Chairside - Glidewell Dental Labs

glidewelldental.com

Chairside - Glidewell Dental Labs

Chairside®

A Publication of Glidewell Laboratories • Volume 7, Issue 2

Photo Essay

Technique for Restoring

Tetracycline-Stained Teeth

Page 14

Repair, Don’t Replace a

Fractured PFM Bridge

Dr. Robert Lowe

Page 19

One-on-One Interview

Master Educator Dr. Lee Ann Brady

Talks Restorative Dentistry

Page 42

Dr. Len Boksman and

Gregg Tousignant, CDT

Things to Consider When Choosing an

Impression Material for Your Practice

Page 35

Dr. Michael DiTolla’s

Clinical Tips

Page 9

COVER PHOTO

Mia Gendreau, Digital Support Technical Advisor, All-Ceramic Department

Glidewell Laboratories, Newport Beach, Calif.


Contents

9 Dr. DiTolla’s Clinical Tips

This issue features four new products that are making it

easier and faster to practice dentistry: the next-generation

formula of Luxatemp provisional material from DMG

America; Centrix GripStrip proximal finishing and polishing

strips; Picasso Lite, an affordable diode laser from AMD

LASERS; and VOCO America’s easy-to-use Rebilda Post

System for endodontic post cementation and core build-up.

14 Photo Essay: Porcelain Veneers for

Tetracycline Using Blockout Method

REALITY Publishing’s Dr. Michael Miller illustrates a

common esthetic challenge we face as dentists: placing

porcelain veneers on tetracycline-stained teeth. See what

techniques this leading clinician uses to mask the stains

and satisfy the patient’s desired tooth color change.

19 Repair, Don’t Replace – Part 1:

Resurfacing an Existing Porcelain

Fused to Metal Restoration with a

Porcelain Veneer

What’s the best way to handle a broken porcelain or

PFM restoration? While the traditional practice is to use

composite resin to repair the chipped porcelain, find

out why Dr. Robert Lowe thinks porcelain veneers are

a better treatment option, especially when dealing with

multiple-unit fixed bridgework.

27 Repair, Don’t Replace – Part 2:

The “Saddle Crown”

In Part 2 of his series on repairing a fractured porcelain

bridge, Dr. Robert Lowe presents a second case

involving a larger fracture exposing the underlying metal

framework. Discover why cementing a modified crown

covering only the facial and lingual surfaces can, in some

cases, be an effective alternative to replacing the entire

multi-unit restoration.

Can’t get enough Chairside? Be sure to check out Chairside Live,

our new Web series featuring dental news, a Case of the Week

from Dr. Michael DiTolla and more — now available on YouTube,

iTunes and at www.chairsidemagazine.com!

Contents 1


Contents

35 Faster Is Not Always Better When It Comes

to Impressioning

When it comes to impression materials, the product

you use can significantly impact the final fit of your

restorations. Exploring the pros and cons of fast-setting

versus standard impression materials on the market today,

Gregg Tousignant, CDT, and Dr. Len Boksman discuss the

many things to consider when choosing a new impression

material for your practice.

42 One-on-One with Dr. Michael DiTolla:

Interview of Dr. Lee Ann Brady

A nationally recognized dental educator who recently reentered

private practice, Dr. Lee Ann Brady has taught at

two of the top continuing education centers alongside some

of the industry’s biggest names. Spend some time with

this experienced clinician in this lively interview covering

occlusion, adhesion, preparation, dental photography and

topics in between.

57 An Introduction to Dental Photography

Keeping photographic records of your dental cases can

be an important part of promoting your dental practice

and increasing your case acceptance. In this brief tutorial,

Dr. Carlos Boudet introduces a simple but effective way of

documenting your cases with dental photography.

Glidewell Publications for iPad

iPAD APP Experience Chairside magazine

on the iPad. Search “Glidewell” in

the iTunes Store and download the free

Glidewell Publications app.

62 Biologic Shaping: An Alternative to

Extracting a Tooth with a Severe Fracture

Extraction is a commonly considered treatment when

dealing with a tooth that fractures subgingivally,

but it isn’t the only option. Biologic shaping, argues

Dr. Daniel Melker, is another, more conservative procedure

that can lead to long-term stability and a successful

restorative outcome.

ALSO IN THIS ISSUE

8 By the Numbers

65 Figures in Dentistry Spotlight

68 The Chairside Photo Hunt

2

www.chairsidemagazine.com


Publisher

Jim Glidewell, CDT

Editor-in-Chief and Clinical Editor

Michael C. DiTolla, DDS, FAGD

Managing Editors

Jim Shuck; Mike Cash, CDT

Creative Director

Rachel Pacillas

Copy Editors

Jennifer Holstein,

David Frickman, Megan Strong

Statistical Editor

Darryl Withrow

Digital Marketing Manager

Kevin Keithley

Graphic Designers

Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame,

Phil Nguyen, Kelley Pelton, Makara You

Web Designers

Jamie Austin, Lindsey Lauria,

Melanie Solis, Ty Tran

Photographer

Sharon Dowd

Illustrator

Wolfgang Friebauer, MDT

Coordinator and Ad Representative

Teri Arthur

(teri.arthur@glidewelldental.com)

If you have questions, comments or complaints regarding

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

chairside@glidewelldental.com. Your comments may be

featured in an upcoming issue or on our website:

www.chairsidemagazine.com.

© 2012 Glidewell Laboratories

Neither Chairside magazine nor any employees involved in its publication

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

liability

Neither

or

Chairside

responsibility

Magazine

for the

nor

accuracy,

any employees

completeness,

involved

or

in its

usefulness

publication

of any

(“publisher”),

information,

makes

apparatus,

any warranty,

product,

express

or process

or implied,

disclosed,

or assumes

or

represents

any liability

that

or

its

responsibility

use would

for

not

the

infringe

accuracy,

proprietary

completeness,

rights. Reference

or usefulness

herein to

of any

any

information,

specific commercial

apparatus, product,

products,

or

process,

process disclosed,

or services

or

by

represents

trade name,

that its

trademark,

use would

manufacturer

not infringe proprietary

or otherwise

rights. Reference

does not

necessarily

herein to

constitute

any specific

or

commercial

imply its endorsement,

products, process,

recommendation,

or services by

or

favoring

trade name,

by the

trademark,

publisher. The

manufacturer

views and

or

opinions

otherwise

of

does

authors

not

expressed

necessarily

constitute

herein do not necessarily

or imply its

state

endorsement,

or reflect

recommendation,

those of the publisher

or favoring

and

shall

by

not

the

be

publisher.

used for

The

advertising

views and

or product

opinions

endorsement

of authors expressed

purposes.

CAUTION:

herein do

When

not necessarily

viewing the

state

techniques,

or reflect those

procedures,

of the publisher

theories

and

and

materials

shall not

that

be

are

used

presented,

for advertising

you must

or

make

product

your

endorsement

own decisions

purposes.

about

specific

CAUTION:

treatment

When viewing

for patients

the techniques,

and exercise

procedures,

personal

theories

professional

and materials

that

judgment regarding

are presented,

the need for

you

further

must make

clinical

your

testing

own

or

decisions

education

about

and

your

specific

own

treatment

clinical expertise

for patients

before

and

trying

exercise

to implement

personal

new

professional

procedures.

judgment

regarding the need for further clinical testing or education and

your own clinical expertise before trying to implement new procedures.

Chairside is a registered trademark of Glidewell Laboratories.

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.

Editor’s Letter

I have always thought it would be a good idea to do an

educational video that focused strictly on restorative

repairs, but this has proven to be a more difficult program

to put together than I expected. It’s not as if fractured

ceramic restorations walk through the door every day, yet

when they do, it sure is nice to have a good solution. So

I thought the next best thing would be a pair of articles

on repairs from Dr. Robert Lowe, a frequent contributor

to Chairside.

In Part 1, Bob shows you how he repairs a broken PFM

restoration with a porcelain veneer, or more specifically,

how he gives new life to an old PFM by “resurfacing” it with

a porcelain veneer. This strategy works well when the metal

substructure is not completely exposed.

In Part 2, Bob makes use of a “saddle crown” to cover a

fully exposed metal substructure, which he has prepared to

give the saddle crown adequate strength and esthetics. This

technique can be extremely helpful when you have completed

a large anterior bridge, for example, and something

chips or breaks within the first year.

The other thing that made me abandon the idea of putting

together a video on repairs is the shrinking number of

repairs I’ve had to do since becoming a predominately

“monolithic” dentist. In other words, I use a lot of

IPS e.max ® in the anterior and a lot of BruxZir ® Solid

Zirconia in the posterior, and I just don’t see either of

these restorations fracturing.

Even though I haven’t done a single-unit PFM in years, I

still use PFMs for bridges. As any bilayered restoration has

the potential for those layers to separate, Bob’s repair techniques

will continue to be useful for the foreseeable future.

Yours in quality dentistry,

Dr. Michael C. DiTolla

Editor-in-Chief, Clinical Editor

mditolla@glidewelldental.com

Editor’s Letter 3


Letters to the Editor

Dear Dr. DiTolla,

Thanks for another great issue of Chairside.

We were disappointed that we received the

Fall 2011 issue on Jan. 2 and the contest

deadline was Dec. 30.

I am using Capture ® impression material

now and am very happy with it. I am using

the green light body. Is there any reason

why you favor the purple medium body over

the green?

I impressed my first no-prep veneer case

(tooth #8–11, with an implant on tooth #7)

this week. Your DVD videos are great! To

prepare, I watched the video online on

tissue contouring and placement of no-prep

veneers (“Diagnosis & Placement of No-

Prep Veneers”), which was very helpful, in

addition to reading Dr. Robert Lowe’s article

in the Winter 2012 issue of Chairside. Is there

a reason why you don’t retract the tissue for

these no-prep veneers? Dr. Lowe seems to

make a very strong case to do so. Either

way, I contoured one area and did pack cord

(no offense!).

What cement are you using to cement these

veneers?

Once again, thanks for teaching me the

dentistry I practice with every day!

– Robert M. Lieder, DDS

Baltimore, Md.

4

www.chairsidemagazine.com

Dear Robert,

Thanks for the kind words!

That early due date was a mistake on

our part, and we will do our best to

make sure it doesn’t happen again.

I use the medium body (purple) as

my syringe material, just to make sure

it doesn’t tear because I get it to go

about 1 mm into the sulcus with the

two-cord technique. Also, it will often

set in contact with the #00 cord, which

can increase the chances of it tearing.

The medium body prevents that

from happening.

Because the margins of no-prep/minimal

prep veneers tend to make a little

speed bump on the tooth, due to there

typically being no prep at the margin,

I prefer to leave that bump at the free

margin of the gingiva, rather than

placing it subgingivally. With conventionally

prepped veneers, I always

place the margins subgingival.

As for not retracting the tissue, that’s

just my personal preference. You

won’t go wrong following Bob Lowe’s

method when it comes to any aspect

of clinical dentistry. He continues to

be one of my clinical mentors, which

is why his articles are in nearly every

issue of Chairside.

My favorite veneer cement continues

to be the translucent shade of NX3

Nexus ® Third Generation from Kerr,

which is something Bob Lowe and I

definitely agree on.

Hope that helps!

– Mike

Dear Dr. DiTolla,

I enjoyed reading the “Figures in Dentistry

Spotlight” on G.V. Black in the Fall 2011 issue

of Chairside. Unfortunately, there was no

mention of his most important contribution

to dental literature, “The Pathology of the

Hard Tissues of the Teeth,” first published in

1906. Most dentists have never heard of this

book, but as I was studying ways to control

caries with a medical model, I ran across a

reference to the book. It took awhile to find

a copy, but when I finally read it, I was totally

blown away by the advanced understanding

that G.V. Black had about the microbiology

of caries. His chapter on treating children

is more advanced than any pediatric dental

text I have ever read, and I have read them

all. I would encourage you to take a look

at this classic. Attached is a little paper

that talks about G.V. Black’s volume in the

context of advances in cariology.

Best wishes,

– Steve Duffin, DDS

Portland, Ore.

Dear Steve,

Thanks for sending me your paper.

I really enjoyed reading it! With

your permission, I would love to

publish your paper in a future issue

of Chairside.

– Mike

Dear Dr. DiTolla,

First, I want to say how much I enjoyed

your recent webinar (“State-of-the-Art

Impression Techniques,” hosted by Catapult

University). What a great way to learn!

I hope it becomes a regular occurrence.

Can you e-mail me about the burs you use

for your crown preps? What brand do you

use? I like the whole idea and am looking

forward to trying the technique. I plan on

doing a lot more BruxZir crowns.

Thanks again,

– Grigg DeWitt, DDS

Salinas, Calif.

Dear Grigg,

Thanks for the kind words!

The burs I use to prep are from the

Reverse Preparation Set from Axis

Dental, available through all dental


dealers. It’s a universal prep technique

that works for all materials, although

as the next letter in this section points

out, the strength of BruxZir ® Solid

Zirconia is starting to change how

much we have to reduce, especially at

the margin.

– Mike

Dear Dr. DiTolla,

First, thank you very much for your

educational support and updated dental

market information. The latest issue of

Chairside (Vol. 7, Issue 1) includes your

very interesting and helpful article “BruxZir ®

Solid Zirconia Anterior Esthetic Challenge.”

I would appreciate it if you could give me

information about labial and palatal crown

thickness (Figs. 31–34). I wonder why you

used a shoulder preparation technique

when the BruxZir website says that feather

edge is acceptable?

Cordially,

– Alex Zavyalov, DDS

New York, N.Y.

Dear Alex,

Good question! I guess the best

answer is that having spent the last

20 years prepping all-ceramic crown

preps at a certain thickness, old habits

die hard. My Reverse Preparation

Technique uses a round bur to ensure

that I get 1 mm of reduction in the

gingival third to help the esthetics and

the emergence profile. As you pointed

out, BruxZir ® Solid Zirconia is the

one monolithic material (besides cast

gold) that can handle a feather-edge

margin, and we are just getting started

with a Minimal Prep Crown Project to

see just how little we can reduce an

anterior tooth and still have a decentlooking

BruxZir crown. Imagine if we

could prep a tooth and stay within the

enamel, yet be able to cement a highstrength

all-ceramic crown, rather

than bonding a veneer. So, yes, even

though I did not prep conservative

margins on those teeth, you certainly

can prep those types of margins with

BruxZir crowns. Even if you were

worried about esthetics on the facial,

you could still prep a conservative

margin on the lingual.

– Mike

Dear Dr. DiTolla,

Regarding Dr. Ellis Neiburger’s article

in the last issue of Chairside, “Is It Time

to Do Routine Adult Pulpotomies?”

(Vol. 7, Issue 1), there should have been

more discussion about using lasers to sterilize

the pulp instead of formocresol, and

other options instead of IRM, like MTA.

– Brian Danielsson, DDS

Ridgecrest, Calif.

Response from Dr. Neiburger:

Dear Brian,

The article focused on time-tested

pulpotomy techniques that, in light of

the world’s poor economic situation,

can be done easily, quickly and

inexpensively. Laser sterilization of

the pulp chamber is relatively new,

has only a small amount of research

to establish efficacy and requires laser

equipment more costly than a $10

bottle of formocresol. It holds promise

and should be further investigated.

