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Chairside®

A Publication of Glidewell Laboratories • Volume 4, Issue 1

One-on-One

An Interview with

Dr. Paul Homoly

IPS e.max ® CAD LT

Photo Essay

Perception is the Only Reality

Four Crowns. Four Price Tags.

Can You Tell the Difference?

Minimally Invasive Dentistry

Combined with Laser Gingival

Plastic Surgery

Dr. Michael DiTolla’s

Clinical Tips


Contents

9 Dr. DiTolla’s Clinical Tips

This month’s tips include 3M ESPE Durelon ,

which used to be one of the more popular permanent

crown and bridge cements in the world. Today

I see it used more as a long-term provisional cement.

For extractions that are atraumatic and efficient, the

Physics Forceps ® lives up to its “one-minute extraction”

reputation. No less valuable are KaVo electric

handpieces, which make prepping and polishing ceramic

a breeze due to its high torque. When it comes

to seating restorations, you will rarely see me without

an Aidaco Bite Stick in my hand.

14 Book Review: The Early Adventures of

Painless Parker

I had heard the name a couple of times, but I did not

fully appreciate the legend of “Painless Parker” until

I stumbled across this book. I loved getting some insight

into the world of a scrappy dentist who sought

to revolutionize how dentistry’s message would be

spread. In my first Chairside book review, I give you

a quick teaser on what I feel is a “must-read” for

anyone who has ever wondered how to attract more

patients.

16 Photo Essay: IPS e.max ® CAD LT

Case Study

Many dentists have asked me about the effectiveness

and esthetics of IPS e.max CAD LT, and I think using

it in a case like this shows that it is becoming

one of my “go-to” crowns. A no-prep Vivaneer on

the adjacent tooth was also necessary to address the

patient’s chief complaint.

27 Minimally Invasive Dentistry Combined

With Laser Gingival Plastic Surgery:

Maximize Your Aesthetic Results

It’s no secret that I hold Dr. Bob Lowe in great esteem

as one of my clinical mentors. Bob is the one

who taught me how to perform soft and hard tissue

crown lengthening, and I think he is the only dentist

presently teaching GPs how to do this. Don’t miss

any opportunity to see Bob lecture near you!

Cover photo by Sharon Dowd

Cover illustration by Wolfgang Friebauer, MDT

Contents 1


Editor’s Letter

I hate to start off the new year with a face full of attitude,

but if there is another dental magazine out there as interesting

as Chairside, I’d like to see it. Other magazines

have good articles here and there, but I strive to make

every article one that you will at least want to read the

callouts and thus get sucked into the article.

Dr. Paul Homoly surprised me yet again in this month’s

interview, as we discussed the culture of dentistry and the

blind pursuit of quality dentistry. As always, Paul looks at

things from a contrarian point of view, and I know you

will find this interesting. Paul generates more e-mail than

any other contributor, and it is all positive.

I stumbled upon a book on eBay about Painless Parker,

and I bought it after I went to the Wikipedia page about

him and became fascinated. I loved the book and wrote

a review about it in this issue. Love him or hate him, you

would be hard-pressed to find a more interesting or controversial

dentist.

The “Perception is the Only Reality” article may open a

few eyes as well. I invite you to vote for your favorite

crown and try to guess which ones are which before you

look at all the prices. (Glidewell was not involved in this

study, so there is no hidden agenda.)

Dr. Neiburger has written a fascinating article on the evolution

of tooth wear and how teeth have changed over the

years. Is the way we prepare food today preventing the

natural, healthy wearing of our teeth?

Dr. Bob Lowe rounds out this issue with another excellent

clinical article on how he uses lasers to deal with gingival

issues. The more cosmetic dentistry you do, the more you

realize the major role the gingival plays, and how unpredictable

it can be.

I also include a case study with one of my favorite materials:

IPS e.max ® CAD LT, used with no-prep veneers. Try

IPS e.max on a patient, and see if you like this cementable

all-ceramic restoration as much as I do.

Yours in quality dentistry,

Dr. Michael DiTolla

Editor in Chief, Clinical Editor

mditolla@glidewelldental.com

Publisher

Jim Glidewell, CDT

Editor in Chief

Michael DiTolla, DDS, FAGD

Managing Editors

Jim Shuck

Mike Cash, CDT

Creative Director

Rachel Pacillas

Clinical Editor

Michael DiTolla, DDS, FAGD

Copy Editors

Melissa Manna

Martin Yan

Magazine Coordinators

Sharon Dowd

Lindsey Lauria

Graphic Designers

Jamie Austin, Deb Evans, Joel Guerra,

Phil Nguyen, Gary O’Connell, Rachel Pacillas

Staff Photographers

Sharon Dowd

Illustrators

Wolfgang Friebauer, MDT

Phil Nguyen

Ad Representative

Lindsey Lauria

(lindsey.lauria@glidewelldental.com)

If you have questions, comments or complaints regarding

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

at chairside@glidewelldental.com. Your comments may be

featured in an upcoming issue or on our Web site.

© 2009 Glidewell Laboratories

Neither Chairside Magazine nor any employees involved in its publication

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

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

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

represents that its use would not infringe proprietary rights. Reference

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

trade name, trademark, manufacturer or otherwise does not necessarily

constitute or imply its endorsement, recommendation, or favoring

by the publisher. The views and opinions of authors expressed

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

shall not be used for advertising or product endorsement purposes.

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

that are presented, you must make your own decisions about

specific treatment for patients and exercise personal professional judgment

regarding the need for further clinical testing or education and

your own clinical expertise before trying to implement new procedures.

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.


Contents

34 One-on-One with Dr. DiTolla

In our previous discussion, Dr. Paul Homoly and I

shared our thoughts on how to communicate with

patients who had large restorative needs. Now, in

our latest interview, we discuss the culture of dentistry

and the dangers of too much patient education.

50 Perception is the Only Reality

LMT conducted a nationwide experiment to determine

whether technicians and dentists could actually

differentiate between expensive and inexpensive

crowns. After hundreds of comparisons among the

best in the industry, there seems to be one conclusive

answer. I took the liberty of sharing with you

their findings, and the results may surprise you.

55 The Evolution of Human Occlusion—

Ancient Clinical Tips for Modern Dentists

In this well-chronicled article, Dr. Ellis Neiburger

discusses the general evolution of our teeth and addresses

occlusal problems throughout the centuries.

I was fascinated by this article and think about it every

time I perform occlusal adjustment on a crown.

Contents 3


Letters to the Editor

“Dear Dr. DiTolla,

I really love the Reverse Preparation Technique.

It has made my life so much easier!

One question though: I still find that I don’t

have enough reduction on the lingual surfaces

of tooth 8 and 9. Any suggestions on

how I can make sure I have enough reduction

in these areas?”

- Dr. Darryl Duval, Jacksonville, FL

Dear Darryl,

Good question! I usually eyeball it,

but as we both know that doesn’t

always work. When I have doubts,

I use The Reduction Ring (www.

reductionring.com). I find it to be

pretty fail-proof; in fact, I should

use Reduction Rings all the time and

put them in the Reverse Preparation

Technique video.

Please e-mail me back and let me

know if you like them, as there are

other brands out there you may like

better.

- Dr. DiTolla

“Dear Dr. DiTolla,

I recently read your article in Dental Economics

and was very interested in learning

4

Letters to the Editor

more concerning the STA System anesthesia

technique.

I have many of your DVDs and use your

Reverse Preparation Technique religiously.

The STA System technique peaked my

interest, but after seeing you use and endorse

it, it made me want to learn more.

Do you currently have a DVD for this technique?

Also, is it an easy technique to

learn or does it take practice? Any additional

information you can provide would

be greatly appreciated.”

- Dr. Rick Bray, Pennsburg, PA

Dear Rick,

For a single mandibular molar, I start

in the buccal furcation, right at the

buccal midpoint on the STA setting,

not the normal or the more rapid

setting. I wait for the lights to increase

to show that the pressure is

correctly increasing for a PDL injection.

If I don’t get proper pressure

in the furcation, I move the needle

to the MB line angle and try it

there and then move it to the

DB line angle. Due to localized

periodontal conditions,

you may need

to move the needle

to an area that is

healthy enough

for this type of

injection. If I get

a good injection

in the buccal

furcation, I typically

do not

go to the lingual,

although

there is certainly

nothing

wrong

with doing

that. I know

some dentists

who give the injection

at the ML and DL

line angles instead of the furcation,

and they report very good

results with that technique, too.

Basically, it doesn’t matter where

the needle is as long as you are getting

good pressure feedback on the

unit, which tells you it has been a

successful PDL injection. I like it best

when it works in the buccal furcation

because I know I will get great pulpal

anesthesia with that single injection.

For typical maxillary infiltrations, I

use the normal setting if I am starting

in the area of the bicuspids and

moving anteriorly. If I am just anesthetizing

8 and 9, for example, I will

usually start the injections on the

STA speed (the slowest speed), even

though it is not a PDL injection. This

is the most comfortable setting for

the patient and halfway through the

injection, when the patient is partially

anesthetized, my assistant or I will

switch it to normal speed. I hope that

helps!

- Dr. DiTolla


“Dear Dr. DiTolla,

I have happily used Glidewell Laboratories

for several years. I even came down from

Northern California to tour the impressive

facility, where I saw you working.

My question is: What cement do you recommend

for zirconia? Different lecturers

and manufacturers give various strength

numbers. I have been using Panavia F2.0

(Kuraray Dental) and RelyX (3M ESPE)

successfully for many years.”

- Dr. Richard Jergensen, Fairfield, CA

Dear Richard,

Panavia F2.0 is a great choice. RelyX

could be referring to either RelyX

Luting Plus Cement or RelyX

Unicem; either is a great choice as

well. The RelyX Luting Plus Cement

is a resin-reinforced glass ionomer

used for conventional cementation,

and Unicem is a self-etching resin

cement. Both are highly acceptable

choices for zirconia-based restorations.

- Dr. DiTolla

“Dear Dr. DiTolla,

I recently watched your Rapid Anesthesia

Technique on the Glidewell Web site. I

think I understood most of it, but is it basically

a PDL injection?

Also, what gauge and length needle do

you use for this technique? I have had a

hard time finding a heavy enough needle

short in length to use in my conventional

PDL gun.”

- Dr. Mark Pelletier, Irmo, SC

Dear Mark,

The Rapid Anesthesia Technique is

a PDL injection that is done in the

furcation space of a lower molar. I

used to do them by hand, but I now

use the STA System from Milestone

Scientific (www.stais4u.com). In fact,

I now do all my injections with the

STA System—I love it.

I used to have a problem with my

30-gauge extra short needles bending

as well. Since I switched over to

the STA System, you have to use their

needles. They hold up much better,

but you can only use them with their

system. Otherwise, I prefer Accuject ®

needles from DENTSPLY International,

Inc., but they still bend a little at

times.

- Dr. DiTolla

“Dear Dr. DiTolla / Dr. Lowe,

I was wondering what type of camera was

used in Dr. Bob Lowe’s article on pages

24-29 of Chairside ® Volume 3, Issue 2. The

photos were great, and I would like to get

all the information I can on the process

used.

I’d also like to know if Dr. Lowe learned

this technique on his own or if he attended

a class and, if so, where. Finally, what settings

does he keep his camera on? Thank

you for any information you can provide.”

- Tracy Lindamood, CDA, Jacksonville, FL

Dear Tracy,

These pictures have been taken over

a period of many years. Some were

taken with a Fuji S-1 Pro, others with

a Canon 5D. The Fuji had a ring flash,

and the Canon 5D has a side-by-side

dual flash. While a ring flash is easier

to use, especially in the posterior region

of the mouth, it tends to make

images look more two-dimensional.

The side-by-side flash takes a little

practice to learn how to bounce light

to capture posterior exposures. The

anterior exposures are much more

three-dimensional than those taken

with a ring, particularly if you concentrate

the light a little more on one

side.

Dr. Shavell, my mentor, was an outstanding

dental photographer. He

had two rules. The first rule: Fill the

frame with your subject. To show a

photo of one tooth, you need to go

two-to-one. Today, with digital, this

can be done with Adobe ® Photoshop

® and cropping, but that takes

time. I prefer a 2x teleconverter to

take the photo at 2x, then no manipulation

with computer software.

The second rule: Line up the buccal

surfaces of posterior mirror shots

parallel to the top of the viewfinder.

Center facial and labial shots using

the occlusal plane as a guide.

The AACD has a good pamphlet on

taking intraoral photos as far as settings,

which vary from camera to

camera, flash set up to flash set up.

The nice thing with digital is you can

see if the exposure is too light or too

dark and adjust the flash intensity

and/or f-stop accordingly.

Lastly, my friends Dr. Tony Soileau

and Dr. Jim Dunn teach excellent

photography courses. Google them

to get more detailed contact info.

I hope this helps and good luck!

- Dr. Lowe

WRITE US

Chairside Magazine welcomes

letters to the editor, which

may be featured in an upcoming

issue or on our Web site.

Letter should include writer’s

full name, address and

daytime phone number.

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

mail (Letters to the Editor,

Chairside Magazine, Glidewell

Laboratories, 4141 MacArthur

Blvd., Newport Beach, CA

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

Letters to the Editor 5


Contributors

Michael C. DiTolla, DDS, FAGD

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

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

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

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

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

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

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

mditolla@glidewelldental.com, or visit www.glidewell-lab.com.

Paul Homoly, DDS, CSP

Dr. Paul Homoly is a world-class leader in dental education. After practicing comprehensive restorative

dentistry for 20 years, Dr. Homoly earned the highest designation in professional speaking—Certified

Speaking Professional (CSP)—and is the first and only dentist in the world to earn this designation. As

an acclaimed educator for more than 25 years, he is best known for his innovative and practical approach

to dentistry. An accredited member of the ADA, Dr. Homoly is an active author who contributes

to dental journals worldwide, including a monthly column in Dental Economics. He is also president of

Homoly Communications Institute located in Charlotte, N.C. To reach Dr. Homoly, call 800-294-9370,

e-mail paul@paulhomoly.com, or visit www.paulhomoly.com.

Robert A. Lowe, DDS, FAGD, FICD, FADI, FAC

Dr. Robert A. Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982,

and was a Clinical Professor of Restorative Dentistry until its closure in 1993. Since January of 2000,

Dr. Lowe has maintained a private practice in Charlotte, N.C. He lectures internationally and publishes

in well-known dental journals on esthetic and restorative dentistry. Dr. Lowe received fellowships in

the AGD, ICD, ADI, and ACD. In addition, he received the Gordon Christensen Outstanding Lecturers

Award in 2004, and Diplomat status on the American Board of Esthetic Dentistry in 2005. To contact

Dr. Lowe, call 704-364-4711, e-mail boblowedds@aol.com, or visit www.destinationsmile.com.

