A Publication of Glidewell Laboratories • Volume 4, Issue 1
An Interview with
Dr. Paul Homoly
IPS e.max ® CAD LT
Perception is the Only Reality
Four Crowns. Four Price Tags.
Can You Tell the Difference?
Minimally Invasive Dentistry
Combined with Laser Gingival
Dr. Michael DiTolla’s
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
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
16 Photo Essay: IPS e.max ® CAD LT
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
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
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
Jim Glidewell, CDT
Editor in Chief
Michael DiTolla, DDS, FAGD
Mike Cash, CDT
Michael DiTolla, DDS, FAGD
Jamie Austin, Deb Evans, Joel Guerra,
Phil Nguyen, Gary O’Connell, Rachel Pacillas
Wolfgang Friebauer, MDT
If you have questions, comments or complaints regarding
this issue, we want to hear from you. Please e-mail us
at firstname.lastname@example.org. 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
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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.
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.
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
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
Please e-mail me back and let me
know if you like them, as there are
other brands out there you may like
- Dr. DiTolla
“Dear Dr. DiTolla,
I recently read your article in Dental Economics
and was very interested in learning
Letters to the Editor
more concerning the STA System anesthesia
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
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
you may need
to move the needle
to an area that is
for this type of
injection. If I get
a good injection
in the buccal
furcation, I typically
go to the lingual,
there is certainly
that. I know
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
- Dr. DiTolla
“Dear Dr. DiTolla,
I have happily used Glidewell Laboratories
for several years. I even came down from
Northern California to tour the impressive
facility, where I saw you working.
My question is: What cement do you recommend
for zirconia? Different lecturers
and manufacturers give various strength
numbers. I have been using Panavia F2.0
(Kuraray Dental) and RelyX (3M ESPE)
successfully for many years.”
- Dr. Richard Jergensen, Fairfield, CA
Panavia F2.0 is a great choice. RelyX
could be referring to either RelyX
Luting Plus Cement or RelyX
Unicem; either is a great choice as
well. The RelyX Luting Plus Cement
is a resin-reinforced glass ionomer
used for conventional cementation,
and Unicem is a self-etching resin
cement. Both are highly acceptable
choices for zirconia-based restorations.
- Dr. DiTolla
“Dear Dr. DiTolla,
I recently watched your Rapid Anesthesia
Technique on the Glidewell Web site. I
think I understood most of it, but is it basically
a PDL injection?
Also, what gauge and length needle do
you use for this technique? I have had a
hard time finding a heavy enough needle
short in length to use in my conventional
- Dr. Mark Pelletier, Irmo, SC
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
- 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
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
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
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
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 (email@example.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
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
firstname.lastname@example.org, 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 email@example.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 firstname.lastname@example.org, 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.
– ARTICLE by Michael DiTolla, DDS, FAGD
– PHOTOS by Sharon Dowd
CATEGORY...... Polycarboxylate Luting Cement
SOURCE.......... 3M ESPE
St. Paul, MN
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
PRODUCT........ Physics Forceps ®
CATEGORY...... Tooth Extraction
SOURCE.......... GoldenMisch, Inc.
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
PRODUCT........ KaVo ELECTROtorque plus Handpiece
CATEGORY...... Electric Handpieces
SOURCE.......... KaVo Dental Corporation
Lake Zurich, IL
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
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
PRODUCT........ Aidaco Bite Sticks
CATEGORY...... Crown Seating Instrument
SOURCE.......... Temrex Corporation
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 by Peter M. Pronych & Arden G. Christen
– review by Michael DiTolla, DDS, FAGD
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
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 email@example.com to request a copy.
Book Review: The Early Adventures of Painless Parker15
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
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.
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 5 Figure 6
Figures 4-6: The patient’s other main complaint was the shape of tooth 10 and the resultant gingival embrasure between the two teeth. I told
her that if we hoped to close the large black triangle between 9 & 10, we would have to place a restoration on tooth 10 as well.
18 Photo Essay: IPS e.max CAD LT Case Study
Figure 7: 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
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: 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
Figure 10: After the Profound Lite has been rinsed off, I use the
STA System (Milestone Scientific, Livingstone, NJ) to deliver the
Septocaine ® (Septodont, New Castle, DE) on the slowest speed. After
about 20 seconds, I switch the STA System to the normal speed,
as the patient is already anesthetized in that area. This is the easiest
way to give a painless injection.
Photo Essay: IPS e.max CAD LT Case Study19
Figure 11: 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: The crown is popped off with the Christensen Crown
Remover and the prep is evaluated. It is slightly overtapered in the
incisal third, the mesial is slightly underprepared in the gingival
third, and the distal margin is slightly overprepared in the distal.
That said, the prep is still acceptable if we clean up the margins
and get a great impression.
Figure 14: Prior to margin refinement, we place a Size 00 Ultrapak
® cord (Ultradent, South Jordan, UT) as our bottom cord in the
two-cord technique. Since this cord will be in place during the rest
of the procedure, it contains no epinephrine or medicaments. We
“floss” the cord into the distal; no packing instrument is used.
20 Photo Essay: IPS e.max CAD LT Case Study
Figure 15: 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: We use an instrument on the facial surface to pack the
cord into the sulcus because we don’t have a choice. However,
by having the interproximal areas already “flossed” into place, it
makes it much easier to pack the cord atraumatically. If needed,
the ends of the retraction on the lingual can be pulled again, if you
left too much slack on the facial.
Figure 18: The two ends of the cord are cut on the lingual so that
when they are packed in the sulcus they will butt up against each
other and not overlap. If you compare this figure to Fig.13, you will
see the tissue has been retracted approximately 0.5 mm. This is done
so that when we drop the crown margin to the gingival margin, it will
end up approximately 0.5 mm subgingival when the cord is removed.
Photo Essay: IPS e.max CAD LT Case Study21
Figure 19: 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: A Size 2E Ultrapak cord (Ultradent) is the top cord in
the two-cord technique. Since the 00 cord is in contact with the
inflamed base of the sulcus, there is no bleeding when this cord is
placed. The “E” in 2E is for the strand of epi cord in this cord, and
it is also available as a plain 2 cord if you prefer. A loose end of the
2E cord is visible to facilitate easy removal.
