A Publication of Glidewell Laboratories • Volume 7, Issue 3
The Pursuit of Anterior Esthetics for
BruxZir ® Solid Zirconia Restorations
How Scanning Abutments and
Digital Impressions Can
Simplify Your Implant Cases
Dr. Carlos Boudet
Dr. Ellis Neiburger
25 Guidelines for
Practicing ‘Speed Dentistry’
Ultradent’s Dr. Dan Fischer
Discusses the Latest Advancements in
Crown & Bridge Cements
Dr. Michael DiTolla’s
Jordan Semmelmayer, Marketing Department Intern
Glidewell Laboratories, Newport Beach, Calif.
9 Dr. DiTolla’s Clinical Tips
In this issue, I highlight two useful resources for
boosting your practice: a new dentist-conceived
app that is a must-have for the dental office, and a
subscription-based dental coding search engine
pioneered by Dr. Charles Blair that will help you
eliminate costly coding errors and recover lost revenue.
Also featured are LuxaBite from DMG America, my
bite material of choice for its high degree of stiffness
and accuracy; and Ultradent’s UltraCem, the first
liquid-powder RRGI cement that can be mixed and
delivered through a syringe.
14 Photo Essay: The Pursuit of BruxZir
As Glidewell Laboratories works to improve the esthetic
properties of BruxZir Solid Zirconia, it continues to
test what the lab can do with this increasingly popular
restorative material. This photo essay illustrates our
latest anterior case where we replaced an endodontically
treated tooth #8 and an existing PFM on tooth #9 with
BruxZir crowns. After viewing the case, I think you
will see that BruxZir is closer than ever to becoming a
strong contender for esthetic anterior crowns & bridges.
36 One-on-One with Dr. Michael DiTolla:
Interview of Dr. Dan Fischer
For this issue’s featured interview, I checked in with
dental innovator and Ultradent CEO Dr. Dan Fischer
to hear about his company’s latest research and how
his search for a cure for dental caries is coming along.
Give it a read to find out how the company developed
its new liquid-powder RRGI cement, the differences
between powder-liquid and paste-paste cements, and
what led to the company becoming the exclusive distributor
of Triodent products in the U.S.
45 Scannable Abutments:
Digital Impressions for Dental Implants
In this article, Dr. Carlos Boudet aims to increase awareness
of scannable abutments that can be used with
chairside digital impression systems to capture digital
impressions for implant restorations. He demonstrates
the simplicity of this relatively new modality in a case
where he uses one of Glidewell Laboratories’ Inclusive
Scanning Abutments and a widely used digital impression
system to restore a popular brand of dental implant.
Can’t get enough Chairside? Check out our Chairside
Live Web series featuring dental news, Dr. DiTolla’s Case
of the Week and more — now available on YouTube,
iTunes and at www.glidewelldental.com.
49 Case Report: The Creation of a
Soft Tissue Emergence Profile with a
Long-Term Ribbond-THM Provisional
One distinct advantage of using fiber-reinforcing
materials such as Ribbond THM for temporary restorations
in traditional composite restorative techniques
is the significant decrease in gingival microleakage,
suggest Drs. Len Boksman and Robert Margeas. Their
case report illustrates four case examples showing the
type of positive tissue response that can be created
with this approach.
55 Speed Dentistry: Fast Is Better —
Up to a Point
“Modern dentistry … is often practiced slowly; that
is, more slowly than it needs to be,” argues Dr. Ellis
Neiburger in this article exploring the practice of
doing dental treatments faster and better — a concept
he calls “speed dentistry.” Giving 25 guidelines for
dentists to follow, the frequent Chairside contributor
claims that by investing a little bit of time and
energy toward learning to practice speed dentistry,
they can greatly benefit themselves, their patients and
Glidewell Publications iPad App
To experience Chairside magazine on
the iPad, search “Glidewell” in the iTunes
Store and download the free Glidewell
63 Digital Imaging: An Important Visual Aid in
Treatment Planning and Case Acceptance
Dr. Tarun Agarwal suggests that digital imaging should
play a vital role in every dentist’s practice, especially
when treating anterior cases. His clinical case study
helps make his point by demonstrating how an
affordable, off-the-shelf imaging solution can be used
to effectively communicate treatment possibilities and
aid in patient treatment acceptance, leading to final
results that meet or exceed patient expectations.
