering
what I will do if he wants to do the lower arch as well. I’m not a big
fan of doing full crowns on lower anterior teeth and typically prefer
veneers, but I’m not sure whether BruxZir veneers will block out
the dark shades. If he opts for this treatment, you will see it here.
Stay tuned! CM
CASE OF THE WEEK: Episode 32
A Disastrous Double-Arch Impression Tray
– ARTICLE by Michael C. DiTolla, DDS, FAGD
When dentists attend my lectures, they are often fascinated by the clinical cases I show of what other dentists
are sending in to Glidewell Laboratories. “Chairside Live,” our weekly Web series, is a great opportunity for
me to share these cases with dentists on an ongoing basis. Episodes can be viewed online and on demand at
www.chairsidelive.com, or on YouTube and iTunes. If you aren’t already a viewer, I encourage you to start watching now
for informative case examples from our lab and intriguing dentistry-related news stories.
The video stills that follow highlight an interesting Case of the Week from Episode 32 that addresses what is probably
my biggest dental pet peeve: when a double-arch tray is used for a bridge impression. While double-arch impressions
can be suitable for one single-unit crown or two single-unit adjacent restorations, they should never be used for a bridge.
A closer look at the case illustrates why.
Figure 1: When walking through Glidewell’s crown & bridge department
the other day, I stopped to ask a technician what one thing dentists do in
cases they send to the lab that drives him crazy. “I’m glad you asked!” he
said, and handed me this impression.
Figure 2: Looking closer at this impression, we can see that it is for a 4-unit
bridge, but it was taken in a double-arch tray. I learned from Dr. Gordon Christensen
many years ago that this is a no-no, and now this technician wants me
to know that he dislikes this technique just as much as Gordon does.
A Disastrous Double-Arch Impression Tray39
Figure 3: Turning the impression, we can see that the prep was in contact
with the tray — another no-no. As hard as it may be to believe, all it takes
is one point of contact like this between tray and prep to prevent the entire
bridge from seating properly.
Figure 4: The impression itself around the splinted abutments is so-so;
tooth #29 appears to have a void on the facial and the lingual margins,
while tooth #28 has some very thin material on the facial and distolingual
margins. This always makes me nervous as we pour the die stone because
the material is heavy enough to bend those margins.
Figure 5: The margins on tooth #31 also appear thin and friable, and it’s
hard to tell definitively whether tissue retraction took place. Using the twocord
impression technique, or to a lesser degree by using a diode laser, we
can create enough lateral retraction to end up with a big, thick margin on
the impression that won’t distort.
Figure 6: As I flip the impression over, notice that we are missing the second
molar opposing the bridge and that the first molar is the most distal
tooth. You may recall that we are missing the first molar on the lower arch
as well, which is going to make it more difficult to verify a correct bite.
Figure 7: Here is the poured model of the impression. It looks like we have
enough reduction for the BruxZir ® bridge (Glidewell Laboratories) the doctor
prescribed, except for on tooth #28 perhaps. I would have prescribed
a PFM bridge, but that is another story. I am still concerned about the bite
because there aren’t any stops distal to the bridge.
Figure 8: When I spin the articulator around and view the case from the
anterior, my fears are confirmed. I have a hard time believing that the bite
from the impression is correct. I cannot believe that the patient only bites
on that cuspid. Without any unprepped teeth on the opposite side to hand
articulate, the situation looks dicey.
Figure 9: As I look at the lower anterior teeth, I realize the bite problems
are getting bigger because this patient spends some serious time with
these teeth in contact with the uppers. Every once in awhile you will see a
case like this with an anterior open bite, but if this isn’t one of these cases,
this bite will drive the patient crazy.
Figure 10: A little twist of the articulator brings the other two anterior
teeth into contact, but now there is a huge gap between the posterior
teeth. Again, there is no way to verify where the bite is correct. If only we
had a full-arch impression on the upper and the lower, we could take an
Figure 11: Look at all these wonderful wear facets; usually, these make it a
no-brainer for us to hand articulate a case. Even a separate bite registration
over the preps could have saved this impression — if you ignore the fact
that many bridges made from double-arch trays don’t fit. Bottom line: This
case needs to go back to the doctor for new, full-arch impressions.
Figure 12: As I was leaving the technician’s workstation, he also handed
me these full-arch impressions. I was instantly suspicious when I saw the
trays the dentist used. Do you recognize them? You do if you do Invisalign ®
(Align Technology Inc.; San Jose, Calif.). These are the plastic trays you
have to take Invisalign impressions in so that the company’s X-ray scanner
can read through the trays.
While double-arch impressions can be suitable for one
single-unit crown or two single-unit adjacent restorations,
they should never be used for a bridge.
A Disastrous Double-Arch Impression Tray41
Impression errors are especially important to avoid when
dealing with multiple-unit impressions because any mistakes
will be multiplied across the entire length of the bridge.
Figure 13: I thought we had seen it all when it comes to impressions, but
this may be a first. It’s a 3-unit bridge impression on the lower, but the dentist
took what looks like a half-arch impression with a full-arch tray. There
is also some material placed on the other side of the tray to impress two
molars and a bicuspid. Was this done purposely?
Figure 14: Apparently, this was done intentionally. Even on the opposing
model the doctor put a large amount of impression material on the side
opposing the bridge — impressive! He then put some material on the other
side to impress four additional teeth. How much money did the dentist
save by not impressing that lateral and cuspid? Twelve cents? Pouring
these impressions is going be a challenge and make excursions tougher
to accurately replicate.
Using a double-arch tray looks so easy and seems so
tempting when taking an impression on just one side of the
mouth, but it very rarely makes for an accurate multiple-unit
impression. Impression errors are especially important to
avoid when dealing with multiple-unit impressions because
any mistakes will be multiplied across the entire length of
the bridge. Even if the bridge still fits the patient’s teeth,
the bite will likely be off, which does not make for a happy
patient. For any bridge case like this, you, the lab and your
patient will be better served if you use a full-arch lower
impression tray and a full-arch upper impression tray, as
well as a bite registration between the opposing teeth and
the preps. CM
How to Watch
To view past and current
Also available on iTunes and YouTube.
For clinical technique tips on taking a bridge impression, watch “Chairside Live
Episode 36: The Do’s and Don’ts of Taking an Impression for a Bridge.”
Interview with David Harris
– INTERVIEW of David Harris, MBA, CMA
by Michael C. DiTolla, DDS, FAGD
David Harris is a licensed private investigator and the CEO of Prosperident, a
company that specializes in the investigation of frauds and embezzlements
committed against dentists. I first heard about David when I came across his
seminar “How to Steal from a Dentist” listed in the program for a dental meeting
where I was lecturing. The title of his lecture captured my fascination, especially
when I saw that it was a course designed to help dentists detect and protect
against dental-practice embezzlement. I wasn’t able to attend his lecture during
the dental meeting, so I thought the next best thing would be to ask him to share
his expertise on the subject in Chairside magazine.
Interview with David Harris45
Dr. Michael DiTolla: For those of our readers who haven’t had
the opportunity to see your lecture on dental-practice fraud yet,
can you tell me a little bit about your background and how you
got involved in dental embezzlement investigation?