Figure 22: A Roeko Anatomic Comprecap (Coltene/Whaledent,
Cuyahoga Falls, OH) is placed on the preparation to keep pressure
on the gingival and to keep the cord in place. Comprecaps come
in handy when you are impressing teeth that you shouldn’t be because
the gingiva is thrashed, namely posterior teeth with broken
cusps that have been packing food for a few months.
22 Photo Essay: IPS e.max CAD LT Case Study
Figure 23: 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: Tooth 8 is an IPS e.max CAD LT crown. “LT” stands for
low translucency and, in this case, it did a great job of blocking
out a dark root and a gold post. It is notable that IPS e.max has
no understructure, yet it can still be cemented conventionally and
block-out dark stump shades—something not possible with IPS
Empress ® , for example.
Figure 26: The left lateral smile shows the laboratory did a nice job
of closing the huge black triangle between tooth 9 & 10. In doing
so, we made the tooth larger than the average lateral incisor. But,
then again, the patient’s main complaint was the black triangle.
Photo Essay: IPS e.max CAD LT Case Study23
Figure 27: The right lateral smile shows that the contours of both the
crown and the no-prep veneer are acceptable. This is the view that
really shows if we have achieved a nice facial profile or if the restorations
look bulky, which can easily happen with no-prep veneers.
Figure 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.
24 Photo Essay: IPS e.max CAD LT Case Study
– ARTICLE and CLINICAL PHOTOS by Robert A. Lowe, DDS, FAGD, FICD, FADI, FAC
– COVER PHOTO by Sharon Dowd
Minimally invasive dentistry
combined with laser gingival plastic surgery:
Maximize Your Aesthetic Results
In order to design the optimal outcome for a patient during aesthetic enhancement, the restorative
dentist must seek to create a symmetrical and harmonious relationship between the lips, the gingival
architecture, and the positions of the natural dentate forms. In the author’s experience, the Waterlase ®
YSGG laser (BIOLASE Technology, Inc., Irvine, CA) has been a useful adjunct for performing aesthetic
surgical crown lengthening procedures. This article will highlight the associated biological principles and
demonstrate techniques for the application of this laser in closed and open crown lengthening procedures
in conjunction with the use of porcelain veneers for aesthetic dental reconstructions.
Maximize Your Aesthetic Results27
■ THE DENTOGINGIVAL COMPLEX
The dentogingival complex consists of a connective tissue
attachment, an epithelial attachment (or junctional epithelium),
and the gingival sulcus. As described by Spear 1 and
Kois 2 , the most critical relationship for biologic health,
when the clinician is placing a restoration at or below the
free gingival margin (FGM), is the margin location relative
to the crest of bone. Kois states that the distance from the
FGM to the osseous crest on the facial aspect is 3.0 mm.
Interproximally on anterior teeth, this distance is 4.0 mm
due to the curvature of the cementoenamel junction. The
height of the interdental papilla can also be predictably
maintained at 4.0 mm incisal to the osseous crest between
anterior teeth with normal root proximity, approximately
2.0 to 3.0 mm at the osseous crest. With these parameters
in mind, the clinician must first decide where the
restorative margin will be placed. With all-ceramic restorations,
if one does not have to block out undesirable
dentin colors or core materials, then it may be desirable
to place the restorative margin at the free gingival crest
or even slightly supragingival. However, if an intracrevicular
margin is required for aesthetic reasons, it should
be placed no further than 0.5 mm into the gingival sulcus
to avoid adverse biologic responses due to encroachment
upon the attachment apparatus.
Kois and Coslet, et al. 3
also describe a variation in biologic width that compares
the distance from the alveolar crest to the FGM and divide
this into three categories: normal crest, high crest,
and low crest. In simplified terms, normal-crest patients
(about 70 percent) have approximately a 2.0 mm combined
epithelial and connective tissue attachment and 1.0
mm average sulcus depth. If the sulcus depth is greater
than 1.0 mm, the free gingival excess can be safely resected
and upon healing will result in a dentogingival
complex measuring 3.0 mm on the facial aspect. Patients
with a high crest often have a shallower sulcus depth
and a combined epithelial and connective tissue attach-
“If diastemata are present, the
interproximal margin of the
preparation should be carried
lingually to the linguoproximal
line angle and be placed slightly
intracrevicularly in the proximal
area to help ‘squeeze’
the gingival papilla.”
28 Maximize Your Aesthetic Results
ment of less than 2.0 mm. These patients have relatively
stable FGM positions and are not prone to recession upon
manipulation of the tissues.
Low-crest patients often have
normal sulcus depth (1.0 mm to 3.0 mm) and a combined
epithelial and connective tissue attachment that is less
than 2.0 mm. These patients are highly prone to recession
and must be treatment planned accordingly. The FGM of
low-crest patients will tend to apically reposition and turn
into a normal-crest situation after gingival retraction or
surgery. Therefore, the most important factor in achieving
post-restorative gingival health and stability is the position
of the restorative margin relative to the bony crest,
not the preoperative health and/or the position of the
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.
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.
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
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.
stated, the finished maxillary central incisors should
be 10.0 to 12.0 mm in length. While the incisal edges
can be shortened when adequate freeway space exists
posteriorly, the amount depends on the patient’s pattern
of disclusion. The shortened incisal edges must
still disclude the posterior teeth in all eccentric movements
to maintain occlusal harmony. A tissue marker
Figure 3: A Waterlase YSGG laser is used during an “open flap” procedure
to adjust the height of the alveolar crest. The tip of the laser can be
marked 3.0 mm from the end so that it can be used as a guide to position
the bone level precisely 3.0 mm apical to the restorative margins of the
provisional restorations, ensuring that biologic width will be maintained.
Figure 4: This photo shows the patient with the definitive ceramic restorations
after corrective gingival and bony surgery. Tooth proportion and
gingival zenith heights show improved aesthetics, and the amount of
gingival display has been decreased.
Maximize Your Aesthetic Results29
Figure 5: This patient had a minimal biologic width encroachment on
the distoproximal margin after removal of a defective restoration.
Figure 6: The Waterlase YSGG laser is used first to remove the epithelial
and connective tissue attachments, and then to correct the osseous
level to re-establish a 3.0 mm zone from the restorative margin to the
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
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.
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
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.
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.