ALSO IN THIS ISSUE
8 By the Numbers
68 Chairside Photo Hunt Results
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
Emily Arata, Jamie Austin, Deb Evans,
Joel Guerra, Audrey Kame, Phil Nguyen,
Kelley Pelton, Makara You
Jamie Austin, Melanie Solis, Ty Tran
Wolfgang Friebauer, MDT
Coordinator and Ad Representative
If you have questions, comments or complaints regarding
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featured in an upcoming issue or on our website:
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herein do not necessarily
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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.
It was interesting to read recently that students at NYU
College of Dentistry received a letter from the faculty
informing them that the dental school’s default direct
restorative material was being changed from amalgam
to composite. It’s not that the school has completely
abandoned amalgam — the amalgam technique will still
be taught in preclinical, and dental school patients with
clinically acceptable amalgams will not have to have those
restorations replaced — but new amalgam restorations will
now require justification by faculty for placement. I wonder
how often amalgams will be approved?
A main reason for the faculty’s decision to make composite
the dental school’s default restoration is the material’s ability
to be used as a “caries-specific restoration.” In other words,
the faculty feels that with bonded composite resin, the
students only need to remove the caries and the surrounding
affected dentin before restoring the lesion. This is in contrast
to an amalgam preparation that needs to be a certain depth
for strength, regardless of the depth of the caries. So they
made the decision to conserve as much tooth structure as
possible by going with composite over amalgam.
When you consider that amalgam has been a successful
restorative material for nearly 150 years, some might think
the conservative choice would be utilizing the material with
that amazing track record. In the letter to the students,
the faculty quotes a 12-year study showing that bonded
composite performs as well or better than amalgam over
that time period. It would seem there is more than one way
to define conservatism in dentistry.
At the laboratory, our most popular product is BruxZir ®
Solid Zirconia. While it doesn’t have the track record of
PFMs, it is the most conservative material we have for fullcoverage
crowns — with the exception of full-cast gold.
Considering that many patients are reluctant to have cast
gold placed in their mouths, BruxZir crowns are the only
tooth-colored crowns we offer that can be prepared with
feather-edge margins and milled as thin as 0.6 mm.
I didn’t think I would live to see composite become the
restoration of choice in a dental school, or a time when
a high-strength, cementable all-ceramic restoration like
BruxZir Solid Zirconia would outsell PFMs by a margin of
3-1, but both are here.
Yours in quality dentistry,
Dr. Michael C. DiTolla
Editor-in-Chief, Clinical Editor
Editor’s Letter 3
Letters to the Editor
Dear Dr. DiTolla,
I have been watching the free clinical videos
on the Glidewell website and am impressed.
Thank you for making these resources available
at a price that’s hard to beat.
If you wouldn’t mind, could you answer a
few questions? These questions focus on
the video “Diagnosis & Placement of No-
1) Would it be helpful to relate midsagittal
and interpupillary planes to the lab, as in
a Kois Dento-Facial Analyzer (Panadent;
Colton, Calif.), or in your experience is this
2) What brand of retractors were used (two
types are shown)?
3) How do you deal with interproximal contact
issues — hyper or hypo — at try-in,
especially as there is no gingival margin to
act as a stop?
4) How do you know when you need to use
– Vincent Johnson, DDS
Bay City, Mich.
Thanks for writing and for the kind
words! Here are some attempts at answering
1) It is very helpful to include that
information; however, if you parallel
the incisal edges of your preps to the
interpupillary line, that is our default
way of mounting the cast. That being
said, it is much easier for us to do
that if a Kois Dento-Facial Analyzer, or
even a stick bite, is included.
2) The one I like best is the SeeMORE
retractor from Discus Dental. There
are rumors that they may stop selling
that product, so I am looking into having
it made here at the lab because we
have an injection-molding machine on
3) The contact/seating issue is the
worst thing about no-prep veneers.
Sometimes I have the lab make a little
finger of ceramic on the incisal edge
of the veneer to prevent overseating,
but then you have to grind that
all away after bonding it into place.
Really, it all comes down to “feel” and
some educated guesswork. I hate procedures
like that, but I haven’t found a
better way yet.
4) You never have to ask for shadeadjustable
ceramic anymore because
it is now the material we use on all
these types of cases, except for the
ones where we are trying to block out
a darker shade of tooth — something
lower in value than an A3. In those
cases, we either need to opaque the
inside of the veneers or have the doctor
prep the tooth so we can make the
veneer a little thicker.