Ellis Neiburger, DDS

Dr. Ellis “Skip” Neiburger graduated from the University of Illinois College of Dentistry in 1968. After

postgraduate research in Oral Pathology and Forensic Dentistry at the U.S. Armed Forces Institute of Pathology,

Dr. Neiburger pursued a career as a paleopathologist. He has been curator of anthropology at

the Lake County Museum for 17 years. Dr. Neiburger’s research on ancient anatomy and occlusion has

taken him throughout the world, and his studies have been widely published in the areas of prehistoric

pathology, dental computing and clinical dentistry. He is editor and vice president of the American Association

of Forensic Dentists, and has written five books on dentistry. Dr. Neiburger has a general practice

in Waukegan, Ill., and may be contacted at 847-244-0292 or by visiting www.drneiburger.com.

Contributors 7


– ARTICLE by Michael DiTolla, DDS, FAGD

– PHOTOS by Sharon Dowd

PRODUCT........ Durelon

Dr. DiTolla’s

CLINICAL TIPS

CATEGORY...... Polycarboxylate Luting Cement

SOURCE.......... 3M ESPE

St. Paul, MN

800-364-3577

www.3m.com

When I graduated from dental school in 1988, Durelon

was my permanent cement of choice. It seemed

to work well until it started to turn mushy about five

years after cementation. Maybe it’s not a bad idea

to have the crown fall off every five years to check

the prep! When all the hype with glass ionomer cements

started, I switched over. But when I had too

many cases of post-operative sensitivity to ignore, I

went running back to Durelon. With the advent of an

excellent class of resin-reinforced glass ionomer cements,

Durelon has decreased in use as a permanent

cement. My reintroduction to Durelon was through

Dr. Bill Strupp, who has used Durelon as a temporary

cement for decades. We started using it about

10 years ago for our BioTemps ® in large crown and

bridge cases, and the temps simply don’t come off.

Due to its relatively neutral pH value, there is essentially

no post-operative sensitivity with this cement,

and it is well tolerated by the gingival as well.

Dr. DiTolla’s Clinical Tips 9


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Physics Forceps ®

CATEGORY...... Tooth Extraction

SOURCE.......... GoldenMisch, Inc.

Detroit, MI

877-987-2284

www.oneminuteextractions.com

There are some great product names in dentistry—

you may know that my favorite has long been Algi-

Not, the alginate replacement product from Kerr.

However, Physics Forceps from GoldenMisch, Inc.,

should win an award for its reputation as the “One

Minute Extraction Forceps.” That pretty much sums it

up, doesn’t it? We have a lot of overpromised/underdelivered

products in dentistry, and I was pretty sure

Physics Forceps was going to be about as successful

as the 90-second crown prep, which led to a lot of bad

preps done quickly.

The forceps came with a couple of study models to

practice on, but the teeth seemed to come out a little

too easily. If my patient’s bone was this flexible,

I wouldn’t need forceps. Three days later, a patient

walked in with a broken off upper first molar. My assistant

grabbed the forceps while I looked at the directions

one more time. I engaged the palatal root,

placed the bumper on the buccal plate and, without

squeezing, rotated the forceps. After 60 seconds of

convincing myself nothing was happening, the tooth

started to grow out of the socket! I switched to my

regular forceps and lifted the tooth out 80 seconds

from the time they were applied. This may be the first

advance in exodontia technology in 100 years, but it

was worth the wait!

10 Dr. DiTolla’s Clinical Tips


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ KaVo ELECTROtorque plus Handpiece

CATEGORY...... Electric Handpieces

SOURCE.......... KaVo Dental Corporation

Lake Zurich, IL

800-323-8029

www.kavousa.com

I see my KaVo ELECTROtorque plus handpiece the

same way I see digital radiography: there is no downside

except for cost. Is there any other piece of equipment

that is more linked to our income than our handpieces?

Why try to save money on the instrument you

use to prep every inlay, veneer, crown and bridge in

your practice?

I don’t prep teeth faster with this electric handpiece,

I just prep them better. This is because I can turn the

speed down on the handpiece and turn the water off

as well, due to the decreased heat with the slower

revolutions. Amazingly, you still have all of the torque

that you have when the handpiece is running full

speed. This allows you to make perfect margins and

see what you are doing without the water spray blocking

your view. There is no better way to polish ceramic

material intraorally than with an electric handpiece.

In fact, I am not even sure you can really polish porcelain

well with a traditional handpiece. That may sound

a little overdramatic, but if you have loupes it will be

pretty obvious to you as well. Polishing porcelain is

all about torque, and you owe it to yourself to demo

the KaVo ELECTROtorque plus handpiece at the next

convention you attend.

Dr. DiTolla’s Clinical Tips11


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Aidaco Bite Sticks

CATEGORY...... Crown Seating Instrument

SOURCE.......... Temrex Corporation

Freeport, NY

800-645-1226

www.temrex.com

The ubiquitous orangewood bite sticks! They show up

in practically all of my DVDs because I use them on

nearly every case. I was first introduced to Aidaco Bite

Sticks right out of dental school, during the two years

that I practiced with my dad. He used them with a

mallet to hammer in anterior crowns, and he would

tell patients they were going to feel a “slight tapping

sensation.” Their body language suggested they were

feeling a “massive jackhammer sensation.” One day I

had him tap on tooth 9 in my mouth with his mallet

and bite stick, and the force he was able to deliver

was shocking! That was the day I decided to retire

the mallet and to just use the orangewood sticks with

my hands. In Dad’s defense, the cements of his day

did not have the thin film thickness of today’s cements

and may have needed to be pounded into place.

When you try to seat crowns with just finger pressure,

the crowns indent into your fingertips and it’s

hard to tell if you are holding the crown in place. As

you have seen, I use the sticks for crowns, veneers,

even no-prep veneers in the anterior. In the posterior,

I use them on every bridge by having the patient

bite down on a bite stick during try-in for eight to

10 minutes. Whether we like it or not, preps shift in

the two weeks between appointments, even with welldone

provisionals—biting on the stick helps stubborn

bridges go down into place. When you look at remake

rates for our doctors, bridges always have a higher remake

rate due to prep shifting. It certainly helps to do

some “instant orthodontics” by having the patient bite

down on an orangewood bite stick with the bridge in

place prior to declaring it a remake. Often my dental

assistant will do this before I even enter the room, so

I can begin evaluating contacts and margins as soon

as I walk in.

Dr. DiTolla’s Clinical Tips13


Book Review:

The Early

Adventures

of Painless

Parker

– Book by Peter M. Pronych & Arden G. Christen

– review by Michael DiTolla, DDS, FAGD

I

am a big fan of biographies of successful

people from all walks of life. I don’t

think I have ever read a biography I haven’t

learned something from that I can relate to my pursuit

of success. Unfortunately, the opportunities to read a biography of an

icon in our industry are few and far between. So when I happened to find

one floating around on the Internet, I jumped at the chance to read the

story of a dentist who, at one point, was more famous than the President.

Early in my career, I remember working on an older woman who was slightly

apprehensive about having an extraction. I was able to complete the extraction

without her feeling any pain, and at the end of the extraction she said,

“Wow, you are a real Painless Parker.” I thanked her for the compliment, but

asked her about the expression, as I had never heard it before. She went on to tell me

about Painless Parker, a dentist from the turn of the century who was world-renowned for performing painless extractions.

That made no sense at all to me because my dad had been practicing dentistry since the early 1960s, and he told

me how unreliable Novocain was then…let alone 60 years before. I forgot all about the offhanded compliment until

a couple months ago when another patient mentioned Painless Parker, and my curiosity sent me to the center of all

knowledge: Wikipedia. A quick search brought me to his page, and as I read I became more fascinated with the man

who had a passion for bringing dentistry to the working class for an affordable price.

I found a book on Painless Parker and, once I picked it up, I could not put it down. I wanted to review it in Chairside ®

because I knew how many of you would be interested in this fascinating story. Whether you love or hate his tactics, I

guarantee you won’t be bored with the trials and tribulations of Painless Parker. Incidentally, when the Dental Board of

California told him he could no longer call himself “Painless Parker,” he went to court and legally changed his name from

“Edgar” to “Painless.” Awesome! Believe it or not, that is one of the least controversial things he did.

In May of 1892, Parker graduated from Philadelphia Dental College with a Doctor of Dental Surgery degree. His graduating

class consisted of four other students. After graduation, he decided to practice in his hometown of St. Martins in

New Brunswick, Canada. While he wanted to tell the locals about his skills, he had been taught in dental school that it

was unethical to solicit work directly. Parker was taught, however, that it was acceptable to solicit work by joining clubs

and to never decline an invitation to be seen at a public place.

Parker had been well-known in his hometown as an adolescent for some of his escapades, and he felt joining his local

church might help shore up his reputation and get some patients in the office. When that failed to produce any patients,

14 Book Review: The Early Adventures of Painless Parker


Parker decided to attend both Sunday services to

appear even more pious. He began to sit in the

front pew at church and took to carrying a huge

Bible with him. Since he had yet to see a patient

in his office, he began to volunteer for all of the

tasks in the church. Parker also assisted with the

services and taught Sunday school—anything

to make them think he was an ideal citizen. As

Parker put it, “I was determined to be ethical at

all costs.” Six weeks after opening his office, he

still had not seen a single patient.

Hope finally arrived in the shape of a local sign

painter who Parker knew hated his dentures.

Parker offered to make him new dentures in exchange

for a sign for the practice. The painter

wanted Parker to make the dentures

first so he could try them,

and then he would make the

sign. Parker agreed since he was

out of money. The painter loved

the dentures and, with much

appreciation, made a huge new

sign with gold paint for Parker’s

practice. Parker was somewhat

embarrassed by its size, so he instructed

the painter to put it up

at night so no one would see. The

next day Parker expected there to be

a line of patients around his office, but it

never materialized. In fact, when Parker showed up

to work the next day, he found the sign was missing! Later that

day, he found it nailed to the train station’s outhouse door, most likely by

one of the town’s other dentists. Embarrassed to be seen taking the sign down, Parker once again waited for the cloak

of night to remove his sign and replace it at work. His sign attracted one patient in his first 90 days of practice, a tourist

who needed an extraction. Parker removed the tooth and charged him one dollar ($21 in the present day, adjusted

for inflation). The patient only had 75 cents with him, but Parker was happy to take the money and finally get paid for

performing dentistry.

Parker saw fire and brimstone preachers on the street corner converting people with their vivid descriptions of hell,

messages that were considered socially acceptable. He just could not believe why it was unethical to preach the importance

of taking care of your teeth, and the “hell” that awaited you if you became edentulous.

Armed with an aqueous solution of cocaine he called “hydrocaine,” Parker takes his message to the street corner offering

painless extractions for 50 cents. He promised that if the extraction hurt, he would pay the patient five dollars! That

first night he extracted 12 teeth and didn’t have to give anyone the five dollars, which he found surprising because he

ran out of hydrocaine after the seventh patient!

While I certainly wouldn’t want to follow in Parker’s footsteps, I was drawn into the story of his personal struggles.

Parker starts his practice with dignity, but soon finds that dignity won’t pay the bills. Unlike most dentists, he finds he

likes being a dentist and a salesman at the same time, and this drives his decision to take the story of preventive dentistry

straight to the people.

This is on my required reading list for all dentists, young and old.

One of the authors, Dr. Arden G. Christen, has limited copies of the book available for purchase, although “The Early Adventures of Painless Parker” is technically out of

print. Contact Dr. Christen at achriste@iupui.edu to request a copy.

Book Review: The Early Adventures of Painless Parker15


Photo Essay

IPS e.max ® CAD LT Case Study

– ARTICLE & CLINICAL PHOTOS by Michael DiTolla, DDS, FAGD

– COVER PHOTO by Sharon Dowd

16 Photo Essay: IPS e.max CAD LT Case Study


I

wanted to share this case with you for a couple of reasons. First of all, it features the IPS e.max ® CAD

LT crown from Ivoclar Vivadent (Amherst, NY) that I have been asked by many dentists about. It’s a

restoration I am very pleased with and find myself using in more situations. This case involved

removing a zirconia-based crown, which is as bad as it gets when removing old restorations. It gave

me a chance to show you the two-cord technique one more time, and it required the use of a no-prep veneer

on the tooth adjacent to the crown in order to address the patient’s chief complaint: the interproximal black

triangle between tooth 9 and 10.

Figure 1

Figure 2

Figure 3

Figures 1-3: This 39-year-old female patient came to the office unhappy with the existing PFM crown on tooth 9. The tooth had been endodontically

treated 10 years prior, and four years ago a zirconia-based crown was placed. Since then, there had been some recession of the

gingival, which had exposed the darkened root from the endo.

Photo Essay: IPS e.max CAD LT Case Study17


Figure 4

Figure 5 Figure 6

Figures 4-6: The patient’s other main complaint was the shape of tooth 10 and the resultant gingival embrasure between the two teeth. I told

her that if we hoped to close the large black triangle between 9 & 10, we would have to place a restoration on tooth 10 as well.

18 Photo Essay: IPS e.max CAD LT Case Study


Figure 7

Figure 8

Figure 7: This occlusal view is imperative when deciding what type

of veneers to place on a patient. Dentists frequently send me smile

pictures and ask if the patient needs no-prep or minimal-prep veneers,

but you can’t have that discussion without an occlusal picture.

In this case, tooth 10 is an excellent candidate for a no-prep

veneer.

Figure 8: A close-up look at the zirconia-based crown on tooth 9

shows that the incisal edge is longer than tooth 8, and the overall

shape of the crown does not match 8 either. We decided to use an

all-ceramic crown without a substructure to replace the zirconia

crown, in hopes of getting a better match. I opted to use an IPS

e.max CAD LT crown.

Figure 9

Figure 10

Figure 9: I still give the patient some local anesthesia since I will be

placing two retraction cords. I used to try to avoid local anesthesia

when possible, but since developing a painless injection technique,

it is not an issue. Here I place Profound Lite (Steven’s Pharmacy,

Costa Mesa, CA) topical anesthetic for 45 seconds and then rinse

it off.

Figure 10: After the Profound Lite has been rinsed off, I use the

STA System (Milestone Scientific, Livingstone, NJ) to deliver the

Septocaine ® (Septodont, New Castle, DE) on the slowest speed. After

about 20 seconds, I switch the STA System to the normal speed,

as the patient is already anesthetized in that area. This is the easiest

way to give a painless injection.

Photo Essay: IPS e.max CAD LT Case Study19


Figure 11

Figure 12

Figure 11: If you have never had the pleasure of cutting off a zirconia

crown, you are in for a treat. You can make the task much easier

by having some specialty burs on hand, such as this ZIR-CUT Bur

(Axis Dental, Coppell, TX) available through all dental dealers. The

blue stripe on the shank identifies it as a ZIR-CUT Bur.

Figure 12: It is much easier to cut through the zirconia coping with

an electric handpiece because of the additional torque. Regardless,

make sure you try to cut through it with a soft touch. As the

bur cuts through the last of the zirconia, you will inadvertently cut

into the tooth if you have too much pressure on the handpiece.