CONNECT WITH CHAIRSIDE

FOLLOW US ON TWITTER

Find us @GlidewellDental

FIND US ON FACEBOOK

Search “Glidewell” to see

what’s new.

ITUNES WATCH AND

LEARN

Go the iTunes store and search

Glidewell.” Plus, download

the free Glidewell Publications

app for iPad.

SHARE YOUR THOUGHTS

Visit www.chairsidemagazine.com

and select “Contact Us.” Or write to:

Glidewell Laboratories

ATTN: Chairside magazine

4141 MacArthur Blvd.

Newport Beach, CA 92660

ACCESS OUR RESOURCES

Clinical videos, product information

and patient resources are a click

away at www.glidewelldental.com.

ADVERTISE/SUBMIT AN

ARTICLE

Call 888-303-4221

Letters should include writer’s full name,

address and daytime phone number. All

correspondence may be published and

edited for clarity and length.

Letters to the Editor 5


Contributors

Michael C. DiTolla, DDS, FAGD

Dr. Michael DiTolla is a graduate of University of the Pacific Arthur A. Dugoni School of Dentistry. As

director of clinical education and research at Glidewell Laboratories in Newport Beach, Calif., 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 experiencing his commitment to

excellence through his prepping and placement of their restorations. He is a CR Foundation 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 or e-mail mditolla@glidewelldental.com.

Leendert Boksman, DDS, BSc, FADI, FICD

Dr. Leendert “Len” Boksman is a former tenured associate professor and adjunct professor at the Schulich

School of Medicine and Dentistry in London, Ontario, Canada, and former director of clinical affairs for

Clinical Research Dental/CLINICIAN’S CHOICE. He retired from practice at the end of 2011, and currently

does freelance consulting and lecturing. He also authors articles of interest to the general practitioner.

Contact him at lenboksman@rogers.blackberry.net.

Carlos A. Boudet, DDS, DICOI

Dr. Carlos Boudet graduated from Medical College of Virginia (now VCU Medical Center) in 1980 with a

DDS degree. Soon after, he became a commissioned officer for the United States Public Health Service. His

tour ended in 1982, when he was asked to serve as director of four dental clinics around Lake Okeechobee,

Fla. Dr. Boudet established his dental practice in West Palm Beach. Fla., in 1983 and has been in the same

location for 26 years. He is a Diplomate of the International Congress of Oral Implantologists, a member of

the Central Palm Beach County Dental Society and sits in the board of directors of the Atlantic Coast Dental

Research Clinic. Contact him at www.boudetdds.com or 561-968-6022.

Lee Ann Brady, DMD

Dr. Lee Ann Brady is a privately practicing dentist and nationally recognized educator and writer. She has

worked in practice models ranging from small fee-for-service offices to large insurance-dependent practices,

as an associate and practice owner. From 2005 to 2008, Dr. Brady held the positions of resident faculty and

clinical director for the Pankey Institute. In 2008, she moved to Scottsdale, Ariz., to join Dr. Frank Spear in

the formation of Spear Education, where she served as executive VP of clinical education until June 2011.

As director of education and president of Lee Ann Brady LLC, she offers daily clinical and practice content

through her website, www.leeannbrady.com, as well as innovative online and live education programs.

Contact her at lee@leeannbrady.com.

6

www.chairsidemagazine.com


Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE

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

a clinical professor in restorative dentistry at the school until its closure in 1993. Since January 2000,

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

frequently published in dental journals on esthetic and restorative dentistry. Dr. Lowe received fellowships in

the Academy of General Dentistry, International and American Colleges of Dentists, Academy of Dentistry

International and the International Academy for Dental-Facial Esthetics, and in 2005, Diplomat status on

the American Board of Esthetic Dentistry. He was also awarded the 2004 Gordon Christensen Outstanding

Lecturers Award. Contact Dr. Lowe at 704-364-4711 or boblowedds@aol.com.

Daniel J. Melker, DDS

Dr. Daniel Melker graduated from the Boston University School of Graduate Dentistry in 1975 with specialty

training in periodontics. Since then, he has maintained a private practice in periodontics in Clearwater,

Fla. Dr. Melker lectures at the University of Florida Periodontic and Prosthodontic graduate programs on

the periodontic-restorative relationship. He also presents at the University of Alabama at Birmingham,

University of Houston, Baylor University and Louisiana State University’s graduate periodontal program.

Dr. Melker has published several articles in national dental magazines, as well as The International Journal

of Periodontics & Restorative Dentistry, and has twice been honored with the Florida Academy of Cosmetic

Dentistry Gold Medal. Contact him at 727-725-0100.

Michael B. Miller, DDS

Dr. Michael Miller is the co-founder, president and editor-in-chief of REALITY, and maintains a dental

practice in Houston, Texas. He is a Fellow of the Academy of General Dentistry, as well as a founding and

accredited member and Fellow of the American Academy of Cosmetic Dentistry, for which he created its

acclaimed accreditation program. Dr. Miller has contributed to several texts and authors regular columns

for General Dentistry, the AGD’s peer-reviewed journal. He is also a founding board member of the National

Children’s Oral Health Foundation. He can be reached at mm@realityesthetics.com.

Gregg Tousignant, CDT

Gregg Tousignant graduated from George Brown College with a dental technology degree in 1992. Two

years later, he earned CDT designation from the National Board for Certification in Dental Laboratory

Technology. He lectures and teaches hands-on courses for the general and cosmetic dentist and at dental

and hygiene schools across Canada on tooth whitening, impressioning, temporization, adhesives, and

direct anterior and posterior composites. Gregg currently serves as manager of technical support for

Clinical Research Dental, where he provides continuing education programs consistent with the company’s

philosophy, “Teaching Better Dentistry.” Contact him at gtousignant@clinicalresearchdental.com.

Contributors 7


Numbers

by the

52%

Percentage of dentists in

Virginia who sent cases to

Glidewell Laboratories in 2011

50,000

Number of case evaluation

slips filled out by Glidewell

customers in 2011

96% MARGINS

Percentage of those

slips marked as

“GOOD”

57%

Percentage of Americans over the

age of 65 who wear either full or

partial removable dentures

Source: www.orawave.com

856,250

Total number of full

or partial removable

dentures fabricated by

Glidewell Laboratories

since 1993

Percentage of

80%

metal-based (PFM and

28%

cast gold) vs. all-ceramic

crowns & bridges

fabricated by Glidewell

Laboratories in 1997

Percentage of

metal-based (PFM and

cast gold) vs. all-ceramic

crowns & bridges

fabricated by Glidewell

Laboratories in 2012

8

www.chairsidemagazine.com


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Rebilda ® Post System

SOURCE........... VOCO America Inc. (Briarcliff Manor, N.Y.)

888-658-2584, www.vocoamerica.com

Considering that placing posts and cores isn’t an everyday procedure

for most dentists, it’s surprising how many e-mails I get asking which

post-and-core system I prefer. I continue to try different systems on an

ongoing basis, but it’s a niche filled with me-too products for the most

part. I recently ordered the Rebilda Post System from VOCO America

and was pleasantly surprised from the moment I opened the box and

found the directions on the lid — the rest of the industry could learn a

thing or two from VOCO about directions! Beyond that, the fiber posts

are highly translucent, while being more radiopaque than the posts I was

using before, and the drill sizes are well-matched to the post sizes. The

kit also includes VOCO’s bonding agent and dual-cure build-up material

to ensure the chemistry will work to provide maximum retention.

Dr. DiTolla’s Clinical Tips 9


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ GripStrip

SOURCE........... Centrix (Shelton, Conn.)

800-235-5862, www.centrixdental.com

It would be impossible to practice modern adhesive dentistry without finishing strips, yet I haven’t seen many

products to get excited about in the last few years. Enter GripStrip diamond-coated strips. Someone really

smart over at Centrix realized how much easier it would be for dental professionals to control the use of metal

finishing strips if there was a better way to hold onto them, and the perforated tabs at either end of these

finishing and polishing strips solve that problem. There is an uncoated zone in the middle of each strip where

there is no abrasive, allowing you to pull it through tight interproximal areas. Each strip also has a 40-micron

grit side for finishing and a 15-micron grit side for polishing. It’s pretty much the perfect interproximal strip.

Here’s hoping they come out with a serrated version for breaking through inadvertently fused contacts.

10 www.chairsidemagazine.com


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Luxatemp ® Ultra

SOURCE........... DMG America (Englewood, N.J.)

800-662-6383, www.dmg-america.com

Has it really been two decades since Luxatemp was introduced? Much like when your oldest child turns

21, this is one of those times when you ask, “Where did the time go?” Maybe it’s because Luxatemp

has been my only chairside temporary material for 20 years, except when using BioTemps ® provisionals.

In the past, I hated not being able to reline BioTemps with Luxatemp, due to its quick-setting reaction.

It was the only time I would have to break out the stinky methyl methacrylate. The new Luxatemp Ultra

has an elastic phase, so you can pump the BioTemps up and down on the preps to ensure they don’t get

stuck in an undercut. Now, after being my longtime chairside temporary material of choice, Luxatemp’s

newest formulation has become my BioTemps reline material of choice as well.

Dr. DiTolla’s Clinical Tips11


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Picasso ® Lite

SOURCE........... AMD LASERS ® LLC (Indianapolis, Ind.)

866-999-2635, www.amdlasers.com

I use my diode laser on nearly half of my patients, typically for small amounts of gingival recontouring or

pre-impression troughing. There really isn’t any other instrument that can do what the diode does as quickly

and as bloodlessly. When I ask most dentists why they don’t have a diode laser in their operatory, it’s always

the same answer: “I’m waiting for the price to come down.” Good news: That day has come. The affordable

laser is here. You can now have a full-featured Picasso Lite diode laser in your practice, without losing any

sleep over what you paid for it. Whether you use it to clean up tissue prior to taking an impression or seating

a crown, perform a gingivectomy next to Class V decay, or make the clinical crown length of tooth #8 match

tooth #9, you’ll wonder how you ever lived without your Picasso Lite.

12 www.chairsidemagazine.com


Photo Essay

Porcelain Veneers for Tetracycline

Using

Blockout

Method

– ARTICLE and CLINICAL PHOTOS by

Michael B. Miller, DDS

NOTE FROM THE EDITOR: I don’t know how

many dental books you own, but I have a

couple of cabinets full of them. Most of them

start gathering dust after my initial read, some

come out a couple times per year (especially my

favorite local anesthesia book), but only one

has its own permanent parking spot on my

desk: REALITY Publishing’s “The Techniques:

Volume 1.” This publication, based on everyday

applications of research and clinical

experience, is the greatest gift young dentists

could receive to help them achieve success in

esthetic dentistry. It is also a useful reference

manual for us older dentists. Dr. Michael Miller

put this volume together and has been generous

enough to share excerpts of it in Chairside. In

this installment, Dr. Miller shares an esthetic

challenge we have all faced: placing porcelain

veneers on tetracycline-stained teeth. Visit

www.realityesthetics.com for more infor mation

on REALITY’s various publications.

14 www.chairsidemagazine.com


1

2

3

4

5

Figures 1–5: Patient, with recently completed orthodontics and

maxillary all-ceramic crowns on incisors and porcelain veneers on

canines and premolars, wants mandibular veneers to mask tetracycline

stains, despite not showing his mandibular teeth in a full smile. This

type of color change can be done with an extended regimen of home

bleaching instead of the expense and invasive nature of veneers, but

patient wants immediate improvement and is not concerned about the

upkeep necessary or cost for veneers.

Note that the tetracycline stains are in the incisal half of each tooth,

except for the central incisors, where the stains extend almost to the

gingival crest. Masking stains in the more incisal portions of the teeth is

much easier than when the stains are at the gingival margins. Because

the stains are more incisal, the gingival color is quite normal.

Porcelain Veneers for Tetracycline Using Blockout Method15


6

Figure 6: Cord is placed prior to the preparation to accelerate the

procedure.

7

Figure 7: Finished preparations. Note that tetracycline teeth usually

become darker when they are prepared. The bonded lingual retainer

obviously eliminates interproximal extensions.

8

9

Figures 8, 9: Areas of preparations not to be masked with opaquer are covered with resin blockout material. Only dark stained areas need to be masked.

Resin blockout material keeps etchant and adhesive off stained areas.

10

Figure 10: Opaquer has been applied to dark stained areas after

etching and adhesive application. Even though the preparations are

relatively aggressive, mandibular teeth cannot be reduced to the extent

possible for larger maxillary siblings. Therefore, the opaquer must be

kept quite thin.

11

Figure 11: Resin blockout has been removed. Note that only darkstained

areas are covered by the opaquer.

16 www.chairsidemagazine.com


12

Figure 12: Veneers returned from the lab. Note that, despite their

polychromatic buildup, the veneers have built-in masking ability. This

built-in masking can eliminate the need to apply opaquer directly

on the teeth in all but the darkest cases, assuming the veneers are at

least 1 mm thick.

13

Figure 13: Mandibular anterior teeth at luting appointment two weeks

after preparations. No provisionals were placed, but tissue is still

inflamed.

14

15

16

17

Figures 14–17: Postoperative views two months after seating veneers. Maxillary and mandibular restorations match perfectly. There is no evidence of

dark stains and tissue health has improved. Patient has been using an electronic interproximal cleaning device, which may have caused minor recession

of papillae. CM

Dr. Michael Miller is the co-founder, president and editor-in-chief of REALITY. He maintains a dental practice in Houston, Texas. Contact him at mm@realityesthetics.com.

Reprinted by permission of REALITY Publishing. REALITY: The Information Source for Esthetic Dentistry, The Techniques, Volume 1, 2003, REALITY Publishing Company,

pp. 272–74.

Porcelain Veneers for Tetracycline Using Blockout Method17


Repair,

Don’t

Replace

Part 1

Resurfacing an Existing Porcelain Fused to

Metal Restoration with a Porcelain Veneer

– ARTICLE and CLINICAL PHOTOS by

Robert A. Lowe

DDS, FAGD, FICD, FADI, FACD, FIADFE

Introduction: The Porcelain “Repair”

Repairing a broken porcelain (or porcelain-fused-to-metal)

restoration is a clinical reality in every dentist’s practice.

The traditional technique is to use composite resin to repair

chipped porcelain. This is an attempt to use unlike materials

to accomplish a long-term repair, but it rarely works.

Early “porcelain repair kits” used 37 percent phosphoric

etch, silane primer, and adhesive and composite resin to

repair chipped porcelain. This system did not work because

37 percent phosphoric acid cannot appreciably etch a

porcelain surface. Without adequate micromechanical retention

to affix the composite resin to the porcelain surface,

any repair will likely not withstand the forces of mastication.

The use of hydrofluoric acid provides an adequate etched

surface to create an improved micromechanical bond of

composite to porcelain. However, the bond of composite

to porcelain is not the only clinical problem. Another is the

finishing and polishing of the porcelain-composite interface.

Regardless of the finishing and polishing technique and

materials used, the fine line of demarcation between the

composite and porcelain is hard to eradicate.

Repair, Don’t Replace – Part 119


Figure 1: A smile in need of a remake. The patient requested a porcelain

makeover of the esthetic zone with occlusal corrections to prevent future

porcelain fracture. The posterior bridgework is clinically acceptable; however,

the anterior abutments in the esthetic zone will require resurfacing to

match the anterior units.