Since that video was produced, however,
I now do nearly all my veneers
in IPS e.max ® (Ivoclar Vivadent; Amherst,
N.Y.). Because it is three-times
stronger than IPS Empress ® (Ivoclar
Vivadent), I have yet to experience
any of the incisal chipping or breakage
that I did over the years with IPS
Empress. In fact, IPS Empress is dying
a slow death in our laboratory, while
the number of IPS e.max veneers we
do continues to grow. I foresee a time
in the not-too-distant future when all
veneers will be IPS e.max because of
its optimum esthetics and strength.
Hope that helps!
Dear Dr. DiTolla,
Just wanted to send you a note to say
how much I enjoy reading your interviews
in Chairside magazine. The two with
Drs. Howard Farran and Paul Homoly are
must-reads for all dentists. Sometimes I
feel you read my mind with your questions.
Keep up the good work.
– Steven Bellantese, DDS
Thank you for your kind words. I love
long-form interviews, yet they seem to
be such a rarity in dental magazines
these days. I never feel like I learn
anything from the one-pagers. It takes
a few pages to ask follow-ups and give
someone the space to answer.
Dear Dr. DiTolla,
Thank you very much for the practically
helpful educational support your lab provides
to dentists. I wonder if you give written
directions or drawings to the lab technician
about the desired thickness of the wax-up
design (in other words, how much dental
tissue it is safe to prep). As a rule, technicians
overprep teeth on the model, which
leads to extra time to fit.
– Alex Zavyalov, DDS
New York, N.Y.
Yes, when I am having a diagnostic
wax-up done, I will often send along
one of my 0.6 mm depth cutters from
my Reverse Preparation Set (Axis
Dental; Coppell, Texas), and have the
technician use it to place depth cuts.
I let the technician know that is the
most I want removed from the teeth to
ensure that I stay in enamel.
Dear Dr. DiTolla,
I really enjoy watching the educational
videos you provide through the Glidewell
website. Recently I have noticed an
increased incidence of porcelain fracturing
from the zirconia (Prismatik CZ and some
NobelProcera [Nobel Biocare; Yorba Linda,
Calif.]). I have started to use more BruxZir ®
restorations in the posterior, but its limited
esthetics are sometimes a problem. I
fear I may have to return to PFMs. Any
– Dr. Fred Curcio
Ridgefield Park, N.J.
Like you, I noticed a good deal of fracturing
restorations and have drifted to monolithic
BruxZir Solid Zirconia. I find
BruxZir restorations to be esthetically
acceptable on first and second molars,
especially when the patient’s other
choice is cast gold! I am also very
happy with the results I am getting
with IPS e.max. So, basically, I usually
go for IPS e.max in the anterior and
BruxZir restorations in the posterior.
I haven’t done a single-unit PFM in
two years, but I still use porcelainfused-to-metal
for many bridge cases
where I don’t trust BruxZir as much —
it’s still an all-ceramic product. Also,
as you may have noticed, I am starting
to put more anterior BruxZir cases on
our website, but keep in mind these
cases are being accomplished with the
help of an in-office technician.
If you aren’t happy with the esthetics
of BruxZir restorations, you may have
to return to PFMs, unless you are
convinced that IPS e.max is strong
enough for the posterior. My personal
feeling is that with 1.5 mm of occlusal
reduction, IPS e.max is strong enough,
but many dentists don’t give us that
Hope that helps!
Dear Dr. DiTolla,
I recently watched a video from Glidewell
Laboratories where you were discussing the
“cleaning” process for the internal surface
of a zirconia crown (BruxZir ® crown, etc.)
prior to cementation. You mentioned using
Ivoclean (Ivoclar Vivadent; Amherst, N.Y.)
and a zirconia primer. I will typically cement
my zirconia crowns with the RMGI RelyX
Luting Plus (3M ESPE; St. Paul, Minn.).
Would you recommend using Ivoclean and
the zirconia primer prior to cementing with
RelyX Luting Plus or only with resin-type
cements (RelyX Unicem or RelyX Ultimate)?
Thanks so much for your help. I really enjoy
your videos through the lab and find them
all very helpful.
– Kevin G. Jones, DDS
Little Rock, Ark.
It comes down to how retentive your
prep is. If the prep is, say, 4 mm in
vertical height and has no more than
10 degrees of taper, then cementing
with a RMGI without the zirconia
primer will work fine. As the prep
gets shorter or more tapered, that
is when you should consider using
Ivoclean and Z-PRIME Plus (BISCO;
Schaumburg, Ill.) in conjunction with
an RMGI such as RelyX Luting Plus.