Figure 13

Figure 14

Figure 13: The crown is popped off with the Christensen Crown

Remover and the prep is evaluated. It is slightly overtapered in the

incisal third, the mesial is slightly underprepared in the gingival

third, and the distal margin is slightly overprepared in the distal.

That said, the prep is still acceptable if we clean up the margins

and get a great impression.

Figure 14: Prior to margin refinement, we place a Size 00 Ultrapak

® cord (Ultradent, South Jordan, UT) as our bottom cord in the

two-cord technique. Since this cord will be in place during the rest

of the procedure, it contains no epinephrine or medicaments. We

“floss” the cord into the distal; no packing instrument is used.

20 Photo Essay: IPS e.max CAD LT Case Study


Figure 15

Figure 16

Figure 15: We then grab the other end of the 00 cord and “floss” it

into the mesial portion of the sulcus. We try to use an instrument as

little as possible so we don’t cause any bleeding at this point. Once

this cord is in place and we are packing the top cord, we can safely

use an instrument without bleeding.

Figure 16: We then grab both ends of the 00 cord on the lingual

with cotton pliers, and pull them lingually until the cord pulls tight

against the facial surface. You may also do this by hand (as I used to

until I read that latex powder on retraction cords may inhibit the set

of impression materials, although I have not seen proof of this).

Figure 17

Figure 18

Figure 17: We use an instrument on the facial surface to pack the

cord into the sulcus because we don’t have a choice. However,

by having the interproximal areas already “flossed” into place, it

makes it much easier to pack the cord atraumatically. If needed,

the ends of the retraction on the lingual can be pulled again, if you

left too much slack on the facial.

Figure 18: The two ends of the cord are cut on the lingual so that

when they are packed in the sulcus they will butt up against each

other and not overlap. If you compare this figure to Fig.13, you will

see the tissue has been retracted approximately 0.5 mm. This is done

so that when we drop the crown margin to the gingival margin, it will

end up approximately 0.5 mm subgingival when the cord is removed.

Photo Essay: IPS e.max CAD LT Case Study21


Figure 19

Figure 20

Figure 19: Using an 856 025 bur (Axis Dental), the margin of the restoration

has been dropped to the gingival margin. When dropping

margins on cases like this, make sure to keep the axial walls in the

gingival third nearly parallel without undercutting them. Since the

incisal third is overtapered, we can gain some retention and resistance

in the gingival third.

Figure 20: The occlusal view of the completed preparation. The distolingual

is still overprepared, as it was when we removed the existing

crown. However, the rest of the margin has been made more

uniform through the use of the fine grit 856 025 bur. If the post had

been inadequate, I would have removed and replaced it and built

the tooth up.

Figure 21

Figure 22

Figure 21: A Size 2E Ultrapak cord (Ultradent) is the top cord in

the two-cord technique. Since the 00 cord is in contact with the

inflamed base of the sulcus, there is no bleeding when this cord is

placed. The “E” in 2E is for the strand of epi cord in this cord, and

it is also available as a plain 2 cord if you prefer. A loose end of the

2E cord is visible to facilitate easy removal.

Figure 22: A Roeko Anatomic Comprecap (Coltene/Whaledent,

Cuyahoga Falls, OH) is placed on the preparation to keep pressure

on the gingival and to keep the cord in place. Comprecaps come

in handy when you are impressing teeth that you shouldn’t be because

the gingiva is thrashed, namely posterior teeth with broken

cusps that have been packing food for a few months.

22 Photo Essay: IPS e.max CAD LT Case Study


Figure 23

Figure 24

Figure 23: After 8-10 minutes, the top cord is removed. If there is

bleeding at the gingival margins prior to cord packing, it is a good

idea to re-wet the top cord before pulling it. This was a tough picture

to take—I was trying to show how open the sulcus is with the

two-cord technique; it is visible on the lingual.

Figure 24: A Clinician’s Choice anterior QUAD-TRAY (New Milford,

CT) was used to make this impression. Today, I believe an

acceptable impression has to have material beyond the gingival

margin to be an acceptable impression. If the impression ends at

the gingival margin, it is unacceptable. Years of being at the lab

have shown me this is true.

Figure 25

Figure 26

Figure 25: Tooth 8 is an IPS e.max CAD LT crown. “LT” stands for

low translucency and, in this case, it did a great job of blocking

out a dark root and a gold post. It is notable that IPS e.max has

no understructure, yet it can still be cemented conventionally and

block-out dark stump shades—something not possible with IPS

Empress ® , for example.

Figure 26: The left lateral smile shows the laboratory did a nice job

of closing the huge black triangle between tooth 9 & 10. In doing

so, we made the tooth larger than the average lateral incisor. But,

then again, the patient’s main complaint was the black triangle.

Photo Essay: IPS e.max CAD LT Case Study23


Figure 27: The right lateral smile shows that the contours of both the

crown and the no-prep veneer are acceptable. This is the view that

really shows if we have achieved a nice facial profile or if the restorations

look bulky, which can easily happen with no-prep veneers.

Figure 27

Figure 28: The incisal view shows that the facial profile of tooth 9

& 10 are acceptable. Restored teeth always have a tendency to be

larger than their adjacent unrestored teeth. These two teeth, however,

are fairly close in size even though 10 is a no-prep veneer.

Figure 28

24 Photo Essay: IPS e.max CAD LT Case Study


– ARTICLE and CLINICAL PHOTOS by Robert A. Lowe, DDS, FAGD, FICD, FADI, FAC

– COVER PHOTO by Sharon Dowd

Minimally invasive dentistry

combined with laser gingival plastic surgery:

Maximize Your Aesthetic Results

In order to design the optimal outcome for a patient during aesthetic enhancement, the restorative

dentist must seek to create a symmetrical and harmonious relationship between the lips, the gingival

architecture, and the positions of the natural dentate forms. In the author’s experience, the Waterlase ®

YSGG laser (BIOLASE Technology, Inc., Irvine, CA) has been a useful adjunct for performing aesthetic

surgical crown lengthening procedures. This article will highlight the associated biological principles and

demonstrate techniques for the application of this laser in closed and open crown lengthening procedures

in conjunction with the use of porcelain veneers for aesthetic dental reconstructions.

Maximize Your Aesthetic Results27


■ THE DENTOGINGIVAL COMPLEX

The dentogingival complex consists of a connective tissue

attachment, an epithelial attachment (or junctional epithelium),

and the gingival sulcus. As described by Spear 1 and

Kois 2 , the most critical relationship for biologic health,

when the clinician is placing a restoration at or below the

free gingival margin (FGM), is the margin location relative

to the crest of bone. Kois states that the distance from the

FGM to the osseous crest on the facial aspect is 3.0 mm.

Interproximally on anterior teeth, this distance is 4.0 mm

due to the curvature of the cementoenamel junction. The

height of the interdental papilla can also be predictably

maintained at 4.0 mm incisal to the osseous crest between

anterior teeth with normal root proximity, approximately

2.0 to 3.0 mm at the osseous crest. With these parameters

in mind, the clinician must first decide where the

restorative margin will be placed. With all-ceramic restorations,

if one does not have to block out undesirable

dentin colors or core materials, then it may be desirable

to place the restorative margin at the free gingival crest

or even slightly supragingival. However, if an intracrevicular

margin is required for aesthetic reasons, it should

be placed no further than 0.5 mm into the gingival sulcus

to avoid adverse biologic responses due to encroachment

upon the attachment apparatus.
Kois and Coslet, et al. 3

also describe a variation in biologic width that compares

the distance from the alveolar crest to the FGM and divide

this into three categories: normal crest, high crest,

and low crest. In simplified terms, normal-crest patients

(about 70 percent) have approximately a 2.0 mm combined

epithelial and connective tissue attachment and 1.0

mm average sulcus depth. If the sulcus depth is greater

than 1.0 mm, the free gingival excess can be safely resected

and upon healing will result in a dentogingival

complex measuring 3.0 mm on the facial aspect. Patients

with a high crest often have a shallower sulcus depth

and a combined epithelial and connective tissue attach-

“If diastemata are present, the

interproximal margin of the

preparation should be carried

lingually to the linguoproximal

line angle and be placed slightly

intracrevicularly in the proximal

area to help ‘squeeze’

the gingival papilla.”

28 Maximize Your Aesthetic Results

ment of less than 2.0 mm. These patients have relatively

stable FGM positions and are not prone to recession upon

manipulation of the tissues.
Low-crest patients often have

normal sulcus depth (1.0 mm to 3.0 mm) and a combined

epithelial and connective tissue attachment that is less

than 2.0 mm. These patients are highly prone to recession

and must be treatment planned accordingly. The FGM of

low-crest patients will tend to apically reposition and turn

into a normal-crest situation after gingival retraction or

surgery. Therefore, the most important factor in achieving

post-restorative gingival health and stability is the position

of the restorative margin relative to the bony crest,

not the preoperative health and/or the position of the

gingival tissues.

Figure 1: A preoperative photo of a Class II, Division II patient reveals

“square” veneers on the maxillary central incisors and excessive gingival

display with unaesthetic gingival levels. She had previously declined the

option of a LaForte III surgery to correct the maxillary vertical excess.

■ SMILE DESIGN AND TOOTH DIMENSION

Several parameters must be considered when designing

an aesthetic smile. These include the width-to-length ratio

of the maxillary central incisors; the mesiodistal proportional

width of the maxillary anterior teeth; the position of

the maxillary central incisors in the face (i.e., the E position);

and the relative gingival-zenith positions along with

the height of contour.
The width of the average maxillary

central incisor has been measured at approximately 10.0

mm. Utilizing the Golden Proportion as a guideline, one

can arrive at an appropriate measurement for the width

and length of the central incisor. Since the width-to-length

ratio of an aesthetic maxillary central incisor is 75 to 80

percent, a 10.0 mm central incisor, if it is proportionally

correct, should measure 7.5 to 8.0 mm mesiodistally.
The

E position (when a patient says E as a long vowel) shows

the relative amount of maxillary tooth display. In the E

position, it is aesthetically desirable for a patient to show

50 to 70 percent of the maxillary incisor teeth.
Finally, the

height of the gingival tissues over the maxillary central

incisors should be slightly higher (1.0 mm apically) than

the height of the tissue over the maxillary lateral incisors.


The height of the maxillary canines should be at the

same level apically as the central incisors, or slightly

more apical. The gingival zeniths should be located

at the distolabial line angles, thus creating a “raised

eyebrow” over the central incisors.

■ LASER-ASSISTED CROWN LENGTHENING

Use of the Waterlase YSGG laser for gingival and

bony recontouring has had a tremendous impact on

the way periodontal surgery is performed. Since the

laser cuts only at the end of the tip, the user has effective

control of both soft and hard-tissue resection.

Using the YSGG with a tapered tip allows the operator

to make scalloped gingivectomies with surgical

precision and no bleeding. When using traditional rotary

instruments to perform osseous resection, there

is always a risk that their rotation will damage adjacent

root surfaces. Additionally, since the surgical

laser wound is less traumatic, there is less chance of

bony damage due to frictional heat, which is always a

problem when using rotary instrumentation without

proper irrigation. This minimally invasive technology

translates into less postoperative discomfort and

quicker healing.

Figure 2: This photo demonstrates the surgical plan for the patient. An

indelible marker is used to “map” the surgical plan. The gingival heights

above the maxillary central incisors should be about 1.0 mm apical to

the tissue levels over the maxillary lateral incisors. The gingival levels

over the maxillary cuspids should be at the same position as the central

incisors or slightly apical. The incisal edges are shortened accordingly to

“move the teeth apically in space” without making them disproportionately

long in the cervico-incisal direction.

The Open Technique

For an aesthetic gingival display, it is critical that symmetry

(right and left) exists as it relates to cervicoincisal

tooth height and gingival zenith positions.

Patients that exhibit asymmetrical gingival levels, or

those with greater than 3.0 mm of maxillary gingival

display, or both, may be candidates for surgical gingival

and/or alveolar bone repositioning to improve

their aesthetics. Typically, these patient types have

adequate amounts of attached gingiva so that after

the resective procedure the mucogingival junction

will not be encroached upon. If adequate amounts of

free gingiva exist, minor asymmetries can be corrected

with gingivectomy or gingivoplasty alone. A minimum

sulcus depth of 1.0 mm must always remain after

any tissue resection unless the alveolar bony crest

is also repositioned in the apical direction as well. To

give the appearance of spatially moving teeth in the

cervical direction to alleviate excessive gingival display

or asymmetry, often an osseous correction must

be performed in conjunction with soft-tissue resection

because of sulcus depth violation.
As previously

stated, the finished maxillary central incisors should

be 10.0 to 12.0 mm in length. While the incisal edges

can be shortened when adequate freeway space exists

posteriorly, the amount depends on the patient’s pattern

of disclusion. The shortened incisal edges must

still disclude the posterior teeth in all eccentric movements

to maintain occlusal harmony. A tissue marker

Figure 3: A Waterlase YSGG laser is used during an “open flap” procedure

to adjust the height of the alveolar crest. The tip of the laser can be

marked 3.0 mm from the end so that it can be used as a guide to position

the bone level precisely 3.0 mm apical to the restorative margins of the

provisional restorations, ensuring that biologic width will be maintained.

Figure 4: This photo shows the patient with the definitive ceramic restorations

after corrective gingival and bony surgery. Tooth proportion and

gingival zenith heights show improved aesthetics, and the amount of

gingival display has been decreased.

Maximize Your Aesthetic Results29


Figure 5: This patient had a minimal biologic width encroachment on

the distoproximal margin after removal of a defective restoration.

Figure 6: The Waterlase YSGG laser is used first to remove the epithelial

and connective tissue attachments, and then to correct the osseous

level to re-establish a 3.0 mm zone from the restorative margin to the

alveolar crest.

Figure 7: A three-year postoperative photo shows the closed crown

lengthening technique surgical site. Note the pink, healthy marginal and

papillary gingival tissues.

30 Maximize Your Aesthetic Results

can be used to plan the soft-tissue surgery (Figures 1

and 2). Following the guidelines for aesthetic tissue

levels, the perceived final gingival level is traced, thus

creating the heights of contour at the distolabial line

angles.
The YSGG laser is used to remove the gingival

tissue and to create symmetry according to the proposed

surgical plan. The preparation margins are then

adjusted to the corrected FGM. As the biologic width

will be encroached upon, it is important that the same

amount of bone be removed to recreate normal biologic

parameters. An intracellular internal bevel incision

is made, and a full-thickness mucoperiosteal

flap is elevated. The alveolar crest correction is made

using the YSGG laser and either a Z-14 600-µm or a

9 mm 600-µm tip. Since the laser only cuts at the tip,

it is set against the side of the root, parallel with the

long axis of the tooth (Figure 3). This ensures that the

dentin/cementum surface is never damaged.
A black

marker can be used to place a line at a point 3.0 mm

from end of the tip. This is used as a guide to apically

position the bone 3.0 mm from the restorative

margin. Only the alveolar bone will be ablated by the

laser-energized water. The root surface is then planed

using a back-action chisel. The alveolar architecture

should thus mimic the restorative margin 3.0 mm apically,

allowing for biologic width restoration to a normal

crest position. (The interproximal bone on facial

aesthetic correction cases is not altered.) The flap is

then sutured back using 3-0 silk and an interrupted

suture technique.
At the delivery appointment, the

heights of the gingival zeniths above the maxillary

central incisors are adjusted apically using a closed

crown lengthening technique. The definitive restorations

are shown three years after corrective gingival

and bony surgery with the YSGG laser (Figure 4).