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
Gingival margins should be placed
at the gingival crest, or slightly above. The interproximal
margins should be carried into the lingual portion of the
contact area. If diastemata are present, the interproximal
margin of the preparation should be carried lingually to
the linguoproximal line angle and be placed slightly intracrevicularly
in the proximal area to help “squeeze” the
gingival papilla. Also, when closing spaces, it is important
to prepare the gingival margins far enough into the
proximal areas so that the restoration margins are not
visible from a three-fourths or oblique view, when the
patient turns the head to the side.
After the preparations
are finished, it is recommended to use a fine finishing
diamond to make the preparations as smooth as possible.
An Enhance ® point (DENTSPLY Caulk, Milford, DE) can
also be used to round and smooth the corners and line
angles. Fine sandpaper strips can be used interproximally
to smooth interproximal enamel surfaces without compromising
the proximal contact (Figures 8 through 10).
“‘Minimally invasive’ also
applies to a standard of
restorative excellence that
allows a case to have
aesthetic and functional
longevity, so that the teeth are
not continually assaulted and
‘reprepped to death.’”
■ THE DEFINITIVE AESTHETIC RESTORATION
One key to optimal aesthetics is the creation of the correct
gingival and bony architecture in order to properly
“frame” the teeth. This concept, combined with naturallooking
ceramic restorations that are the minimal thickness
required for structural strength and aesthetic beauty,
results in an outcome that is truly magnificent while being
minimally invasive. Shavell 4 once said, “Many teeth
are sacrificed on the altar of ‘false’ conservatism.” Is it
really more conservative (minimally invasive) to use a
no-prep technique, creating overcontoured teeth and the
potentially negative periodontal ramifications? On the
other hand, it is definitely not necessary to over-reduce
teeth with no apparent rhyme or reason as a short-cut approach
to restorative dentistry.
Maximize Your Aesthetic Results31
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
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.
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
Figure 11: A preoperative view of a patient with altered passive eruption
32 Maximize Your Aesthetic Results
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
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
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
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
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
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
PH: And patients are probably the last ones aware of quality above and beyond what they can
readily recognize—a shade match, an appropriate bite, a ballpark reasonableness of clinical accuracy.
So clinical quality doesn’t come from the patient’s experience, but from the experience of the
dentist and the dental team.
When I was in practice, I’d typically have a surgical patient who would arrive early, take the meds,
follow instructions about not eating, and so on. When the anesthetist hit the vein with the IV, the
patient would go into deep conscious sedation without a problem. I’d prep the mouth and face,
make rapid incisions and clean dissections. The operating field was bloodless. I’d create implant
receptor sites, drop implants into place, close the flap effortlessly—like I had magic hands. Everything
worked well. That’s clinical quality—like a candle whose flame burns bright and the whole
team feels it.
But quality is the experience of the practitioner creating the dentistry; it’s not the outcome for the
patient. Only the dental team shares that experience; the patient isn’t a participant in that event.
What the patient experiences is some degree of “suitability,” which is different than quality. Suitability
for the patient includes questions about being able to afford this treatment. It also includes
a clean facility, friendly dental team, conveniently located office, and workable appointment times.
Interview with Dr. Paul Homoly37
To sum up, suitability refers to being an easy place to do business with.
Now, what if suitability replaced clinical quality as the profession of dentistry’s cultural center?
What if we consciously pursued suitability with the same vigor, intensity, and resources we put into
pursuing clinical quality? Then we’d no longer have permission, in the cultural sense, to make huge
blunders in the name of clinical quality—blunders most people can’t perceive.
MD: That certainly would require creative destruction!
PH: Yes. We would have to take an intricate look at who we are and ask, “Am I a provider of quality
clinical services or am I provider of suitable clinical services?” I’m not arguing against the inner
experience of quality here. That inner experience kept me on fire for 20 years and drives most
dentists. That’s in a dentist’s nature and culture both.
However, sometimes our culture evolves more slowly than the world does. For example, I’m Catholic
and when I was growing up, it was a mortal sin to eat meat on Friday. If you ate meat on Friday,
and you knew it was Friday, and if you died right after that, you would go straight to hell. Well, I
went to a public high school and I remember going to the cafeteria line and getting the meat ravioli.
I would forget what day it is as I sat down to eat. I’m ready to eat this meat ravioli when one of
my Catholic buddies across the table would say, “Hey, Homoly, it’s Friday.” So, I’d have to choose:
do I starve or do I go to hell?
The whole concept of not eating meat on Friday was set aside several years ago by one of the
popes. Today, it’s perfectly okay to eat meat on Fridays for Catholics except during Lent and on
holy days of obligation. But you know what? When I go to a restaurant, look at the menu, and get
ready to order, what’s the first thing I think about?
MD: What day is it?
38 Interview with Dr. Paul Homoly
PH: What day is it! This cultural belief hasn’t gone away. It’s still there. The culture of that belief—
don’t eat meat on Friday—doesn’t go away even though the world has changed. But as dentists,
we’re still experiencing a cultural belief that needs to include factors of suitability. Adopting a
culture of suitability, we create an environment that participants find acceptable so they’ll remain
with the practice a long time.
That’s right at the heart of what is going on now in the economic downturn. Because of people’s
cash flow and financial worries, they’re not ready to select a dental practice for the long run. A
practice driven on clinical quality alone will tend to drive those people away. Why? Because in an
environment focused on clinical quality, they can get educated right out of the practice.
MD: That’s a new concept—educating patients right out of the practice. How does that hold true, especially
in tough economic times?
PH: Here’s a good example. A patient needs two 3-unit bridges and a garden-variety crown. Let’s
say this bridge case is $8,000 to $9,000. This patient comes in complaining how his IRA has just
gone down 35 percent. After a complete examination, the dentist lays out a treatment plan based
on clinical quality. The patient hears the high price tag and responds, “I’m not ready. I need to go
home and think about it.” Six months later this patient comes back for a cleaning and the hygienist
asks, “Are you ready for your bridgework?” The patient says no because of the cost. At the next
cleaning six months later, the hygienist again asks. Again, he says no. Six months later at his next
cleaning, he remembers feeling irritated and says, “Don’t talk to me about the bridge!” Then he
breaks his next appointment for cleaning. When he finally has the money, he gets the bridgework
done by a different dentist who didn’t nag him.