David Harris: I’ve been investigating dental embezzlement
for about 22 years. Before that I did various things. I was
in the Army for a while; I did investigation for a bank. After
retiring from working for the bank, I was sitting at home
not doing a whole lot when I got a call from a friend of
mine who happened to be a dentist. He said, “I think my
front-desk person is stealing from me, and you’re the only
guy who I can think of to turn to on this.” So I went to his
office that night, we found the fraudulent employee and we
got rid of her. I went back to watching TV and really didn’t
give it another thought.
It was a coincidence when about three weeks later I went to
my own dentist for a hygiene appointment and saw through
the glass of the office door the same person who we had
terminated from the other office three weeks earlier! So I
ran away quickly hoping that she didn’t see me, went to
the nearest pay phone — this story pre-dates me having
a cell phone in my pocket — and phoned the dentist. I
got put through to him on some pretext and I said, “I’m
not coming in for my appointment today, but when I tell
you why you’ll probably forgive me.” I told him about the
time bomb he had sitting at the front desk, and he asked
me what he should do next. Halfway through my second
sentence he hired me. Things have changed a lot since then
in a whole bunch of ways. I was doing this on my own then,
and now I have a decent-sized company that helps me with
investigations, but the basics haven’t changed.
MD: That’s an amazing story. In terms of dentistry, I guess it’s
not that surprising in the sense that in most of our communities,
and even nationally, dentistry is a very tight-knit group where
you know and see a lot of the same people. Even in corporate
dentistry, with the dental product manufacturers, you’ll see
somebody leave one company and then a new CEO gets hired
at another company. It seems like the same people are shifting
slots and moving around. So I guess it’s not shocking that
somebody who gets fired from one dental office job turns up at
another dental office.
DH: It’s what they know. In the case of this particular
woman, it was lucrative because she was getting paid her
official salary and then her, shall we say, “unofficial” salary.
MD: It’s not like when she got fired from the first practice
that there was a scarlet letter put on her forehead to identify
her as an embezzler on any interview she might go on after
DH: Thieves are pretty good at doctoring their résumés
enough to hide their backgrounds. One of the most common
lines is simply telling the new employer that they’re still
working at the previous place and saying, “My old employer
doesn’t know I’m leaving, so please don’t call him.”
MD: That’s an interesting line. I get the feeling that we’re going
to hear about some slightly ingenious — albeit evil — things
like that today. I guess these people have figured out how best to
cover their tracks.
DH: Thieves are pretty clever. One of the most interesting
parts of my job is witnessing the sheer creativity that some
of these folks show. I will now have to disappoint your
readers a little bit because our policy in an uncontrolled
forum like this one is not to talk specifics. My recurrent
nightmare is to turn thieves into better thieves. We do talk
about specifics in closed seminars, but in this interview,
I feel a little bit constrained. Some of the stuff we see is
almost spectacular in its ingenuity. You can’t help thinking
The serial embezzlers ... cater to what I sometimes call the ‘wet-fingered fantasy’
some dentists have. A fantasy where they get into their office every
morning, do high-quality dentistry on a relatively small number
of patients and then go home, without having to
get dragged into the messiness of
managing their practice.
about what these folks could accomplish if they put their
minds to honest labor.
MD: I guess what they’re doing on a small scale is what happens
in big Wall Street firms when there is embezzlement. I don’t
know if you have come across any studies or surveys on this, but
what percent of dentists would you say will have embezzlement
be an issue in their office at some point in their career?
DH: In the published statistics, there are two or three
surveys saying that somewhere between 50 and 60 percent
of dentists will be victims. But there is a confounding factor
to this because there is a fair amount of embezzlement that
never gets detected by anybody and therefore won’t be in
the statistics. So the true number is probably higher, but I
think it’s safe to tell your audience that at least three in five
dentists will be victims at some point in their careers.
MD: Wow, that seems like a pretty high number. I wonder
how much of that is from repeat offenders like the person you
referenced in your first story where she goes from one office to
another. Is that a common occurrence?
DH: It definitely happens. We call them serial embezzlers.
There was one woman who was working in the Toronto,
Canada, area. Over a period of four years, she worked in
13 different practices and stole from all of them. She was
really good at getting hired, but as a thief — despite a fair
amount of practice — she wasn’t all that skilled. So she
would get caught fairly quickly and get terminated, then
move to the next office.
MD: If these so-called serial embezzlers can come up with
creative schemes that continue to impress you, I would guess
that they have decent verbal skills when it comes to lying.
So couldn’t they show up at an office and seem to be a
DH: Absolutely. The serial embezzlers are very much takecharge
people. They cater to what I sometimes call the
“wet-fingered fantasy” some dentists have. A fantasy where
they get into their office every morning, do high-quality
dentistry on a relatively small number of patients and then
go home, without having to get dragged into the messiness
of managing their practice. The serial embezzlers cater to
that. They know the computer systems really well; they’re
organized and efficient. They look like they are working
hard. It’s what every dentist wants. So it’s easy for them to
get hired because when they’re in the door, they cater to
this idea. They’re the people who will run personal errands
for you on their lunch hours.
MD: To back up the impression that they are somebody who
would take a bullet for you, so how could they ever embezzle?
DH: That’s right. Now, having said all that, the vast majority
of embezzlement is not carried on by the serial embezzlers.
It’s done by long-time employees. The big stuff that we
investigate is usually from employees who have been in
your office for 3, 5 or 12 years. Generally speaking, we think
that these people had no plan to embezzle from you when
they were hired. But then something happened to them
that put their backs to the wall financially, and they decided
that instead of going downtown and stealing people’s
wallets, just sitting at the same desk where they work every
day and handling the paperwork a little differently was a
MD: Wow, so it’s often somebody who started off as a trusted
employee and probably has a well-deserved good reputation?
DH: Clean employment record, no blemishes on it at all.
One morning they just woke up and said, “Today is the day
I’m going to steal from my employer.”
MD: Yeah, or something happens. Maybe they lose their house,
a spouse loses a job, or they get divorced. There might be a
situation that makes them desperate enough to steal from a
person they might have previously held a lot of affection and
DH: What I’ll suggest is that there are different definitions
of desperation. There are some real hardship cases like
the examples you mentioned; you know, somebody who
is three months behind on their mortgage payment and is
about to lose their house. We also find people who steal
to get things that you and I probably wouldn’t consider
necessities. We’re wrapping up an investigation now where
the woman who was stealing was spending $800 a month
on a personal trainer, and she also belonged to something
called the Shoe of the Month Club. I wouldn’t consider her
to be desperate. But of course what I think doesn’t matter;
it’s her perception that governs her behavior.
MD: Exactly. Do you think dentists are more prone to this type
of embezzlement than other small businesses?
DH: Probably. There is one differentiating characteristic
between the way dentistry operates compared to, say, a
plumbing business. The differentiation has nothing to do
with the amount of business knowledge that each owner
has, or the amount of attention that each spends on
business versus the other things in their trade. What sets
dentistry apart is that a lot of it is paid for by third parties.