The Closed Technique

For minor, localized biological width and/or aesthetic

gingival zenith corrections, the YSGG laser can be

used in lieu of a flap procedure to make the correction

and complete the restorative process. This can be

done without the necessary healing time required for

open crown lengthening surgeries. Patients with normal

or thick biotypes (i.e., normal to thick keratinization)

are good candidates for this procedure.
The soft

tissue is resected using a 400-µm tapered tip on facial

areas or a 600-µm tip in proximal areas, creating the

new apical position and scallop of the FGM. The osseous

crest is sounded using a periodontal probe to

determine the distance from the free gingival crest.

Using a 9 mm 600-µm tip, the laser is then used to

remove bone, holding the tip adjacent to the tooth

and “walking” the tip across the affected area using

a “sewing machine” (up and down) movement to a

3.0 mm depth (Figures 5 and 6). After establishing the


corrected crestal level, the bone is “smoothed” by setting

the laser at 50 pulses per second and moving the tip in a

horizontal direction over the crestal bone. It is important

to note that with both of these movements the tip of the

laser is in contact with the bony crest. Next, a periodontal

probe is used to verify depth by sounding to 3.0 mm.
For

interproximal biologic width corrections, the tip of the laser

can be angled away from the tooth, slightly toward the

adjacent root to blend adjacent bone and avoid digging a

trench around the tooth. A final impression can then be

made and provisional restoration fabricated and cemented

to place. The definitive restoration can be seated two

to three weeks after the closed crown lengthening procedure.

The surgical area will heal by secondary intention

around the finished restoration with ideal tooth contours,

unlike with an ill-fitting temporary restoration. The criteria

for clinical health of the dentogingival complex are a

pink color demonstrating the absence of inflammation,

re-establishment of a probable gingival sulcus, and the

absence of bleeding upon probing (Figure 7).

Figure 8: A preoperative view of a patient with a diastema between

tooth 8 & 9. The teeth can be proportionally widened and lengthened,

closing the space while maintaining proportions with the lateral incisors

without the need to restore them.

■ TOOTH PREPARATION FOR PORCELAIN VENEERS

The amount of tooth reduction required depends on the

specific clinical situation. In general, 0.5 to 0.7 mm of

tooth reduction is needed. If changes in tooth position are

required, some areas of the tooth may be prepared more,

others less. It is recommended first to contour the teeth to

ideal position using a cylindrical diamond, and then to use

depth cutters to remove a uniform amount of tooth structure

to compensate for the thickness of the restoration. In

extreme situations, if the dental pulp is encroached upon,

root canal therapy is recommended rather than choosing

to overcontour the final restoration.
In cases where a low

value (dark) preoperative tooth color is to be changed

to a high value (light) color, more tooth structure should

be removed (1.0 to 1.5 mm) to create enough space for

opacious dentin and/or opaquers to block out the underlying

darkness. In general, indirect labial veneers are so

thin that the underlying tooth color and luting cement

may influence the final shade of the restoration. For some

patients, preoperative tooth whitening may be indicated

to increase the value of the underlying tooth structure, allowing

for less tooth structure to be removed during the

preparation process.
Gingival margins should be placed

at the gingival crest, or slightly above. The interproximal

margins should be carried into the lingual portion of the

contact area. If diastemata are present, the interproximal

margin of the preparation should be carried lingually to

the linguoproximal line angle and be placed slightly intracrevicularly

in the proximal area to help “squeeze” the

gingival papilla. Also, when closing spaces, it is important

to prepare the gingival margins far enough into the

proximal areas so that the restoration margins are not

visible from a three-fourths or oblique view, when the

patient turns the head to the side.
After the preparations

are finished, it is recommended to use a fine finishing

diamond to make the preparations as smooth as possible.

An Enhance ® point (DENTSPLY Caulk, Milford, DE) can

also be used to round and smooth the corners and line

angles. Fine sandpaper strips can be used interproximally

to smooth interproximal enamel surfaces without compromising

the proximal contact (Figures 8 through 10).

“‘Minimally invasive’ also

applies to a standard of

restorative excellence that

allows a case to have

aesthetic and functional

longevity, so that the teeth are

not continually assaulted and

‘reprepped to death.’”

■ THE DEFINITIVE AESTHETIC RESTORATION

One key to optimal aesthetics is the creation of the correct

gingival and bony architecture in order to properly

“frame” the teeth. This concept, combined with naturallooking

ceramic restorations that are the minimal thickness

required for structural strength and aesthetic beauty,

results in an outcome that is truly magnificent while being

minimally invasive. Shavell 4 once said, “Many teeth

are sacrificed on the altar of ‘false’ conservatism.” Is it

really more conservative (minimally invasive) to use a

no-prep technique, creating overcontoured teeth and the

potentially negative periodontal ramifications? On the

other hand, it is definitely not necessary to over-reduce

teeth with no apparent rhyme or reason as a short-cut approach

to restorative dentistry.

Maximize Your Aesthetic Results31


■ CONCLUSION

Figure 9: Minimal preparation was done for stacked porcelain veneers.

Tooth 9 was prepared to include the previous composite so that the

veneer would replace the bonded portion of the incisal edge.

Each case must be evaluated for the aesthetic end result

(shade) and amount of tooth reduction necessary

to create aesthetic contours and occlusal (functional)

harmony. “Minimally invasive” also applies to a standard

of restorative excellence that allows a case to

have aesthetic and functional longevity, so that the

teeth are not continually assaulted and “reprepped to

death.” The use of excellent dental materials, precise

technique, and steadfast attention to biologic principles

allows the restorative dentist to create minimally

invasive, naturally aesthetic dental restorations that

can withstand the test of time (Figures 11 through 12).

Figure 12: A postoperative view of the patient. The gingival display

has been lessened apical to teeth 7-10. Width-to-length ratios

have been improved. This 19-year-old patient has gone from having

a smile with “childlike” teeth to having the smile of a beautiful

young woman.

Figure 10: Two completed porcelain veneers (Venus Porcelain [Heraeus

Kulzer, South Bend, IN]) on tooth 8 & 9 immediately after delivery.

To contact Dr. Robert Lowe, call 704-364-4711, e-mail boblowedds@aol.

com, or visit www.destinationsmile.com.

References

1. Spear FM, Kokich, VG, Mathews D. Interdisciplinary management of

anterior dental aesthetics. J Am Dent Assoc. 2006;137(2):160-169.

2. Kois JC. Altering gingival levels: the restorative connection, part 1:

biologic variables. J Esthet Dent. 1994;6(1):3-9.

3. Coslet GJ, Vanarsdall R, Weisgold A. Diagnosis and classification of

delayed passive eruption of the dentogingival junction in the adult. Alpha

Omegan. Dec 1977;70(3):24-28.

4. Shavell HM. Extreme occlusal makeover: a morphoaesthetic approach

to thedynamics of occlusion. Presented at The Holiday Dental Conference,

Charlotte, NC, December 1, 2005.

Reprinted with permission of Dentistry Today. Copyright ©2009 Dentistry

Today.

Figure 11: A preoperative view of a patient with altered passive eruption

and diastemata.

32 Maximize Your Aesthetic Results


I

34 Interview with Dr. Paul Homoly


Interview with Dr.Paul Homoly

– INTERVIEW of Paul Homoly, DDS, CSP

by Michael DiTolla, DDS, FAGD

– PHOTOS by Sharon Dowd

In this month’s “One-on-One” interview, I had the opportunity

to speak with Dr. Paul Homoly again. One of the things that I

like about Paul is his contrarian viewpoint, and this interview is

no exception. Paul talks about the culture of dentistry and how

it affects what we do and say as practitioners. Our “accidental

education,” the beliefs we acquire unintentionally while learning

clinical dentistry, begins in dental school and continues through

organized dentistry, publications and CE courses. Read this interview

with an open mind and see how you feel about Paul’s

unique thoughts regarding patient education.

Interview with Dr. Paul Homoly35


Paul Homoly: The culture of dentistry is like any culture in any other

community. A culture is based on a widely held belief of the community.

Culture means “shared belief, shared behavior, shared activity.” Our actions,

our thinking, and our behavior are largely driven by belief systems. It’s similar

to traveling to Italy where you’ll find a certain culture in place. Coming

back to the United States after traveling there, suddenly you notice certain

things about this country you didn’t see before. That’s true with professional

cultures, too.

Michael DiTolla: I had that same experience and here’s an example. When I came

back to the United States from Europe, I noticed everybody watched television in

the evening, while there, everybody socialized, often going to the pub. I miss that

socializing.

PH: In the sixteen years I’ve worked with dentists, I’ve spent time in other

professional cultures—principally financial services and legal organizations.

In working closely with these lawyers and financial planners—both personally

and their associations—it’s become obvious that these industries have a

culture of their own. In this sense, the culture refers to how people have developed

shared beliefs, shared behavior, and often a shared language.

“Now, what if suitability

replaced clinical quality

as the profession of dentistry’s

cultural center?

What if we consciously

pursued suitability with

the same vigor, intensity,

and resources we put into

pursuing clinical quality?

Then we’d no longer have

permission, in the cultural

sense, to make huge

blunders in the name

of clinical quality—blunders

most people can’t

perceive.”

When I returned to dentistry, I noticed that this profession has a cultural

center, which is called clinical quality. All roads lead to clinical quality. Compare

that to the cultural center of financial services—its education, periodicals,

universities, academic drive—which is geared toward a return on investment.

In law, the industry’s cultural center points toward influence. Whether an attorney

is influencing a jury or a judge or a community or the constitution, the

focus is on influence.

In my experience, the standard of dental care in the United States is the best—

which is a good thing. What’s the downside? Dentists might sacrifice other aspects

of their lives and practices to have that high degree of clinical quality.

For example, dentists might make business decisions that work against them—

building or remodeling an office that’s too big, for example, and draining their

finances as a result. They might drive up their overhead by purchasing too

much equipment, building a facility that’s too large, or hiring too many people.

Consequentially, they paint themselves into a corner. Economic pressure

mounts. It gets harder to produce clinical quality. Why? Because of too much

stress related to the business side. They move from a 1,500-square-foot facility

to a 5,500-square-foot monster with an in-house laboratory and the whole

bit. They end up with a $6,500 a month mortgage. They’re financially stressed,

but their production doesn’t go up significantly. Then they become depressed;

their relationship skills go down; they lose staff members. Ultimately, their

pursuit of clinical quality ends up destroying their lives.

MD: It’s amazing to think that a dentist might purchase something like a piece

of equipment in the name of clinical quality, but it’s so expensive, the cost of that

equipment hampers the dentist’s ability to deliver quality dentistry. As you say,

prosperity is not our cultural center—not what we seek. Consequently, a lot of

dentists are out there pursuing clinical quality, many times at the expense of their

prosperity. Their decisions to pursue quality are often counter to their creating

wealth in their lives.

PH: Yes, you’re not aware of a particular culture you’re in until you leave it.

And most dentists have never left. They know what they’ve learned in dental

school, from their dental colleagues, at dental society and association meetings,

and from books and periodicals—all culturally influenced. As a result,

36Interview with Dr. Paul Homoly


ank-and-file dentists never question the cultural beliefs because they don’t fully recognize the

ones in place!

MD: And there might even be a subset of the dental culture in the dental school with the full-time instructors

versus part-time instructors who have private practices on the outside, so dental students may get

exposed to a certain brand of this outside culture.

When you’re a student in dental school, you’re a sponge ready to absorb all this information—more so

than in any future point of your career. You get exposed to a certain subset of this culture which may or

may not serve you well in private practice. But while you’re focused on the gutta-percha on the X-ray,

you’re getting all this cultural education at the same time.

PH: Yes, these dentists think they’re doing the right thing, but it becomes an invisible poison. That

is, doing things in the name of quality actually poisons them in the long term.

You see, when dentists feel economically stressed, patients can sense a neediness or desperation,

depending on the language used. If a dentist gets uptight about money, his or her behavior and

language could cause a dissonance in the dental practice. The staff picks up on the negative vibes.

What results? An environment of fear. And that’s the poison. Isn’t it ironic that it happens in the

context of striving for quality?

MD: With the staff, it might go beyond sensing pressure to feeling it, even panicking. The dentist might

say, “We’re having a bad month. We need to get these three patients to accept treatment plans and start

them today.”

PH: Absolutely. It happens all the time. Some practice management specialists actually teach dentists

how to have this conversation with their team, saying, “Okay, here’s the deal. We need to make

production, and we need to sell these cases.” This heave-ho approach can become toxic, which

ultimately disturbs the dental practice’s ability to produce quality.

You see, quality as defined in our dental culture includes the physical specifications and technical

characteristics of clinical outcomes. Think of it as the tightness of the margin, a 20-micron margin,

the crispness of the occlusion, the esthetics of the contours, the translucency of the porcelain. But

how many of these clinical specifications can the patient really appreciate?

MD: Not many. It cracks me up the way dentists throw around how many microns a margin may or may

not be open. The only way to measure that is to extract a tooth, section it, and put it under an SEM. Most

patients are unaware of this measure. For dentists, the concept is more nebulous than they care to admit

to themselves.

PH: And patients are probably the last ones aware of quality above and beyond what they can

readily recognize—a shade match, an appropriate bite, a ballpark reasonableness of clinical accuracy.

So clinical quality doesn’t come from the patient’s experience, but from the experience of the

dentist and the dental team.

When I was in practice, I’d typically have a surgical patient who would arrive early, take the meds,

follow instructions about not eating, and so on. When the anesthetist hit the vein with the IV, the

patient would go into deep conscious sedation without a problem. I’d prep the mouth and face,

make rapid incisions and clean dissections. The operating field was bloodless. I’d create implant

receptor sites, drop implants into place, close the flap effortlessly—like I had magic hands. Everything

worked well. That’s clinical quality—like a candle whose flame burns bright and the whole

team feels it.

But quality is the experience of the practitioner creating the dentistry; it’s not the outcome for the

patient. Only the dental team shares that experience; the patient isn’t a participant in that event.

What the patient experiences is some degree of “suitability,” which is different than quality. Suitability

for the patient includes questions about being able to afford this treatment. It also includes

a clean facility, friendly dental team, conveniently located office, and workable appointment times.

Interview with Dr. Paul Homoly37


To sum up, suitability refers to being an easy place to do business with.