That’s how we can educate patients out of our practice. The dental team’s “patient education” feels
like sales pressure to the patient.
MD: And a slow economy not only breeds patient unreadiness, but also causes classically trained dentists
to ramp up their focus on “patient education.”
PH: Yes, people in crisis hang on to their original culture. That’s why when
times get tough, dentists tend to educate more. But as a dentist, I can’t
change the economic climate or the stock market; the only thing I can change
is me and my practice. The solution? Increase the suitability of my practice to
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
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
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
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
clinical quality, they can
get educated right out of
Interview with Dr. Paul Homoly39
to think the way we think and assert ourselves to the point of saying to them,
“This is what you should do with your life.”
Now, it’s extremely difficult to change behavior. If you think it’s easy to change
a person’s behavior, just marry him or her. But why doesn’t education work?
Because the premise is false. Education does not lead to change.
Even the beginning student of instructional design knows that the key to
change is not education; it’s the readiness of a person to change. Take someone
who doesn’t want to lose weight and put him on a weight-reduction plan,
or someone who doesn’t want to stop smoking and put him on a smokingcessation
program, or a person who doesn’t want to stay married and put him
or her into marriage counseling—what happens? It’s their readiness, not their
understanding, that drives their behavior.
MD: In fact, I would assume if somebody came in ready to make a change in their
dental health, they wouldn’t even need to understand the entire process. Education
wouldn’t be the most important factor.
PH: Absolutely. People make decisions when they’re in love with the desired
outcome, even when they’re not fully aware of all the processes involved.
“Yes, people in crisis hang
on to their original culture.
That’s why when times
get tough, dentists tend
to educate more. But as
a dentist, I can’t change
the economic climate
or the stock market; the
only thing I can change
is me and my practice.
The solution? Increase
the suitability of my practice
to my patients.”
40 Interview with Dr. Paul Homoly
So after a decade of trying to change patients’ behavior, and in the absence of
their compliance, dental team members get burned out; they get cynical. They
present a traditional treatment plan and explain all the steps, yet people are
walking out of their offices. One day, they snap and say, “Damn these patients!
They don’t appreciate us; they don’t know what quality is.” The dental team
members never see the real problem: their inherently destructive culture.
MD: They all put their hearts into the practice, but can’t easily see they’re failing.
PH: The lucky practitioner is the one who blames the patients and the staff,
but the practitioner who really gets into trouble is the one who blames himself
or herself. When confidence crashes, it affects the doctor-patient relationship
and the dentist team’s ability to produce clinical quality.
Cynicism is a sustained stress—a sustained negative relationship with the environment.
Cynics aren’t happy about a thing. The psychopathology related to
perfectionism and cynicism directly results from the cultural belief that “we’re
smart enough to change people.” But nobody has that power. Psychologists
know their patients will only change when they are ready, so they become expert
listeners striving to understand people. In fact, psychologists have insurance
codes for understanding patients. But in the dentistry culture, we don’t
have codes for understanding patients. We have codes for educating patients.
In this culture, there is no conversational exchange between dentists and patients.
It’s all directed one way.
Let me ask you this: If you show me a picture of something I want and you’re
not educating me, you’re actually reinforcing my desired outcome. But if you
show that same picture to people who don’t want that pictured outcome,
what’s the result?
MD: You annoy them.
PH: That’s what dentists can do. We explain why our patients should want this
treatment and shouldn’t get annoyed. When they walk away, we say, “Well,
they have low dental IQs.” It becomes the fault of the patient!
But what if the public school education operated like that? What if a teacher
had failing students and the principal came up to her and said, “You know, your students consistently
fail 60 to 80 percent of the time, right?” And the teacher replied, “Well, these students are all
screwed up; they don’t value education.” What would that principal say to that?
MD: “You’re fired?”
PH: That’s right. But nobody has the authority to fire the dentist. So when patients come in who
need advanced-care dentistry, a high percentage of them aren’t ready to invest thousands of dollars.
And when the dentist tries to educate them into readiness, they walk.
Typically, fewer than 5 percent of a dentist’s $10,000-plus case patients are ready to receive care
the first time they hear their treatment recommendation. What about the 5 percent who agree to
treatment? Their decisions are based on a lot of things, but not on the education. They say yes when
their treatment plan fits into their lives, they’re ready for it, and they want the outcome. Many have
already walked in wanting a specific outcome.
MD: You can see how high suicide rates among dentists tie into that. In other cultures like the financial
services industry and the legal industry, you don’t see the same type of belief that you do in dentistry.
PH: The blind pursuit of any cultural icon results in vast disaster. So if you’re a financial services
provider blindly pursuing return of investment, you could ruin lives in the process.
MD: We’re seeing that right now—the blind pursuit of reward without risk, right?
PH: That’s it, Mike. In dentistry, the blind pursuit of clinical quality leads us to outcomes we’d
never thought we’d run up against. The “blind” quality needs to be tempered with this concept
I call “suitability,” which forces dentists to ask, “Is this dental treatment the next best step in this
patient’s life right now?” It’s not heresy to ask this question. In fact, you have to ask if you want to
develop a practice that sustains downturns in the economy, and if you want to develop a practice
that provides exquisite, consistent, high-quality care.
There’s no downside to what I’m saying. When you engage the patient in a conversation about
how suitable this dentistry is at this time, you’re setting into place a process that will protect your
relationship with the patient in the absence of readiness. If you say, “You know, Ed, now that I’ve
looked in your mouth, I know we can help you. But I’m not sure how this plan best fits into your
life right now. You’ve mentioned you’re traveling to Europe a couple times a month and you’ve got
boys in college. How do we fit this treatment into your life? Do we do it now, do it later, or do it a
little bit at a time?” That conversation seeks to find suitability, doesn’t it?
What if the center of dentistry wasn’t the blind pursuit of clinical quality but providing suitable
dentistry—dentistry that fits into the patient’s life and exceeds standard of care? Here’s the good
news. Most dentists already meet 50 percent of these criteria for suitability. Most dentists have already
gotten the “exceeds standard of care” part.
