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Chairside®

A Publication of Glidewell Laboratories • Volume 8, Issue 1

Photo Essay

Another Use for Anterior

BruxZir ® Restorations

Page 22

Small-Diameter Implants:

Poor to Excellent Function in

One Day!

Dr. Ara Nazarian

Page 14

Embezzlement and the

Dental Practice

An Interview with

Prosperident CEO David Harris

Page 44

The Viability of Prosthetic

Tooth Repositioning

Dr. Robert Lowe

Page 55

Dr. Michael DiTolla’s

Clinical Tips

Page 9

COVER PHOTO

Jennifer Folbigg, Customer Service Representative

Glidewell Laboratories, Newport Beach, Calif.


Contents

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.

Contents 1


Contents

38 Chairside Live Case of the Week:

Episode 32 — A Disastrous Double-Arch

Impression Tray

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

www.chairsidemagazine.com.

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

Perspective

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.

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Contributors

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 mditolla@glidewelldental.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 boblowedds@aol.com.

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.

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Publisher

Jim Glidewell, CDT

Editor-in-Chief and Clinical Editor

Michael C. DiTolla, DDS, FAGD

Managing Editors

Jim Shuck; Mike Cash, CDT

Creative Director

Rachel Pacillas

Copy Editors

Jennifer Holstein, David Frickman,

Chris Newcomb, Megan Strong

Statistical Editor

Darryl Withrow

Digital Marketing Manager

Kevin Keithley

Graphic Designers

Jamie Austin, Deb Evans,

Joel Guerra, Audrey Kame, Phil Nguyen,

Kelley Pelton, Makara You

Web Designers

Jamie Austin, Kevin Greene,

Allison Newell, Melanie Solis, Ty Tran

Photographer

Sharon Dowd

Videographers

James Kwasniewski, Sam Lea

Illustrator

Wolfgang Friebauer, MDT

Editor’s Letter

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

Teri Arthur

to technology, we are able to give you, our dentists, the

(teri.arthur@glidewelldental.com)

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

chairside@glidewelldental.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.

www.chairsidemagazine.com.

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

Neither

(“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,

of trade any name, information, trademark, apparatus, manufacturer product, or otherwise or process does disclosed, not necessarily

constitute that its or use imply would its endorsement, not infringe recommendation, proprietary rights. or Reference favoring

or

represents

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

herein

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.

CAUTION:

materials your own that clinical are presented, expertise before you must trying make to implement your own new decisions procedures. about

mditolla@glidewelldental.com

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.

5

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

Bellaire, Texas

Dear Jeff,

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

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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!

– Mike

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

to believe.

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,

it’s not.

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

Houston, Texas

Dear Michael,

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

resin cements.

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;

53(1):28-31).

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.

– Mike

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

Bedford, Texas

Dear Marea,

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

primers.

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

acid.

– Mike

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

lecture again.

– Nadia Navid, DDS

Petaluma, Calif.

Dear Nadia,

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!

– Mike

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Letters to the Editor 7


Numbers

by the

2,827,512

Total number of BruxZir ® crowns placed

Source: Glidewell Laboratories internal data

25

Number of countries where

BruxZir ® Solid Zirconia is sold

Source: Glidewell Laboratories internal data

10.6

Dentistry personnel per 10,000 people in the U.S. Dentistry

Source: Wolfram|Alpha, www.wolframalpha.com

0.39

personnel per 10,000 people in China

Source: Infodent International magazine


5,232

Number of Glidewell

Laboratories customers

in 2012 that had

ZERO remakes

(160,939 restorations

were fabricated for

these customers)

Source: Glidewell Laboratories

internal data

Unemployment rate of U.S.

1.5%

dentists (one of the lowest

of all U.S. professions)

Source: U.S. Bureau of Labor Statistics

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15%

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


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Bluephase ® Style

SOURCE........... Ivoclar Vivadent Inc. (Amherst, N.Y.)

800-533-6825, www.ivoclarvivadent.com

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


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Tooth & Gums Tonic ®

SOURCE........... Dental Herb Company ® Inc.

(Lancaster, N.H.)

800-747-4372, www.dentalherb.com

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!


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Triodent V3 Sectional Matrix System

SOURCE........... Ultradent Products Inc. (South Jordan, Utah)

888-230-1420, www.ultradent.com

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


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Smile Reminder

SOURCE........... Solutionreach (Lehi, Utah)

866-605-6867, http://tinyurl.com/smilereminder

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.


14 www.chairsidemagazine.com


Poor to Excellent

Function in One Day!

– ARTICLE by Ara Nazarian, DDS, DICOI

Introduction

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


Case Report

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

(Fig. 2).

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

implant placement.

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.

16 www.chairsidemagazine.com


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

of treatment.

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

properly established.

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

housing pick-up.

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

National

Average

National

RV

D5875

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

D6053

Implant/abutment-supported

removable denture

$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.

Closing Comments

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

www.aranazariandds.com.

Disclosure: Dr. Nazarian reports no disclosures.

Reprinted by permission of Dentistry Today, © 2012 Dentistry Today.

18 www.chairsidemagazine.com


22 www.chairsidemagazine.com


Photo Essay

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!

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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

have guessed.

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

margins.

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.

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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

the procedure.

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

esthetic result.

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.

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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

“bonus” reduction).

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.

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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

direct temporary.

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.

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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

temporary hemostasis.

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.

34 www.chairsidemagazine.com


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

Solid Zirconia.

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


GENERAL REFERENCES

• Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to

zirconia: clinical and experimental considerations. Dent Mater. 2011

Jan;27(1):83-96.

• 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

Apr;23(2):71-2.

• 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;

40(9):783-6.

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

36 www.chairsidemagazine.com


38 www.chairsidemagazine.com


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.

40 www.chairsidemagazine.com


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

educated guess.

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.

Conclusion

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

episodes visit

www.chairsidelive.com.

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.”

42 www.chairsidemagazine.com


44 www.chairsidemagazine.com


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

that, right?

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

dream employee?

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

better answer.

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

trust for.

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

48 www.chairsidemagazine.com


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

be noticed.

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

or another.


DH: Definitely.

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

usually taken?

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

toilet paper?

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

handle on.

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

practice management

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

dirty stuff.


that should give them concern. We probably have a better

knowledge than the dentist of what embezzling behavior

looks like.

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

strong case?

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

dirty stuff.

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

emergency@dentalembezzlement.com.

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 emergency@dentalembezzlement.com.

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

Introduction

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.

Case Preparation

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

overcontoured teeth.

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).

56 www.chairsidemagazine.com


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

restorative means.

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

all-ceramic restorations.

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.

58 www.chairsidemagazine.com


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

(“diamond-driven orthodontics”).

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

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Figure 22: The delivered maxillary restorations and the provisionalized

mandibular arch.

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

remarkable transformation!

Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases61


Conclusion

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

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.

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

boblowedds@aol.com or 704-450-3321.

Acknowledgement

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.

62 www.chairsidemagazine.com


Biologic Shaping from a

Restorative Perspective

– ARTICLE by Daniel J. Melker, DDS

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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:

5.

6.

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

ratio.

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.

1.

2.

3.

4.

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,

Case Presentation

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

concavities.

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.

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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

in place.

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.

REFERENCES

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.

68 www.chairsidemagazine.com

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