Now, what if suitability replaced clinical quality as the profession of dentistry’s cultural center?

What if we consciously pursued suitability with the same vigor, intensity, and resources we put into

pursuing clinical quality? Then we’d no longer have permission, in the cultural sense, to make huge

blunders in the name of clinical quality—blunders most people can’t perceive.

MD: That certainly would require creative destruction!

PH: Yes. We would have to take an intricate look at who we are and ask, “Am I a provider of quality

clinical services or am I provider of suitable clinical services?” I’m not arguing against the inner

experience of quality here. That inner experience kept me on fire for 20 years and drives most

dentists. That’s in a dentist’s nature and culture both.

However, sometimes our culture evolves more slowly than the world does. For example, I’m Catholic

and when I was growing up, it was a mortal sin to eat meat on Friday. If you ate meat on Friday,

and you knew it was Friday, and if you died right after that, you would go straight to hell. Well, I

went to a public high school and I remember going to the cafeteria line and getting the meat ravioli.

I would forget what day it is as I sat down to eat. I’m ready to eat this meat ravioli when one of

my Catholic buddies across the table would say, “Hey, Homoly, it’s Friday.” So, I’d have to choose:

do I starve or do I go to hell?

The whole concept of not eating meat on Friday was set aside several years ago by one of the

popes. Today, it’s perfectly okay to eat meat on Fridays for Catholics except during Lent and on

holy days of obligation. But you know what? When I go to a restaurant, look at the menu, and get

ready to order, what’s the first thing I think about?

MD: What day is it?

38 Interview with Dr. Paul Homoly

PH: What day is it! This cultural belief hasn’t gone away. It’s still there. The culture of that belief—

don’t eat meat on Friday—doesn’t go away even though the world has changed. But as dentists,

we’re still experiencing a cultural belief that needs to include factors of suitability. Adopting a

culture of suitability, we create an environment that participants find acceptable so they’ll remain

with the practice a long time.

That’s right at the heart of what is going on now in the economic downturn. Because of people’s

cash flow and financial worries, they’re not ready to select a dental practice for the long run. A

practice driven on clinical quality alone will tend to drive those people away. Why? Because in an

environment focused on clinical quality, they can get educated right out of the practice.

MD: That’s a new concept—educating patients right out of the practice. How does that hold true, especially

in tough economic times?

PH: Here’s a good example. A patient needs two 3-unit bridges and a garden-variety crown. Let’s

say this bridge case is $8,000 to $9,000. This patient comes in complaining how his IRA has just

gone down 35 percent. After a complete examination, the dentist lays out a treatment plan based

on clinical quality. The patient hears the high price tag and responds, “I’m not ready. I need to go

home and think about it.” Six months later this patient comes back for a cleaning and the hygienist

asks, “Are you ready for your bridgework?” The patient says no because of the cost. At the next

cleaning six months later, the hygienist again asks. Again, he says no. Six months later at his next

cleaning, he remembers feeling irritated and says, “Don’t talk to me about the bridge!” Then he

breaks his next appointment for cleaning. When he finally has the money, he gets the bridgework

done by a different dentist who didn’t nag him.

That’s how we can educate patients out of our practice. The dental team’s “patient education” feels

like sales pressure to the patient.

MD: And a slow economy not only breeds patient unreadiness, but also causes classically trained dentists

to ramp up their focus on “patient education.”


PH: Yes, people in crisis hang on to their original culture. That’s why when

times get tough, dentists tend to educate more. But as a dentist, I can’t

change the economic climate or the stock market; the only thing I can change

is me and my practice. The solution? Increase the suitability of my practice to

my patients.

MD: So what types of things can we dentists look at differently?

PH: Let’s address the usefulness of patient education, which is at the center

of our culture, one of its commandments. Is educating people really the right

thing as we’ve been taught?

Now, of everything our role models and teachers have said, some have worked,

some didn’t—just like some things my parents said haven’t worked out. But

just because some of their advice didn’t work out doesn’t invalidate their entire

body of work. Even though I don’t advocate a lot of the cultural beliefs

traditional dental gurus espouse, that does not mean I don’t respect or love or

honor them, as I do my parents. I think dentists have a hard time with that.

They’ll listen to a dental guru and believe they have to do everything he or she

is doing, but that’s not the case.

In fact, part of what never worked for me as a practicing dentist was blind adherence

to the patient education model geared at changing patients’ behaviors.

In the process, we aim to increase the value of dentistry in their eyes by educating

them about the conditions in their mouths. We even attempt to change

their beliefs about what’s important in their lives, making statements like, “You

shouldn’t go on this vacation; you should get your teeth fixed instead.”

MD: That goes beyond education.

PH: Yes. Some would call it supervised neglect. That’s when patients aren’t

ready for care, but they need the care so we accommodate them in our practice

without doing that care. We are, in fact, guilty of supervising the neglect

of their teeth. In a way, we are tacitly approving their self-neglect. The believers

and the proponents of the supervised neglect axiom believe you should

remove patients from your practice who are not taking your treatment recommendations

seriously.

MD: Then they drive that point home by saying it will be one the biggest areas of

litigations within the next 10 to 15 years, and dentists will be sued.

PH: Yes. They throw a fear factor out there and dentists become afraid to do

anything. Why?

Well, let’s look at the patient education model. It’s based on dentists changing

their patients, believing that if we educate them well, we can change their

belief and value systems. Once we educate them, they will see the light and

fully appreciate the care, skill, and judgment of their dentists. Then, when presented

with treatment recommendations, they’ll willfully embrace them and

integrate them into their life. Their treatment recommendations will supersede

other priorities they have in their life. I remember a guru saying that when

patients fully understand their conditions in their mouths, they’ll happily go

through treatment.

MD: That simply fails to take into account many different variables.

PH: But from dentistry’s cultural point of view, this makes perfect sense. Traditionally,

the pursuit of quality is what we’re about. We influence our patients

“Because of people’s

cash flow and financial

worries, they’re not ready

to select a dental practice

for the long run. A

practice driven on clinical

quality alone will tend to

drive those people away.

Why? Because in an environment

focused on

clinical quality, they can

get educated right out of

the practice.”

Interview with Dr. Paul Homoly39


to think the way we think and assert ourselves to the point of saying to them,

“This is what you should do with your life.”

Now, it’s extremely difficult to change behavior. If you think it’s easy to change

a person’s behavior, just marry him or her. But why doesn’t education work?

Because the premise is false. Education does not lead to change.

Even the beginning student of instructional design knows that the key to

change is not education; it’s the readiness of a person to change. Take someone

who doesn’t want to lose weight and put him on a weight-reduction plan,

or someone who doesn’t want to stop smoking and put him on a smokingcessation

program, or a person who doesn’t want to stay married and put him

or her into marriage counseling—what happens? It’s their readiness, not their

understanding, that drives their behavior.

MD: In fact, I would assume if somebody came in ready to make a change in their

dental health, they wouldn’t even need to understand the entire process. Education

wouldn’t be the most important factor.

PH: Absolutely. People make decisions when they’re in love with the desired

outcome, even when they’re not fully aware of all the processes involved.

“Yes, people in crisis hang

on to their original culture.

That’s why when times

get tough, dentists tend

to educate more. But as

a dentist, I can’t change

the economic climate

or the stock market; the

only thing I can change

is me and my practice.

The solution? Increase

the suitability of my practice

to my patients.”

40 Interview with Dr. Paul Homoly

So after a decade of trying to change patients’ behavior, and in the absence of

their compliance, dental team members get burned out; they get cynical. They

present a traditional treatment plan and explain all the steps, yet people are

walking out of their offices. One day, they snap and say, “Damn these patients!

They don’t appreciate us; they don’t know what quality is.” The dental team

members never see the real problem: their inherently destructive culture.

MD: They all put their hearts into the practice, but can’t easily see they’re failing.

PH: The lucky practitioner is the one who blames the patients and the staff,

but the practitioner who really gets into trouble is the one who blames himself

or herself. When confidence crashes, it affects the doctor-patient relationship

and the dentist team’s ability to produce clinical quality.

Cynicism is a sustained stress—a sustained negative relationship with the environment.

Cynics aren’t happy about a thing. The psychopathology related to

perfectionism and cynicism directly results from the cultural belief that “we’re

smart enough to change people.” But nobody has that power. Psychologists

know their patients will only change when they are ready, so they become expert

listeners striving to understand people. In fact, psychologists have insurance

codes for understanding patients. But in the dentistry culture, we don’t

have codes for understanding patients. We have codes for educating patients.

In this culture, there is no conversational exchange between dentists and patients.

It’s all directed one way.

Let me ask you this: If you show me a picture of something I want and you’re

not educating me, you’re actually reinforcing my desired outcome. But if you

show that same picture to people who don’t want that pictured outcome,

what’s the result?

MD: You annoy them.

PH: That’s what dentists can do. We explain why our patients should want this

treatment and shouldn’t get annoyed. When they walk away, we say, “Well,

they have low dental IQs.” It becomes the fault of the patient!

But what if the public school education operated like that? What if a teacher


had failing students and the principal came up to her and said, “You know, your students consistently

fail 60 to 80 percent of the time, right?” And the teacher replied, “Well, these students are all

screwed up; they don’t value education.” What would that principal say to that?

MD: “You’re fired?”

PH: That’s right. But nobody has the authority to fire the dentist. So when patients come in who

need advanced-care dentistry, a high percentage of them aren’t ready to invest thousands of dollars.

And when the dentist tries to educate them into readiness, they walk.

Typically, fewer than 5 percent of a dentist’s $10,000-plus case patients are ready to receive care

the first time they hear their treatment recommendation. What about the 5 percent who agree to

treatment? Their decisions are based on a lot of things, but not on the education. They say yes when

their treatment plan fits into their lives, they’re ready for it, and they want the outcome. Many have

already walked in wanting a specific outcome.

MD: You can see how high suicide rates among dentists tie into that. In other cultures like the financial

services industry and the legal industry, you don’t see the same type of belief that you do in dentistry.

PH: The blind pursuit of any cultural icon results in vast disaster. So if you’re a financial services

provider blindly pursuing return of investment, you could ruin lives in the process.

MD: We’re seeing that right now—the blind pursuit of reward without risk, right?

PH: That’s it, Mike. In dentistry, the blind pursuit of clinical quality leads us to outcomes we’d

never thought we’d run up against. The “blind” quality needs to be tempered with this concept

I call “suitability,” which forces dentists to ask, “Is this dental treatment the next best step in this

patient’s life right now?” It’s not heresy to ask this question. In fact, you have to ask if you want to

develop a practice that sustains downturns in the economy, and if you want to develop a practice

that provides exquisite, consistent, high-quality care.

There’s no downside to what I’m saying. When you engage the patient in a conversation about

how suitable this dentistry is at this time, you’re setting into place a process that will protect your

relationship with the patient in the absence of readiness. If you say, “You know, Ed, now that I’ve

looked in your mouth, I know we can help you. But I’m not sure how this plan best fits into your

life right now. You’ve mentioned you’re traveling to Europe a couple times a month and you’ve got

boys in college. How do we fit this treatment into your life? Do we do it now, do it later, or do it a

little bit at a time?” That conversation seeks to find suitability, doesn’t it?

What if the center of dentistry wasn’t the blind pursuit of clinical quality but providing suitable

dentistry—dentistry that fits into the patient’s life and exceeds standard of care? Here’s the good

news. Most dentists already meet 50 percent of these criteria for suitability. Most dentists have already

gotten the “exceeds standard of care” part.

However, suitability isn’t in our culture like it is in residential real estate sales. I’ve worked with

real estate agents and companies as a consultant and speaker. I’ve bought several houses, and you

know how the process goes. You and your honey walk into a realty office, plop down into the

chair, and start talking. “We’d like to buy a house.” The real estate agent asks, “What’s your price

range?” and “How much money do you have for a down payment?” and “What neighborhood would

you like to live in?” These questions land firmly on the side of suitability. That agent is “qualifying

the client.”

Now, if a dentist refers to “qualifying the patient,” it sounds like a mortal sin in the dentistry culture.

It sounds like, “Oh, you’re just diagnosing the patient’s wallet.” Yet somebody has to make the case

suitable. There’s nothing wrong with diagnosing a person’s wallet if it’s done in the spirit of suitability.

You buy a car and look at the sticker price first. But there’s no sticker price on dentistry.

MD: In dentistry, communicating fees is usually saved for the end of the initial appointment. Dentists

frontload the conversation with expectations of clinical quality before they drop the cost bomb

Interview with Dr. Paul Homoly41


at the end.

42 Interview with Dr. Paul Homoly

PH: Although it sounds ridiculous, that’s how it’s always been taught and what feels right. But if

suitability were at the core what dentistry’s culture, it would completely change the conversation.

The typical dental exam would change, both for a comprehensive care patient and a modest-care

patient. There would be less emphasis on what and how we’d do the treatment, and more emphasis

on when. The conversation turns to them with questions like, “Tell me about what will work for

you. Let me tell you what your outcome can be. When you and I agree on the outcome you want,

I can design a path to help you get there.”

Here’s another example. In financial services, a fee-based planner gets paid on giving advice only,

no commission from an insurance plan or will or pension. It’s purely an advocacy role. The word

“advocate” means to guide. So you and your spouse visit your fee-based financial planner and say,

“We’re thinking about building a $700,000 home. The whole project might cost us a million dollars.”

The financial planner says, “Let’s see, you have $250,000 in savings right now. You have some

bonds over here, some cash over there.” After crunching the numbers, he says, “Based on market

conditions and how much money you have, it’d be wise to hold off buying for a year. Let’s stash

some cash instead so you can increase the down payment and get a better interest rate.” The point

is, the fee-based financial planner helps find a way to build your house but doesn’t help you build

it. That’s the role of the advocate.

So the way to manifest suitability is to increase the dentist’s role as the patient’s advocate. Dentists

help their patients find a way to get their teeth fixed.

MD: When does this conversation occur in the relationship?

PH: In a new patient interview. This conversation replaces details about how often you floss or

brush every day. Yes, we’d still do exams, but the emphasis, the energy, and the intention of the

conversation is being the patient’s advocate, not the patient’s educator.

In my conversations with patients, I’m carefully listening for condition-related disabilities. Why are

they unhappy with the partial? Why are they unhappy with their front teeth? I need to get a sense

of how the condition is interrupting their lives. This sets the stage in the patient’s mind that it’s a

dental office quite unlike any other because we discuss the suitability of care based on the outcome

he or she wants. In fact, we discuss the suitability issues before the technical issues.

Here’s an example. Michelle comes in and she’s got unsightly front teeth; she’s not happy about

the large composite fillings, incisal edge irregularities, and so on. I ask, “Michelle, how does this

bother you? Tell me about a time when it really bothered you the most.” (This is a great question to

discover disability.) She replies, “I own an art studio and people are coming in. They’re looking at

my teeth and it’s embarrassing. I’ve really lost confidence with customers.” That’s her disability.