However, suitability isn’t in our culture like it is in residential real estate sales. I’ve worked with
real estate agents and companies as a consultant and speaker. I’ve bought several houses, and you
know how the process goes. You and your honey walk into a realty office, plop down into the
chair, and start talking. “We’d like to buy a house.” The real estate agent asks, “What’s your price
range?” and “How much money do you have for a down payment?” and “What neighborhood would
you like to live in?” These questions land firmly on the side of suitability. That agent is “qualifying
Now, if a dentist refers to “qualifying the patient,” it sounds like a mortal sin in the dentistry culture.
It sounds like, “Oh, you’re just diagnosing the patient’s wallet.” Yet somebody has to make the case
suitable. There’s nothing wrong with diagnosing a person’s wallet if it’s done in the spirit of suitability.
You buy a car and look at the sticker price first. But there’s no sticker price on dentistry.
MD: In dentistry, communicating fees is usually saved for the end of the initial appointment. Dentists
frontload the conversation with expectations of clinical quality before they drop the cost bomb
Interview with Dr. Paul Homoly41
at the end.
42 Interview with Dr. Paul Homoly
PH: Although it sounds ridiculous, that’s how it’s always been taught and what feels right. But if
suitability were at the core what dentistry’s culture, it would completely change the conversation.
The typical dental exam would change, both for a comprehensive care patient and a modest-care
patient. There would be less emphasis on what and how we’d do the treatment, and more emphasis
on when. The conversation turns to them with questions like, “Tell me about what will work for
you. Let me tell you what your outcome can be. When you and I agree on the outcome you want,
I can design a path to help you get there.”
Here’s another example. In financial services, a fee-based planner gets paid on giving advice only,
no commission from an insurance plan or will or pension. It’s purely an advocacy role. The word
“advocate” means to guide. So you and your spouse visit your fee-based financial planner and say,
“We’re thinking about building a $700,000 home. The whole project might cost us a million dollars.”
The financial planner says, “Let’s see, you have $250,000 in savings right now. You have some
bonds over here, some cash over there.” After crunching the numbers, he says, “Based on market
conditions and how much money you have, it’d be wise to hold off buying for a year. Let’s stash
some cash instead so you can increase the down payment and get a better interest rate.” The point
is, the fee-based financial planner helps find a way to build your house but doesn’t help you build
it. That’s the role of the advocate.
So the way to manifest suitability is to increase the dentist’s role as the patient’s advocate. Dentists
help their patients find a way to get their teeth fixed.
MD: When does this conversation occur in the relationship?
PH: In a new patient interview. This conversation replaces details about how often you floss or
brush every day. Yes, we’d still do exams, but the emphasis, the energy, and the intention of the
conversation is being the patient’s advocate, not the patient’s educator.
In my conversations with patients, I’m carefully listening for condition-related disabilities. Why are
they unhappy with the partial? Why are they unhappy with their front teeth? I need to get a sense
of how the condition is interrupting their lives. This sets the stage in the patient’s mind that it’s a
dental office quite unlike any other because we discuss the suitability of care based on the outcome
he or she wants. In fact, we discuss the suitability issues before the technical issues.
Here’s an example. Michelle comes in and she’s got unsightly front teeth; she’s not happy about
the large composite fillings, incisal edge irregularities, and so on. I ask, “Michelle, how does this
bother you? Tell me about a time when it really bothered you the most.” (This is a great question to
discover disability.) She replies, “I own an art studio and people are coming in. They’re looking at
my teeth and it’s embarrassing. I’ve really lost confidence with customers.” That’s her disability.
Then I engage in a casual conversation and say, “Michelle, tell me about your art gallery.” Doing
that levels the playing field between the dentist and the patient. The dentist is no longer in the authority
position. There’s no more expert-novice relationship in that moment; we are both equals. So
Michelle talks about her gallery and the conversation leads to talk about home and family. As she’s
disclosing details about her life, I’m disclosing bits of mine. During that conversation, I’m listening
for details that will relate to the appropriateness of her full-mouth care. I find out how stressed
she is, how much money she’s spending, what social and family obligations she has. I learn that
Michelle has a black-tie event coming up, that she’s active in the local Chamber of Commerce, and
she travels on buying trips, going to Italy and Spain four times a year. She’s a busy woman.
Then I do the exam, sit the chair up, and think about the suitability of a treatment plan for her more
than I think about clinical quality. Ninety-nine out of 100 dentists sit the chair up and talk to their
patients about the clinical aspects of their cases. The conversation is about what’s wrong clinically
and how they can fix the problems in the mouth.
MD: Instead, what would make them feel more comfortable is knowing the dentist takes into consider-
ation the suitability of a dental treatment for the person’s current circumstances.
PH: Exactly right. In this case, I talk about the outcome Michelle is seeking,
then I link that to her circumstances. When I sit that chair up, I’d say, “Michelle,
we see a lot of folks just like you—folks who want to look better at work and
have more confidence in social situations. We want you to know you’ve come
to the right place. I can do all those things for you.”
That’s an outcome statement to assure her that she’s in the right place. Then I
say, “Michelle, I know that I can help you, but I don’t know when is the right
time for you to do all of this.” I’m also saying that dentistry of this nature can
be complex, expensive, and time consuming, so it can interrupt her work flow.
Then I ask this question: “You’re traveling four times a year to Europe and
you’re working long hours at the gallery. How can we fit this into your life,
Michelle? Do we do your care now, do it later, or do it a little bit at a time? Give
me a sense of how we can pace this for you.”
MD: What a liberating question for the dentist, but more importantly, for the patient!
To be able to put the ball in their court, let them dictate the pace of treatment
rather than trying to force it along. I can see how patients would react positively to
this approach. They may actually do it faster than if you dictated the pace because
they now have a say in the treatment plan. It reminds me of how patients are able
to control pain medication at hospitals by pushing a button themselves. Even a
recent study on mammograms showed how women would push down on the plate
10 percent harder when allowed to do it themselves. How powerful that is—giving
patients control over their treatments.
$1,000 $3,000-$5,000 $10,000+
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.
$1,000 $3,000-$5,000 $10,000+
44 Interview with Dr. Paul Homoly
PH: It completely takes off the pressure. In dentistry, we use the label “patient-centeredness”
but every damn seminar I’ve taken that addressed a patient-centered approach has really been a
dentist-centered approach. You’ve heard the adage “patients don’t care how much you know until
they know how much you care.” Is the way to show how much you care by doing a complete periodontal
examination? I say that’s bull because it reinforces our own dentist-centered culture belief
by imposing our beliefs onto our patients.