Figure 2: Preparations for porcelain veneers on tooth #27 and #28. The

small metal exposures will not appreciably affect the bond of the veneers

to the porcelain surface.

Figure 3: A 2x magnified facial view of the veneer preparations

Figure 4: A dentin desensitizer with antibacterial agent (AcquaSeal B,

AcquaMed Technologies) is applied to cleanse the prepared tooth surface

prior to the etching procedure.

If the broken restoration is a single unit, a complete remake

may be the most predicable solution. But what about

multiple-unit fixed bridgework? It may not be feasible

economically or clinically to sacrifice a long-span restoration

for one unit with a porcelain fracture. In esthetic cases, a

clinically acceptable posterior bridge may not be the same

shade as the one chosen for the anterior reconstruction. So,

for these clinical problems, is there a long-term solution

short of replacing the entire restoration?

Reveneering Existing Porcelain Restorations

The patient in Figure 1 presented with the desire to remake

his porcelain reconstruction. Some of the anterior units

were fractured due to occlusal issues. The patient’s desire

was to remake the restorations in the esthetic zone with a

high value shade. The posterior bridgework was clinically

acceptable, but the shade was much lower in value and hue

than the desired anterior shade. Figure 2 shows a segment

of this reconstruction, where an old single-unit crown was

replaced and a veneer preparation was made into the existing

anterior abutment of the posterior bridge immediately distal

to it. The key to success with this procedure is the original

thickness of porcelain on the existing bridge. The goal is

to have little or no metal exposed. Tooth #27 and #28 are

prepared for stacked porcelain veneer restorations (Fig. 3).

The total thickness of the labial reduction of the natural

tooth surface and porcelain surface is 0.5 mm facially and

1 mm incisally.

20 www.chairsidemagazine.com


Figure 5: Hydrofluoric acid is used to etch the porcelain preparation.

Figure 6: Phosphoric acid is used to etch the prepared tooth surface.

Figure 7: Both solutions are rinsed off with copious amounts of water.

Figure 8: Preparations prior to placement of adhesive resin

Once preparations are complete, the natural tooth surface

is treated with a dentin desensitizer that has an antibacterial

component (AcquaSeal B [AcquaMed Technologies; West

Chicago, Ill.]) (Fig. 4). The porcelain preparation is treated

with hydrofluoric acid for 60 seconds (Fig. 5). This material

can be caustic to the gingival tissues, so if tissue contact is

anticipated, a light-cured “liquid dam” is applied for patient

protection. Thirty-seven percent phosphoric acid is applied

for a 15-second total etch to the prepared tooth surface

(tooth #27) (Fig. 6). Thoroughly rinse both the tooth and

porcelain surface with water for 60 seconds (Fig. 7). Figure 8

shows the natural tooth surface and porcelain surface

after rinsing and air-drying. AcquaSeal B is reapplied to

tooth #27 and the excess is removed using a high-volume

Without adequate micromechanical

retention to affix

the composite resin to the

porcelain surface, any repair

will likely not withstand the

forces of mastication.

Repair, Don’t Replace – Part 121


Figure 9: Bonding resin is applied to both prepared surfaces.

Figure 10: Bonding resin is light-cured for 30 seconds.

Figure 11: Facial view of the prepared surfaces after curing of the adhesive

resin. Note the shiny appearance of both the dentin and porcelain surfaces.

This clinically shows the presence of the hybrid zone for bonding.

Figure 12: The porcelain veneer for tooth #28 is filled with resin cement

and placed on the preparation.

suction. A moist, wet surface is left for the application of

a hydrophilic bonding resin, and adhesive resin is applied

in multiple applications to create a quality hybrid zone for

bonding (Fig. 9).

Following air thinning, the adhesive resin is light-cured

(Fig. 10). Figure 11 shows the prepared surfaces after the

adhesive resin has been placed and cured. The porcelain

veneers are now ready for placement. A dual-cured resin

cement is placed on the inside surface of the veneer

restoration and the veneer is placed on the porcelain

prepared surface (Fig. 12). A number 2 Keystone brush

(Patterson Dental; El Segundo, Calif.) is used to remove

excess resin cement prior to reaching a gel set (Fig. 13). The

porcelain veneer restoration is then placed on tooth #27

(Fig. 14). The porcelain veneer on tooth #27 is stabilized

using veneer stabilizers (Nash/Taylor Esthetic Instrument

Kit [Hu-Friedy; Chicago, Ill.]) while the gel set is completed

(Fig. 15). After using a scaler to remove marginal cement

excess post gel set (Fig. 16), a cotton pledget is used to

complete resin cleanup prior to light curing (Fig. 17).

22 www.chairsidemagazine.com


Figure 13: The excess resin cement can be removed with a Keystone

brush.

Figure 14: The restoration is placed on tooth #27.

Figure 15: The veneer is stabilized while the gel set is completed.

Figure 16: The excess can then be removed easily with a sharp scaler

or explorer.

It may not be feasible

economically or clinically

to sacrifice a long-span

restoration for one unit

with a porcelain fracture.

Figure 17: Before the final cure, any excess resin can be removed from the

surface of the restoration with a cotton pledget.

Repair, Don’t Replace – Part 123


Figure 18: Cross section through a crown that had been veneered with

porcelain. The distal abutment of this bridge had failed, necessitating

removal. Note the uniform thickness of the remaining porcelain and the

veneer restoration. The film thickness of the resin cement is also very

uniform and micromechanically lutes the surfaces together.

Figure 19: A full-smile, retracted view after delivery of restorations on

tooth #4–12 and #21–28. The veneers on tooth #4 and #5 are veneered to

a long-span PFM bridge as well. Note how well these restorations blend

in with the new anterior restorations.

Figure 18 shows a cross section through a porcelainfused-to-metal

crown that was reveneered with porcelain

to change the facial color to a brighter value, in order to

match the adjacent restorations. Note the uniform thickness

of resin cement and veneered porcelain. The bond of the

porcelain veneer to the prepared porcelain surface is as

strong as that bonded to dentin. Figure 19 shows the

affected area in a full-arch, retracted view after placement

of the esthetic anterior restorations. The previous bridge

was retained, however the facial surface that was visible in

the patient’s smile (tooth #28) was altered with a porcelain

veneer to match the anterior restorations.

Conclusion

This technique demonstrates how to repair existing porcelain

restorations by bonding a porcelain veneer to the affected

porcelain surface. By taking advantage of the strength of a

porcelain-to-porcelain bond using resin cement technology,

we can now make predictable porcelain repairs and resurface

existing porcelain (and porcelain-fused-to-metal) crown &

bridge restorations in a very predictable manner. CM

Dr. Robert Lowe is in private practice in Charlotte, N.C. He lectures internationally

and publishes on esthetic and restorative dentistry. Contact him at 704-364-4711

or boblowedds@aol.com.

24 www.chairsidemagazine.com


Repair,

Don’t

Replace

The “Saddle Crown”

Part 2

– ARTICLE and CLINICAL PHOTOS by

Robert A. Lowe

DDS, FAGD, FICD, FADI, FACD, FIADFE

In the first part of this series on repairing an existing bridge (“Repair, Don’t

Replace – Part 1,” page 19), a case was presented where a patient fractured the

facial ceramic of a maxillary central incisor on a six-unit porcelain-fused-to-metal

bridge. The facial fracture was stress related and did not involve the exposure of

the underlying metal substructure. A successful repair was made by creating a

veneer preparation into the ceramic and placing a new porcelain veneer on top

of the affected surface.

Now, what happens if the ceramic fracture is substantially larger and involves

the exposure of the underlying metal framework? The following case will demonstrate

how, in some circumstances, the remaining porcelain can be removed

from the metal and a “saddle crown” can be fabricated and cemented over the

existing bridge.

Repair, Don’t Replace – Part 227


Figure 1: A preoperative view of tooth #7, part of a multiple-unit fixed

bridge that has sustained a porcelain fracture on the facial surface

Figure 2: An incisal view of the fractured abutment showing a porcelain

fracture down to metal on the disto-incisal angle

Figure 3: The fractured unit has been prepared using rotary diamond

instrumentation down to the metal understructure, then polished with a

fine diamond and rubber polishing abrasives. Care was taken not to disturb

the porcelain on the adjacent teeth and the metal covering the damaged

unit, especially the interproximal metal bridge connectors.

Figure 4: Lingual view showing the surface after preparation. The original

bridge had metal lingual surfaces, so preparation was made into the metal

to create space for the “saddle crown” on the functional surface. Some

of the metal was removed to tooth structure, but care was taken not to

remove so much as to compromise the integrity of the original bridge.

A patient presented with a porcelain fracture on an anterior

multiple-unit fixed bridge (Fig. 1). The fracture involved

the entire facial surface of tooth #7 and exposed the metal

framework at the disto-incisal angle. When viewed from

the lingual aspect (Fig. 2), the fracture extends down to

the porcelain-metal junction of the mostly metallic lingual

surface. Because of the occlusal forces placed on this tooth

in both protrusive and lateral excursions, it was decided to

prepare the remaining porcelain down to the metal understructure

and create a “saddle crown” to repair the defect.

The saddle crown consists of a facial and lingual surface

only. These surfaces are only joined proximally incisal to

the solder joint of the existing bridge. The preparation

is designed to create negative space for this “telescopic”

structure without compromising the structural integrity of

the bridgework below.

A round-ended, tapered, coarse diamond is used to prepare

the remaining porcelain and metal. Care must be

taken not to score the adjacent proximal ceramic surfaces

during the preparation phase (Figs. 3, 4). Also, be careful

not to create undercuts when preparing the cervical areas

of the preparation. In this case, it was a challenge to create

sufficient space on the lingual surface without prepping

away some of the existing metal framework. This should

be kept to an absolute minimum to avoid compromising

the strength of the existing bridge.

Figure 5 shows the incisal clearance created for the saddle

crown as the patient closes into centric occlusion. This

28 www.chairsidemagazine.com


Figure 5: This view shows the space created for incisal reduction as

the patient closes to centric occlusion. 1.5 mm of space is needed in all

functional movements.

Figure 6: Retraction cords in place on the facial and lingual surfaces prior

to the registration of the master impression

Figure 7: Facial view of the gingival retraction cords in place

Figure 8: The #00 cord is left in place after removal of the #1 cord, leaving

an obvious sulcus prior to injection of the light-bodied impression material.

clearance is checked in protrusive and lateral excursions

as well, to make sure adequate space has been provided.

The preparation is polished with a round-ended 30 micron

finishing diamond, followed by rubber polishing abrasives

to smooth the cut metal substructure and porcelain.

Next, a retraction cord (UltraPak ® [Ultradent; South Jordan,

Utah]) is placed on the facial and lingual marginal

areas of the preparation (Figs. 6, 7). A two-cord technique

is used, first placing a #00 cord, then a #1 on top of it.

After a few minutes, the top cord is removed leaving

the #00 in the sulcus (Fig. 8). The master impression is

then made using a syringeable light-bodied and heavybodied

vinyl polysiloxane impression material (Honigum

[DMG America; Englewood, N.J.]) (Fig. 9).

Figure 9: The impression is made using a polyvinyl siloxane impression

material. Note the margin is captured, as well as approximately 0.5 mm

of tooth or root surface apical to the prepared margin. This will ensure an

accurate fit of the saddle crown.

Repair, Don’t Replace – Part 229


Figure 10: A provisional restoration is fabricated from a preoperative

impression taken prior to preparation of the fractured unit. Flowable composite

resin was used to fill in the fracture prior to taking the impression, so

that the provisional restoration would have the correct contours.

Figure 11: The fabricated saddle crown on the master laboratory model,

shown from the facial aspect

The saddle crown consists of a

facial and lingual surface only.

These surfaces are only joined

proximally incisal to the solder

joint of the existing bridge.

Figure 12: Incisal view of the preparation as seen on the master laboratory

model

A provisional restoration is then fabricated using a bisacrylic

provisional material (Luxatemp ® [DMG America])

and is cemented with polycarboxylate cement (Fig. 10).

Digital photographs are provided to the ceramist to aid

in characterization.

Figure 11 is a facial view of the saddle crown on the laboratory

cast model. An incisal view of the master cast shows

the preparation design that basically strips the porcelain

down to the metal substructure on the facial and lingual,

and is “tied in” with a continuous mesial and distal proximal

finish line on the metal connectors of the preexisting

bridge (Fig. 12). A proximal view of the completed restoration

highlights the “saddle” design (Fig. 13). Interproximal

margins are in metal and are located incisal to the metal

connectors of the understructure. The lingual surface of

the restoration is made in metal to match the preexisting

bridge and limit the amount of lingual reduction (Fig. 14).

The completed saddle crown is tried in after removal of

the provisional restoration (Fig. 15). After verification of fit

and checking occlusion with articulating paper, the restoration

is ready for cementation. In this case, resin-modified

glass ionomer cement was used (Fig. 16). A 4-META-type

cement is also good to cement metal to metal if retention

is less than ideal. The cement is mixed according to the

manufacturer’s instructions (Fig. 17) and pushed into place

on the preparation (Fig. 18). It is recommended to hold the

30 www.chairsidemagazine.com


Figure 13: The saddle crown shown from the proximal view

Figure 14: The saddle crown on the master laboratory model from the

lingual aspect

Figure 15: After removal of the provisional restoration, the saddle crown

is tried in and the fit is evaluated.

Figure 16: A resin ionomer cement (RelyX Luting Cement [3M ESPE;

St. Paul, Minn.]) is dispensed prior to mixing.

Figure 17: The mixed cement is placed into the saddle crown.

Figure 18: The saddle crown is held in place while the cement is allowed

to set.

Repair, Don’t Replace – Part 231


Figure 19: A lingual view of the cemented saddle crown

Figure 20: A view of the completed saddle crown on tooth #7 from the

facial aspect

Figure 21: A view of tooth #7 prior to the fracture. Compare this to

Figure 20, which is the same view of the repaired bridge using a saddle

crown. A beautiful, esthetic and functional match was made without having

to remake the entire bridge.

restoration in place until the cement is completely set, as

hydraulic pressure can in some cases push the restoration

incisally as the cement sets.

Figure 19 is a lingual view of the cemented restoration.

The metal lingual surface of the saddle crown fits the adjacent

metal margin of the bridge like an inlay. Figure 20 is

a facial view of the completed saddle crown. Compare this

to Figure 21, which is a facial view of the previous bridge

prior to the fracture.

The esthetics of a repair made using a saddle crown makes

it an excellent alternative to replacing the entire multiunit

restoration. This solution works well in anterior and

posterior regions for pontics as well as abutments. CM

Dr. Robert Lowe is in private practice in Charlotte, N.C. He lectures internationally

and publishes on esthetic and restorative dentistry. Contact him at 704-364-4711

or boblowedds@aol.com.

The esthetics of a repair

made using a saddle crown

makes it an excellent

alternative to replacing the

entire multi-unit restoration.