Then I engage in a casual conversation and say, “Michelle, tell me about your art gallery.” Doing

that levels the playing field between the dentist and the patient. The dentist is no longer in the authority

position. There’s no more expert-novice relationship in that moment; we are both equals. So

Michelle talks about her gallery and the conversation leads to talk about home and family. As she’s

disclosing details about her life, I’m disclosing bits of mine. During that conversation, I’m listening

for details that will relate to the appropriateness of her full-mouth care. I find out how stressed

she is, how much money she’s spending, what social and family obligations she has. I learn that

Michelle has a black-tie event coming up, that she’s active in the local Chamber of Commerce, and

she travels on buying trips, going to Italy and Spain four times a year. She’s a busy woman.

Then I do the exam, sit the chair up, and think about the suitability of a treatment plan for her more

than I think about clinical quality. Ninety-nine out of 100 dentists sit the chair up and talk to their

patients about the clinical aspects of their cases. The conversation is about what’s wrong clinically

and how they can fix the problems in the mouth.

MD: Instead, what would make them feel more comfortable is knowing the dentist takes into consider-


ation the suitability of a dental treatment for the person’s current circumstances.

PH: Exactly right. In this case, I talk about the outcome Michelle is seeking,

then I link that to her circumstances. When I sit that chair up, I’d say, “Michelle,

we see a lot of folks just like you—folks who want to look better at work and

have more confidence in social situations. We want you to know you’ve come

to the right place. I can do all those things for you.”

That’s an outcome statement to assure her that she’s in the right place. Then I

say, “Michelle, I know that I can help you, but I don’t know when is the right

time for you to do all of this.” I’m also saying that dentistry of this nature can

be complex, expensive, and time consuming, so it can interrupt her work flow.

Then I ask this question: “You’re traveling four times a year to Europe and

you’re working long hours at the gallery. How can we fit this into your life,

Michelle? Do we do your care now, do it later, or do it a little bit at a time? Give

me a sense of how we can pace this for you.”

MD: What a liberating question for the dentist, but more importantly, for the patient!

To be able to put the ball in their court, let them dictate the pace of treatment

rather than trying to force it along. I can see how patients would react positively to

this approach. They may actually do it faster than if you dictated the pace because

they now have a say in the treatment plan. It reminds me of how patients are able

to control pain medication at hospitals by pushing a button themselves. Even a

recent study on mammograms showed how women would push down on the plate

10 percent harder when allowed to do it themselves. How powerful that is—giving

patients control over their treatments.

100%

% Case

Acceptance

0%

$1,000 $3,000-$5,000 $10,000+

Figure 1

43

Interview with Dr. Paul Homoly


PH: “Liberating” is the perfect way to describe this conversation. I call this

conversation an “advocacy” dialogue, and the role of the advocate is to guide.

This guiding conversation does a couple of things.

One, it states the outcome to the patient: “Michelle, I know I can help you. I’ve

seen patients like you all the time who are busy with careers, but at the same

time, you have some dental challenges that need to be addressed. We do this

work all the time and we love doing it. I know I can help you.”

Two, I’m telling the patient what she’s already thinking, which is, “Wow, what

am I getting into?” She’s got these problems, she’s talked to friends who’ve

had dental work, she’s heard good and bad reports about this condition. How

bad is it for her?

Next, I say to Michelle, “Listen, I know I can help you, but I don’t know if this

is the right time for you.” And that’s exactly what she’s thinking, too. I’ve just

made it okay for her to speak the truth instead of hiding it. And a statement

like “I want to go home and think about it” is never the truth.

MD: This is a good example of showing the patient how much you care by saying,

“Yes, I can help you. I do this all the time. We just need to figure out how this

works into your life.” The compassion in that statement of wanting to work with

the patient is amazing. Dentists often tell me, “I don’t like selling, I don’t want to

be in sales.” Well, there is no sales required this way. It’s no longer about whether

or not they need this dentistry; it’s about accommodating them and saying, “I can

fix you; how does this plan fit into your schedule?” It takes pressure off the dentist

and the patient, too.

100%

% Case

Acceptance

Dental IQ

Dental IQ

0%

$1,000 $3,000-$5,000 $10,000+

Figure 2

44 Interview with Dr. Paul Homoly


PH: It completely takes off the pressure. In dentistry, we use the label “patient-centeredness”

but every damn seminar I’ve taken that addressed a patient-centered approach has really been a

dentist-centered approach. You’ve heard the adage “patients don’t care how much you know until

they know how much you care.” Is the way to show how much you care by doing a complete periodontal

examination? I say that’s bull because it reinforces our own dentist-centered culture belief

by imposing our beliefs onto our patients.

However, using the advocacy approach, we can be truly patient-centered because we’re asking,

“When will it work for you?” The question is not if I’m going to fix the patient’s teeth; it’s when I

do it based on that person’s lifestyle.

As a dentist, my desired outcome is for the patient to sustain a relationship with me because I

know that 95 percent of the time, a patient won’t say yes to a $10,000 case the first time. But by

sustaining a good relationship, that patient will come to me one or two or three years from now to

do the work. In the meantime, I’ll do all the nickel-and-dime dentistry like cleanings and patching

and fixing small things.

To the purist—the person driven by our dental culture—that’s supervised neglect. But I’ll go toeto-toe

with any proponent of that philosophy and say, “You take all the patients ready for complete

care now; I’ll take all the patients who aren’t. In a few years, we’ll see who has the more vital

practice.” It will be mine.

MD: But if Michelle doesn’t have any money, is the purist going to treat her for free?

PH: A purist probably won’t treat a patient for free, but there’s another way to treat patients—by

being an advocate. Again, the role of advocacy is to ask “when?” And if she doesn’t have money or

if the dentist is unable to do ideal restorations, the advocate will still help her find a way.

The way isn’t to achieve optimal clinical quality. If that was the case, everybody would do implants

and fix bridge work. The way is to offer suitability to a patient who doesn’t have money, which may

mean tooth extractions and full dentures. Then the conversation becomes about adapting. It’s not

looking so much at the clinical result but finding the suitable result for that person.

When I have a patient who will lose his teeth because he can’t financially handle comprehensive

care, I say something like, “Stanley, in the absence of comprehensive care, there is a high probability

you’ll lose some or all of your teeth. I will help you in that process of transitioning from

teeth to no teeth, and I’ll be sure to preserve your dignity in that process. And if or when you can

replace the missing teeth, I want you to know that we’re experts at that, too.” You see, preserving

the patient’s hope and dignity is more important than preserving each tooth.

Why? Because if I can preserve a person’s dignity, I preserve the relationship; and if I preserve the

relationship, that puts me in a position to influence that patient for the rest of his or her life.

But, what if I get on my high horse and say, “Well, Stanley, if you can’t afford to do this, then

you can’t be a patient in this practice.” Then I’ve lost all opportunity to influence him ever again.

Chances are he’ll end up in the hands of a low-quality provider.

MD: Exactly right.

PH: So, there you have it. The patient education process is born out of the cultural belief that our

role is to change people. But I believe that our role is to understand people. And that happens primarily

by understanding how dentistry can fit in their lives right now. It happens through a series

of lifestyle conversations that replace those about the number of overhangs and malocclusions.

We save those technical conversations for consent purposes, but not for case acceptance conversations.

MD: For some dentists reading this column, their heads will snap around because, from day one, they

bought into this culture of having a technical conversation being one of the most basic truths in dentistry.

What would it take to change that part of the culture? Could it ever happen?

Interview with Dr. Paul Homoly45


46 Interview with Dr. Paul Homoly

PH: Yes, through articles like this, Mike. Realize that, at one time, the whole idea of anteriorguidance

was ridiculous. If you go back far enough into dentistry, the movement of the mandible

was allegedly believed to be controlled by posterior determinants, condylar angles, and cusp-fossa

angles. Remember that? Once the whole concept of anterior-guidance was introduced, dentists

said, “Ah, okay.” And once they understood anterior-guidance, it made understanding the rest of

the mouth easier, right?

This is similar; it’s just a matter of getting to a tipping point. The illustration on page 43 (Figure 1)

shows the level of case acceptance relative to the size of the dental fee. The case acceptance stays

fairly level at 80 to 90 percent or higher up to about the $2,500 to $3,000 fee level. Then after the

fee goes above $4,000, it’s a straight nosedive down to $10,000 plus.

Now, the second illustration (Figure 2) on page 44 is the same graph, but this time, it has two arrows

pointing up. On the left side, between 3000 and the 0, an arrow points up indicating a rise in

the dental IQ. On the right side, the arrow will be twice as big because, if the patients have twice

the number of problems, they will need twice the amount of education. Historically, that’s what we

believe, right?

But if that were true, why would the first graph be true? If raising the dental IQ was the key to case

acceptance, then why does case acceptance go dramatically down when the case goes over $5,000

if it were, indeed, IQ-driven behavior?

Well, the truth is it’s not IQ-driven behavior. The doctor-patient relationship conversation is related

to case acceptance because relationship-building in the dental practice is not based on patient education.

The education model is a cultural trap that requires escaping from. For most dentists, that

feels unnatural—like eating meat on Friday felt unnatural for me.

The third illustration (Figure 3) is the crown-jewel of this article because it shows an inverse relationship

to be aware of when dealing with patients. The horizontal axis represents the complexity

of care as defined by the level of fee; the vertical axis is its relative impact on case acceptance.

When the case fee is low, like $800, $1000, $2000, the cultural belief of educating the patient

serves us well. Patients with typically minor conditions need to be educated about those conditions

because they probably don’t know they have them in their mouth. Raising their dental IQ

becomes the driving energy for patients to say “yes” to the treatment plan. They get educated into

readiness.

Now, let’s review the role of advocacy, which is the attitude that we help patients find ways to get

their teeth fixed by saying, “I know I can help you, but is this the right time for you? Let me find

the best way.”

The role of advocacy below the $3,000 level doesn’t operate that much because dental insurance,

credit cards, CareCredit, and third-party payers help ease the financial crunch. Also, small cases

like that don’t take much time—two or three appointments—so they’re not as disruptive to

the patient as long treatment plans can be. This tells us that suitability is not that big an issue

below $2,000.

But as the case fee increases and complexity of care increases, the role of IQ decreases and the role

of advocacy increases to the point where they cross. Then, at the $10,000 level, IQ plays almost no

role at all and advocacy plays the dominant role.

MD: The first time I looked at that, I thought, “It seems counterintuitive for the dental IQ to be sloping

downward like that.” But I took that to mean the higher the dollar amount on the case, the more obvious

the problem’s going to be to the patient as opposed to back at $1,000, where they have two areas of interproximal

decay. When you get to a $10,000 treatment plan, dental disability is a big problem. There’s no

way a patient doesn’t know about it.

PH: That’s exactly right, Mike. Patients in that category are totally aware of their disability—not all

the details but certainly the overriding condition. So, in the absence of disability, IQ dominates.


In the absence of disability, raising the patient’s IQ dominates relative to case

acceptance. Why? Patients are not aware of the condition because disability

isn’t a factor.

But in the presence of disability—and especially in extreme disability—the

role of advocacy takes over. It’s more related to the size of the fee and the

hassle of the case than to the depth of the disability. This is what should replace

the blind pursuit of patient education—a situational approach based

on current conditions and issues. For complex cases, a situational leadership

model replaces the blind pursuit of education. That way, we don’t educate our

patients right out of our offices.

MD: I see. We approach our patients with education, but when they don’t accept

treatment, it stresses us and our staff. It’s a vicious circle started by this cultural

belief that’s been around so long, no one knows who came up with it. But I think

it’s been around the last 50 years.

PH: Here’s my call to action for your readers, Mike. They can enlarge Figure

3 or have it available to download on a computer. Then they laminate it and

keep it in the lab or on the desk in the treatment planning area. When they’re

about to see a new patient or present a treatment plan, they pick up this

laminated illustration, look at it, and ask themselves, “What do I need to do

here? Do I need to be educating this patient? Or do I need to be this patient’s

advocate?”

Typically, dentists haven’t asked this question before because the culture hasn’t

allowed for it. But what if the culture changed? How much easier would this

High

Impact on

Acceptance

Dental

IQ

Low

Advocacy

$1,000 $3,000-$5,000 $10,000+

Figure 3

47

Interview with Dr. Paul Homoly


e for the patient? How much easier would this be for the dentist? How much

easier would it be to manifest clinical quality at the level deemed most appropriate

in the presence of prosperity and the absence of stress?

MD: Yes, and what would it do for the perception of the profession as more people

and dentists start to approach these types of situations this way? It’s not about the

quality; it’s about suitability.

PH: The patients have always known this; the dentists are just now discovering

it. When I teach suitability in workshops, many times dentists and team

members approach me afterward and say, “You know, Homoly, this suitability

thing you’re talking about is just good common sense.”

They’re right; it is just good common sense. And chances are that if dentists

were never exposed to the existing quality-centered culture, the suitabilitycentered

approach would evolve naturally in their practices. Why? Because

successful suitability models exist in many other business models.

Unfortunately, most of us—me and you included, Mike—were educated out of

common sense in the prevailing culture of dental education. It’s time to evolve

our culture.

MD: What’s a good starting point for dentists to evolve their thinking along these

lines, Paul?

PH: If your readers like this article, they’d love reading my book, Making It

Easy for Patients to Say “Yes”. They can order it online at www.paulhomoly.

com, or call my office at 800.294.9370 and my team will send it out.

And one more thing, Mike. Thanks for making the effort to spread the message

by publishing this article. It’s a big part of evolving our culture and making

everyone’s life easier.

To contact Dr. Paul Homoly or to purchase his book, call 800-294-9370, visit www.paulhomoly.com, or e-mail

paul@paulhomoly.com.

48 Interview with Dr. Paul Homoly


Perception is the only reality

Four crowns. Four price tags.

Can technicians and dentists tell the difference?

– ARTICLE by Kelly Fessel Carr, Editor of LMT

– Reprinted with permission from LMT’s September 2008 Issue

Can technicians and dentists tell the difference between a $25 crown and a $325 crown?

The answer, for the most part, is “no!” according to an exclusive Lab Management Today

(LMT) research study.

LMT selected four crowns from four different laboratories that participated in its 2007 Crown Challenge, a competition

in which 228 individuals and technician teams fabricated the same crown using the same prescription and duplicate

models provided by LMT. LMT chose these four crowns in particular because they had price tags that differed by $100,

starting at $25 and topping out at $325. It’s important to note that the LMT Crown Challenge participants were knowingly

putting their best foot forward in hopes of winning the competition, meaning this is not a random sampling.

LMT traveled the country to ask dentists and technicians to examine these four crowns on the models and match them

with the correct price tag. Of the 70 dentists who participated, only 3 percent matched all four crowns correctly; among

the 106 technician participants, only 10 percent did so.

