PDF Version - Glidewell Dental Labs

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 


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


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 


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


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


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


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. 


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. 


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. 


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. 


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. 


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. 


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 


– 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. 


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. 


■ 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. 


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.” 


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.” 


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 


at the end. 


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 


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? 



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. 


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. 


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 


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, 


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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