A Publication of Glidewell Laboratories • Volume 7, Issue 2
Technique for Restoring
Repair, Don’t Replace a
Fractured PFM Bridge
Dr. Robert Lowe
Master Educator Dr. Lee Ann Brady
Talks Restorative Dentistry
Dr. Len Boksman and
Gregg Tousignant, CDT
Things to Consider When Choosing an
Impression Material for Your Practice
Dr. Michael DiTolla’s
Mia Gendreau, Digital Support Technical Advisor, All-Ceramic Department
Glidewell Laboratories, Newport Beach, Calif.
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
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
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!
35 Faster Is Not Always Better When It Comes
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
ALSO IN THIS ISSUE
8 By the Numbers
65 Figures in Dentistry Spotlight
68 The Chairside Photo Hunt
Jim Glidewell, CDT
Editor-in-Chief and Clinical Editor
Michael C. DiTolla, DDS, FAGD
Jim Shuck; Mike Cash, CDT
David Frickman, Megan Strong
Digital Marketing Manager
Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame,
Phil Nguyen, Kelley Pelton, Makara You
Jamie Austin, Lindsey Lauria,
Melanie Solis, Ty Tran
Wolfgang Friebauer, MDT
Coordinator and Ad Representative
If you have questions, comments or complaints regarding
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Neither Chairside magazine nor any employees involved in its publication
(“publisher”), makes any warranty, express or implied, or assumes any
not infringe proprietary
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or imply its
those of the publisher
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the need for
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.
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
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
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
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
What cement are you using to cement these
Once again, thanks for teaching me the
dentistry I practice with every day!
– Robert M. Lieder, DDS
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
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!
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.
– Steve Duffin, DDS
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
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.
– Grigg DeWitt, DDS
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
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?
– Alex Zavyalov, DDS
New York, N.Y.
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.
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
Response from Dr. Neiburger:
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.
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Letters to the Editor 5
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 firstname.lastname@example.org.
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 email@example.com.
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 firstname.lastname@example.org.
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 email@example.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 firstname.lastname@example.org.
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 email@example.com.
Percentage of dentists in
Virginia who sent cases to
Glidewell Laboratories in 2011
Number of case evaluation
slips filled out by Glidewell
customers in 2011
Percentage of those
slips marked as
Percentage of Americans over the
age of 65 who wear either full or
partial removable dentures
Total number of full
or partial removable
dentures fabricated by
metal-based (PFM and
cast gold) vs. all-ceramic
crowns & bridges
fabricated by Glidewell
Laboratories in 1997
metal-based (PFM and
cast gold) vs. all-ceramic
crowns & bridges
fabricated by Glidewell
Laboratories in 2012
PRODUCT........ Rebilda ® Post System
SOURCE........... VOCO America Inc. (Briarcliff Manor, N.Y.)
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
SOURCE........... Centrix (Shelton, Conn.)
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.
PRODUCT........ Luxatemp ® Ultra
SOURCE........... DMG America (Englewood, N.J.)
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
PRODUCT........ Picasso ® Lite
SOURCE........... AMD LASERS ® LLC (Indianapolis, Ind.)
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.
Porcelain Veneers for Tetracycline
– 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.
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
Figure 6: Cord is placed prior to the preparation to accelerate the
Figure 7: Finished preparations. Note that tetracycline teeth usually
become darker when they are prepared. The bonded lingual retainer
obviously eliminates interproximal extensions.
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.
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.
Figure 11: Resin blockout has been removed. Note that only darkstained
areas are covered by the opaquer.
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.
Figure 13: Mandibular anterior teeth at luting appointment two weeks
after preparations. No provisionals were placed, but tissue is still
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 firstname.lastname@example.org.
Reprinted by permission of REALITY Publishing. REALITY: The Information Source for Esthetic Dentistry, The Techniques, Volume 1, 2003, REALITY Publishing Company,
Porcelain Veneers for Tetracycline Using Blockout Method17
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.
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).
Figure 13: The excess resin cement can be removed with a Keystone
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
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.
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
The “Saddle Crown”
– 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
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
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
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
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
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
Figure 13: The saddle crown shown from the proximal view
Figure 14: The saddle crown on the master laboratory model from the
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
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
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
The esthetics of a repair
made using a saddle crown
makes it an excellent
alternative to replacing the
entire multi-unit restoration.
– 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
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
Figure 5: Inaccurate margins due to lack of flow, lack of hydraulics or
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
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.
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
1. Freedman G. Buyers’ guide to impression materials. Dent Today. 2006
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
6. ADA Professional Product Report. Elastomeric impression materials.
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
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 email@example.com.
Faster Is Not Always Better When It Comes to Impressioning39
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
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
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
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
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
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.
Give me an example of a case that might be one of those highrisk
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
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.
Figure 1: Documenting treatments with high-quality “before” images
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
3. For cosmetic cases, an anterior retracted view with the
teeth apart is very helpful. This makes for six intraoral
photos instead of five.
Figure 2: This “after” photograph shows just how well the case was
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.
Figure 3: With the chair completely horizontal, you can take the
maxillary and mandibular occlusal mirror views.
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.
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
• 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
• 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
Figures 5a–9b illustrate the series of standard photographs
Figures 6a, 6b: The two occlusal shots of the maxilla and the
An Introduction to Dental Photography59
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.
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
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
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.
• Goldstein MB. Digital photography update: 2011. Dent Today. 2011 May;
• 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.
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,
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.
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
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
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.
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
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
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.
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
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.
Figures in Dentistry Spotlight:
• Doc Holliday •
– ARTICLE by Michael C. DiTolla, DDS, FAGD
and Megan Strong
onsidering the incredible
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.
Congratulations, Chairside ® PHOT
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.
• 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.
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:
Attn: Chairside magazine
4141 MacArthur Blvd.
Newport Beach, CA 92660
Or scan your entry and e-mail it to
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.
Entries must be received by
July 6, 2012. The results will be
announced in the summer issue of
City, State of Practice