Four crowns were fabricated for LMT’s 2007 Crown Challenge using the following prescription: Pin and section the master model and die,

and fabricate a PFM crown in shade VITA A3.5, using a noble alloy, for tooth 14 with a small circumferential metal collar. Place some light fissure

staining in the occlusal grooves to simulate a lifelike appearance.

Please note that the crowns and models may have marks on them from the articulating paper used during evaluation.

Crown 1 : $125. Fabricated by a 10-person full service laboratory located in the Southeast.

50 Perception is the Only Reality


The message

Given that there are no universal technical standards in our industry and that

participants were judging the crowns on the model, not in the mouth, the results

aren’t all that surprising. Many of the dentist-participants readily admitted

that they had no idea which crown sold for which price. Their overall impressions

of the four crowns ranged from one end of the spectrum to the other; for

instance, one said, “None of these crowns excite me,” while another said, “All

these crowns are very nicely done with good marginal fit.”

So if quality is in the eye of the beholder and your dentist-clients agree with

one dentist-participant who said, “A crown is just a crown,” how do you distinguish

yourself from the competition? With such a disparity of opinions about

the definition of quality, saying you offer a “quality product” isn’t enough of

a sales pitch.

Providing a restoration with acceptable form, fit and function is a given in

today’s technical world. But what would make a dentist pay $100 more for a

particular crown is his perception of value, which is influenced by your marketing

efforts, positioning strategy and additional services. Technical support,

customer service and ability to be a valuable resource to your clients are paramount

to his opinion of your work, and the fee he’s willing to pay.

Kristen Cabral (left), district sales manager

at Knight Dental Group in Oldsmar,

Fla., was among the 10 percent of

technicians who correctly identified the

prices of all four crowns. LMT’s Managing

Editor, Kim Molinaro, looks on.

Listening to the dentist-participants’ comments during the evaluation process provides a first-hand review of what they

look for in a laboratory relationship.

Here are some fundamental points to help get inside your dentist-client’s head:

Consistency is king: “This is a decent $25 crown, but will you get that same quality from restoration to restoration?”

asked one dentist-participant. “Consistency over time is what I look for in a laboratory.” Whether your laboratory

is positioned as high-end, economy, or somewhere in between, your clients expect consistency on every case they receive

from your laboratory.

One dentist’s ceiling is another one’s floor: Dentist-participants had differing opinions about the technical

aspects of these four crowns: one liked the anatomy on the $125 crown, another thought it was bulky; one liked

the esthetics and staining on the $225 crown, another didn’t. Just as your employees need to know what you expect,

you need to have a clear understanding of your dentist-clients’ technical expectations and document his preferences,

such as how he likes his contacts and style of laterals and metal collars. Also, your employees need to have the technical

expertise to be flexible in their case design in order to execute client preferences.

The power of packaging: Several dentist-participants mentioned that sloppy model work and inexpensive ar-

Crown 2 : $325. Fabricated by a seven-person C&B laboratory located in the West.

Perception is the Only Reality51


Crown 3 : $25. Fabricated by a 10-person full service laboratory located outside the U.S.

ticulators are often indicative of lower-priced work, while sophisticated pinning systems and expensive die stone are

synonymous with higher-priced work. This may or may not be the reality, but it’s a perception worth noting and underscores

the need to focus on the esthetics of all aspects of your case presentation—not just the denture tooth setup or

porcelain layering, but also your exterior packaging.

Four crowns. Four price tags. Who matched them correctly?

LMT selected four crowns with fees that differed by $100, starting at $25 and topping out at $325. Technicians and

dentists examined the crowns and tried to match them with the correct price tag. Here are the percentages of correct

answers for the 106 technician-participants vs. the 69 dentist-participants:

0 correct 1 correct 2 correct All correct

Technicians (106 total) 26% 32% 32% 10%

Dentists (69 total) 38% 26% 33% 3%

The $25 crown vs. the $325 crown

• The $25 crown was made by a 10-person full service lab located outside the U.S.

• The $325 crown was made by a seven-person C&B lab in a western U.S. state.

Ramzy Abdullah, owner of Highlands

Dental Lab in Needham, Mass., feels all

four crowns are of average quality.

Scott Graule, owner of Anchor Dental

Lab, Charleston, S.C., sitting with

LMT’s Associate Publisher/Editor, Kelly

Carr, at LAB DAY Chicago.

Debbie Green, director of technical

services at Alpine Dental Laboratory,

Lehi, Utah, scrutinizes the four crowns

during the CAL-Lab Meeting in February

in Chicago.

52 Perception is the Only Reality


Crown 4 : $225. Fabricated by a two-person full service laboratory located in the Southeast.

• Of the four crowns in LMT’s exclusive research study, the $325 and $25 were the only ones that were articulated.

• Nine percent of technician-participants put a $325 price tag on the $25 crown, whereas 33 percent of dentistparticipants

did so.

• Nearly half of the technician-participants correctly identified the $325 crown; only 32 percent of dentist-participants

did so.

No conSensus among technician-participants

“You could seat any one of these crowns.”

“All of these crowns are acceptable.”

“I wouldn’t pay $325 or $225 for any of them.”

“If there’s a $25 crown here, it’s a GOOD $25 crown.”

“I don’t think there’s a $325 crown here.”

“There’s not as much difference between the $25 and $325 crowns as you’d expect.”

“All are high in occlusion.”

“None of the model work is worthy of $325.”

“There’s not one here worth $325, but whoever’s getting that—God bless ‘em!”

Reprinted with permission from LMT ® Communications, Inc. Copyright ©2008. Visit www.lmtcommunications.com

Crown photos provided by Brad Stanton Photography, Danbury, CT

Perception is the Only Reality53


of

the evolution

human occlusion—

Ancient Clinical Tips for Modern Dentists

– ARTICLE and PHOTOS by

Ellis Neiburger, DDS

Man evolved in an environment in which the occlusion was worn down quickly, resulting in flattened occlusal

and interproximal surfaces. This rapid wear reduced occlusal decay, traumatic occlusion, malaligned teeth,

impactions, and temporomandibular disease (TMD). In the last 250 years, however, new food production

techniques created an environment that was less dentally abrasive than earlier diets. Teeth were not worn

down as programmed in our “evolutionary blueprint.” This lack of wear resulted in increased caries, cusp

fractures, bruxing, malocclusion, periodontal disease, and TMD. A practical re-creation of ancient dental wear

patterns can help to reduce these modern dental diseases.

Great controversies have erupted recently over the question, “What is normal occlusion?” A variety of scholars, clinicians,

and other experts have suggested numerous hallmarks of “proper” occlusion, including appropriate cusp

heights, degrees of canine rise, and adjustments favoring centric relation and/or centric occlusion. 1-3

The Evolution of Human Occlusion55


Many of these experts and their supporting camps have battled over which theories are correct and how occlusally

related diseases should be treated. In some cases, these theories have taken the forms of mystic religions, with gurus

and their disciples sniping at each other over arbitrary walls of definitional purity.

Today, as in the past, there is no one theory of occlusion w hich, when applied to the many dental diseases found in

our society, explains and leads to cures for all cases and situations. 1,2 The wide use of money-driven new technology,

gadgets, for-profit educational institutes, therapy modalities, and medications has not provided consistent, predictable

relief to those who have temporomandibular disease (TMD) or serial cracked cusp syndrome. Some clinical techniques

will cure one individual but not another who appears to have the same symptoms. 2,3

Dental research into TMD and other occlusion syndromes often is a hit or miss affair with inadequate samples, lack of

meaningful controls, and a general inability to master all of the relevant parameters, such as psychology, physiology,

and individual variation. Many studies omit obvious conditions, which nullify their results. Few TMD researchers and

clinicians conduct an internal examination of the patient’s ears (to check for ear pathology that may trigger TMD) or

consider the high incidence of TMD-related headaches and myalgias reported by patients taking common drugs such

as Isordil (25 percent incidence), Prozac (20 percent), and Procardia (23 percent). 4

As more clinicians become enamored and then disillusioned with one theory/technique or another, the need for an

accurate and universal understanding of occlusion becomes imperative for the educated dentist. We must know what

“normal” occlusion is and how to treat the deviations that result in pathology for our patients and frustration for us.

This article presents a historic definition of normal occlusion and evidence-based recommendations established by our

evolutionary history.

Recent history

Modern theories defining normal occlusion began in the mid-1800s with Carabelli (1844) and Angle (1899) refining a

classification of occlusion based on the position and interdigitation of the teeth. 5 Early theories seemed to stress religion

(Bonwill’s triangle of the lower jaw [1899]: “This is God’s architecture”), temperament (Angle [1900, 1907]: “though

the length of overbite varies, being greater in the teeth indicating the bilious and nervous temperaments. . .”), ideals

(Christensen [1905]: “the ideal bite path must always follow spherical surfaces”), or combinations of these nonscientific

notions (e.g., Monson, Moses) mixed with quasi-scientific observations. 5

Many dental authors today quote and derive their theories and treatments from the inspired, anecdotal scientific work

of these early dentists. Jankelson’s theory of neuromuscular occlusion (1970) and Dawson’s stress reduction/harmony

theory of jaw function (1989) currently are in favor. 3,6

Evolution

Man is the product of his evolutionary history. “Normal” occlusion, like all other aspects of human anatomy-physiology,

is the result of man’s evolution. The major evolutionary pressures of heredity and environment have shaped us over our

4+ million year history. 5,7,8 These forces have had a great impact on our body design and function (Figure 1).

Heredity, the first evolutionary force, links the new generations with their ancestors. Modern humans (Cro-Magnons), as

compared to earlier species (e.g., Homo erectus, the australopithicines, the Neanderthals), have existed no longer than

4,000 generations (100,000 years). Yet our anatomy, including our occlusion (flat plane), is stable and has not changed

significantly (with one exception) (Figures 1–5). 7,8 Our teeth and supporting structures were genetically programmed to

function in an environment of heavy attrition, which generally flattened them interproximally and in occlusion (Figure

6). 5,7,8

The second force in our evolution is environmental. It is the environment, through natural selection processes, that allows

individuals (and their progeny) to survive with a variety of naturally occurring genetic mutations. 7 If a mutation in

one’s anatomy (e.g., size, color, intelligence) gives an advantage to a family in a particular environmental setting, they

will reproduce successfully and thrive as compared to a poorly endowed group who may become extinct during the

ever-present competition for limited nutrition and living space (natural selection).

56 The Evolution of Human Occlusion


Figure 1: Man’s evolutionary development from the ape-like Ramapithecus to modern (Cro-

Magnon) man. It now is believed that the Neanderthals are an offshoot of our species rather

than a direct ancestor.

Successful genetic traits, which have remained stable

over thousands of generations of changing environments,

are strong evidence of positive, well-established,

“normal” phenotypes. Any dental trait (tooth design, jaw

shape, and so on) which has lasted unchanged over the

millennia of our species’ existence must be considered

essentially successful and thus be the norm (“normal”). 10

We know that these traits (e.g., flat plane occlusion) have

evolved and were perfected, so to speak, by natural selection

because they have functioned and continue to

function sufficiently well to ensure continued survival

and success to the humans who have possessed them.

Those individuals whose anatomy deviated from these

traits (mutations) are extinct, attesting to the lack of benefit

derived from the deviated traits.

To identify what is normal occlusion, we must study the

occlusions of our ancestors (evidence-based research)

and, especially, the occlusions of modern (Cro-Magnon)

man in today’s third world and first world societies. By

doing this, important lessons can be learned regarding

what our occlusion is, what it should be, and how we can

treat associated pathology successfully.

Figure 2: An australopithicine skull, more than two million years old,

showing flat plane occlusion acquired by heavy dental attrition.

Flat plane occlusion

The earliest pre-human and human-like animals (the

australopithicines, Homo erectus, Homo hablis, the Neanderthals)

lived in an environment in which the occlusion

was worn quickly (Figures 1–5). 8 Pointed cusps and

deep fossa of new teeth, which served the purpose of

efficient eruption and positioning, were flattened quickly

by coarse, gritty diets and constant, day-long chewing,

as were the grooved occlusal anatomy and pointed interproximal

contacts of new teeth. 5,8,11 Soft, nonabrasive

food was rare, and the life span essentially was determined

by the ability to chew enough food adequately

to extract sufficient nutrition to survive. 7 The lack (until

recently) of fossils and historic skeletons with cuspal occlusion

or less than half of their natural teeth attest to the

fact that early man needed his teeth to survive. In a study

of more than 10,000 ancient skeletons worldwide, fewer

Figure 3: Homo erectus skull, approximately one million years old,

showing flat plane occlusion and an edge-to-edge bite.

The Evolution of Human Occlusion57


than 0.02 percent had cuspal occlusion. 7,8,11-16 In ancient times, life was brutish, mean, and short. Maintaining cuspal

occlusion or losing too many teeth would reduce chances of survival. 15

Early man and many present-day residents of third world nations chewed and lived with flattened, well-worn teeth

(Figures 5–9). 11-15 This condition is termed flat plane occlusion (Figure 6). 12,15 In flat plane occlusion, the occlusal table

is predominately flat. The teeth have low (if any) cusps and shallow fossa. The interproximal areas are worn nearly

flat so that teeth contact each other on a broad surface area (Figure 5). The interproximal distance between teeth is

shortened. There is essentially no canine rise and little incisor guidance. The bite often can be slipped into an edge-toedge

relationship in which centric occlusion (the maximum interdigitation of the teeth) becomes centric relation (the

occlusion manifested by the most superior position of the mandibular condyle in the glenoid fossa). 3 The jaw can slide

easily into all excursions, including protrusion and lateral directions, with most teeth contacting each other. 11,12,15,18 This

condition represents a range of wear in which cusp inclines may vary slightly (between 0 and 20 degrees) and some

teeth may not occlude in concert with their neighbors. Generally, every tooth is naturally flattened and equilibrated

with the others (Figures 5 & 6). 8,11,12

Heavy dental wear is the primary source of flat plane occlusion

(Figures 5, 6, & 8). The most common cause (seen

today and assumed historically) is fine abrasives in food

and a relatively long period of mastication each day. Eating

gritty food contaminated with sand or earth from the

natural environment or from worn millstones (used in

pre-industrial societies) gradually will lead to flat plane

occlusion. Based on skull studies from all societies in human

history (except recently in the industrial world), this

condition has been the norm for most of mankind since

the time of the australopithicines (4 million years ago)

(Figures 1–5). 8,12,16 Essentially, everyone had flat plane occlusion.

Cuspal occlusion in adults was rare (Figure 6).

Flat plane occlusion

compared to cuspal occlusion

People currently living in industrialized societies possess

predominately cuspal occlusion. 8,11,12,15 This form of occlusion

is seen in the majority of patients. This is caused

by the lack of tooth attrition and, with few exceptions,

was first noted 250 years ago when metal rollers replaced

the grit-producing grinding stones used in food production.

7 With cuspal occlusion, the teeth maintain their

cusps and fossa.