When you need maximum retention,
such as on a short mandibular
second molar, you should probably
go with Ivoclean, Z-PRIME Plus and
a self-etching resin cement like RelyX
Unicem. I now use Ceramir ® (Doxa
Dental Inc.; Newport Beach, Calif.) as
my everyday cement. One of its chief
benefits is that it has a natural bond
to BruxZir crowns, once the inside
of the crown has been cleaned with
Ivoclean. I also really like the way
Ceramir cleans up, making it a very
enjoyable cement to use.
Hope that helps!
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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 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.
Tarun Agarwal, DDS, PA
Dr. Tarun Agarwal is a 1999 graduate of the University of Missouri-Kansas City. He maintains a full-time private
practice emphasizing esthetic, restorative and implant dentistry in Raleigh, N.C., and regularly presents
programs to study clubs and dental organizations nationally. Through his real-world approach to dentistry,
practice enhancement and life balance, Dr. Agarwal seeks to motivate dentists and energize team members to
increase productivity and profitability. His work and practice have been featured in numerous consumer and
dental publications. Contact him at email@example.com or visit http://raleighdentalarts.com.
Leendert Boksman, DDS, BSc, FADI, FICD
Dr. Leendert “Len” Boksman is a former tenured associate professor and adjunct professor at the Schulich
School of Medicine and Dentistry in London, Ontario, Canada, and former director of clinical affairs
for Clinical Research Dental and 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 firstname.lastname@example.org.
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 in 1983 and has practiced in the same
location ever since. 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.
Dan E. Fischer, DDS
Dr. Dan Fischer graduated from Loma Linda University with a DDS in 1974. He maintained a full-time
private practice for 15 years, working after hours on research and development. Since 1990, Dr. Fischer has
worked extensively in research and development, but still maintains a part-time practice with an emphasis
on esthetic dentistry. As the president/CEO of Utah-based Ultradent Products Inc., he is extensively involved
in the research and development of many products widely used in the dental profession, with numerous
U.S. and foreign patents granted or pending. Dr. Fischer also serves as an adjunct professor at Loma
Linda University and the University of Texas-San Antonio. He is a member of the ADA, IADR, Academy of
Operative Dentists, AGD and ACD, and received the AACD’s Lifetime Achievement Award in 2005. Contact
him at email@example.com.
Robert C. Margeas, DDS
Dr. Robert Margeas received his DDS from the University of Iowa College of Dentistry in 1986 and completed
an AEGD residency in 1987. He currently serves as an adjunct professor in the Department of Operative
Dentistry at the University of Iowa. He is also a clinical instructor at the Center for Excellence ® in Chicago,
Ill. Dr. Margeas is board certified by the American Board of Operative Dentistry, and is a Fellow of the
AGD. He lectures both nationally and internationally, and he has published several articles in major
dental journals. Dr. Margeas maintains a private practice devoted to esthetic dentistry in Des Moines, Iowa.
Contact him at firstname.lastname@example.org.
Ellis J. Neiburger, DDS
Dr. Ellis “Skip” Neiburger graduated from the University of Illinois at Chicago College of Dentistry in 1968,
where he did postgraduate work on pulp histology in the department of oral pathology. Dr. Neiburger
currently practices general dentistry in Waukegan, Ill. A former vice president of the American Association
of Forensic Dentists, Dr. Neiburger has been the association’s journal editor since 1978. He also was
publisher/editor for Dental Computer Newsletter (the journal that introduced computing to the dental field).
Contact him at 847-244-0292 or email@example.com.
Percentage of Brits over
the age of 73 who have
lost all of their teeth
Source: DENTALFAX Weekly,
number of units for a
Source: Gordon J. Christensen
Practical Clinical Courses,
“Predictable Fixed & Removable
Total number of digital impressions
received at Glidewell Laboratories to date
Percentage of Glidewell
Laboratories’ cases of 3 or
more units that are impressed in
double-arch quadrant trays
BruxZir ® Solid Zirconia is the second-most
prescribed anterior restoration at
PRODUCT........ Kick Your Apps ® DDS App
SOURCE........... Kick Your Apps Inc. (Poway, Calif.)
It took a dentist, Dr. Bob Marcus, to realize how cool it would be for dentists to have an app for their dental
office. Patients can get directions, call the office and request appointments through the app. The “Refer A
Friend” button sends an e-mail with your office info to the patient’s friend with less than 10 seconds of effort.
Another page has maps, hours and services. There is even a before-and-after photo gallery tab. The killer
feature, however, is the “Emergency” button prominently featured in the bottom row. With a touch of a button,
the patient can reach you or your answering service any time they have an emergency. It shows that you walk
the talk and are serious about treating patients right. It’s your chance to look cutting-edge and caring at the
same time. Bob’s company is called Kick Your Apps and charges a one-time fee of $899 to set up your app.