So we have this unstable situation where patients, for the
most part, really don’t understand a whole lot about what
just happened in their mouth, and somebody else is paying
for it anyway. So the amount of attention that patients pay
when leaving your office is minimal. If there is an extra
charge in there or something that shouldn’t be, very few
patients are going to notice it and object.
MD: Especially if it’s an extra charge that is billed to the
insurance company, right?
Interview with David Harris47
DH: That’s right. So somebody gets extra soft tissue work
done today, and it’s billed to their insurance company. Most
of the time the patient won’t notice.
MD: My original perception was that most of the embezzlement
taking place in the dental office was from the cash patients as
opposed to the insurance patients. The latter seems like a more
difficult embezzlement because of the paper trail that is left
with the insurance company. But you’re saying that it is just as
likely to happen with the insurance people as the cash people?
DH: Yes, it is. In fact, most embezzlers do both simultaneously.
Dentists look at an insurance claim as a clinical document.
To me, it’s a check requisition.
MD: That’s a good point. Without giving too much away, are
you saying that if a crown is done on a patient and the frontoffice
person adds an extra buildup that wasn’t done, for
example, that the employee is able to skim that amount off the
top when the whole thing gets deposited?
DH: That’s exactly right.
MD: Interesting. Have you found that the vast majority of
employees who embezzle are front-office staff? This seems like
something that would be much more difficult for a hygienist or
a chairside assistant to pull off.
DH: I don’t think it’s more difficult; they just have to be a
little bit more creative. We all know what has happened in the
past three or four years to the price of gold. A lot of dentists I
know have what they call a “gold jar” in the back of their lab.
This is where they put the crowns they pull out of people’s
mouths for various reasons. A lot of dentists jokingly refer to
this as their retirement. Well, I’ve had a number of them say
to me that since the price of gold has doubled, the gold jars
don’t seem to fill up as quickly as they used to.
MD: Wow, that’s an interesting one, but it seems a little
tougher to prove. Are you able to catch people in those kinds of
situations? Or is that just something that gives dentists a feeling
that something funny may be going on in their offices?
DH: You can catch them if you install cameras. And there
are indicator powders that you can put in places that will
turn people’s fingers purple if they touch it. If you want to
catch them, you can.
MD: I was noticing the other day that cameras seem to be
everywhere. Almost everything we do is being recorded. You
see cameras out on the street, you see them inside stores — you
even see them on the air train that takes you from the airport
terminal to the rental car lot. Do you suggest that dentists start
putting cameras in their offices as well?
DH: I’m trying to make up my mind about that, the
usefulness of cameras with respect to embezzlement. In
terms of catching most embezzlement, I think cameras are
useless. Because you’d have to be the dumbest of thieves to
visibly steal in front of a camera that you know is there. Let’s
say you have four cameras in your office and your office
is open 30 hours a week, your cameras are capturing 120
hours of video a week. The practical issue is: When are you
going to watch the footage? On the other hand, there have
been dentists who have been accused of groping a sedated
patient and things like that, and to me a camera would be
a marvelous way for the dentist to defend against that kind
of thing. So I can see the necessity of cameras in the clinical
area perhaps more than in the administrative areas of the
practice. But even with that, there are a lot of questions.
Placement of the camera is critical to avoid ever being
accused of placing it in a bad place, say in an area where
you could look up women’s dresses or something like that.
MD: With most of the embezzlement that goes on, do you get the
feeling that it happens during working hours while everyone is
there? Or does it happen during off-hours?
DH: A lot of it happens off-hours. One of the things we
frequently see with embezzlers is that they come and go at
weird times. It does happen during office hours, but a lot of
embezzlers want to be alone when they’re doing their stuff.
MD: That also seems to tie in with what you said about the longterm
employees. I would guess that if there are a few employees
who have keys to the dental office that they are probably the
longer-term employees versus the new employees.
DH: Sure, and it will also be the ones who appear to be the
hardest working. They’re the ones who are going to go to
the dentist and say, “There’s some stuff I want to clean up
on Saturdays, can I please have a key?” And then the dentist
is going to think: “This is great, I’ve got a staff member who
is super dedicated. I should give them an outlet for that.”
MD: When you listen to practice management speakers, almost
all of them emphasize that one of the key traits to having a very
successful dental office is your ability to attract and retain longterm
staff members and not have a lot of turnover. This really is
the first time I’ve considered that long-term employees might be
the ones who embezzle more often than the new employee who
is the serial embezzler. Do you find that dentists are conflicted
about this notion?
DH: We can’t lose sight of the fact that the vast majority of
dental office staff members are honest people who got into
dentistry out of a genuine desire to help people. The bad
apples are relatively few in number, but over the course of a
30-year dental career, you’ll go through a lot of employees,
so the chances of getting one of those bad apples at some
point is high. That doesn’t mean that the vast majority of
dental staff members are dishonest. I agree completely
with the practice management consultants when they say
long-term employees are part of your success. They don’t
steal because they’ve been there for a long time. If they
act dishonestly, it’s their longevity that enables them to get
away with it. Because they know the dentist, his habits, and
what the dentist looks at and what he doesn’t, they can craft
their fraud in a way that bypasses scrutiny. For example, if
you’re a dentist who checks your day sheet every day — I
think every dentist should do that — then someone who
is going to embezzle from you knows that. So they’re not
going to do something that leaves a mess on your day sheet.
They’ll have to find a different way to steal.
MD: I know we have a lot of staff members who read our
magazine, so I’m glad you brought that up. Maybe a better way
to state the practice management message is to say that a lot
of a dental practice’s success comes from the dentist’s ability
to find and retain honest, long-term employees. The long-term,
dishonest employee is a counterintuitive thought, and I think
most dentists would be flabbergasted to find out that a longterm
employee is the one embezzling from them. But I think
it’s a good point to make just because of the fact that those
employees would probably be the last people a dentist would
suspect in a situation like that.
DH: A lot of dentists go through a period of disbelief. They’ll
see some signs that somebody is stealing from them, and
then they think about their employees and they’ll sort of
rule everybody out — even those who they think have an
opportunity to embezzle. They’ll convince themselves that
the theft isn’t happening, and then they’ll go back to work.
At some point the noise gets a little bit louder and something
happens that they just can’t categorize as an innocent mistake
anymore, and then they realize they have a problem. A lot of
times there is a denial period that dentists go through when
they have long-term employees because they have a lot of
trust in those employees, whether it’s misplaced or not.
MD: Have you come across instances of a family member working
at the office and being responsible for the embezzlement?
DH: Yes, we have. One scenario is when you have one
spouse who is the dentist and one spouse who is the office
manager. The office manager has decided to get divorced
from the dentist, but hasn’t told the dentist that yet. So they
need to build up a war chest in order to pay their attorney
and find a place to live because their only source of
income is employment income from their spouse, which is
presumably going to be cut off when they drop the divorce
bomb. The spouse knows they will need money under the
mattress and that’s how they get it.