Flat plane occlusion is the main chewing system of prehistoric

and non-industrialized man. 8,12 In flat plane occlusion,

the occlusal tables are flat, reducing prematurities

and traumatic occlusions that occur frequently in

people who have cuspal occlusion. With low or nonexistent

cusps, cracked cusp syndrome and fracturing is rare.

Patients with cuspal occlusion suffer greatly from these

problems, especially as they age and undergo dental

restorations, which allow chewing pressures to fracture

weakened cusps (Figure 6).

In flat plane occlusion, the mandible is free to move, unrestricted,

to any position of the mouth (e.g., occlusolaterly),

reducing excessive stresses (e.g., traumatic oc-

58 The Evolution of Human Occlusion

Figure 4: A Neanderthal skull, approximately 200,000 years old, showing

flat plane occlusion and perfect orthodontic tooth alignment.

Figure 5: Occlusion of modern man (circa 1000 BC) showing flat plane

occlusion. Note the flattened interproximal tooth contacts, which

stabilize the arch, and minimal occlusal groves and fossa, which could

attract plaque and decay.



this condition has been the norm

for most of mankind since the time of

the australopithicines (4 million years ago).


clusion) on individual teeth and the temporomandibular

joint (TMJ). 8,15 This condition is seen often in today’s children.

9 The anterior teeth, unlike those seen in modern

adult populations, are worn down quickly to a shape

that renders them occlusally inert. 11,12,18,19 There is little or

no incisal guidance, no canine rise, and the anterior occlusion

often is noted as being edge-to-edge (Figures 2 &

3). 5,7,8,11,18 In modern populations, with less tooth wear, anterior

teeth will restrict and “guide” excursive jaw movements,

sometimes resulting in stressed periodontium and

TMJ tissues. 3,12,15,20

Tooth malalignments are rare in flat plane occlusion because

the inherently unstable “point” interproximal tooth

contacts seen in cuspal occlusion are worn down quickly

to flat, broad, stable surfaces reminiscent of stone blocks

in a Roman arch (Figures 2–9). In cuspal occlusion, because

of the rounded interproximal contacts, tooth slippage

(buccally or lingually) occurs easily, contributing to

dental malalignments in the arch and future periodontal

pathology (Figure 6). 8,11,13

In flat plane occlusion, mesial drift and interproximal

wear, which often amount to 1.0–1.5 cm per arch, provide

added arch space for the eruption of most third molars,

reducing the incidence of impactions (Figure 6). 5,8,11 In

cuspal occlusion, this beneficial wear is minimal, leaving

a longer tooth-filled arch and causing a higher incidence

of impacted third molars and associated pathology. 13 Until

recent times, this was a major cause of mortality and morbidity

(natural selection). If one of our predental treatment

ancestors developed pericornitis around an impacted

third molar, there was a high probability of the genetic

lineage being terminated.

In flat plane occlusion, crowding of mandibular anterior

teeth seldom is observed because heavy interproximal

wear compensates for the loss of arch space due to the

natural lingual tipping of the anterior teeth (Figures 8 &

9). 8,17 In populations with cuspal occlusion, lower incisor

tipping is a serious cause of crowding and orthodontic

relapse.

Figure 6: Comparison of flat plane occlusion and cuspal occlusion.

(A) Interproximal contacts are pointed in cuspal occlusion, permitting

tooth crowding. (B) Flat plane occlusion’s flattened contacts stabilize

the arch, preventing crowding. (C) Interproximal wear in flat plane occlusion

allows more space for third molar eruption and less space for

interproximal plaque accumulation (periodontal disease). (D) Flat plane

occlusion reduces occlusal food traps and fractured cusps.

Figure 7: The face of this South American Yanomami Indian typifies

the hypertrophied jaw muscles often seen with flat plane occlusion.

These third world people chew a tough, gritty diet for the entire day. As

a result, they rarely report bruxing or experience TMD.

In today’s populations who exhibit flat plane occlusion

(e.g., the non-industrialized third world), chewing is an

important activity and is done throughout the day (Figures

7–9). 15 Because of the toughness of the diet, long periods

of mastication are needed to process food. Essentially,

these people graze all day long on tough, fibrous, low

calorie material. They generally are thin, comfortable, and

The Evolution of Human Occlusion59


appear to gain some psychological satisfaction from the habit. 12,15 Often their jaw muscles are hypertrophied, presenting

the appearance of a wide middle face (Figure 7). 15 TMD is rare. 8,11,15,16

By contrast, in Western societies, chewing times are reduced and usually restricted to soft foods at short prescribed

mealtimes. 16 Apart from meals, mastication generally is limited to soft, high calorie snacks (often eaten all day long)

and softer chewing gum, with many episodes of destructive bruxing apparently fulfilling a need to further exercise the

mastication muscles. 5,12

Flat plane occlusion reduces the size of the tooth’s occlusal fossa and developmental grooves. Often the tooth becomes

a smooth, flat table of enamel and hardened, sclerosed secondary dentin, which is less likely to retain food or promote

decay (Figure 5). There is no apparent loss in nutrition due to the reduced efficiency in this form of occlusion.

Frequently, the enamel edges of the occlusal surface acquire a sharpness, which aids in mastication (thegosis). Cuspal

occlusion, though somewhat more efficient in mastication because of the teeth’s pointed cusps and inclined planes,

provides opportunistic food collection sites and leads to tooth decay and cusp fracture (Figure 6). 7,11-16

Flat plane occlusion causes flattening of interproximal contacts and, with the help of mesial drift, reduction of the

interproximal space between teeth. This in turn reduces the amount of food that can collect in these areas and helps

limit related decay and periodontal disease until old age (Figure 6). 5,11,14-16 As the teeth gradually wear, they slowly erupt,

re-establishing any lost vertical dimension. 10,12

Disadvantages of flat plane occlusion

Because flat plane occlusion relies on tooth wear, it is

possible that people may wear their teeth down to a point

where vertical dimension is lost and chewing is uncomfortable.

Resultant pulp exposures and TMJ strain could

have an adverse effect on health. Severe wear and pulp

exposures would tend to cause starvation unless the society

is supportive (e.g., providing special diets or prechewed

food), which rarely occurs historically.

Excessive interproximal attrition eventually can change

the tooth anatomy to such a degree that increased food

impaction promotes decay and periodontal disease. Tooth

loss from periodontal disease is common in older “primitive”

people. 15-18 It appears that a moderate amount of

tooth attrition is beneficial, while an excessive amount of

wear eventually is harmful. 5,7,8,10-12

Figure 8: The flat plane dentition of a Yanomami Indian. Note that the

lack of anterior crowding, incisal guidance, and canine rise allows centric

relation to be equal to centric occlusion. The jaws can slide easily

to any position with the teeth in full intercuspation.

Discussion

What does this mean to modern dental practices? How

does this evolutionary history influence how we treat patients

or define normal occlusion?

Man’s development through the australopithicines, Homo

erectus, and Cro-Magnon evolutionary stages occurred in

an environment in which the teeth erupted into cuspal

occlusion and quickly were worn into flat plane occlusion,

which constituted the norm. Our anatomy developed,

over time, on the basis of flat, worn dentition. Cuspal

occlusion was relatively rare until recent times (the

last 250 years) in industrialized societies. Though ancient

man had horrific dental problems due to poor hygiene,

60 The Evolution of Human Occlusion

Figure 9: A citizen of the rural southern U.S. with flat plane occlusion,

demonstrating that this condition is not limited to the third world. Note

the lack of anterior crowding and associated pathology.



When restoring a tooth, create shallow anatomy,

low cusps, and fill in any deep grooves or fossa without

seriously altering flat plane occlusal function.


primitive dentistry, and a rugged lifestyle, flat plane occlusion prevented many conditions now seen routinely in individuals

with unworn teeth. Today, in industrialized societies, there is a high incidence of TMD, occlusal decay, bruxism,

traumatic occlusion, fractured cusps, third molar impactions, and orthodontic crowding associated with cuspal occlusion.

19 These afflictions are comparatively rare in fossils, ancient medical writings, and present-day third world patients

who exhibit normal levels of flat plane occlusion (Figures 2–9).

It is the author’s recommendation that we assist our patients in emulating this lost form of occlusion as a means of treating

the pathologies listed above. This does not mean wholesale flattening of all teeth using heatless wheels at the next

appointment, but a gradual re-creation of natural worn dentition as the conditions present themselves. 7,8,11

Patient treatment guidelines

The following guidelines are recommended for treating patients. 20,21 Obviously, discretion is required on a case-by-case

basis (Figures 8 & 9).

When restoring a tooth, create shallow anatomy, low cusps, and fill in any deep grooves or fossa without seriously

altering flat plane occlusal function. It is not necessary to recreate textbook-like secondary developmental anatomy on

the occlusals of every restored tooth. Creating flat plane anatomy will reduce occlusal decay, traumatic occlusion, and

fractured cusps.

When restoring a tooth with an interproximal restoration, shape it so that the contact is wide and flattened instead of

the point contact advocated in many dental school texts. This will reduce food impingement and instability leading to

tooth crowding and other malalignments. It will contribute to interdental space closure (mesial drift), which will reduce

plaque collection.

If possible, treat impactions and slight crowding (as happens frequently in mandibular anterior teeth) by lightly stripping

the contacts of teeth in the arch. Stripping 0.25 mm per contact per tooth can easily gain 4.0+ mm of arch space

without seriously damaging the enamel. This may be sufficient to reduce anterior crowding and allow many impacted

third molars to erupt.

Strip interproximal contacts so they are flat rather than rounded. This will stabilize the teeth and prevent further crowding.

After active orthodontic treatment, flatten the contacts to maintain tooth position.

Gently equilibrate patients at each visit, removing excessive prematurities as if an abrasive food were being eaten, causing

natural attrition. Do this gradually, using articulating paper in all excursions. Ideal occlusion occurs when the jaw

can slide easily into any excursion (i.e., centric occlusion equals centric relation). 3

People have an evolutionary acquired need to chew stiff materials. Encourage patients with common TMD or bruxism

syndromes to gently chew stiff fibrous materials (e.g., toothpicks, stimudents, or popsicle sticks). Chewing gum is too

soft.

Do not build up or restore high cusps, especially on the canines (canine rise). This creates uneven forces, resulting in

TMJ stress and traumatic occlusion. Let the patient’s natural wear patterns guide you. Reconstruct crowns to a morphology

similar to the neighboring teeth. Avoid placing a 20-year-old’s crown anatomy in a 50-year-old’s mouth.

Like natural attrition, these changes must be done gradually, as if the patient were eating pumice on French fries. Follow

the patient’s physiology and jaw movements rather than depending on artificial programs or measuring devices,

which exhibit an inferior and limited design compared with the patient’s jaws and TMJ. Be practical and responsive to

the patient’s symptoms and needs. Reshape teeth as they need repair. Do nothing extreme. If there is an improvement,

The Evolution of Human Occlusion61


your patient will inform you so that you may continue. If not, you may have to rely on the older, traditional dental

treatments.

Remember, our evolutionary history prescribes flat plane occlusion. All living humans were designed to chew with

flattened teeth. It is a part of our natural history and in our genes. Our prehistoric record substantiates this fact. Deviations

from this model may cause serious problems for our patients; when this happens, re-establishing normal occlusion

can help.

Summary

Our evolutionary blueprint, formed by millions of years of natural selection, has programmed us for acquired flat

plane occlusion—that is, the gradual flattening of occlusal and interproximal tooth surfaces. In modern industrialized

societies, the lack of wear on teeth has maintained immature, harmful cuspal occlusion with the resultant problems of

increased occlusal caries, malaligned teeth, bruxism, fractured cusps, traumatic occlusion, and third molar impactions.

Gradually returning patients to a modified flat plane occlusion by use of opportunistic occlusal and interproximal

equilibrations, restorations, and chewing can be of significant benefit.

Acknowledgements

The author would like to thank Andent, Inc., for permission to republish their photos and Drs. H. Sutcher, H. Peck, and

J. Granados for their invaluable assistance.

If you would like to contact Dr. Ellis Neiburger, call 847-244-0292 or visit www.drneiburger.com.

References

1. Dickerson WG, Chan CA,Mazzocco MW. The scientific approach: Neuromuscular occlusion. Signature 2000;7:14-17.

2. Spear F. Occlusion in the new millennium: The controversy continues. Signature 2000; 7:18-21.

3. Dawson PE. Evaluation, diagnosis, and treatment of occlusal problems, ed. 2. St. Louis: Mosby-Year Book;1989:1-29, 434-456.

4. Tollison CD, Kunkel RS. Headache: Diagnosis and treatment. Baltimore: Lippincott, Williams & Wilkins;1993:182-183.

5. Brace CL. Occlusion to the anthropological eye. In: McNamara J, ed. The biology of occlusal development. Ann Arbor, MI: University of Michigan

Press;1977:179-209.

6. Dickerson WG, Chan CA, Carlson J. The human stomatognathic system: A scientific approach to occlusion. Dent Today 2001; 20:100-107.

7. Neiburger E. Flat plane occlusion in the development of man. J Prosthet Dent 1977;38:459-469.

8. Begg P. Stone age man’s dentition. Am J Orthod 1954;40:298-312.

9. Gibbs CH,Wickwire NA, Jacobson AP, Lundeen HC,Mahan PE, Lupkiewicz SM. Comparison of typical chewing patterns in normal children and adults. JADA 1982;

105:33-42.

10. Berry DC, Poole DF. Masticatory function and oral rehabilitation. J Oral Rehabil 1974;1:191-205

11. Begg P. Progress report on observations on attrition of the teeth in its relation to pyorrhea and tooth decay. Aust J Dent 1938; 42:315-320.

12. Davies DM. The influence of teeth, diet, and habits on the human race. London: W. Heineman Medical Books;1972:62-70.

13. Price W. Eskimo and indian field studies in Alaska and Canada. JADA 1936:23,417-437.

14. Heuser H, Panke H. Dental caries and periodontal disease in stone age man. Dental Abstr 1960;5:478-480.

15. Pedersen PO. The dental investigation of the Greenland Eskimo. Proc R Soc Med 1947;14:478.

16. Alt KW, Rosing FW, Teschler-Nicola M, eds. Dental anthropology. New York: Springer Verlag;1998:203-373.

17. Van der Linden FP. Theoretical and practical aspects of crowding in the human dentition. JADA 1974;89:139-153.

18. Dahlberg A. The dentition of the American Indian. In: Laughlin W, ed. Papers on the physical anthropology of the American Indian. New York: Viking Fund;1949:138-

177.

19. Pereira CB, Evans H. Occlusion and attrition of the primitive Yanomami Indians of Brazil. Dent Clin N Am 1975;19:485-498.

20. Kirveskari P. The role of occlusal adjustment in the management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol 1997;83:87-90.

21. McNeill C. Occlusion: What it is and what it is not. J Calif Dent Assoc 2000;28:748-758.

Reprinted with permission from the Academy of General Dentistry. Copyright ©2002 by the Academy of General Dentistry. All rights reserved.

62 The Evolution of Human Occlusion


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