The company is offering a $50 discount to anyone who enters the promo code: Glidewell. And even though
I am all Mac, all the time, I would be remiss if I did not mention that it is available for Android and Blackberry
phones as well.
PRODUCT........ Practice Booster ® Code Advisor
SOURCE........... Practice Booster (Belmont, N.C.)
I am always surprised at how many calls we get at the lab from dentists and front office
staff wanting to know what the best insurance code is for a restoration, especially for
newer ones like BruxZir ® Solid Zirconia or Lava Ultimate (3M ESPE; St. Paul, Minn.).
I quickly refer all of these calls to the man who knows more about insurance coding
than anyone I know: Dr. Charles Blair. I purchased his Practice Booster Code Advisor
and have been thoroughly impressed by how easy he has made it to access so much
information. Because it’s Web-based, it is simple for the company to make updates that
you can see instantly without having to perform a software update. A simple glance at
Code D2950-Core Buildup shows why this program is so valuable. In addition to giving
you warnings and cautions for when these services won’t be covered, it also includes
sample narratives for how to get build-ups approved when they are indicated. You
really have to see it in action to appreciate how thorough it is. Visit the Practice Builder
website to check it out, and stop leaving money on the table.
PRODUCT........ UltraCem RRGI Cement
SOURCE........... Ultradent Products Inc. (South Jordan, Utah)
It’s been a long time since we have seen a new resin-reinforced glass ionomer
(RRGI) on the market, but when it came from the people at Ultradent, I sat up and
took notice because they typically do not come out with a product unless they feel
they have made a leap forward in quality, convenience or both. When the UltraCem
syringe landed on my desk, I stared at it for a good week trying to appreciate just
how much was going on there. You expect Ultradent to put most things in a syringe,
mainly for dispensing purposes, but this was a powder-liquid cement that has to
be mixed prior to using. A simple impression syringe with a mix tip was not going
to work in this situation. Somehow, the research and development department
in Utah figured out how to pull this off! See my interview with Dr. Dan Fischer on
page 36 for a more in-depth discussion about this cement and others. Dan really
opened my eyes with his research and frank opinions about the current state of
paste-paste RRGI crown & bridge cements.
Dr. DiTolla’s Clinical Tips11
PRODUCT........ LuxaBite ® Bite Registration Material
SOURCE........... DMG America (Englewood, N.J.)
For me, the harder bite registration is, the better. I used to watch my dad use wax material for bites, and I
was amazed how easily it could distort, especially once you threw it in a case pan with a couple of stone
models. In dental school we used Aluwax (Aluwax Dental Products Company; Allendale, Mich.), and I
was always worried that I was going to somehow distort it while handling it and would have to get the
patient to come back for a redo. When Blu-Mousse ® (Parkell Inc.; Edgewood, N.Y.) came out, it was a huge
step in the right direction and polyvinyl siloxanes became the de facto standard for bite registrations. We
only see about 15 percent of our crown & bridge cases coming in with wax bites these days, even though
it still seems to be the standard for partial denture cases. Today, LuxaBite is my bite material of choice
because as a bisacryl material it has a higher degree of stiffness and accuracy than any other material on
the market. It also offers little to no resistance to biting when placed on the prep and the patient closes
into it. If you are familiar with LuxaTemp, then you are essentially familiar with LuxaBite because they are
both bisacryl materials. There simply is not a more accurate way to take a bite today.
The Pursuit of BruxZir ®
– ARTICLE by Michael C. DiTolla, DDS, FAGD
Glidewell Laboratories continues to test what the lab can do with BruxZir ® Solid Zirconia crowns & bridges as it
works to improve the esthetic nature of this zirconia material. BruxZir crowns now account for 15 percent of
the anterior crowns fabricated at the lab, and as this number will likely continue to rise, the lab is committed to
increasing the material’s ability to be predictably prescribed in anterior situations. This photo essay illustrates a case where
we are prepping tooth #8 and #9 for BruxZir crowns. Tooth #8 is a natural tooth that has been endodontically treated,
and tooth #9 has an existing PFM that needs to be replaced. To view a live video of the case, visit our Video Gallery at
Figure 1: Following my own advice, I am taking
the shade before I do anything else to ensure
that the teeth have no chance of dehydrating.
When teeth dehydrate, they appear to be higher
in value than they actually are. I am using the
VITA Easyshade ® Compact (Vident; Brea, Calif.)
to determine the shades on the adjacent teeth.