MD: I was thinking more about kids coming to work in the
office, or maybe an in-law. But that’s a great example that
never occurred to me. Do you have a list of potential warning
signs that dentists might see happening in their practice that
could warrant an investigation?
DH: We do. This is maybe where I have a slightly different
view than a lot of people who write and speak about
embezzlement. Many of them try to turn dentists into what
I would call untrained, ill-equipped auditors in their own
practices. These advisors give the dentists lists of things to
We see everything from stealing toilet paper at
the office to frauds that exceed a million dollars.
The average we see these days is probably a
little over $100,000. I think last time we did the
calculation, it came out to about $105,000.
check for and to look at in order to stop embezzlement,
or to find out if it’s happening. My approach is a little
bit different. What I tell dentists is that there might be a
thousand different ways to embezzle from their practice,
but regardless of which of those thousand the thief is
using, the way these thieves behave is very predictable. We
already mentioned the people who are in the office alone
at unusual times. You also might consider that employees
who are reluctant to take vacations might have their finger
in the till. So we have what we call the “Embezzlement Risk
Assessment Questionnaire,” which is a scored questionnaire.
If you score at a certain level, it tells you that you either
have very little risk or, conceivably, that you are at high risk
of embezzlement going on in your office.
MD: So are you saying that one type of employee who might be
suspicious is someone who gets two weeks’ paid vacation from
the dentist but never uses it and cashes it out? Or maybe it’s the
person who wants to stay in the office even when everybody else
goes on vacation?
DH: Yes, that’s a symptom. Whether they get cash for their
vacation or not is irrelevant. To me, the real issue is that
they do not want the office open when they are not there.
MD: I see, so they want to be able to cover their trail at any
moment if something irregular is discovered. They probably
worry that if they are gone for a week and somebody starts
digging through the computer that any irregularities could
DH: What uncovers a lot of fraud is patients asking questions
about things. A very common scenario is when a patient
says, “I was in two weeks ago and I paid by cash, but I just
got my statement and it showed that I paid by check.” If that
call comes to the thief, they can squelch it by saying: “Yes,
I know. We just upgraded our computer system and there
are a couple of bugs. The software vendor is working on
it. We’re very sorry it happened.” It doesn’t matter whether
there is one of those calls a day or a hundred, the thief can
make them go away. On the other hand, if the thief is not
in the office and there is someone else getting these calls,
sooner or later that person is going to say to the doctor that
something funny is going on. And then it unfolds. It’s about
control of information in the practice, and the thief can only
exert that control by being there.
MD: That makes sense. They’d probably even insist on taking
all phone calls, right?
DH: That’s right. They’re often the ones who almost lunge for
the phone when it rings. For a dentist who doesn’t suspect
fraud, this looks like a very motivated, committed employee.
MD: Might this employee work on having the best phone skills in
the office, so it only makes sense to have them answer all calls?
You’ll see hand instruments and
all kinds of consumables that are
for sale online at a lower price
than you can buy them from
a supplier. Theoretically,
I guess some of this stuff is
gray market that somebody
bought in some other country
and imported. But I think a
vast majority of it just kind of
‘fell off the truck’ in one way
MD: From the different cases you’ve seen over the years, what
would you say is the range or average of how much money is
DH: We see everything from stealing toilet paper at the office
to frauds that exceed a million dollars. The average we see
these days is probably a little over $100,000. I think last
time we did the calculation it came out to about $105,000.
MD: Have you actually caught somebody who was just stealing
DH: It’s not one that we normally chase. But it certainly
happens, and we do have dentists complaining to us about
it. Sometimes it’s the tip of a bigger iceberg. But, yes, we
do have lots of dentists who complain about things going
missing when the staff members are probably the only
people with the opportunity to steal. Another thing is, if
you look on eBay, you’ll see all kinds of dental gear for sale.
MD: Interesting. To my knowledge, I have never been embezzled
from. But in preparing for this interview, I was trying to think
like the criminal mind, and ask myself what I would do if I
had the opportunity. A chairside assistant could maybe sell
bleaching kits on eBay, the kind that don’t need custom trays,
like the pre-made ones from Ultradent. Those could be sold on
eBay directly to patients for a markup. Is that the kind of thing
you’re talking about, or do you mean actual equipment?
DH: Both. If a compressor is for sale on eBay, I highly doubt
the dental assistant snuck it out of the office while nobody
was watching. But you’ll see hand instruments and all kinds
of consumables that are for sale online at a lower price than
you can buy them from a supplier. Theoretically, I guess some
of this stuff is gray market that somebody bought in some
other country and imported. But I think the vast majority of
it just kind of “fell off the truck” in one way or another.
MD: Wow, and that’s not really something that anyone polices,
or could even. It seems like a difficult thing to try to get a
DH: I hate to say it, but I think most of the purchasers of
this stuff aren’t end consumers buying bleach kits, but other
dentists saying, “Wow, this stuff is really cheap on eBay.”
MD: In a dental office where the dentist doesn’t pay a lot of
attention to what arrives in the boxes from Patterson Dental or
Henry Schein, you might have somebody ordering things at full
price and then putting them on eBay. Three days later when it
disappears, no one misses it because the dentist didn’t really
need it or even order it in the first place, right?
DH: Yes. Unless it’s enough to distort the ratio of consumables
to productivity, which would have to be a whole lot of stuff
going out the back door, nobody is ever going to notice.
MD: I’ve heard stories about dental assistants, for example,
coming into the office on a Saturday and making bleaching
trays for people and charging for it. Obviously it’s illegal, but is
that considered embezzlement as well?
DH: I’m not sure it meets the formal definition of
embezzlement, but it’s some kind of stealing, yes. What it
really amounts to is practicing unlicensed dentistry. I saw
something the other day about a dental assistant who would
bring her friends in on Saturdays and do fillings on them.
MD: The very first story you told was about a woman who
was fired from one practice for embezzling, who you then ran
into at another practice. Then you told me about the woman
in Toronto who stole from 13 practices. It seems like at some
point they would be prosecuted. Is it up to the dentist to decide
whether they want to prosecute these employees?
DH: Prosecution is the responsibility of the government,
not the individual dentist. So when people say, “I’d like to
press charges,” or “I’d like to not press charges,” they’re
assuming a privilege that they really don’t have. It is the
government that carries that responsibility and the financial
and evidentiary burden that goes with it. Having said that,
what a dentist can do is either communicate their interest in
having somebody charged, or communicate that they really
don’t want a person charged. Most of the time law enforcement
and prosecuting agencies will give some weight to
that. Also, if somebody hires us to investigate and we gather
a fair amount of evidence, they can instruct us whether to
share it with law enforcement. If we don’t share that evidence
with law enforcement, in most cases they will have
no interest in prosecuting because they don’t have the realistic
means of gathering the same information themselves.
MD: Have you seen any cases where it was not a full-time
employee doing the embezzlement, but instead the dentist’s
accountant or somebody who only comes in once a month, an
auxiliary position like that?
DH: The only cases where we’ve seen an appreciable amount
of theft is with some kind of bookkeeper or accountant;
somebody who has some level of control over the banking
function, such as writing checks. A part-time bookkeeper
is the only bookkeeper there, so even if that person only
comes in three days a month, there is nobody else doing the
job when they’re not there. So they can probably succeed
there on a part-time basis. With somebody like a part-time
receptionist, however, we really see very little stealing.