32 www.chairsidemagazine.com


– ARTICLE and CLINICAL PHOTOS by Gregg Tousignant, CDT

and Leendert Boksman, DDS, BSc, FADI, FICD

In practice, many dentists today want to use the fastestsetting

dental products, the fastest curing lights, the fastest

single-step adhesives and the fastest-setting impression

materials. These faster products are desired for a number

of reasons. Some clinicians want to save time in order

to pack more patients into the day. Some want to make

procedures faster and more comfortable for their patients.

Some manufacturers even promote the so-called fast curing

lights in ways to make you think you will save so much

time you can take extra vacation days at the end of the year.

One light manufacturer even claims that all you need is a

one-second cure for a 4 mm layer of composite resin!

Freedman states that “faster setting impression materials

are very advantageous in the efficient practice.” 1 He then

rightly qualifies this statement with “the underlying assumption

is that faster setting in no way compromises the

Faster Is Not Always Better When It Comes to Impressioning35


quality of the impression.” However, in a recent study of

the quality of dental impressions for fixed partial dentures,

89 percent of the impressions had one or more detectable

errors that would impact the final fit of the restorations;

51 percent had voids or tears at the finish line (Fig. 1);

40 percent had air bubbles at the finish line (Fig. 2); and

24 percent had flow problems (Fig. 3). 2 Could there be

any relationship to using fast-set impression materials?

Figure 1: Impression of molar with multiple voids at the margins

Figure 2: Air bubbles and voids incorporated into the light body

When it comes to impression materials, the goal of a fast-set

product is to limit the amount of time the impression is in the

mouth, both for patient comfort and to limit the opportunity

for the patient to move and distort the impression while it is

setting. 3 Although the concept is admirable, many clinicians

experience drags, pulls (Fig. 4), inaccuracies (Fig. 5) and

distortion in their impressions simply because they don’t

understand how much working time they really have.

Terry, in his article on the impression process, gives us two

definitions: “The setting time of impression materials is the

total time from the start of the mix until the impression material

has completely set and can be removed from the oral

cavity without distortion, and the working time is measured

from the start of the mix until the material can no longer

be manipulated without introducing distortion or inaccuracy

in the final impression.” 4 These two processes are, of

course, intimately related by the chemistry of the impression

material. Many clinicians think they know the working

time of their light-body and heavy-body impression

materials, but we can pretty much guarantee that most do

not! One of the disadvantages of PVS impression materials

is their relatively short working time. 5 If you think the

working times of your light-body polyvinyl siloxanes are

what is listed in the manufacturer’s instructions, then you,

too, may not understand the true “intraoral” working times

of your material.

In a recent study of the quality of

dental impressions for fixed partial

dentures, 89 percent of the

impressions had one or more

detectable errors that would impact

the final fit of the restorations.

Figure 3: Flow problems demonstrated as multiple areas of lack of

adaptation

36 www.chairsidemagazine.com


By specification, the working times of impression materials

are calculated at 23 degrees Celsius and at 50 percent relative

humidity. Unfortunately, the oral cavity is much warmer

and significantly wetter. In the ADA Professional Report on

Elastomeric Impression Materials, the ADA found that times

measured at 23 degrees Celsius were 66 to 77 percent longer

than those measured at 35 degrees Celsius (intraoral

temperature range). 6 Some PVS impressioning materials

such as Genie Ultra Hydrophilic (Sultan Healthcare Inc.;

Hackensack, N.J.) and Correct Plus (Pentron Clinical Technologies

LLC; Wallingford, Conn.), whose instructions claim

working times of 135 and 90 seconds respectively, actually

have less than 10 seconds working time intraorally. 6 This

makes it difficult for some, and impossible for others, to

impress a single unit, let alone multiple units, and be able

to deliver the tray prior to the light body setting.

So why is this relevant? In order to ensure a fluid blend

between your light-body and heavy-body PVS impression

materials, both materials must be fluid and unpolymerized

at the time the tray is inserted. If not, this could lead to

gaps or ledges between the different viscosities of material

(Figs. 6, 7), which will lead to inaccuracies and high

occlusion of your final restoration. We as practitioners also

assume that upon insertion of our heavy body material,

it will drive the light body into better adaptation to our

preparation. Of course, this is not possible when the light

body is already set (Fig. 8). This means that unless the

light body is meticulously placed in the first instance, we

cannot improve the impression by the hydraulics of the

heavy body impression material.

Where are your impression materials stored? Are they

stored in a wall cabinet with hot fluorescent lights underneath?

Is your air conditioning on a timer? Do you turn the

air conditioning down to save energy over the weekend?

Figure 4: Drags or pulls resulting from premature set of the impression

heavy body

Figure 5: Inaccurate margins due to lack of flow, lack of hydraulics or

inadequate retraction

To ensure a fluid blend between

your light-body and heavy-body

PVS impression materials,

both materials must be fluid and

unpolymerized at the time

the tray is inserted.

Figure 6: Obvious gap between the light body and heavy body

Faster Is Not Always Better When It Comes to Impressioning37


Figure 7: Gaps and ledges with lack of union between light and

heavy body

Figure 8: Lack of adaptation of light body around implants — light

body was set and could not be moved by heavy-body hydraulics

If your air conditioning is on a timer or the temperature of

your operatory or office is higher than 23 degrees Celsius

over the weekend or during the day, you need to keep in

mind that it takes eight hours for impression materials to

acclimatize. On those hot humid summer days or nights,

your impression materials can get significantly warmer

than room temperature (70 degrees Celsius) and will not

cool back down until eight hours after the air conditioning

comes back on. This is of significant importance when it

comes to your working times. For every 10 degrees above

room temperature, you lose up to 50 percent of your working

time! For some materials, this may mean less than five

seconds intraoral working time. It is impossible to impress

one unit of crown & bridge in this time, let alone multiple

units. Hence the need for a temperature-controlled storage

unit for temperature-sensitive materials or strict control of

the office temperature environment.

In clinical crown & bridge cases where you must take

an impression of multiple units, it can be difficult (if not

impossible) with any standard impression material, due to the

shortened intraoral working times, which for most materials

on the market today is less than half or even a third of what

is stated on the manufacturer’s instructions. However, there

was a product introduced to the market a number of years

ago which is designed specifically for these cases. Multi-Prep

from the Affinity line of impression materials (CLINICIAN’S

CHOICE Dental Products Inc.; New Milford, Conn.) has

the longest intraoral working time on the market today.

Although not the 2:40 minutes stated in the manufacturer’s

instructions, it has an intraoral working time of 90 seconds

followed by a relatively short and independent intraoral set

time. Figure 9 shows a full-mouth reconstruction impression

taken with Multi-Prep, which shows superb detail,

adaptation and marginal capture. Two other materials come

close to this working time for their light bodies as tested

by the ADA: Examix NDS (GC America Inc.; Alsip, Ill.) at

70 seconds and the polyether Impregum Penta Soft Quick

Step (3M ESPE ; St. Paul, Minn.) at 70 seconds.

For every 10 degrees above

room temperature, you lose up to

50 percent of your working time!

For some materials, this may

Figure 9: Full-arch rehabilitation Multi-Prep impression showing

excellent detail, flow, adaptation and marginal capture due to

proper working time

mean less than five seconds

intraoral working time.

38 www.chairsidemagazine.com


If you are trying to make a decision on choosing a new

impression material for your practice, you must beware of

clever marketing and advertisements. Many manufacturers

will make you think singular qualities of their material

should be important in your decision-making process. One

example shows images of the contact angles of water droplets

on the manufacturer’s material, which are lower than the

contact angle of others. What does this prove? The idea is to

make you think that if the contact angle is lower than their

competitors that it must flow better in the presence of moisture

or effectively displace moisture during impressioning.

Some of these tests are done on set impression materials,

which is a clinically irrelevant test, as we use the materials

during the polymerization process. With some PVS materials,

the movement of the surfactant to the surface to affect

the wetting properties becomes limited as the material is

polymerizing. 7 “Hydrophilic” PVS impression materials may

continue to be hydrophobic in the unpolymerized state, and

they will not properly capture detail on wet surfaces, but

the surfactants have enhanced PVS wettability with gypsum

products. 8 There is no relation between the contact angle

and the ability to displace moisture contamination. 9 Similarly,

another example is the “shark fin test,” which is designed

to test how a material flows — the larger the fin, the more

it must flow. Yet, how relevant is this if you have less than

10 seconds to take the impression? There is no correlation

between results of the shark fin test versus dimensional accuracy,

and respectively, surface detail reproduction. 10

References

1. Freedman G. Buyers’ guide to impression materials. Dent Today. 2006

Mar;25(3):144-5.

2. Samet N, Shohat M, Livny A, Weiss EI. A clinical evaluation of fixed

partial denture impressions. J Prosthet Dent. 2005 Aug;94(2):112-7.

3. Pitel ML. Successful impression taking, first time, every time. 1st Ed.

Armonk, NY: Heraeus Kulzer; 2005.

4. Terry DA. The impression process: part 1 — material selection. Pract

Proced Aesthet Dent. 2006 Oct;18(9):576-8.

5. Chee WW, Donovan TE. Polyvinyl siloxanes impression materials:

a review of properties and techniques. J Prosthet Dent. 1992

Nov;68(5):728-32.

6. ADA Professional Product Report. Elastomeric impression materials.

2007;2(3):11.

7. Grudke K, Michel S, Knipel G, Grudler A. Wettability of silicone and

polyether impression materials: characterization by surface tension

and contact angle measurements. Colloids and Surfaces A: Physicochemical

and Engineering Aspects. March 2008;317(1-3):598-609.

8. Trushkowsy R. Accurate impression material and technique for

well-adapted restorations. Dent Today. 2007 Feb;26(2):120, 122-3.

9. Norling BK, Ibarra J, Gonzales J, Cardenas HL. Wettability and

moisture displacement of vinyl polysiloxane impression materials.

University of Texas at San Antonio, IADR/AADR/CADR 82nd General

Session, March 2004, #1927.

10. Balkenhol M, Wöstmann B, Kanehira M, Finger WJ. Shark fin

test and impression quality: a correlation analysis. J Dent. 2007

May;35(5):409-15. Epub 2007 Jan 24.

Reprinted by permission of Oral Health, November 2011.

There are a number of choices for impression materials

on the market today and, as with anything, each has its

pros and cons. Should your decision be based on: water

droplet contact angles, shark fin tests, price, color and

taste, and powerful advertising? Or should it be based on

clinically relevant qualities such as: intraoral working times,

polymerization rate, dimensional stability, tear strength,

accuracy, consistency, quality control, and most important

of all, independent clinically relevant research? CM

Gregg Tousignant, CDT, is a technical support manager for Clinical Research

Dental, where he provides technical support and hands-on courses. E-mail him at

gtousignant@clinicalresearchdental.com.

Dr. Len Boksman retired from practice in London, Ontario, Canada, at the end of

2011 and currently does freelance consulting and lecturing for the general practitioner.

He can be reached at lenboksman@rogers.blackberry.net.

Faster Is Not Always Better When It Comes to Impressioning39


42 www.chairsidemagazine.com


Interview with Dr. Lee Ann Brady

– INTERVIEW of Lee Ann Brady, DMD

by Michael C. DiTolla, DDS, FAGD

As someone who is involved in dental

education, reading Dr. Lee Ann

Brady’s résumé makes my head spin!

Having spent several years teaching side

by side with some of dentistry’s best,

she recently re-entered private practice

to reclaim her nights and weekends.

Lee is smart and funny, and I have

been lucky enough to spend time with

her when lecturing. I hope you enjoy

our conversation.

Interview with Dr. Lee Ann Brady43


Dr. Michael DiTolla: The thing I love about you, Lee, is that

you are dentistry’s version of Justin Timberlake, in the sense

that you really do it all. You teach photography. You teach

occlusion. You teach adhesion. You teach preparation. There’s

almost nothing beyond your reach. I think that’s due to a

combination of talent and your educational background. It’s

been an amazing path that has taken you to where you are

today. So as we get started, for our readers who are not familiar

with your background, take us through what you’ve done since

you graduated from dental school.

Dr. Lee Ann Brady: Absolutely. As you were describing that

broad range of topics, one of the things that came up for

me is that it also mimics what I do in my practice every

day because I’m a general practitioner, so I have to be well

versed in all of those topics. My path did not happen with

intention, so much as it just happened serendipitously. I am

a general dentist, as I said. I graduated from the University

of Florida in 1988 and was in and out of various practice

models in the years between then and 2005, when I was

asked to join the Pankey Institute down in Key Biscayne,

Florida, as a full-time faculty member. So I moved down

to Pankey and taught there full-time. I was their clinical

director for four years.

MD: That’s amazing to me that you got asked to be a part of

Pankey because the only communication I’ve had with Pankey

is they have asked me not to come to the courses.

LB: (laughs) Oh, come on!

I was sitting in one of their classes ...

and Monday morning of that class,

Irwin Becker, who was chairman of the

department of education at the time,

came up to me and said, “I’d really like

for us to talk privately.” And, honestly,

I thought for sure they were kicking

me out. It was like being called into

the principal’s office.

MD: So I’m amazed that they asked you to come on board like

that. How did that happen?

LB: You know, I’ll tell you as best as I know the story.

From a purely factual perspective, I was sitting in one

of their classes — I was taking their second class, which

at the time they called “C2,” their bite splint class —

and Monday morning of that class, Irwin Becker, who

was chairman of the department of education at the

time, came up to me and said, “I’d really like for us to

talk privately.” And, honestly, I thought for sure they

were kicking me out. It was like being called into the

principal’s office.

MD: You thought he was going to hand you a check with a

refund for your tuition and have you leave out the back door?

LB: (laughs) Exactly. “Get out of here!” So I was nervous

until we found a time to talk. We finally found the time

and went to lunch together and he asked me, “Have you

ever considered doing anything in dental education?” That’s

literally how I got asked. Up until that point, I really hadn’t

considered it. I taught briefly at the dental hygiene program

at Santa Fe Community College, which is in Gainesville,

Florida, my first year or two out of dental school, just

because my practice wasn’t busy and I was looking to keep

44 www.chairsidemagazine.com


usy and make a little more money. So I went and taught

in the dental hygiene clinic. But other than that, I had no

experience in dental education. I went in cold turkey.

MD: So that was in 2005. How long were you there?

LB: I was there until the end of 2008, so just shy of four

years. That accounts for my huge background in occlusion.

I had already been doing that. Actually, as a student, I

had decided at one point that I might focus my practice

on TMD patients. I was taking some courses with Mark

Piper. I went through the craniofacial pain mini-residency

at the University of Florida with Henry Gremillion and

was taking Pankey courses. When you’re there full-time at

Pankey for four years, you are immersed in the conversation

on occlusion.

MD: How interesting that early on you thought you might focus

your practice on TMD patients. For most of the dentists I know,

that’s one of the first early referrals they decide to make — pedo

patients and TMD patients. I used to run from those patients.

What drew you to that?