However, using the advocacy approach, we can be truly patient-centered because we’re asking,
“When will it work for you?” The question is not if I’m going to fix the patient’s teeth; it’s when I
do it based on that person’s lifestyle.
As a dentist, my desired outcome is for the patient to sustain a relationship with me because I
know that 95 percent of the time, a patient won’t say yes to a $10,000 case the first time. But by
sustaining a good relationship, that patient will come to me one or two or three years from now to
do the work. In the meantime, I’ll do all the nickel-and-dime dentistry like cleanings and patching
and fixing small things.
To the purist—the person driven by our dental culture—that’s supervised neglect. But I’ll go toeto-toe
with any proponent of that philosophy and say, “You take all the patients ready for complete
care now; I’ll take all the patients who aren’t. In a few years, we’ll see who has the more vital
practice.” It will be mine.
MD: But if Michelle doesn’t have any money, is the purist going to treat her for free?
PH: A purist probably won’t treat a patient for free, but there’s another way to treat patients—by
being an advocate. Again, the role of advocacy is to ask “when?” And if she doesn’t have money or
if the dentist is unable to do ideal restorations, the advocate will still help her find a way.
The way isn’t to achieve optimal clinical quality. If that was the case, everybody would do implants
and fix bridge work. The way is to offer suitability to a patient who doesn’t have money, which may
mean tooth extractions and full dentures. Then the conversation becomes about adapting. It’s not
looking so much at the clinical result but finding the suitable result for that person.
When I have a patient who will lose his teeth because he can’t financially handle comprehensive
care, I say something like, “Stanley, in the absence of comprehensive care, there is a high probability
you’ll lose some or all of your teeth. I will help you in that process of transitioning from
teeth to no teeth, and I’ll be sure to preserve your dignity in that process. And if or when you can
replace the missing teeth, I want you to know that we’re experts at that, too.” You see, preserving
the patient’s hope and dignity is more important than preserving each tooth.
Why? Because if I can preserve a person’s dignity, I preserve the relationship; and if I preserve the
relationship, that puts me in a position to influence that patient for the rest of his or her life.
But, what if I get on my high horse and say, “Well, Stanley, if you can’t afford to do this, then
you can’t be a patient in this practice.” Then I’ve lost all opportunity to influence him ever again.
Chances are he’ll end up in the hands of a low-quality provider.
MD: Exactly right.
PH: So, there you have it. The patient education process is born out of the cultural belief that our
role is to change people. But I believe that our role is to understand people. And that happens primarily
by understanding how dentistry can fit in their lives right now. It happens through a series
of lifestyle conversations that replace those about the number of overhangs and malocclusions.
We save those technical conversations for consent purposes, but not for case acceptance conversations.
MD: For some dentists reading this column, their heads will snap around because, from day one, they
bought into this culture of having a technical conversation being one of the most basic truths in dentistry.
What would it take to change that part of the culture? Could it ever happen?
Interview with Dr. Paul Homoly45
46 Interview with Dr. Paul Homoly
PH: Yes, through articles like this, Mike. Realize that, at one time, the whole idea of anteriorguidance
was ridiculous. If you go back far enough into dentistry, the movement of the mandible
was allegedly believed to be controlled by posterior determinants, condylar angles, and cusp-fossa
angles. Remember that? Once the whole concept of anterior-guidance was introduced, dentists
said, “Ah, okay.” And once they understood anterior-guidance, it made understanding the rest of
the mouth easier, right?
This is similar; it’s just a matter of getting to a tipping point. The illustration on page 43 (Figure 1)
shows the level of case acceptance relative to the size of the dental fee. The case acceptance stays
fairly level at 80 to 90 percent or higher up to about the $2,500 to $3,000 fee level. Then after the
fee goes above $4,000, it’s a straight nosedive down to $10,000 plus.
Now, the second illustration (Figure 2) on page 44 is the same graph, but this time, it has two arrows
pointing up. On the left side, between 3000 and the 0, an arrow points up indicating a rise in
the dental IQ. On the right side, the arrow will be twice as big because, if the patients have twice
the number of problems, they will need twice the amount of education. Historically, that’s what we
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
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
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
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
$1,000 $3,000-$5,000 $10,000+
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
MD: What’s a good starting point for dentists to evolve their thinking along these
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
48 Interview with Dr. Paul Homoly
Perception is the only reality
Four crowns. Four price tags.
Can technicians and dentists tell the difference?
– ARTICLE by Kelly Fessel Carr, Editor of LMT
– Reprinted with permission from LMT’s September 2008 Issue
Can technicians and dentists tell the difference between a $25 crown and a $325 crown?
The answer, for the most part, is “no!” according to an exclusive Lab Management Today
(LMT) research study.
LMT selected four crowns from four different laboratories that participated in its 2007 Crown Challenge, a competition
in which 228 individuals and technician teams fabricated the same crown using the same prescription and duplicate
models provided by LMT. LMT chose these four crowns in particular because they had price tags that differed by $100,
starting at $25 and topping out at $325. It’s important to note that the LMT Crown Challenge participants were knowingly
putting their best foot forward in hopes of winning the competition, meaning this is not a random sampling.
LMT traveled the country to ask dentists and technicians to examine these four crowns on the models and match them
with the correct price tag. Of the 70 dentists who participated, only 3 percent matched all four crowns correctly; among
the 106 technician participants, only 10 percent did so.
Four crowns were fabricated for LMT’s 2007 Crown Challenge using the following prescription: Pin and section the master model and die,
and fabricate a PFM crown in shade VITA A3.5, using a noble alloy, for tooth 14 with a small circumferential metal collar. Place some light fissure
staining in the occlusal grooves to simulate a lifelike appearance.
Please note that the crowns and models may have marks on them from the articulating paper used during evaluation.
Crown 1 : $125. Fabricated by a 10-person full service laboratory located in the Southeast.
50 Perception is the Only Reality
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
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
• Nearly half of the technician-participants correctly identified the $325 crown; only 32 percent of dentist-participants
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
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
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 : “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 : “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
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
The second force in our evolution is environmental. It is the environment, through natural selection processes, that allows
individuals (and their progeny) to survive with a variety of naturally occurring genetic mutations. 7 If a mutation in
one’s anatomy (e.g., size, color, intelligence) gives an advantage to a family in a particular environmental setting, they
will reproduce successfully and thrive as compared to a poorly endowed group who may become extinct during the
ever-present competition for limited nutrition and living space (natural selection).