Typically, I try to position the tip of the device
in the middle third of the tooth, avoiding the
increased chroma in the gingival third and the
increased translucency in the incisal third.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics15
Figure 2: This case does a good job of illustrating
why I like the VITA 3D-Master ® shade guide
better than the VITA Classical shade guide.
Notice that on tooth #7, the VITA Easyshade
Compact is telling me that the closest Classical
shade is A2, while the closest 3D-Master shade
is 2.5R2. It will soon be evident why it’s helpful
that the VITA Easyshade compact takes both
Figure 3: The VITA Easyshade Compact has a
relatively short learning curve, but the first step
in using it successfully is understanding how
to maximize the surface area of the tip that is
in contact with the tooth surface. As the facial
surfaces of anterior teeth are rarely flat, the tip
will not fit completely flush against the tooth
structure. I always have a finger ready to stabilize
the tip and allow me to make slight rotations
so that most of the tip comes in contact with
Figure 4: The shade reading from the middle
third of tooth #10 also is an A2 on the Classical
guide, but a 2R2 on the 3D-Master guide.
Because of the considerable jumps between
adjacent shades in the Classical system, many
teeth that register as Classical A2s can be
more accurately classified within the 3D-Master
system. (View the “Modern Shade Taking
Methods for Enhanced Lab Communication”
video online at www.glidewelldental.com for an
in-depth explanation of this.)
Figure 5: This is the shade taken from tooth #8,
the natural tooth that I will be prepping. Again,
the measurement from the middle third of the
tooth gives us an A2 reading on the Classical
scale, while the 3D-Master shade registers as a
2M2.5. That’s three different 3D-Master shades
that are being called an A2 by the Classical
system. In an instance such as this, I assure you
that our technicians can make a closer shade
match with a 3D-Master shade.
Figure 6: The all-new VITA 3D-Master
Linearguide is my shade guide of choice today.
Because my three shade choices are all in the
“2” family, I remove the 2 shade guide and
check to see how these shades compare to
the natural adjacent teeth. Even if tooth #7, #8
and #10 are all different shades, we will have
to make some compromise because #8 and #9
have to be identical to avoid asymmetry.
Figure 7: I decide on 2M2.5 as my final shade
for the BruxZir crowns on tooth #8 and #9.
Shade 2M2.5 is made by mixing 2M2 and 2M3
in equal amounts, something not possible in
the Classical system (there is no such thing as
A2.5). Even if the lab uses an A2 shade in the
material you request, they will have the 2M2.5
shade tab to help with characterization before
it leaves the lab. This is why 3D-Master shades
work better, even if the material you request is
only available in VITA Classical shades.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics17
Figure 8: Correctly selecting the closest shade
is half the battle. No shade matches a tooth
perfectly, so it is incredibly helpful to the dental
technician if you take and include a digital
photograph of the selected shade tab next to
the tooth you are matching. There is no easier
way to immediately improve your esthetic results
than to e-mail some digital shade pictures with
your case. Technicians simply try harder when
you give them a road map to follow.
Figure 9: Now I am placing the PFG gel (Steven’s
Pharmacy; Costa Mesa, Calif.), an important first
step in giving a pain-free injection. Placing the
gel with an Ultradent syringe makes it easier to
“sneak” some of the anesthetic into the sulcus,
so that the patient does not feel the insertion
of the needle through the attachment. After 60
seconds, we wash the PFG gel off tooth #8 and
#9 and begin the injection.
Figure 10: Part of the advantage of using the
STA Single Tooth Anesthesia System ® device
(Milestone Scientific; Livingston, N.J.) is being
able to give painful infiltrations right under a
patient’s nose. The STA device allows me to
predictably get pulpal anesthesia with a painfree
PDL injection. I slide the 30 gauge extra
short needle into the sulcus without going
through the attachment. I step on the STA
foot pedal and give a few drops of Septocaine
into the sulcus prior to going through the
attachment. I honestly don’t know if this helps
in any way, but I know it doesn’t hurt, and it
makes me feel better. Once I give a few drops,
I continue to express the Septocaine while the
needle tip is advanced through the attachment
until it reaches the crest of the bone.
Figure 11: Because of the pressure that is
generated with any PDL injection, if you move
the needle to reposition it, anesthetic will squirt
out that we don’t want the patient to taste.