LB: I still do a fair number of those patients. But I decided

that, as much as I enjoyed TMD, I also missed restorative

dentistry. I loved that, too. So I’ve created a balance now in

my practice. What I love about it is the unknown and the

mystery. In the beginning, it’s daunting, and you wonder

how you will ever figure it out. The more I got to learn

about it, the more I realized it’s just a puzzle that can be

solved if you are willing to stay curious and stay in the

puzzle with the patient, and combine what they’re telling

you with what you are finding in an exam. You really have

to work through it. One of the things that I think is hard for

folks to grasp when they start treating TMD patients is, you

don’t actually know when you start what we call “therapy,”

which for most of us is an appliance, that this is actually

the therapy. The appliance is almost as much diagnostic as

it is anything else, because you make it based on a design

you think might work. But then, if it does or doesn’t work,

that’s diagnostic information. It makes you go, “Oh, I need

to go down this other path.” So I like that piece of it. I like

the investigative piece of it; that it’s different and always a

challenge. It’s not repetitive, like doing an MO composite.

MD: That might be where the disconnect is for some dentists.

We take a bitewing radiograph. We find some decay. We go in

and we drill it out. We place a restoration. It’s done, problem

solved, and we’re on to the next thing. But TMD is not like

that. It’s ongoing and you have to be inquisitive. You have

to interpret what the patient is telling you and what you’re

seeing through the therapy you’re providing.

LB: Exactly. If you’re one of those folks where you like to

just do what you do and be done, and then in your mind

it’s handled, TMD should not be the part of dentistry you

go into. If you like the challenge of it being a continuous

process and asking what’s next and how are we going to

do this, then TMD is a great aspect of dentistry that has

that, whereas a lot of other aspects of restorative dentistry

don’t. For me, like I’ve said, I’ve balanced it. I like treating

TMD patients in my practice, but I would miss restorative

dentistry, so I don’t do that every day that I’m in my office.

I have created a balance, and I think a lot of other folks can

do that, too.

MD: So you like to be able to mix it up and change gears a

little bit, go in and solve a few problems, and then also see a

few TMD patients. This is starting to sound like what might be

called the “thinking man’s dentistry,” if you will. Less about

handpieces and injections, and more about interpretation and

trying to figure out what might make the situation better.

LB: That’s the best way I’ve ever heard it explained!

MD: Well, then we’re going to end the interview here. Thanks so

much for being with us. (laughs) So you were at Pankey until

the end of 2008?

LB: Yep. Then I was asked to join Frank Spear. It was right

when he was moving the Seattle Institute for Advanced

Dental Education from Seattle and partnering with the

Scottsdale Center for Dentistry, which of course now

has become Spear Education and is based in Scottsdale

(Arizona). So he asked me to be part of that transition, and

be the person who moved to Scottsdale, because he and

Greg Kinzer and Gary DeWood were still all in Seattle at

that point. So I did that at the end of 2008, and I was there

full-time until last year.

MD: How did that invitation come about? Because now, for the

second time in your illustrious career, you’re being tagged by

one of the more powerful people in dentistry to come be part

of their organization. Are you just relying on your good looks?

How did this happen?

LB: You know, that could be a part of it, and we won’t dismiss

that piece. But, honestly, I knew Frank as a student because

I had taken his classes in my own continuing education

journey, and he also used to come down to Pankey once

a year to do a program called “Masters Week,” so I got to

know him even better at that point. Gary DeWood, who is

a dear friend who I worked with at Pankey, was already

in Seattle and had joined Frank at the Seattle Institute for

Advanced Dental Education. I also had three kids at that

point, and my daughters, who are now almost done with

high school, were just on the crux of being teenagers. So I

really was looking to not live in Miami anymore, to have my

kids someplace where I felt more comfortable with them

learning to drive and starting to date and do all of those

things in a less cosmopolitan setting. Gary knew that, so I’m

sure that was part of it. And, talk about having your heart

stop, there’s nothing on the planet like having your phone

ring (at that point I still had an actual house phone) and

Interview with Dr. Lee Ann Brady45


you go over and the caller ID says “Frank Spear,” and you’re

like, “Really?” I can remember that evening at my house

because I went over to the phone and was screaming to my

husband, “It says Frank Spear.” My kids were like: “Answer

it. What’s your problem?”

MD: That’s great. And when you answered the phone, did you

say, “Frank, I’d love to talk, but I’ve got Gordon Christensen on

the other line”?

LB: (laughs) No. Unfortunately, I was so tongue-tied that I

don’t know what I said!

MD: I don’t blame you! So what was your role at Spear?

LB: I was the executive VP of clinical education.

MD: And you were there for how many years? About the same

amount of time you were at Pankey?

LB: A little bit less. I was there for almost three years fulltime.

MD: And you recently decided to get back into private practice

and spend a little more free time with your family?

LB: Absolutely. June of last year I left Spear Education as

an employee and went back into private practice. I practice

here in Glendale, Arizona. I am still teaching. My intent was

always to continue to teach some. But I really wanted a lot

more control over my schedule because, as I said, I’ve got

three kids and two of them are in high school and the other

is just about to be in high school. The other part of it for

me was I felt like I really needed to be seeing patients in

order to continue to grow as an educator. I had spent eight

years in formal general continuing education with very little

opportunity to interact with patients, so I wanted to go out

and do the things I was talking to other folks about.

MD: As I alluded to earlier, that really is an amazing

background. With the experience you’ve had, I’m not sure

what’s left for you to do, except maybe I’ll nominate you for

ADA president because it sounds like you have a hard time

saying “no.” But it really is an amazing background, and it

has all added up to someone who is not only able to do all these

things in your practice, but you’re able to teach it and teach it

well. That’s a gift, too.

To get back to occlusion, because I know you’re so well

grounded in that, here at the laboratory, about 75 percent of

the restorations we do are single-unit restorations, and then

another 11 percent are 2 adjacent units. Basically, 86 percent

of what we do here at the lab is either 1 or 2 units. So, from our

perspective, for the typical dentist out there sending us work,

it looks like dentistry is being done one crown at a time; not

big, full-mouth rehabs. For the doctors who spend most of their

time doing single-unit crowns, I think occlusion is having the

patient bite on the paper, see the blue dot and getting rid of an

interference, and that may be all they need to be concerned

about. But for those kind of basic cases, what do you do? What

do you look for? Are you doing full-mouth occlusal adjustments

on those patients who come into your practice and maybe just

need one crown?

LB: That’s a great question, and my practice really mirrors

what you guys are seeing in the lab. For the majority of my

patients, we do dentistry in very small units. Honestly, even

when I do patients where we’ve talked together about a

comprehensive treatment plan and the patient is ready to

do that, because of their time constraints or their economic

constraints, we have to figure out how we do dentistry in

little pieces over 10 years. So that’s mostly what I send to

the laboratory.

MD: Wouldn’t you agree that it’s much easier for most of us to

do 28 units of crown & bridge one or two crowns at a time then

it is to do it all at once?

LB: It depends what you mean by easier, but I think there

are pieces of it that are easier. It’s easier on the patient,

definitely, from a patient experience. Unless you’ve been

a patient and sat in the chair and had 14 units prepped

on the same day, you have trouble comparing that. There

are pieces of it that are easier from a treatment-planning

perspective, from a case-presentation perspective.

I guess for me, when you ask what people should know

about occlusion, it does go back to that planning piece. I

think we need to spend a little bit of energy understanding

who are our high-risk patients from an occlusal perspective.

Those are the ones where you do the single-unit or the

2-unit, and now you find yourself in a situation you’re

not sure how to get out of. So you lose your clearance on

your prep, or you grind the crown in and the patient never

feels that their bite is the same. You’re looking at the dots

thinking it looks right to you and wondering what the heck

they’re talking about. Or maybe, the worst one, where you

come in and there’s a hole in the provisional. In the old days

with porcelain fused to metal, at least you knew you could

adjust through and the worst thing that would happen is

you would tell the patient they had a little silver amalgam

in their crown. With all-porcelain, now you don’t have that

opportunity to back out any more. So I would say, figure

out who those high-risk patients are and, at a minimum,

know for yourself and have a conversation with the patient,

so if some of those sequelae happen, now it’s something

you knew might happen and it’s something you’ve already

talked about and predicted. It’s not something where you’re

wondering how you are going to make it right.

MD: Give me an example of a typical case that might walk in

off the street, something simple like a single-unit crown. The

patient walks in with a broken cusp — it’s cutting their tongue

or their cheek — and they’re basically begging you to prep it.

46 www.chairsidemagazine.com


Give me an example of a case that might be one of those highrisk

cases.

LB: Well, the first one I think of, which is super common

in your scenario of a fractured cusp, is you’re going to do

an upper or lower second molar. For most folks, if we look

at, percentage-wise, which tooth in the arch is the one that

trains our lateral pterygoid and has our brain know how to

find intercuspal position, it’s going to be on a second molar.

Now you look at that tooth and you don’t know, when you

prep the rest of the occlusal table away, if they are going

to lose that muscle memory, and therefore, the instant you

do your prep, you go in to check and there’s no occlusal

clearance. I don’t know if you’ve done this, but I’m geeky

enough that I’ve actually looked at the research, and five

minutes is nowhere on the bell curve for normal supereruption.

Teeth don’t do that. If you lose your occlusal

clearance literally while you’re prepping, it’s because the

lateral pterygoid muscle is relaxing and releasing and the

condyle is receding.

So what do I look for in that situation? Sometimes it’s hard

if the cusp is broken because they may have just eliminated

their own first point of contact. But I look for wear because

patients who have wear on their second molars — no place

else on their arch but on their second molars — what runs

through my head is they get their condyles back in centric

relation. They either peri-function back there or this is a

place they go to. I need to be thinking about this. I also

always look for the difference between intercuspal position

and that seated condylar position from a standpoint of the

relationship of their front teeth. How much do their front

teeth come apart vertically? Is there an A-P piece of that?

What’s the distance? Because if their front teeth open 3 or

4 millimeters when you get their condyle seated, and that

gets deprogrammed, that is going to translate to 1 or 1.5

millimeters off the top of your prep, and there goes your

clearance. If the discrepancy is little, which fortunately for

us it is in 85 percent of the population — it’s less than

1 to 1.5 millimeters — we’re never even going to notice on

that second molar.

MD: OK, let’s say the patient comes in and it’s not a broken

cusp. Somebody’s got a large amalgam in a lower second molar

and it’s got a little recurrent decay and you’re getting ready to

prepare it. How do you handle that and how do you go into that

to minimize the risk of those kinds of sequelae happening when

you prep that second molar?

LB: For me, it’s super simple. I reach for a leaf gauge. I keep

a leaf gauge on my exam tray. It takes me probably less

than a minute with a leaf gauge to find out, number one, if

they have a positive load test, which tells me their lateral

pterygoid is kind of tight. If I can get it released, can I find

first point of contact? Is it marking on the tooth I’m about

to prep? If it’s marking on a different tooth, my risk is really

For the majority of my patients, we do

dentistry in very small units. Honestly,

even when I do patients where we’ve

talked about a comprehensive treatment

plan and the patient is ready to

do that, because of their time restraints

or their economic restraints, we have

to figure out how we do dentistry in

little pieces over 10 years.

Interview with Dr. Lee Ann Brady47


low. If I’m about to prep away that contact, now the risk

just went up. I can also see visually with the leaf gauge in,

when they’re touching that first contact, how far apart their

front teeth are. Again, if the number is 3 or 4 millimeters

and something changes, I know I’m going to see it and it’s

going to affect my prep.

MD: So the take-home message for dentists is that the most

common trap we’re going to fall into is on those second molars?

LB: Exactly. Then, statistically, are there first molars? Sure,

but it’s a smaller number. Are there people who have it on a

pre-molar? Sure, but now it’s a really small number. Maybe

you do nothing more than stopping before you prep the

second molar and asking if this is the tooth that’s the first

point of contact. I used to get really weird about that when

I thought I had to do a bilateral manipulation, and I don’t

think I’m unique to that. I think that’s a technique where

people aren’t sure what the heck they’re doing. But do it

with a leaf gauge, and it’s super simple. You can learn to do

it with a leaf gauge very quickly, probably one time using it

and having someone explain it to you, and now you have it

on your tray so you can figure that out.

MD: I’m sure that is of the things you teach in your course. In

fact, you do some online courses as well. Is that one of them, the

occlusal therapy course?

LB: Absolutely. I just completed the online course called

“Occlusal Diagnosis: Identifying Risk,” and it really is

geared toward the general dentist, the restorative dentist.

What we talk about is how you do an exam in a way that,

if somebody is going to have risks from joints, muscles

or their occlusion, you can identify those people; those

red flags are obvious. With this group of people you can

say to yourself, I’m going to slow down and get more

information, versus the folks where you can just prep

the teeth.

MD: If people want to find that online and sign up for that

course or watch that course, where do they go?

LB: They just go to my website: www.leeannbrady.com.

MD: Perfect. That would be a great place for them to go.

I was just reading the American Association of Cosmetic

Dentistry’s State of the Cosmetic Dentistry Industry report they

released for 2011, and it talks about how cosmetic dentistry

has really been down. How veneers have been down almost 10

percent since 2007. When you break down the veneer numbers

here in our laboratory, the IPS Empress ® veneers (Ivoclar

Vivadent) continue to shrink and shrink at an alarming rate.

But the good news is, at least for the veneer department, that the

IPS e.max ® (Ivoclar Vivadent) numbers for veneers continue

to grow, and that mirrors what I do for any multi-veneer case

now. IPS e.max is my go-to material, and I love something that

looks essentially as esthetic as IPS Empress, though maybe not

exactly the same in terms of esthetics, but certainly no patient

can tell the difference. I love the fact that it’s three-times as

strong as IPS Empress. Are you finding yourself using e.max

more for veneers as well?

LB: That is a great question. Of my posterior restorations in

my practice now, I can’t tell you what percentage are e.max,

but the vast majority of them are lithium disilicate. For me,

it has really replaced porcelain fused to metal. I do lithium

disilicate almost exclusively in the posterior now. For the

anterior, it’s a place where I’m playing with it. I go to the

research and I look up how important that extra strength

is in the anterior. Really the science doesn’t support that

it makes much difference around materials, and we went

through that for years when we talked about the different

kinds of ceramics in the anterior. Now if you want to talk

about a patient who is a bruxer, who has edge-to-edge

wear, I wouldn’t even think twice about it now. When

people say, “I want to do beautiful anterior veneers and

I’m concerned about strength,” e.max, or lithium disilicate,

is definitely the material of choice. But in patients where

that’s not a concern, I don’t have a strong preference.

I’ll tell you how I do it: I actually talk with my technician.

I send my technician all of the pre-op photographs for the

case. I tell them what the pre-op shade is. I show them

that this is what the patient wants. The patient wants this

much of a shade change in the final restoration. They want

Hollywood, where it’s monochromatic and it’s really high

value, or they want totally natural. I give the technician all

of those parameters, and then I say, “What do you think you

can get me the best results with? What do you feel like you

work with the best to get me those results?” At that point,

it’s really an esthetics decision. I have preferences over what

kind of composite I use for different esthetic situations, and

I want them to know that I happen to like this color system

or this staining system better, but because the ceramist is

the person stacking the material and working with it, they

get to choose.

One of the technicians I work with all of the time is a

huge fan of lithium disilicate, so I have had a chance to

do a number of anterior cases, veneer cases, using lithium

disilicate. What they have done with the esthetics is just

dramatic in the last couple of years. With the esthetics of

Ivoclar’s new Opal series, their ingots and their blocks, it’s

going to get to a place here really, really quickly, where

it’s going to be hard to differentiate, from an esthetic point

of view, what material was used. In that case, sure, why

wouldn’t we use the strongest thing we have out there?