56 The Evolution of Human Occlusion
Figure 1: Man’s evolutionary development from the ape-like Ramapithecus to modern (Cro-
Magnon) man. It now is believed that the Neanderthals are an offshoot of our species rather
than a direct ancestor.
Successful genetic traits, which have remained stable
over thousands of generations of changing environments,
are strong evidence of positive, well-established,
“normal” phenotypes. Any dental trait (tooth design, jaw
shape, and so on) which has lasted unchanged over the
millennia of our species’ existence must be considered
essentially successful and thus be the norm (“normal”). 10
We know that these traits (e.g., flat plane occlusion) have
evolved and were perfected, so to speak, by natural selection
because they have functioned and continue to
function sufficiently well to ensure continued survival
and success to the humans who have possessed them.
Those individuals whose anatomy deviated from these
traits (mutations) are extinct, attesting to the lack of benefit
derived from the deviated traits.
To identify what is normal occlusion, we must study the
occlusions of our ancestors (evidence-based research)
and, especially, the occlusions of modern (Cro-Magnon)
man in today’s third world and first world societies. By
doing this, important lessons can be learned regarding
what our occlusion is, what it should be, and how we can
treat associated pathology successfully.
Figure 2: An australopithicine skull, more than two million years old,
showing flat plane occlusion acquired by heavy dental attrition.
Flat plane occlusion
The earliest pre-human and human-like animals (the
australopithicines, Homo erectus, Homo hablis, the Neanderthals)
lived in an environment in which the occlusion
was worn quickly (Figures 1–5). 8 Pointed cusps and
deep fossa of new teeth, which served the purpose of
efficient eruption and positioning, were flattened quickly
by coarse, gritty diets and constant, day-long chewing,
as were the grooved occlusal anatomy and pointed interproximal
contacts of new teeth. 5,8,11 Soft, nonabrasive
food was rare, and the life span essentially was determined
by the ability to chew enough food adequately
to extract sufficient nutrition to survive. 7 The lack (until
recently) of fossils and historic skeletons with cuspal occlusion
or less than half of their natural teeth attest to the
fact that early man needed his teeth to survive. In a study
of more than 10,000 ancient skeletons worldwide, fewer
Figure 3: Homo erectus skull, approximately one million years old,
showing flat plane occlusion and an edge-to-edge bite.
The Evolution of Human Occlusion57
than 0.02 percent had cuspal occlusion. 7,8,11-16 In ancient times, life was brutish, mean, and short. Maintaining cuspal
occlusion or losing too many teeth would reduce chances of survival. 15
Early man and many present-day residents of third world nations chewed and lived with flattened, well-worn teeth
(Figures 5–9). 11-15 This condition is termed flat plane occlusion (Figure 6). 12,15 In flat plane occlusion, the occlusal table
is predominately flat. The teeth have low (if any) cusps and shallow fossa. The interproximal areas are worn nearly
flat so that teeth contact each other on a broad surface area (Figure 5). The interproximal distance between teeth is
shortened. There is essentially no canine rise and little incisor guidance. The bite often can be slipped into an edge-toedge
relationship in which centric occlusion (the maximum interdigitation of the teeth) becomes centric relation (the
occlusion manifested by the most superior position of the mandibular condyle in the glenoid fossa). 3 The jaw can slide
easily into all excursions, including protrusion and lateral directions, with most teeth contacting each other. 11,12,15,18 This
condition represents a range of wear in which cusp inclines may vary slightly (between 0 and 20 degrees) and some
teeth may not occlude in concert with their neighbors. Generally, every tooth is naturally flattened and equilibrated
with the others (Figures 5 & 6). 8,11,12
Heavy dental wear is the primary source of flat plane occlusion
(Figures 5, 6, & 8). The most common cause (seen
today and assumed historically) is fine abrasives in food
and a relatively long period of mastication each day. Eating
gritty food contaminated with sand or earth from the
natural environment or from worn millstones (used in
pre-industrial societies) gradually will lead to flat plane
occlusion. Based on skull studies from all societies in human
history (except recently in the industrial world), this
condition has been the norm for most of mankind since
the time of the australopithicines (4 million years ago)
(Figures 1–5). 8,12,16 Essentially, everyone had flat plane occlusion.
Cuspal occlusion in adults was rare (Figure 6).
Flat plane occlusion
compared to cuspal occlusion
People currently living in industrialized societies possess
predominately cuspal occlusion. 8,11,12,15 This form of occlusion
is seen in the majority of patients. This is caused
by the lack of tooth attrition and, with few exceptions,
was first noted 250 years ago when metal rollers replaced
the grit-producing grinding stones used in food production.
7 With cuspal occlusion, the teeth maintain their
cusps and fossa.
Flat plane occlusion is the main chewing system of prehistoric
and non-industrialized man. 8,12 In flat plane occlusion,
the occlusal tables are flat, reducing prematurities
and traumatic occlusions that occur frequently in
people who have cuspal occlusion. With low or nonexistent
cusps, cracked cusp syndrome and fracturing is rare.
Patients with cuspal occlusion suffer greatly from these
problems, especially as they age and undergo dental
restorations, which allow chewing pressures to fracture
weakened cusps (Figure 6).
In flat plane occlusion, the mandible is free to move, unrestricted,
to any position of the mouth (e.g., occlusolaterly),
reducing excessive stresses (e.g., traumatic oc-
58 The Evolution of Human Occlusion
Figure 4: A Neanderthal skull, approximately 200,000 years old, showing
flat plane occlusion and perfect orthodontic tooth alignment.
Figure 5: Occlusion of modern man (circa 1000 BC) showing flat plane
occlusion. Note the flattened interproximal tooth contacts, which
stabilize the arch, and minimal occlusal groves and fossa, which could
attract plaque and decay.
this condition has been the norm
for most of mankind since the time of
the australopithicines (4 million years ago).
clusion) on individual teeth and the temporomandibular
joint (TMJ). 8,15 This condition is seen often in today’s children.