Likewise, when we finish the injection and
remove the needle, anesthetic will squirt out
again. As shown here, my assistant places a
saliva ejector next to the insertion point to make
sure that when the anesthetic spills out, she is
able to control it. A cotton roll placed next to the
needle tip can serve the same purpose.
Figure 12: Another benefit of the STA device
is the nature of the syringe itself. In order to
inject with a typical syringe, the thumb, index
and middle fingers must be in predetermined
positions to generate the force to express the
anesthetic. With the STA device, you are able to
grasp the syringe at any point along its length,
so I typically hold it much closer to the tip, as
shown here. This gives me a greater degree of
control and assists me in rolling the syringe if I
need to reorient the bevel.
Figure 13: The fastest way I’ve found to remove
an existing PFM is to use an aggressive carbide
like the Razor ® Carbide bur (Axis Dental;
Coppell, Texas). This bur easily cuts through the
ceramic material and the metal substructure.
In the past, I would use an old diamond to cut
though the porcelain material and would then
switch to a carbide to cut through the metal
substructure. The Razor Carbide does the job of
both of these burs and can be used with a light
touch when cutting through the metal, so as not
to inadvertently damage the tooth underneath.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics19
Figure 14: Once the prep is exposed, I use a
Christensen Crown Remover (Hu-Friedy; Chicago,
Ill.) to loosen the crown. You will notice
that I do not cut through the metal coping at
the gingival margin. Too often when I try to cut
through that last strap of metal, I inadvertently
tear up the facial tissue in the one area where I
would like to have very healthy tissue. Using the
Christensen Crown Remover, I can usually rock
the crown loose without having to cut through
the last strip of metal.
Figure 15: Now that the crown on tooth #9
has been removed, we can start prepping
tooth #8. Because this tooth has not yet been
prepared, I am able to take advantage of the
Reverse Preparation Technique. The mesial
contact is already broken from when I removed
the adjacent crown, so I now break the distal
contact with a #55 bur as you can see here. The
reason we break the contacts first is because
this technique requires the first retraction cord
to be placed immediately.
Figure 16: The first cord I use is an Ultrapak
cord #00 (Ultradent; South Jordan, Utah). This
is a plain cord that has not been soaked in any
medicaments, and I literally floss it into place on
the mesial and distal as though it were dental
floss. With the two interproximal portions of the
cord locked into place, I now pack the facial
Figure 17: On the lingual, I cut the two ends
of the retraction cord so they will butt up
against each another, as I do not want them
to overlap. Because this #00 cord is hollow,
it packs very easily into the sulcus. I have to
yet to find a sulcus that it will not fit into. It is
important to make sure that none of this cord is
visible supragingival because in addition to not
providing vertical retraction, there would be a
chance the bur could catch it during prepping.
Figure 18: The pre-existing crown on tooth #9
has irritated the gingiva, so before I try to pack
a #00 cord around this tooth, I do a pre-emptive
strike with some ViscoStat ® Clear (Ultradent).
This is a 25 percent aluminum chloride gel, so
it will not discolor either the gingival tissue or
the prep itself. Even when there is no bleeding,
I often use ViscoStat Clear in the anterior to
“pre-seal” the capillaries before I pack the cord.
Figure 19: I take a look with the mirror and
can see some of the #00 cord peeking out
from under the tissue. Now that the rest of the
retraction cord is in place, it is often easier to
get any difficult-to-pack segments subgingival.
Not having the #00 cord subgingival also
presents problems later in the pre-preparation
technique when we place the #2E cord on top
of this cord. It is imperative that when the #2E
cord is placed, it does not get underneath the
#00 cord; otherwise, when we pull out the top
cord, the bottom cord will come out as well,
which will lead to bleeding right before we take
Photo Essay: The Pursuit of BruxZir Anterior Esthetics21
Figure 20: The #00 bottom cord provides about
0.5 mm of vertical retraction of the tissue. This
retraction allows us to prep the gingival margin
right at the free margin of the gingiva, knowing
that when the #00 cord is removed, we will end
up with a margin that is slightly subgingival.
Even though we have many esthetic choices for
anterior crowns, I still prefer to hide my margin
just slightly subgingival.
Figure 21: I use the 801-021 round diamond bur
from the Reverse Preparation Set (Axis Dental)
to cut a half-circle into the gingival third of the
tooth. This half-circle is the formation for the
perfect margin. After we do the axial reduction,
we will be left with a perfect quarter-circle,
which will end up being our deep chamfer or
shallow shoulder. Not only do we end up with
a simple, nearly perfect margin, but we also
ensure that we reduce enough in the gingival
third, an area that is typically under-reduced.