MD: If you look at the numbers of what we’re doing in the

lab, probably the most shocking thing in the last two years

has been how the PFM is literally disappearing. It’s gone from

being about two-thirds of the crowns we made here five years

48 www.chairsidemagazine.com


ago to less than a quarter of the crowns we make here today.

You would almost think that a bunch of research came out

saying PFMs are causing cancer or something because of the

way dentists are turning and running from them. But, really,

it’s these high-strength, cementable all-ceramics like IPS e.max,

and a product that is a little less researched and a little uglier

than IPS e.max, the full-contour zirconia material BruxZir ®

Solid Zirconia — the one that we’re doing here at Glidewell.

It’s amazing. We totally underestimated how much more the

average American dentist was concerned about strength than

they were about esthetics. So with what I’ve seen here in the

laboratory, it has evolved to the point where I’m doing mainly

BruxZir restorations in the posterior and the less esthetic

areas, and mainly IPS e.max in the anteriors. I don’t do that

many single-unit PFMs anymore. For me, the PFM has just

really become a bridge material. Is that what you find for

PFMs as well?

LB: Exactly. I cannot think of the last single-unit PFM that

I did. Actually, I can. I had a patient who had some of the

worst discolored teeth — combinations of secondary dentin

and old metal post/cores — and we just decided to go with

PFMs with metal cutbacks to try to maximize the esthetics.

But that was a very unique situation. Single-unit PFMs in

the posterior? I can’t remember the last time I did one. And,

yes, Glidewell is right on the cutting edge of developing

those materials.

I guess it doesn’t surprise me how it’s been adopted, simply

because I think a lot of dentists, like me, have the experience

of recommending a crown for a person and having them get

this weird look on their face. If you actually stop and ask

them about their reaction, they ask if the crown is going to

have this “black line”? And they point someplace in their

mouth to an old PFM that was done with a metal margin. It’s

amazing to me how patients find that so offensive, where

they can see that metal margin, way more so than having to

have the exact shade of a posterior tooth match. It’s really

rare for me with a patient, especially when you are doing

single teeth, to have the patient say, “Oh no, I don’t want

you to cement that one because it’s slightly darker than my

tooth or slightly brighter than my tooth.” I actually show

them. I will actually hand them a mirror and say, “I want

you to look at the color before it’s fully cemented in.” And

they usually look at me and say, “Why are you asking me

this?” But that metal margin, they just hate. So my guess is

that other folks’ experiences are similar. And then you know

you have a material that’s strong, which has always been

the PFM’s claim to fame. Why wouldn’t you use something

that’s all-porcelain? You also have patients who say to you

that they don’t want any metal in their mouth.

MD: I’ve had a couple of patients over the years get really

demonstrative about that, and they did happen to be women

— probably because they pay more attention to themselves

than men do! Once most men get married, we just give up

and stop caring about how we look. But I had a woman get

really upset because she could see a lingual metal margin on

an upper second molar. I told her no one was ever going to see

it, and she said, “You can see it if I’m lying on my back with

my mouth open.” I had to ask her what she did for a living. I

mean, how often does someone find themself in this situation?”

I saw a patient who had a gold stud in her nose, but shuddered

when I mentioned placing gold in her mouth on a lower second

molar where I didn’t think I would be able to get enough

occlusal reduction. So there is something weird. Gold is highly

acceptable around your neck, hanging from your ears, stuck

through your nostril, for some people, but you put it next to a

tooth and it’s a cardinal sin.

LB: I agree. I think that’s been a huge boon to it. I also think

the other part of it is it allows us to be more conservative,

if we don’t have to put all of the margins subgingival. And

dentists love saving a half-millimeter or a millimeter. I think

that’s one of the things I love about our profession, how

concerned we are about preserving tooth structure.

MD: Well, OK, I’ll give you that. I know that you’re conservative

and you want to do that, but many of us under-reduce

and when called out on it, we say we were trying to be

conservative. If a dentist prescribes a PFM, for which our lab

and the manufacturers of the materials have always asked

for 2 millimeters of occlusal reduction, and they give us threequarters

of a millimeter, I’m not going to say, “Oh, doctor,

you’re so conservative.” If you’re that conservative, prescribe

a cast gold crown because you’re under-preparing. It’s either

laziness or not having a system to reduce enough. But I hear

what you’re saying because one of the things about BruxZir,

or any solid zirconia for that matter, is it can be made thinner

than, for example, an IPS e.max crown, especially if it’s not on

a posterior tooth. You can’t go below a half-millimeter with a

contoured zirconia restoration on a posterior tooth, but on an

anterior tooth, you can get away with a half-millimeter, maybe

a little less.

I’m going to start experimenting with minimally invasive

crowns, where we remove the least amount of material possible

and see what it looks like to put one of these super-thin, highstrength

crowns on top of it. We’re not going to start selling

those anytime soon, but we are going to start experimenting

with those. It would allow us to be more conservative, like we’ve

seen for veneers. When I went through LVI, we were not only

prepping veneers into dentin, but prepping into deep dentin.

Have you noticed over the years the change in the way that you

prepare veneers, in terms of the depth?

LB: Oh, absolutely. I am much more conservative now. I

make decisions about the amount of tooth reduction based

on things like how much I am going to change the shade of

the tooth. I don’t want to tie my technician’s hands behind

his back and say, “I’ve given you 0.3 millimeter of reduction,

but can you take this from an A5 to an OM3 please?” Part of

Interview with Dr. Lee Ann Brady49


that is we have to give the technician adequate reduction. I

would tell you from the experience of teaching a lot of handson

preparation courses — and I think every technician in

every laboratory I’ve ever talked to agrees with this — that

under-reducing is the classic problem in dentistry when we

do indirect restorations. When I work with dentists on prep

design, what I find is they mentally know how much tooth

reduction they want to send the laboratory. Where it breaks

down is they’re using their visual cues to try to assess how

much they have, instead of actually using hard facts like

depth-cutting diamonds to know how much they’re doing

their depth cuts and reduction, and then going back and

checking the amount of reduction.

I do a thing in my prep course where

I have everybody prep a tooth without

measuring. I have them write down

how much they want to prepare,

then prep the tooth. Then I go back

and show them how to measure, and

everybody, across the board, underreduces.

I do it! If I don’t measure,

I always under-reduce.

I do a thing in my prep course where I have everybody

prep a tooth without measuring. I have them write down

how much they want to prepare, then prep the tooth. Then

I go back and show them how to measure, and everybody,

across the board, under-reduces. I do it! If I don’t measure, I

always under-reduce. Now, one of the things that’s happened

after a couple of years of doing a prep design technique,

where I have been very meticulous about measuring my

reductions, is that now my eye is getting better because

I’m sort of training it. But I still don’t trust it. So one of

the classic things that I’ve gone back to, if I’m going to do

occlusal reduction on a posterior tooth, is placing depth

cuts. But you’ve got to know what you’re doing. Pull out

an old 330 carbide bur. Everybody has one of those in the

office somewhere. You don’t use them for anything because

they’re too wimpy for most preparations anymore, but

they’re exactly 1.5 millimeters from the tip of the bur to

where the shank starts. Just drop a bunch of pinholes in an

occlusal table. Go up on the cuspid. Go on the inclines. Go

on the central groove. And then connect the dots.

MD: Yeah, I had to do that when I started practicing in the

lab and we started filming everything. I realized I had to start

getting better in a hurry. I was a chronic under-prepper, too.

I stumbled onto these depth-cutting burs, these self-limiting

depth-cutting burs that come in different depths. There’s a

1.5 and 2 millimeter. I was shocked when I put a 2 millimeter

hole in the occlusal surface of a molar and then prepped until

I thought I was done. I had half the hole left the very first time!

And I thought, no wonder I was chronically under-preparing,

because if you’re not used to seeing 2 millimeters, it looks like a

really deep hole. It looks like an endo access.

LB: It does!

MD: But the weird thing is that dentists will never give us,

as a laboratory, 2 millimeters of occlusal reduction because

when you under-prep for so long, it feels like malpractice to

do 2 millimeters of occlusal reduction. But, meanwhile, they’ll

do 2 millimeters of occlusal reduction for a Class I amalgam

or composite, or a Class II amalgam or composite all day

long because every time you do a crown prep and make a

50 www.chairsidemagazine.com


2 millimeter hole in a molar, it goes all the way down to the

base of the amalgam. So, for some reason, dentists don’t have a

problem prepping 2 millimeters into the tooth if it’s for a direct

restoration, but when it comes to an indirect restoration, all

of sudden, 2 millimeters seems like it’s over the top. I’ve never

quite figured out where that disconnect comes from.

LB: I actually don’t know. I haven’t thought about that.

But, you’re right, that’s my experience of it, as well. I don’t

know, maybe it looks more aggressive when the cusps are

gone, but with a Class I or Class II direct restoration, it

looks like there’s tooth there. I’m old enough that, when I

first learned how to do crown preps, we actually depended

on retention form and resistance form to keep them in.

So my brain is going, “How much wall height do I go?”

Nowadays, we bond everything, so that’s really almost

become a non-conversation.

I know that when I really started paying attention to this,

one of my least favorite words ever in dental school was

“armamentarium.” If someone says that to me again, I’m

going to lose it. Every day in the clinic you’d go to get ready

and they would say, “Tell me about your armamentarium.”

Oh man! Now I teach that to dentists and I use that word

because, especially when it comes to preps and indirect

preps, you’ve got to know what you’re putting in that

handpiece. Tell me the diameter of that bur. Tell me the

length of that bur. Tell me what the tip looks like. Are you

trying to cut a chamfer or a shoulder? Well you need to put

the right bur in the handpiece to do that, or you’re going

to frustrate yourself and your lab is going to wonder what

they’re supposed to do with it.

MD: Exactly, and so my prep technique — I just had to come

up with it for myself because I couldn’t prep well without it —

is really intellectually insulting, in a sense. I’m a professional,

and my whole prep technique is a 2 millimeter hole on the

top and a 1.5 millimeter one on the axial and a 1 millimeter

round bur cut on the gingival. At times I think, “I should be

better than this.” I graduated the same year you did. I should be

able to prep this tooth and get it right without any depth cuts.

But, you know what, it’s not a big deal. Pilots have a checklist

before they take off in a plane for the 2,000th time. To me, it’s

just an easier way to do it than to prep it and then go in with

bite registration after the fact, or wax and calipers, and try to

measure how much you took off. Just put some holes there and

prep until you can’t see the holes.

LB: That’s exactly how I do it. The other thing I would

say on that is, I think it’s actually more efficient. When I

watch dentists prep, it seems less efficient when they’re

taking the same burs in and out of the handpiece multiple

times, versus using this one first until they’re done, this

one second until they’re done. I find that by having those

marks on the tooth, I can cut a tooth way faster and more

efficiently than I ever did before, and it’s more effective! So I

don’t get those phone calls from the laboratory. We love you

guys and all, but I have to tell you that when my assistant

tells me the lab is on the phone during the day in the office,

I’m thinking: “Oh really? What did I screw up?” (laughs)

MD: Exactly. Once you have the depth cuts in, it’s just a race

to see how quickly you can get the rest of the tooth structure

off because you know exactly where you’re going. And, by the

way, I hate the word “armamentarium,” too. I want to back

you up on that. It’s my second least favorite word. My least

favorite word in dentistry is “dentifrice.” Why are we calling it

dentifrice? I hate when we try to sound like we know more than

the patient does. “I’m going to suggest a dentifrice for you that

I think is going to help with your abrasion problem.”

One of the things I teach at my courses, which I’ve learned from

being here in the laboratory, is there doesn’t seem to be any

easier or quicker thing you can do to get better results from

your laboratory when it comes to esthetic dentistry than digital

photography. I just notice here when I watch the technicians

work that they try harder when there is a digital photograph in

front of them because now they see what they’re aiming at. We

are here in California, but we have dentists that prep crowns on

tooth #8 and #9 in New Jersey, and they’ll send us the impression

to make crowns on #8 and #9 using IPS e.max, shade A2, and

there’s no photograph that goes with it. We can match the shape

of the laterals next to it on the model, but there’s nothing about

what the teeth look like, what the lateral incisors look like. It

seems like a tall order for the technicians, and they have to

think: “You’ve got to be kidding me. You want me to make

crowns and match these teeth based on a yellow stone model?”

I see what happens when we give them digital photographs.

Then they know it’s a dentist who cares, who has a little bit

higher standards. Even if they weren’t great photographs, I

think digital photography is a great way to ensure that you

get the highest-quality esthetic dentistry your lab is capable of.

I know you teach courses on digital photography, and I just

want to get your take on that.

LB: I couldn’t agree more. I couldn’t practice without

photography. Let’s go back one step even before laboratory

work. I would tell you that taking photographs in my

practice is the thing that transformed my case acceptance,

even if it’s just four simple photographs. You just want to

take an upper and lower occlusal, a smile and a retracted

with the front teeth in it. Now you and the patient can sit

and look at the same thing. We don’t think about the fact

that our patients don’t know what their teeth look like.

They don’t know what their mouth looks like.

MD: Did you use an intraoral camera at any point, or have

you always done it with digital photography?

LB: Yes, I used to use an intraoral camera myself. I actually

still have an intraoral camera and both of my hygiene

operators have them. To show a patient a single tooth, such

as a recall patient where everything is healthy, but there

Interview with Dr. Lee Ann Brady51


is one little spot where there’s a little recurrent decay or a

little recession, I think an intraoral camera is great for that.

I always use my digital camera, mostly for new patients. I

want them to see their whole mouth. I want to be able to

talk to them about that ugly, old black filling on their lower

first molar, and have them be able to see, without me saying

it, that there are four more on their lower teeth, because

they are all in the photograph.

MD: I take it you’re not just showing them this on the little LCD

screen on the back of a camera after you shoot these four shots.

LB: No. Our protocol is I take the four photographs: upper

and lower occlusal, full smile, and then with retractors

in and the patient’s upper and lower teeth apart so both

occlusal planes are visible. Then we take the card out of the

camera, throw it into a card reader that’s connected to a PC

in my office, Microsoft Photo Viewer comes up, which is

preprogrammed on every Windows PC in the world, and it

lets us print those four pictures on a single sheet of paper.

I actually do it on plain paper; I don’t buy photo paper. I’ll

print them and take them to the patient. My conversation

with patients will be, “We’ve got these in your chart as a

part of your permanent record, but I thought you might

want a copy of these,” and I’ll hand them to the patient.

Most patients will then look at them. As soon as they do, my

next comment is: “Do you see anything in the photographs

of your teeth that you’re curious about or that you have a

question about? Let’s really make sure we talk about that,”

and I’ll hand them a pen.

MD: Wow. See, I hand it to them and say things like, “I bet you

didn’t know your smile was so ugly!” That’s too strong maybe.

LB: (laughs) That might be less effective. So I can’t imagine

practicing without photography. For me, when I’m sending

stuff to the laboratory, I actually need to go overboard and

send too many photographs. This has made such a big

difference for me as far as what I get back in shade matching.