Somebody who mans the front desk on Fridays is going to
have a tough time getting away with much.
MD: Might another warning sign be an employee who insists
on doing all the insurance claims herself?
Interview with David Harris51
DH: Yes, refusal to delegate is one thing. Another sort of
related symptom is refusal to cross-train. A lot of these
people come off as perfectionists. They tell the dentists
that if somebody else does it and messes it up, then they
have to fix it. In the meantime, your cash flow suffers
because all these claims have been sent to the wrong
place. The employee convinces the dentist that he or she
is a perfectionist, which generally we consider a positive
with employees rather than a negative characteristic. So the
dentist tends to be receptive to this argument and the thief
gets away with it.
MD: It has to be even more confounding for a dentist to have an
employee with all these fantastic traits that they wish all their
employees had, and then to find a knife in their back with that
employee’s fingerprints on it. Are you aware of some dentists
who have been embezzled from multiple times?
DH: Definitely. In fact, once you’ve been embezzled from
once, the probability of you being a repeat victim is actually
higher than the general dental population. About two-thirds
of recorded embezzlement is from people who have already
been a victim. The probability goes up from 50 to 60 percent
to something closer to 70 percent.
MD: How do you explain that?
DH: I think the short answer is that some dentists are
probably easier to steal from than others. What makes them
easier to steal from could be anything from personality to
how they run their office to who else is working in the
office. There could be a lot of factors. Again, the chances
of hiring a bad apple in your career are pretty good. The
chances of hiring two are also pretty good.
MD: Once somebody in the office is caught and nothing about
the way the office is run changes, do you think it gives other
people in the office the idea to do the same thing?
DH: I don’t think that is what happens. I think five years
goes by, somebody else gets hired and that person steals.
The not checking the day sheet thing is a little bit of a red
herring. But if I’m a nice, easygoing dentist, for example,
the staff might get the idea that they can steal from me
without me really doing anything, because I’m just way too
nice. So I think if one staff member can form that opinion
about a dentist, so can two or three more.
MD: Let’s say I think I’m having an issue in my office and I give
you a call. Can you tell me a little bit about what the process is
like after that?
DH: Sure. The first thing we do is have somebody reasonably
senior at my company interview the dentist to see what the
dentist is seeing, and just try to validate that there could
be a problem. Sometimes we get dentists who don’t really
think there is a problem, but they have an employee who
did one thing to them once three years prior that they
think could be symptomatic of stealing. We usually tell that
doctor that if this person is embezzling, they’re going to see
more manifestations than one instance three years ago. We
try to help the dentist sort out what the employee is doing
One message I’ll give
your readers is that it is
really important to have
individual logins for your
soft ware. Some offices
have what I call the
‘unicode,’ a single code
that everybody uses to
log in with, which makes
it very tough for us to
track who is doing the
that should give them concern. We probably have a better
knowledge than the dentist of what embezzling behavior
Once we mutually decide that an investigation should
happen, the next thing we do is obtain their computer data.
We don’t like to work on the dentists’ computers because
they’re live systems and stuff is constantly changing. Plus,
if we’re connected remotely to a dentist’s computer, there
is a reasonable possibility that the staff member might
realize what we are doing. One thing that we emphasize
to every dentist we deal with is that an investigation has
to be stealthy. The staff cannot know that you are doing an
investigation until the process is complete and you have
an answer. Because if you think there is fraud when there
isn’t and you let the employees know that, you’ve destroyed
the employment bond and rebuilding it will be close to
impossible. On the other hand, if there is embezzlement
going on, you want to spring a trap on the thief as opposed
to the other way around. So stealth is important. What
we do is we get a complete copy of someone’s practice
management software data. So if you’re using Dentrix ®
(Henry Schein; American Fork, Utah), for example, there
is a folder on your server that has all the data. We get it
and bring it into our computer lab, where we analyze it
using our copy of Dentrix and look for patterns that are
consistent with embezzlement.
MD: Once you’ve identified that there might be some embezzlement
going on, do you set the trap at that point? Or do you
have to have another occasion or two to be able to make a
DH: No, most of the time at that point we can see what
has gone on. A lot of times we’re helped by third parties.
For example, if we see a situation where there was money
billed to an insurance company but the money didn’t come
to the practice. Then we can go back to the insurance
company and ask where the check went. If it went into the
receptionist’s bank account, then we know.
We also look at login names on the computer and who
is logged into the practice management software. We also
check if someone is coming and going at strange hours and
if there is either an alarm system in the office or if there
is some kind of building log that tracks access. If we can
correlate transactions to a specific person’s access, then we
have them. One message I’ll give your readers is that it is
really important to have individual logins for your practice
management software. Some offices have what I call the
“unicode,” a single code that everybody uses to log in with,
which makes it very tough for us to track who is doing the
DH: I highly doubt it will stop anybody from stealing, but
it will make the job of pinning their hide to the wall far
easier afterward. I’ll say the same thing about alarm systems
in the office. I go into a lot of offices where there is one
code that everybody in the office uses, including the office
cleaners that were fired who used to work there three years
ago. It’s important that everybody has their own unique
login code for the alarm system, and that they are changed
periodically. Because it stops employees from scooping up
someone else’s code by watching over their shoulder when
they’re entering it.
MD: That is another great tip. I love your example about the
office cleaners who were fired three years ago. I would present
individual login codes to the staff as a protection measure
against outside theft more than internal theft, but also suggest
that they keep the codes to themselves regardless. That way
people aren’t looking at one another wondering who is stealing
from the office or thinking that is why the practice is going
through all the security trouble.
So if a dentist does think something funny is going on in their
office and they want to give your company a call, what is the
best way for them to contact you?
DH: We have one e-mail address that we refer to as the
“embezzlement hotline.” The e-mail address is emergency@
dentalembezzlement.com. We have an on-duty fraud
investigator 365 days a year, and that e-mail address
is monitored by whoever is on duty. So if you send an
e-mail to that address on a Sunday, you will typically get
a response the same day from an investigator who will
say, “Let’s find a time when you are able to speak freely,
and go from there.” We also have a phone number and
other e-mail addresses, but the absolute best way to get
in touch with us if you have embezzlement concerns is
MD: Any tips about where they should be sending that e-mail
from, just in case the embezzler is going through their e-mail?
DH: If they’re not sure about their e-mail security, the best
advice I can give your readers is to set up a new Hotmail
or Gmail account and send it from there. Just because we’ll
know that one is secure. CM
For more information, contact David Harris at 888-398-2327 or by visiting
www.dentalembezzlement.com. For immediate concerns about potential dental
fraud being committed in your office, e-mail firstname.lastname@example.org.
MD: Individual logins seem like a good preemptive thing to
have in place, so employees know that anything they do on the
computer is going to be able to be traced back to them.