9 The anterior teeth, unlike those seen in modern
adult populations, are worn down quickly to a shape
that renders them occlusally inert. 11,12,18,19 There is little or
no incisal guidance, no canine rise, and the anterior occlusion
often is noted as being edge-to-edge (Figures 2 &
3). 5,7,8,11,18 In modern populations, with less tooth wear, anterior
teeth will restrict and “guide” excursive jaw movements,
sometimes resulting in stressed periodontium and
TMJ tissues. 3,12,15,20
Tooth malalignments are rare in flat plane occlusion because
the inherently unstable “point” interproximal tooth
contacts seen in cuspal occlusion are worn down quickly
to flat, broad, stable surfaces reminiscent of stone blocks
in a Roman arch (Figures 2–9). In cuspal occlusion, because
of the rounded interproximal contacts, tooth slippage
(buccally or lingually) occurs easily, contributing to
dental malalignments in the arch and future periodontal
pathology (Figure 6). 8,11,13
In flat plane occlusion, mesial drift and interproximal
wear, which often amount to 1.0–1.5 cm per arch, provide
added arch space for the eruption of most third molars,
reducing the incidence of impactions (Figure 6). 5,8,11 In
cuspal occlusion, this beneficial wear is minimal, leaving
a longer tooth-filled arch and causing a higher incidence
of impacted third molars and associated pathology. 13 Until
recent times, this was a major cause of mortality and morbidity
(natural selection). If one of our predental treatment
ancestors developed pericornitis around an impacted
third molar, there was a high probability of the genetic
lineage being terminated.
In flat plane occlusion, crowding of mandibular anterior
teeth seldom is observed because heavy interproximal
wear compensates for the loss of arch space due to the
natural lingual tipping of the anterior teeth (Figures 8 &
9). 8,17 In populations with cuspal occlusion, lower incisor
tipping is a serious cause of crowding and orthodontic
Figure 6: Comparison of flat plane occlusion and cuspal occlusion.
(A) Interproximal contacts are pointed in cuspal occlusion, permitting
tooth crowding. (B) Flat plane occlusion’s flattened contacts stabilize
the arch, preventing crowding. (C) Interproximal wear in flat plane occlusion
allows more space for third molar eruption and less space for
interproximal plaque accumulation (periodontal disease). (D) Flat plane
occlusion reduces occlusal food traps and fractured cusps.
Figure 7: The face of this South American Yanomami Indian typifies
the hypertrophied jaw muscles often seen with flat plane occlusion.
These third world people chew a tough, gritty diet for the entire day. As
a result, they rarely report bruxing or experience TMD.
In today’s populations who exhibit flat plane occlusion
(e.g., the non-industrialized third world), chewing is an
important activity and is done throughout the day (Figures
7–9). 15 Because of the toughness of the diet, long periods
of mastication are needed to process food. Essentially,
these people graze all day long on tough, fibrous, low
calorie material. They generally are thin, comfortable, and
The Evolution of Human Occlusion59
appear to gain some psychological satisfaction from the habit. 12,15 Often their jaw muscles are hypertrophied, presenting
the appearance of a wide middle face (Figure 7). 15 TMD is rare. 8,11,15,16
By contrast, in Western societies, chewing times are reduced and usually restricted to soft foods at short prescribed
mealtimes. 16 Apart from meals, mastication generally is limited to soft, high calorie snacks (often eaten all day long)
and softer chewing gum, with many episodes of destructive bruxing apparently fulfilling a need to further exercise the
mastication muscles. 5,12
Flat plane occlusion reduces the size of the tooth’s occlusal fossa and developmental grooves. Often the tooth becomes
a smooth, flat table of enamel and hardened, sclerosed secondary dentin, which is less likely to retain food or promote
decay (Figure 5). There is no apparent loss in nutrition due to the reduced efficiency in this form of occlusion.
Frequently, the enamel edges of the occlusal surface acquire a sharpness, which aids in mastication (thegosis). Cuspal
occlusion, though somewhat more efficient in mastication because of the teeth’s pointed cusps and inclined planes,
provides opportunistic food collection sites and leads to tooth decay and cusp fracture (Figure 6). 7,11-16
Flat plane occlusion causes flattening of interproximal contacts and, with the help of mesial drift, reduction of the
interproximal space between teeth. This in turn reduces the amount of food that can collect in these areas and helps
limit related decay and periodontal disease until old age (Figure 6). 5,11,14-16 As the teeth gradually wear, they slowly erupt,
re-establishing any lost vertical dimension. 10,12
Disadvantages of flat plane occlusion
Because flat plane occlusion relies on tooth wear, it is
possible that people may wear their teeth down to a point
where vertical dimension is lost and chewing is uncomfortable.
Resultant pulp exposures and TMJ strain could
have an adverse effect on health. Severe wear and pulp
exposures would tend to cause starvation unless the society
is supportive (e.g., providing special diets or prechewed
food), which rarely occurs historically.
Excessive interproximal attrition eventually can change
the tooth anatomy to such a degree that increased food
impaction promotes decay and periodontal disease. Tooth
loss from periodontal disease is common in older “primitive”
people. 15-18 It appears that a moderate amount of
tooth attrition is beneficial, while an excessive amount of
wear eventually is harmful. 5,7,8,10-12
Figure 8: The flat plane dentition of a Yanomami Indian. Note that the
lack of anterior crowding, incisal guidance, and canine rise allows centric
relation to be equal to centric occlusion. The jaws can slide easily
to any position with the teeth in full intercuspation.
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
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
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
Do not build up or restore high cusps, especially on the canines (canine rise). This creates uneven forces, resulting in
TMJ stress and traumatic occlusion. Let the patient’s natural wear patterns guide you. Reconstruct crowns to a morphology
similar to the neighboring teeth. Avoid placing a 20-year-old’s crown anatomy in a 50-year-old’s mouth.
Like natural attrition, these changes must be done gradually, as if the patient were eating pumice on French fries. Follow
the patient’s physiology and jaw movements rather than depending on artificial programs or measuring devices,
which exhibit an inferior and limited design compared with the patient’s jaws and TMJ. Be practical and responsive to
the patient’s symptoms and needs. Reshape teeth as they need repair. Do nothing extreme. If there is an improvement,
The Evolution of Human Occlusion61
your patient will inform you so that you may continue. If not, you may have to rely on the older, traditional dental
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
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.
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.
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
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;
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-
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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