People say to me all the time, people who are techie, “But

it’s not all color corrected,” and I say that’s almost not the

point. The point is that the technician can actually see,

relative to the other teeth, what that looks like. They can

see nuances from the standpoint of chromo-gradient and if

there are little decalcification spots. My experience is that

every technician I’ve ever met sees 100 times more in a

photograph of teeth than I do as a dentist because they

have that eye.

MD: Exactly. Technicians love to have, not only the picture of

the teeth, but let’s say an A2 in there next to the adjacent tooth.

It doesn’t need to be a perfect match. They just need to see how

it looks relative to the A2 shade tab because they’ve got that

same shade tab in the lab and they can use that as a reference.

Are you taking all of those pictures, or is your staff able to take

those four pictures if you’re off doing something else?

LB: My assistants are all trained to use the camera and take

digital photography. I’d say that a few of them are better

photographers than I am. So we can switch in and out to do

that. If I’m doing a single central and it’s really challenging

because it’s a high-esthetic-demand patient, I’ll probably go

in and do the photographs, because then I can get analretentive

and do stuff like exposure bracketing, give the

ceramist one that’s a little dark and one that’s a little light.

But that’s not my routine. My routine is usually two to four

photographs with the shade tab in there, without the shade

tab in there, and the ladies in my office all do that very well.

MD: I bring that up mainly because I want dentists to

understand that this isn’t something they have to do themselves.

In fact, my assistant is as good as I am at this point, and she

complains less. If I have to take those four photographs, and

she’s not in there to help me, I’m pissed! But somehow she does

all four without me anywhere near her, so in that respect I

guess she does it better than I do. But I don’t want the doctors

to feel like this is something else that’s thrown on their plate.

This isn’t. You could just walk into the operatory and have the

patient already be holding the sheet with the four pictures on it,

and you could just sit next to them, say hi, ask them what they

think, and let them tell you.

LB: Exactly. I’m a huge fan of photography, and it’s so

much easier than it used to be. Most of the cameras we

use in dentistry now are basically the same camera bodies

that you can buy anywhere, so you can learn to use them.

Dental photography companies have training sessions,

there’s online stuff, there’s stuff on YouTube. There are so

many resources now to get over the initial learning curve,

and most of the new cameras can be set on automatic.

MD: Exactly. I understand why dentists were turned off from

it in the past. I remember you would shoot Kodachrome

or Ektachrome, and you would have to send it out for E-6

processing and you’d get it back a week later. Before you could

even prep the case, you had to make sure the “before” pictures

turned out. That was crazy. But it’s instantaneous feedback

now and, literally, any dental assistant can be taught to do it

now. There are plenty of good classes like yours, and there are

tutorials on YouTube. For all we know, we’re two years away

from taking these pictures with our iPhone and then sending

them to the laboratory.

LB: Exactly.

MD: As you do a lot of stuff with adhesive dentistry, I want

to talk to you about self-etching adhesives. One of the things I

noticed after I came out of LVI and started doing a lot of deep

veneer preps using the total-etch technique was that I had more

postoperative sensitivity than I cared to see. It always bothered

me when a patient came in, completely asymptomatic, and we

did 10 veneers on them, and now he had two teeth that were

pretty hot for a few months and maybe one of them needed

endo. That was always one of the things that disappointed

52 www.chairsidemagazine.com


me. I can’t blame the technique or the materials or myself. It

was some combination of all three — I’m willing the take the

blame. But when self-etching materials came out, it seemed like,

by lowering the postoperative sensitivity potential, that it was

going to be a step in the right direction, even if we didn’t have

the same high bond strengths. I interviewed Dr. Jose-Luis Ruiz a

few months ago, and he has gone fully self-etch for everything.

He does not use total-etch anymore. So that’s one far end of

the spectrum. I think over at the other far end of the spectrum

are the dentists who just love total-etch and still use it all the

time. Maybe they will use self-etch under a direct composite,

or something like that. What has your experience been with

self-etch adhesives, and where do you find yourself using

them most?

LB: I’m probably one of the folks in the middle. I was, for

years, a total-etch fourth generation. I used to teach it as

the gold standard. Technically, if you just want to look at

brass tacks research numbers for bond strength, it’s still the

gold standard. The challenge, for most people, is that it’s

so technique sensitive that whether you talk about post-op

sensitivity from the etching technique or marginal integrity

because of the film thickness those generations of dentists

use, the average general practitioner runs into trouble.

So now we have three other generations of self-etching

products and new total-etch products.

What I use right now is what we call a “selective etching

technique.” I actually use phosphoric acid and I etch only

the enamel, and then I let it go for 25 seconds and I rinse it

off and dry it. What do I avoid with that technique? I’m not

worried about over-etching, which is having the phosphoric

acid against the dentin for more than 15 seconds, or overdrying

the dentin; these are the two big reasons why

dentists have post-op sensitivity with phosphoric acid. Then

I switch to a self-etching dentin adhesive. I apply it over

all of the dentin surfaces — if I get it on the enamel, it’s

not going to hurt anybody, and I use a self-etcher to do the

dentin. Actually, I was recently reading up on some new

research, and what folks are finding in the newer research

with the newer generation of self-etchers, is that it actually

gets higher bond strength than the old, fourth generation

total-etch technique.

I can’t imagine practicing without

photography. For me, when I’m sending

stuff to the laboratory, I actually need

to go overboard and send too many

photographs. This has made such a

big difference for me as far as what

I get back in shade matching.

MD: Wow. Isn’t it ironic? When we graduated in 1988, I

remember Ultradent, in addition to the etch they made, also

made something to put on the dentin to identify it so we didn’t

accidentally etch it. So now you’re talking about a technique

that’s a great middle ground, with the ability to etch the enamel

like that with selective etching, and then go in and do a selfetch

on the dentin. It’s kind of the best of both worlds and really

represents a step forward in terms of common sense for what

we’ve been doing in adhesive dentistry.

LB: I think so, too. It takes the stress off of worrying about

the phosphoric acid, but it also takes the stress off of

Interview with Dr. Lee Ann Brady53


worrying that self-etchers don’t have the same bond strength

to enamel. So you are getting the best of both worlds. It’s

a technique I’ve been using now for almost a year, and it’s

working really, really well. The other thing I like about it is

I can do it for both direct and indirect. I can use the same

technique, and that makes it easy as well. I’m fond of my

new technique.

MD: So tell me what you’re going to do on a deep, Class I

posterior composite, something simple like that.

LB: How deep? Am I worried about the pulp? Am I thinking

pulp cap?

MD: No. You’ve got 1.5 millimeters of remaining dentin. I just

mean something that’s primarily bonding to dentin with an

enamel rim around it. Are you doing your selective etching on

those direct composites as well?

Whether it’s a Class I, Class II or

Class III composite, even a metal

Class V composite, I do selective

etching. I put phosphoric acid just on

the enamel. One of the things about

that is you have to play with your

etchings because you want one that

is very viscous. It can’t be runny, or it

runs everywhere.

LB: I am. I’m doing my selective etching on those. I have

been doing adhesive dentistry for a lot of years, and I really

don’t have a lot of reason in my practice to not trust dentin

bonding. Even with that, I like preparations that have enamel

margins, and I want to make sure I have a great bond to

that enamel. So even with something like that, whether it’s a

Class I, Class II or Class III composite, even a metal Class V

composite, I do selective etching. I put phosphoric acid just

on the enamel. One of the things about that is you have

to play with your etchings because you want one that is

very viscous. It can’t be runny, or it runs everywhere. I’m

actually using the new Select HV Etch from Bisco, and I

use it for that reason, because it’s very thick. But the other

reason I love it is the tip on there is teeny-tiny, so you can

get literally a band of phosphoric acid that’s no more than

a millimeter wide.

MD: Are you placing any kind of flowable in there as the base

of that restoration?

LB: You know, I’m not. The only place I use flowable in my

direct composites is on Class II and Class III, and I just run

a little bead of it at the marginal interface on the box. I only

do that because we still know that there are issues with

adequate condensation right down into the corners of those

proximal boxes. I’m not using it as a liner.

MD: Are you finding much use for self-etching resin cements?

Walk me through what you might use for a PFM bridge; for an

IPS e.max crown; and for a bonded, single-tooth restoration,

an all-ceramic in the anterior. I’m curious to see if you’re

finding much use for the self-etching resin cements.

LB: I do use the self-etching, self-priming resin cement

family. I use them when I want to cement; when I have a

prep that has retention form and resistance form, so I’m

not worried about the bonding being my retention, and I

want something translucent. If I’m doing a PFM and I’ve got

54 www.chairsidemagazine.com


subgingival margins, I don’t need something translucent.

I’ll probably go with a resin-modified glass ionomer. If I’m

doing that PFM and I’ve got supragingival margins because

I did a 360 porcelain butt joint, I’ll use a self-etching, selfpriming

resin cement because I don’t want the white at the

margins; I want the translucency of those resin cements.

If I’m doing full-coverage or I’m doing BruxZir or I’m

doing lithium disilicate, but my prep is such that I’ve got

great retention form and great resistance form, I’ll use a

self-etching, self-priming resin cement. Or, I might actually

even bond and go to a true dual-cure resin cement, and that

would more depend on isolation than it would the material.

So if I’m going to have problems isolating and I need to get

in and out quick and I want a true cement, I’m using a selfetching,

self-priming. If I have great isolation and I really

want to bond this, I’m going to go to something dual-cure

in the posterior. In the anterior, I just use regular light-cure

veneer cement.

MD: Our dentists love brand names. Give me some examples of

your favorite resin-modified glass ionomers.

LB: Right now, my favorite resin-modified glass ionomer

is RelyX Luting Plus (3M ESPE ), and I’ve actually been

using that for years. I used that when it was Vitremer

Luting Cement. They’ve just changed the name a few times

over the years. So I am still using that. As far as my dualcure

resin cement, right now I’m using NX3 Nexus ® Third

Generation from Kerr, and I use that because one of the

things you run into with dual-cure resin cements is you

need to think about your dentin adhesive and make sure

it’s compatible. Kerr’s new self-etching OptiBond XTR

actually is cured by their NX3, so it turns it into a dual-cure

dentin adhesive. I am a little old-fashioned because I still

don’t cure dentin adhesives prior to indirect placement.

MD: Oh, look at you. You’re bucking the trend! You are going

old school. It makes sense, as long as you’re confident in your

ability to cure that. I think that’s a good idea.

LB: Exactly. So I’ll use the OptiBond XTR with the NX3.

I also use Multilink ® Automix from Ivoclar. I use them

interchangeably. When do I choose one versus the other?

Part of it, for me, probably has to do with working time.

If I’ve got a patient that’s really great, and I’m not worried

about getting in and out, I’ll probably using NX3. Multilink,

for me, sets so much faster. If I do need to get in and out

and get it cured because I’m worried about patient isolation

or something like that, I’ll go to Multilink.

MD: I think that makes sense.

LB: For anteriors, Variolink ® Veneer (Ivoclar Vivadent) is

my preferred veneer cement. I also do keep RelyX Veneer

Cement (3M ESPE ) in the office. The reason I keep the

RelyX is because it’s more viscous. So if I think I need

something to fill a bigger gap underneath, then I’ll use the

RelyX. Especially with a 0.3 or 0.5 millimeter veneer, I like

that the Variolink isn’t viscous; it doesn’t feel like you’re

going to crack something when you seat it.

MD: Exactly. I know doctors who actually use Herculite ®

(Kerr) to seat veneers. And you know they’re prepping at least

a millimeter to be able to push a veneer down and not have

it crack with an actual composite resin underneath it, versus

cement. So as I have gotten more conservative and our veneers

have gotten thinner and thinner, I have gone to something

that’s a little less viscous, where you feel like you can get it

completely seated, move it around and really get it settled

without feeling like you’re going to crack the veneer down the

middle. That would obviously be a mess.

Well, Lee Ann, I want to thank you so much for your time today.

It’s been a fascinating look at how you got to where you are,

and what you’re currently doing in your practice. I like that it

all has a common sense ring to it. Even though you spent all

the time that you have at these institutions of higher learning,

it sounds like you still have that connection to what most of us

are going through on a daily basis as we treat these patients. It

doesn’t sound like you’re telling us to go in and do full-mouth

equilibration on every patient who walks in the door, even if

they are just there for a Class I composite.

LB: No, I don’t do that. (laughs)

MD: I like that. That’s what I like about you, that your approach

is more common sense. That’s what really resonates with

dentists. They need something that’s going to work for them in

their practices and in the outside world, where they can still

make a good living. But, like you said, they need to be able to be

focused on not stepping into those huge potholes, where you’re

prepping those lower second molars and things like that. That’s

why I think your courses are so good, because they’re going to

help dentists avoid those nightmare cases, the ones you never

forget and make it hard to sleep at night.

I’m going to recommend that our readers go to your website

and see where you’re going to be next. If they can’t get out to

one of your lectures, I hope they will look you up and find one

of your webinars, so they can connect with you that way.

Chairside readers: Please read Lee’s blog. It’s a fantastic blog; I

read it all the time. She’s very dedicated to making sure she puts

something up on a regular basis. In fact, I’m kind of jealous

and wish I had the drive to be able to update something as often

as she does.

I appreciate what you do for our profession, Lee, and I

appreciate you spending an hour with us. Thanks so much.

LB: My pleasure. It’s always fun to talk with you. CM

Dr. Lee Ann Brady is a privately practicing general dentist in Glendale, Ariz., and a

nationally recognized educator and writer. Contact her at www.leeannbrady.com or

lee@leeannbrady.com.

Interview with Dr. Lee Ann Brady55


– ARTICLE and CLINICAL PHOTOS by Carlos A. Boudet, DDS, DICOI

After many years of sharing information with colleagues, I have noticed that

the majority of dentists do not take the time to document their work — even

the interesting cases — with photographic records. In today’s economic and

business environment, it has become increasingly necessary to adequately

promote your practice, and I consider taking photographs to be a very important

part of that.

With this article, I would like to introduce a simple, but effective way of

documenting your cases with dental photography. Following these guidelines

will help your practice in many ways.

An Introduction to Dental Photography57


Photo Documentation

Dental photography has two parts: intraoral and extraoral

photography. Here are some basic tools you will need:

1. A camera that allows you to take both full-face and profile

pictures, as well as intraoral close-up shots.

2. Two sets of intraoral photographic mirrors and two sets

of retractors. There should be one occlusal mirror and

one lateral mirror in each set.

I have adopted a simple series of standard dental photographs

to document my cases. I take one set of preoperative

pictures, and I take another postoperative set to document

the final results. Simple before-and-after pictures of your

work can help patients visualize and accept the work they

need done (Figs. 1, 2). If I think I might make a presentation

of the case, I take additional photos of the procedural steps.

1

Figure 1: Documenting treatments with high-quality “before” images

is important.

Standard Photos

The required views for clinical case submission to the

American Academy of Cosmetic Dentistry are 12 preoperative

views and 12 postoperative views. My standard set of

photographs consists of the following:

1. Three extraoral photos: Two frontal views of the face

(one in repose and one smiling) and one profile shot

2. Five intraoral photos: Five retracted views, including

an anterior view, a right view and a left view, and two

mirror occlusal shots (one of the mandible and one of

the maxilla)

3. For cosmetic cases, an anterior retracted view with the

teeth apart is very helpful. This makes for six intraoral

photos instead of five.