Interview with David Harris53
Prosthetic Tooth Repositioning:
A Viable Treatment Option for Select Cases
– ARTICLE by Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE, FASDA
For many years, patients with esthetic and functional problems
due to tooth malposition have had few treatment
options. Orthodontics is the first option to correct tooth
malposition; however, not all patients are willing to follow
through due to the length of time it takes to complete treatment.
In a certain percentage of these cases, orthognathic
surgery is also suggested to correct maxillary and mandibular
jaw position prior to orthodontic therapy. Often, the
patient is still faced with the prospect of restorative dentistry
when these therapies are completed to gain a full esthetic and
functional correction. Therefore, many patients never have
the opportunity to receive the treatment they seek unless
they agree to this lengthy regimen.
With the advent of dentin bonding and advancements in
dental porcelains, elective esthetic dentistry has never before
been in such high demand. For a select group of these
patients with minor tooth malposition, such as spacing (diastemata),
crowding (mesial and distal overlapping), minor
rotations and facial-lingual arch form displacement, esthetic
and functional correction may be accomplished purely by
restorative means. The patient, however, must understand that
correction of these malpositions will require a more aggressive
preparation of the teeth involved to align the arch form.
A diagnostic wax-up is absolutely necessary to help determine
the amount of tooth preparation that will be required.
A silicone or plastic preparation guide, or stent, is fabricated
from the diagnostic wax-up that is approved by the
patient. In some cases, intentional endodontics is required
to gain the proper space for the correction of tooth position.
It is imperative that the patient be aware of this possibility
before any treatment is started. However, as long as the
patient is fully informed of all treatment options, the patient
should have the opportunity to pursue this type of elective
treatment, if that is what the patient desires.
In order to determine if a patient is a candidate for prosthetic
tooth repositioning, mounted study casts are
required. It is recommended to duplicate the models so a
preoperative model can be kept as part of the permanent
record. The second model is prepared to assess how much
tooth reduction is required to gain an optimal result. Depth
cuts and preparation dimensions can be recorded for use
during the operative phase of treatment. Once the teeth are
prepared, a wax-up is done to correct tooth contour and
position. Keep in mind proper tooth length and width when
designing the esthetics, or “Golden Proportion,” of the case.
When preparing crowded dentition, the first step is to
perform an enameloplasty on teeth that are outside of the
proposed arch form to bring them into better alignment. Next,
the proximal contacts between the teeth are broken. Crowded
or overlapped teeth will require wrap-around veneers
Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases55
or full-coverage crowns. It is recommended to use a very thin
diamond instrument, such as a 30-micron interproximal composite
finishing diamond, or mosquito diamond, to shape
opposing proximal surfaces and vertically break the contact
between the roots. These surfaces can later be highly polished
with 50-micron finishing burs, discs and fine curettes.
One key to achieving good results is having adequate
interradicular space for development of a healthy gingival
papilla that can easily be cleaned by the patient. Teeth
that are out of line in the buccolingual dimension must be
corrected by over-preparing the side of the tooth that is out
of alignment. The opposite side of the tooth, in most cases,
will only need slight preparation in the marginal area. It is
important to mention that so-called “no-prep techniques”
cannot possibly correct misalignment of functional surfaces
without adding thickness to the tooth form, resulting in
Figure 1: A preoperative, full-arch, retracted view showing the amount
of crowding present in this Class II Division 1 patient.
Figure 2: A preoperative incisal view of the maxillary arch showing the
rotation and crowding of the maxillary anterior segment.
Figure 3: This incisal view of the preoperative cast shows the areas
in black that need to be reduced to create proper arch form before
reducing for the restorative material.
Figure 4: The completed maxillary and mandibular composite mockup
for the patient.
Case Report #1
The patient in this case has a Class II Division 1 malocclusion
with normal overjet and crowding of the maxillary
and mandibular anterior segments (Figs. 1, 2). The areas of
tooth structure outside the proposed arch form are marked
on the preoperative study model (Fig. 3). For labiolingual
malpositions, the proposed arch form will be positioned
halfway between the most facially positioned tooth and the
most lingually positioned tooth. This will allow for more
conservation of tooth structure by avoiding a full correction
on any one malpositioned tooth.
It is important to inform the patient that this type of case
may require correction of both arches because, with normal
overjet, the mandibular malpositioned teeth will get in the
way of correcting the maxillary teeth in the lingual direction
if only a maxillary arch alignment correction is attempted.
This must first be verified by preoperative cast preparation
and composite mock-up (Fig. 4).
Figure 5: The areas that need to be reshaped as determined on the
preoperative cast are marked prior to preparation.
Figure 6: The provisional stents in place to be used as preparation
guides to evaluate for proper tooth reduction.
Figure 7: A maxillary arch incisal view of the completed case. Compare
the postoperative arch form to the preoperative view shown in Figure 1.
Figure 8: A retracted facial view of the completed case.
Figure 9: An eight-year postoperative view of the completed case.
For a select group of
patients with minor tooth
malposition … esthetic and
functional correction may
be accomplished purely by
If the case is determined to be reasonable to perform, the
patient must then approve the mock-up to ensure that the
proposed correction will meet his or her expectations. If desired,
the actual teeth can be marked in the same fashion as
the study models using a sterile marker to show where the
teeth need to be reshaped prior to depth-cut placement and
tooth preparation for the restorative material (Fig. 5). Clear
provisional stents made from the composite mock-ups can
also serve as three-dimensional preparation guides to verify
proper tooth reduction (Fig. 6).
A completed incisal view and full-smile retracted view are
shown in Figures 7 and 8. Compare these to the preoperative
views (Figs. 1, 2) to visualize prosthetic corrections.
Figure 9 is an eight-year postoperative, full-arch, retracted
facial view. This case has been esthetically and functionally
stable over this period of time.
Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases57
Figure 10: A full-arch retracted preoperative view of a patient in
centric relation with no posterior tooth contact. He has no TMJ
symptoms at this time.
Figure 11: As the incisal edges of teeth #7–10 are reduced out of
contact, the posterior teeth begin to come into contact.
Figure 12: Following the incisal reduction of teeth #7–10, contacts of
the posterior maxillary teeth can be seen from this maxillary arch view.
Figure 13: Tooth preparation of the maxillary incisors completed for
Case Report #2
The patient shown in a preoperative, retracted view in
Figure 10 is positioned in centric relation. It is evident
that this patient is occluding on the anterior only and has
no posterior tooth contact. He has been told that his only
option is to have jaw surgery followed by orthodontics and
restorative therapy. After mounting the preoperative study
models in centric relation on a semi-adjustable articulator,
it was determined that if the maxillary anterior arch form
could be slightly expanded facially (increasing the overjet),
it would likely allow the mandible to close and the posterior
teeth to contact.
When the maxillary teeth #7–10 are reduced incisally, the
posterior teeth will come into contact. Therefore, the operative
plan will be to prepare teeth #7–10 and place 360-degree
ceramic restorations to correct the arch form in the facial
direction and tilt the long axis of the crowns slightly toward
the facial aspect, creating overbite and overjet. As the incisal
edges are shortened, the posterior teeth come into contact
(Figs. 11, 12). Once this occurs, the teeth must then be depth
cut on the facial and palatal aspects to allow for the thickness
of the ceramic material (Fig. 13).