2

Figure 2: This “after” photograph shows just how well the case was

completed.

Camera Choices

Now let’s talk about cameras. Undoubtedly, the best camera

system is an SLR digital camera like a Canon T3i or a Nikon

D90, with a dedicated 100 mm macro lens and a ring flash.

In this basic tutorial, however, we use a point-and-shoot

camera. It’s simpler to use because there are no settings to

change and focusing is automatic. This simple system was

chosen because of the different levels of expertise exhibited

by the dentists attending our courses, as well as the need

for a camera that could take the use and abuse.

We chose the Pentax Optio W90 for its simple-to-use

instructions, as well as for its shockproof and waterproof

characteristics. This 12-megapixel camera allows you to

take great face shots and intraoral views without changing

settings on the camera.

3

Figure 3: With the chair completely horizontal, you can take the

maxillary and mandibular occlusal mirror views.

58 www.chairsidemagazine.com


Patient Positioning

You can take the necessary pictures with the chair in two

positions: completely horizontal and at 45 degrees from

horizontal (Figs. 3, 4). With the chair at an inclination of

about 45 degrees, you can take the anterior, right and left

retracted views, as well as the three headshots. For nicer

looking pictures, you can take the three headshots with the

patient standing in front of a contrasting background.

Tips for Better Photos

• Standardize the photographs by taking them at the same

distance from the subject every time. That way, it will be

easier to compare “before” and “after” shots.

• Do not change the “P” or program mode in the Pentax

Optio W90. This will standardize your exposure settings

because the camera’s default setting will adjust the focus

and the exposure for you automatically, and the lighting

should not change in the operatory.

4

Figure 4: With the chair inclined at about 45 degrees, you can

take the anterior, right and left retracted views, as well as the three

headshots.

• Proper positioning of the camera avoids the errors associated

with canting and taking the shots at angles that are

“too high” or “too low.”

• Reposition the patient’s head slightly instead of leaning

over the patient.

• For better headshot photographs, use a background. Do

not place the patient too close to the background as this

can create shadows.

• Try to take the occlusal views looking down the incisal

edges of the anteriors.

5a 5b 5c

Figures 5a–5c: The three headshots (full-face resting, profile and

full-face smiling)

• Use the interpupillary line and the vertical midline to

orient the camera.

• Finally, try to remove anything that would make the

picture look bad, such as excess saliva, blood and food.

The full-face shots should be at about a 1:10 magnification,

while all the other frontal, lateral and occlusal retracted

views should be at a 1:2 magnification. When you are taking

headshots with the Optio W90 camera, be sure to place

the camera about five feet from the patient’s face and zoom

in or out to frame the patient’s head on the screen. For

the intraoral shots, the retracted frontal and lateral views

should be taken about one foot away from the patient’s

face at maximum optical zoom, and about two feet away for

the occlusals.

Figures 5a–9b illustrate the series of standard photographs

previously described:

6a

6b

Figures 6a, 6b: The two occlusal shots of the maxilla and the

mandible

An Introduction to Dental Photography59


Photo Editing

A photo editing program is a very useful tool when working

with digital pictures. There are a lot of good ones on the

market, from free applications such as GIMP, Picasa and

Photoscape, to those geared toward the professional such

as Adobe Photoshop. Other programs include Adobe

Photoshop Lightroom, Adobe Photoshop Elements, Corel

PaintShop Pro and ArcSoft PhotoStudio.

7a

These programs will let you tweak your photos by cropping,

rotating and adjusting exposure so they look great,

even if you are not the greatest photographer. As a final

note, make sure that your patients sign a simple photography

release form that gives you permission to show their

pictures.

This brief tutorial was written in the hope that it will

encourage more dentists to document their cases with

photography. This will increase your cosmetic and implant

case acceptance, and lead to patients inquiring about having

you do their dental work. It will also benefit your marketing

efforts, while making you a more humble and better dentist

in the process. CM

7b

Figures 7a, 7b: The right and left lateral retracted views

Dr. Carlos Boudet is in private practice in West Palm Beach, Fla. Contact him at

www.boudetdds.com or 561-968-6022.

General References

• Goldstein MB. Digital photography update: 2011. Dent Today. 2011 May;

138-142.

• American Academy of Cosmetic Dentistry. Photographic documentation and

evaluation in cosmetic dentistry: a guide to accreditation photography.

• Maher R. Practical dental photography & high tech case presentation. 2005.

8

Figure 8: The anterior view

• Soileau T. Dental digital photography columns. Dent Econ.

• Terry DA, Snow SR, McLaren EA. Contemporary dental photography: selection

and application. Compend Contin Educ Dent. 2008 Oct;29(8).

• Bengel W. Mastering digital dental photography. 1st ed. Quintessence. Berlin,

Germany. 2006.

9a

9b

Figures 9a, 9b: The 1:1 views are reserved for case documentation,

such as when you want to show one to three teeth in the picture, as

in a step-by-step documentation of a case.

60 www.chairsidemagazine.com


BIOLOGIC SHAPING

An Alternative to Extracting a

Tooth with a Severe Fracture

– ARTICLE and CLINICAL PHOTOS by

Daniel J. Melker, DDS

When a cusp of a tooth is fractured subgingivally

approximating the bone, extraction is a commonly

considered treatment, due to concern about the significant

bone removal required by other procedures to create

space for the biologic width. That being said, addressing

this primary concern of removing bone to create space for

the biologic width presents the alternative procedure of

biologic shaping.

The premise for traditional crown lengthening to preserve

a fractured tooth is that the surgeon must remove enough

bone, starting from the most apical portion of the fracture,

to create space for the biologic width. This method can

result in a significant loss of bone, tooth mobility and, if

the fracture is located near the furcation, a compromised

furcation area.

Biologic shaping offers an alternative to conventional crown

lengthening through removal of the fractured portion of the

tooth, allowing for a new biologic width to reform without

significant removal of bone. The case presented here

illustrates this technique.

62 www.chairsidemagazine.com


CASE EXAMPLE

Figure 1: Provisional crown placed after the buccal cusps of tooth

#30 fractured approximating the bone

Figure 2: Removal of provisional crown to access the fractured tooth

surface

Figure 3: Reflected tissue verifying location of fracture into the

furcation and approximating the bone

Figure 4: Removal of fractured tooth surface using a coarse

diamond bur

Biologic Shaping: An Alternative to Extracting a Tooth with a Severe Fracture63


Figure 5: Smoothing the tooth’s surface using a superfine diamond

bur (40 microns) to completely remove the old fractured portion of

the tooth surface

Figure 6: Smoothing the root surface creates a parabolic architecture

to mimic the soft tissue contours, allowing for a new biologic width to

reestablish without having to significantly alter the bone.

CONCLUSION

When performing traditional crown lengthening for a

fractured tooth, the potential need to remove excessive bone

to create space for the biologic width is cause for concern.

Conventional thinking is to locate the apical location of

the fracture and start removing bone from that point. With

biologic shaping, however, the fractured portion of the

tooth is removed first to preserve as much bone as possible.

This conservative procedure can avoid excessive removal

of bone and help preserve bone in the furcation area,

leading to long-term stability and a successful restorative

outcome. CM

Figure 7: After 12 weeks of healing and the establishment of the

biologic width, a new crown was placed just coronal to the gingival

collar. Notice that the location of the new margin is in perfect harmony

with the adjacent teeth.

Dr. Daniel Melker is in private practice in Clearwater, Fla., and lectures nationwide

on periodontics. Contact him at 727-725-0100.

64 www.chairsidemagazine.com


Figures in Dentistry Spotlight:

• Doc Holliday •

– ARTICLE by Michael C. DiTolla, DDS, FAGD

and Megan Strong

onsidering the incredible

fear surrounding

extractions, root canals

and dental work in general,

being known as “history’s most

fearsome dentist” wouldn’t exactly

bode well for one’s private practice. You

get the feeling that his reviews on Yelp

would have been less than stellar, and that

word-of-mouth referrals would be few and far

between. As a dentist in a time when any dental

procedure seemed like something out of a nightmare,

Dr. John Henry “Doc” Holliday was a man unafraid of

blood, guts and violence. Doc spent his short but historically

eventful life roaming the dusty trail in search of

danger, fortune and caries.

Born in Georgia to a wealthy family, Doc came into this

world on Aug. 14, 1851. After losing both his mother and

adopted brother to tuberculosis,

Doc went on to attend the

Pennsylvania College of Dental

Surgery, which his cousin, Robert

Holliday, founded. He graduated in 1872

with a thesis titled “Diseases of the Teeth.”

The next time you feel like complaining about

how difficult state boards were, consider yourself

lucky that you didn’t have to write a thesis. Or even

read a thesis, for that matter.

Shortly after graduating with a dental degree, Doc began

work as a dentist in the office of Dr. Arthur C. Ford in

Atlanta, Ga. It wasn’t long after starting his practice that

he came down with tuberculosis, the same disease that

claimed his mother and brother. Thinking the drier climate

of the Wild, Wild West would be better for his health, he

headed to the other side of the country.

Figures in Dentistry Spotlight65


Doc moved to Dallas, Texas, and quickly picked up his

instruments again as he started work with Dr. John A.

Seeger. However, his dental career came to a screeching

halt as the coughing spells from his disease began to scare

patients away. Even though universal precautions wouldn’t

be adopted for another 100 years or so, these patients had

the good sense not to let someone with active tuberculosis

cough into their open mouth. Doc Holliday was forced to

find another way to earn a living.

Naturally, he did what any dentist would do and turned

to a career in gambling. An intelligent man, Doc was a

successful gambler. Doc was made miserable, however, by

the knowledge of his impending death. Moody, a heavy

drinker and with no fear of death, he perhaps was more

prone to the life he came to lead.

Knowing he had to protect himself, given his dangerous

occupation and his disease-weakened body, he began to

train with a six-shooter. He quickly gained a reputation as

word of this nearly 6-foot-tall, gun-slingin’ dentist spread

like wildfire. After his first accounted gunfight on Jan. 2,

1875, when Doc and a local saloonkeeper had a disagreement

that quickly turned violent, Doc became increasingly

fearless and dangerous. While several shots were fired, neither

Doc nor the saloonkeeper was struck and both men

were arrested, reported the Dallas Weekly Herald. Initially,

the locals thought the gunfight was amusing, until just a

few days later when Doc got into another disagreement,

this time killing a prominent citizen with two aimed bullets.

Only Wyatt Earp strolled out of it unharmed. Despite the

name, the gunfight actually went down six doors west of

the rear entrance to the O.K. Corral, as well as in the middle

of the street. Shots were fired, and bullets flew for about

30 seconds. Ike Clanton filed murder charges against the

Earp brothers and Doc, but they were all acquitted.

Doc was a nomadic creature, moving from one town to the

next, staying only long enough to win some money at the

table and put someone in their place. Dodging any serious

jail time, Doc continued his wild rampage engaging in

infamous showdowns and run-ins with the law, only to be

eventually taken down not by a gun, but by his tuberculosis.

When his health began to rapidly deteriorate in 1887, he

headed to Glenwood Springs, Colo., in hopes that the

natural hot springs there would improve his condition.

Unfortunately, he did not recover, and a few months later,

died at the age of 36. As the story goes, Doc always figured

he would be killed with his boots on, so when he found

himself barefoot on his deathbed, he asked for a glass of

whiskey and drank it down. Then, looking at his feet, said,

“This is funny,” and died. CM

Fleeing Dallas, Doc moved to Jacksboro, Texas, where he

found a job dealing Faro, a notoriously crooked French

card game. He had become an expert shot, and quickly got

caught up in some more wild shenanigans. Even though he

left one man dead in the dust in a series of gunfights, no

legal action was taken against him. However, his luck turned

in the summer of 1876, when Doc killed a soldier, bringing

the U.S. government into the matter. A reward went out for

his capture, and the Army, Texas Rangers, U.S. Marshalls,

local lawmen and ordinary residents all pursued him.

To escape his inevitable demise if captured, Doc fled to

the Kansas Territory (present-day Colorado), making stops

along the way, where he left three more dead bodies in his

wake. From there, Doc engaged in numerous shoot-outs

and brawls, making friends and enemies along the way.

Most notably, he gained the friendship of Wyatt Earp and

his brothers, who were by his side fighting in the famous

gunfight at the O.K. Corral in Tombstone, Ariz.

On Oct. 26, 1881, outlaw cowboys Billy Clanton, Tom

McLaury and his brother Frank McLaury battled it out

against the Earp brothers (Wyatt, Virgil and Morgan) and

Doc Holliday. Cowboys Ike Clanton and Billy Clairborne ran

from the fight, but Billy Clanton and both McLaurys were

killed. Doc and Morgan and Virgil Earp were wounded.

66 www.chairsidemagazine.com


Congratulations, Chairside ® PHOT

A

Hunt Winners!

This must have been the most

challenging Chairside Photo

Hunt yet because not one set

of your trained eyes found all

27 differences. Based on your

submissions, the toughest to

find were the three differences

circled in green. I guess we

outdid ourselves this time!

To reward your efforts, we

decided to grade this contest

on a curve and award the

usual first-, second- and thirdplace

prizes to those of you

with the strongest results.

• First-place winners:

21 dentists will receive

$500 in lab credit each.

• Second-place winners:

39 dentists will receive

$100 in lab credit each.

B

• Third-place winners:

53 dentists will receive

$100 in lab credit each.

If you need a suggestion for

using your lab credit, you

might consider prescribing

BruxZir ® Solid Zirconia for

your next crown or bridge

case. As durable as ever, this

monolithic zirconia restoration

is now more esthetic for use

in the anterior. What’s more,

we consistently hear from

dentists that the margins on

their BruxZir crowns & bridges

feel better to their explorer

than those on the PFMs they

used to prescribe.

Chairside Photo Hunt Contest entries

were individually scored after being

sent to the lab via e-mail and standard

mail. Prizewinners were notified by

standard mail and/or phone. In total,

113 prizes were awarded.

Contest Results67


The Chairside® PHOT Hunt

This photo was taken during one of

the continuing education courses

I give on digital intraoral scanning

at the Glidewell International Technology

Center. My assistant and I

are demonstrating how to use various

digital impression systems on

a live patient.

How many differences between the

two pictures can you find? Circle

the differences on version B below.

Then, write down how many differences

you found, tear out this page

and send it to:

Glidewell Laboratories

Attn: Chairside magazine

4141 MacArthur Blvd.

Newport Beach, CA 92660

Or scan your entry and e-mail it to

chairside@glidewelldental.com.

A

Due to legibility issues, faxed entries

will not be accepted. One

entry per office. Participation grants

Chairside magazine permission to

print your name in a future issue or

on its website.

The winner of the Vol. 7, Issue 2,

Chairside Photo Hunt Contest will

receive $500 in Glidewell credit

or a $500 credit toward his or her

account. The second- and thirdplace

winners will each receive

$100 in Glidewell credit or a $100

credit toward their account.

B

Entries must be received by

July 6, 2012. The results will be

announced in the summer issue of

Chairside magazine.

______________________________

Name

____________________________

City, State of Practice

____________________________

Phone

Total Found:________

68 www.chairsidemagazine.com

More magazines by this user
Similar magazines