Figure 14 shows the case completed after the four maxillary
incisor restorations are delivered. Note the functional
contact that now exists in centric occlusion for the patient.
Although the crossbite cannot be addressed without restoration
of the posterior teeth and a full-mouth reconstruction,
the patient has gained a stable occlusal situation by the restoration
of four teeth without invasive orthognathic surgery.
Figure 14: After placement of the ceramic restorations, contacts in
the posterior region can now be seen back to the first molar region,
giving this patient a more stable intercuspation in centric occlusion.
Figure 15: A preoperative smile view of a dentally compensated
Class II malocclusion.
Figure 16: From this preoperative incisal/occlusal view, there is a
great deal of crowding and rotation because the teeth are tipped lingually,
constricting the arch form and pushing teeth out of the arch.
Figure 17: An incisal view of teeth #5–8 after breaking the proximal
contacts and separating the teeth (interproximal reduction, or IPR). It
is important to separate the root forms at the gingival crest interproximally
with a mosquito diamond, allowing retraction cord to be placed.
This will ensure proper space for the emergence profiles and healthy
interproximal gingival tissue.
Case Report #3
The patient shown in Figure 15 presented with a dentally
compensated Class II malocclusion. He had never pursued
esthetic dental treatment because he was consistently told
that his functional and esthetic dental problems could not
be corrected without orthognathic surgery and orthodontics
prior to restorative therapy. In his opinion, the cure was
worse than the disease.
After working up the case on study models as previously described,
it was determined that this patient could be helped
prosthetically without surgical intervention. Figure 16 is an
occlusal/incisal view of the preoperative maxillary arch. The
orthodontic approach to unraveling this crowded arch would
be expansion, or tipping the teeth in the labial direction. This
would increase the arch length and allow for proper tooth
alignment. It would also increase the overjet, resulting in a
more Class II-like appearance.
When planning to orthodontically prepare these teeth, it is
important to note that correcting the lingual inclination of
the clinical crowns will have the same effect in gaining arch
length. There will be very little need to prepare these teeth
on the facial surfaces. The majority of the tooth reduction
will be on the proximal and lingual surfaces to orthodontically
correct the clinical crown angulation with the bur
Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases59
Figure 18: A facial view of teeth #5–8 after selective reduction on the
facial and lingual surfaces to remove excess tooth structure outside
the proposed arch form.
Figure 19: An incisal view of the preparations for teeth #5–8 after
depth cutting and two-plane reduction. This process is referred to as
“orthodontic tooth preparation.” Note that the prepared incisal edges
now follow a nice arch form that will be followed in the definitive restorations.
Compare this to the varied directions of the incisal edges in
the preoperative condition in Figure 16.
Figure 20: A facial view of the completed preparations. These
orthodontically prepared teeth are now ready to accept restorations
that will not only correct the clinical crown positions, but will also
be structurally sound and esthetic due to the space created for the
proper thickness of restorative material.
Figure 21: A facial view of the correction of the maxillary arch after
provisionalization with a rubberized urethane provisional material
(Tuff-Temp [Pulpdent Corporation; Watertown, Mass.]).
Interproximal reduction, or IPR, is performed in a similar
fashion to that of conventional orthodontics. The goal is to
separate the prepared teeth at the free gingival crest (Fig. 17).
The facial surfaces of the rotated teeth are reshaped in areas
that are facial to the proposed completed arch form (Fig. 18).
Lastly, depth cutting and two-plane reduction is performed
to allow for the proper positioning and thickness of the
definitive restorations (Fig. 19).
Figure 20 shows the completed preparations from the facial
view. Looking only at the final shape of the final preparations
of the teeth prior to master impression-making, one
would be hard-pressed to know how severe the preoperative
crowding and rotations were.
After making the master impression, taking a facebow
transfer and making interocclusal records, the preparations
Figure 22: The delivered maxillary restorations and the provisionalized
Figure 23: An incisal/occlusal view of the definitive restorations on
the maxillary arch after delivery. Compare this to the preoperative
view in Figure 16. Note that the crown forms have normal anatomic
contours and incisal edge thickness even after prosthetic correction
of the original misalignment.
Figure 24: An incisal/occlusal view of the definitive restorations on
the mandibular arch after delivery.
Figure 25: A postoperative smile view of the completed case. This
patient chose A1 as the final shade of the ceramics (IPS e.max ®
[Ivoclar Vivadent; Amherst N.Y.]). Compare this to the preoperative
smile view in Figure 15. An amazing transformation in esthetics and
arch form accomplished without surgery or braces was achieved for
this patient with careful planning and precise clinical execution from
preparation and provisionalization to delivery.
are provisionalized using a rubberized urethane provisional
material and a clear plastic stent made from a diagnostic
mock-up of the case (Fig. 21).
At the following appointment, the maxillary restorations are
delivered and the mandibular arch is prepared in the same
fashion as previously described, and then provisionalized
(Fig. 22). Figure 23 shows the completed maxillary arch
from the occlusal/incisal view after delivery of the definitive
restorations on teeth #5–13. Figure 24 shows the completed
mandibular restoration from the occlusal/incisal. The completed
smile view is shown in Figure 25. Compare this final
result to the preoperative smile view in Figure 15 to see the
Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases61
Prosthetic tooth repositioning is a viable treatment option
for select malocclusions that require esthetic and functional
correction. The stability of these cases has been shown
clinically when proper guidelines have been followed. Some
specialists have editorialized that this type of treatment is a
“quick-fix cop-out,” arguing that patients should be talked
into the ortho/surgical approach for these types of cases. It
is important to note that crowded dentition is very difficult
to clean, which can pose a challenge to maintaining proper
periodontal health, so it is very common to see these patients
with chronic marginal and interproximal gingivitis and, in
later years, full-blown periodontitis when these problems
are not addressed and corrected. Therefore, it is important
to emphasize to patients that these corrections, no matter
how they are accomplished, are needed for dental health
reasons as much as they are for esthetic correction. Just ask
these patients if the sacrifice of a little more tooth structure
versus the more “conservative” surgical approach was worth
it for them. It is always best to present all of the treatment
options and let patients help decide the course of treatment
that best suits their needs. CM
repositioning is a viable
treatment option for select
malocclusions that require
esthetic and functional
correction. The stability
of these cases has been
shown clinically when
proper guidelines have
Dr. Robert Lowe is in private practice in Charlotte, N.C. He also lectures internationally
and publishes on esthetic and restorative dentistry. Contact him at
email@example.com or 704-450-3321.
The author would like to acknowledge the ceramic artistry of William “CK”
Kim, CDT, of Yes Dental Lab in Case #1; Mike Felgenhauer, CDT, of Dental Arts
Precision Laboratory in Case #2; and Nadar Hedeshi, CDT, in Case #3.
Biologic Shaping from a
– ARTICLE by Daniel J. Melker, DDS
In today’s world of advanced dental procedures and
technology, traditional or classic dental principles can
easily be lost. This may especially be true with the
decision-making process of saving teeth. Implants are
wonderful options when appropriate, but they should not
be selected when a tooth can be saved using a predictable
perio or restorative protocol that yields excellent long-term
prognoses. Too often today, good teeth are being removed
in favor of implant placement that is occurring in a clinical
environment of inadequate bone and soft tissue, as well
as biomechanical compromise. Biologic shaping and soft
tissue grafting offer a classic, proven methodology for
treating teeth with absolute predictability.
Often our restorative treatment plans lead us to subgingival
margins, furcation involvement, root flutes and concavities,
in addition to a multitude of complex issues. Many of the
issues we face are in the subgingival environment and require
periodontal corrective procedures to return the foundation
to a healthy state. Traditionally, crown lengthening was
indicated for deep subgingival margins, not only to facilitate
impression making but also to correct biologic width
infringements. Biologic shaping is a periodontal corrective
procedure reported in the literature 1 that may complement
traditional crown lengthening, yet it differs from traditional
crown lengthening in the following ways:
calculus and caries formation. Biologic shaping
leaves the subgingival area as smooth as glass; there
are no areas for plaque, calculus or caries to hide.
Traditional crown lengthening worsens crown-toroot
ratio. Biologic shaping maintains crown-to-root
Traditional perio is about pockets and probing. Biologic
shaping is about preserving bone, smoothing
out the rough spots, and making restorative dentistry
predictable and a joy to perform.
The concept of biologic shaping is presented in the case
that follows. The procedure stresses a 360-degree removal
of tooth surface irregularities as well as all cementoenamel
junctions (CEJs) and existing margins. An important aspect
of the procedure is to remove any concavities or furcation
involvements. Once the root surfaces are perfectly smooth,
the flap is placed just coronal to the osseous surface and
sutured in place. After 12 to 14 weeks of healing, the
restorative dentist simply places a new margin just coronal
to the gingival collar, which allows for a perfect impression
to be taken. This case also features the specific correction of
a mesial concavity on an upper first bicuspid.
Traditional crown lengthening moves the bone away
from the margin. Biologic shaping moves the margin
away from the bone.
Traditional crown lengthening requires osseous
surgery to re-establish the biologic width. Biologic
shaping may require minor osseous surgery, but
it generally avoids major osseous surgery and still
re-establishes biologic width because you have the
choice to locate your restorative margin coronal to
the old restorative margin (0.5 mm apical to the core
is the coronal extent).
Traditional crown lengthening may open furcations
and render a poor prognosis. Biologic shaping
preserves the integrity of the furcation because
aggressive osseous surgery was not needed.
Traditional crown lengthening does not eliminate
flutes, concavities or root clefts, leaving the
postoperative lengthened crown at risk for disease
recurrence due to increased susceptibility for plaque,
Figure 1: This patient will undergo a maxillary full-arch restoration to
correct occlusal issues and mild periodontal disease. When performing
definitive restorative procedures, it is critical to have an ideal periodontal
foundation to restore. There was an initial discussion on whether to restore
the bicuspids. After review of occlusal issues, it was decided to include the
bicuspids in the provisional phase of treatment.
Biologic Shaping from a Restorative Perspective65
Figure 2: Upon reflection of the tissue with a full-thickness flap due to
the existing thick bone, the tooth surfaces exhibited calculus located in
Figure 3: From a slightly different angle, the irregular contours of the bone
can be seen. Osseous contouring will be necessary to create contours that
will be compatible with the soft tissue when it is replaced. Once the flap is
reflected, a split-thickness dissection is used to preserve the periosteum
for suturing of the flap and for stability.
Figure 4: Using a C847-016 diamond bur (Axis Dental; Coppell, Texas), the
tooth surface is gently smoothed to remove any irregularities of the root
surface, as well as all CEJs. The concavity on the upper first bicuspid is also
removed by gently blending the line angles approximating the concavity.
Removal of the middle tooth surface of the bicuspid was avoided so as
not to deepen the concavity.
Figure 5: Once the gross removal of tooth structure is completed, an
F847-016 diamond bur (Axis Dental) is used to smooth the root surface.
Biologic shaping and soft tissue grafting offer a ... proven
methodology for treating teeth with absolute predictability.
Figure 6: A C801L-023 diamond round bur (Axis Dental) is then used to
properly contour the bone to mimic the soft tissue. The term for this procedure
is “creating a parabolic architecture,” and it is the key to forming an
ideal interface between bone, tooth and tissue. This phase of the surgery
helps to avoid the formation of pockets between the bone and soft tissue
when the tissue is replaced.
Figure 7: Upon completion of the biologic shaping and osseous contouring,
an ideal foundation is created over which the soft tissue can be sutured
Figure 8: 5-0 chromic gut suture material is used to replace the flap just
coronal to the osseous underlying foundation. An important aspect of
suturing the flap is to involve the periosteum as an attachment apparatus
for the suture. The suture grabs the periosteum apically to allow for perfect
placement of the flap so that no movement or displacement of the flap can
occur. There is no need for any dressing to be placed.
Figure 9: An occlusal view showing as much primary closure of the flaps
as possible. This allows for decreased discomfort in the healing phase.
Also note that no CEJs are present on any of the teeth. A recent article
by Rapley and Cobb, et al. 2 demonstrated with electron microscopy that
the CEJs tend to hold biofilm and that these areas can be a source of
periodontal breakdown. It is the belief of the author that by removing the
CEJs, we are treating a cause of future breakdown, thus changing the
environment for long-term maintenance.
The procedure stresses a 360-degree removal of tooth
surface irregularities ... all CEJs and existing margins.
Biologic Shaping from a Restorative Perspective67
Biologic shaping is about preserving bone,
smoothing out the rough spots, and making
restorative dentistry predictable and a joy to perform.
Figure 10: The day of the reline appointment after four weeks of healing.
The provisionals will be closed to fit the teeth, leaving 1 mm of space
between the provisional and the tooth surface to allow for future biologic
width growth in a coronal direction. No prepping of the tooth surface is
done at this appointment.
Figure 11: Impressions day, 12 weeks post-op. All margins are placed
just coronal to the gingival collars. A size 7/00 SilTrax ® cord (Pascal
International; Bellevue, Wash.) is placed in the sulcus to allow for the lab
technicians to trim the dies.
Figures 12–14: Final restorations placed. All are IPS e.max ® crowns
(Ivoclar Vivadent; Amherst, N.Y.) with the exception of full-coverage gold
on the second molars. All margins are supragingival. Ideal health exists
between the crowns and the soft tissue with no inflammation present.
(Restorations courtesy of Dr. Howard Chasolen of Sarasota, Fla.) CM
Dr. Daniel Melker is in private practice in Clearwater, Fla., and lectures nationwide
on periodontics and prosthodontics. Contact him at 727-725-0100.
1. Melker DJ, Richardson CR. Root reshaping: an integral component of periodontal
surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296-304.
2. Satheesh K, MacNeill SR, Rapley JW, Cobb CM. The CEJ: a biofilm and calculus
trap. Compend Contin Educ Dent. 2011 Mar;32(2):30, 32-7.