Figure 22: I then take the 801-021 round bur and
trace it around the gingival margin on the lingual
as well. BruxZir crowns work with feather-edge
margins, so I don’t necessarily have to do this,
but because most of our dentists would use
IPS e.max ® (Ivoclar Vivadent; Amherst N.Y.) in
a situation like this, this technique will provide a
great margin for either restoration. As this round
bur is typically too large to fit interproximally,
I take the bur from mesial contact to distal
contact. I will connect the facial and lingual
round bur cuts later with an 856-025 diamond
Figure 23: I make my next depth cut to ensure
adequate incisal reduction. I use the MADC-020
bur (Axis Dental) to place 2 mm depth cuts in the
incisal edge of tooth #8. This 2 mm of reduction
will give the technician a good opportunity to
build an esthetic, strong incisal edge. It also
helps to keep the final restoration from being
too far to the facial, aka too “bucky.” However,
if you are planning on adding some length to
the central (0.5 mm for example) you only need
to reduce 1.5 mm to give your technician 2 mm
Figure 24: I now switch to the MADC-015 bur
(Axis Dental), which gives me a self-limiting
depth cut of 1.5 mm. I turn the handpiece so
that it is perpendicular to the facial surface of
the tooth and place a 1.5 mm depth cut at the
junction of the incisal and middle thirds. The
placement of this depth cut ensures that there
will be enough facial reduction to enable the
technician to create a flat facial profile on the
final crown. When crowns are too “fat” facially,
they will never blend in naturally with the
surrounding natural dentition.
Figure 25: At this point, all of the depth cuts
are in place. We can see the half-circle in the
gingival third that is approximately 1 mm deep.
The 1.5 mm depth cut is at the junction of the
incisal third and the middle third, and the 2 mm
depth cuts in the incisal edge are there as well.
The beauty of these depth cuts is that there is no
guessing whether we have reduced enough —
we simply prep until the depth cuts are no
longer present. Once you break through the
enamel surface with a diamond, it becomes very
difficult to judge how much you have reduced. I
have not found an easier way to prep teeth than
with depth cuts.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics23
Figure 26: It’s now time to connect all the
depth cuts with the workhorse bur in the
Reverse Preparation Set: the 856-025 bur. I love
prepping with this large bur because it cuts very
smoothly and does not have a tendency to dip
into the tooth, even if you have build-up material
on the tooth. As shown here, the reduction is
already finished in the gingival third, so we are
working on reducing the incisal and middle
thirds and blending these planes together.
Figure 27: This is also the time when we need to
blend our facial reduction with the interproximal
reduction that was started with the 55 bur.
Because tooth #9 has already been prepped, we
were able to use the round bur interproximally
on the mesial, which we usually cannot do. A
glance back at Figure 25 shows that round bur
cut on the mesial of tooth #8. Because tooth #9
is already prepped, we are also able to take the
856-025 bur onto the mesial surface. Typically,
we have to switch to the 856-016 bur (Axis
Dental) to do this, which is the same shape, but
has a smaller diameter.
Figure 28: The reduction on the lingual surface
is accomplished with an Alpen 379-023 football
bur (Coltène/Whaledent Inc.; Cuyahoga Falls,
Ohio). I typically do not place a depth cut on
the lingual surface of anterior teeth because
I find it easy to check the reduction against
the lower anterior teeth simply by having the
patient close. Unlike on posterior teeth where
eyeballing occlusal reduction is very difficult
(especially on lingual cusps), I don’t have this
same problem on maxillary anterior teeth. Of
course, if you wanted to place a 1 mm depth cut
on the lingual, there would be nothing wrong
Figure 29: Toward the end of the preparation
sequence, when most of the gross reduction
has been done, I need to be able to visualize
what I am doing at the margin. I turn off the
water to my KaVo ELECTROtorque handpiece
(KaVo Dental; Charlotte, N.C.), turn the speed
down to around 3,000 rpm, and slowly take
my 856-025 bur back and forth across the
margin, smoothing it out. With the water off, I
can see everything I am doing, and by turning
the rpm down low, I can keep from overheating
the tooth. Being able to run a handpiece at
low speeds with no water and high torque
is the number one reason I insist on using
Figure 30: I notice we still have some decay
on the mesial of tooth #8, so I remove that now
with some Sable Seek ® and Seek ® Caries
Indicator (Ultradent) and a small round bur. I find
it easier to remove any remaining caries at the
end of the preparation sequence rather than at
the beginning, mainly for better access to the
lesion itself, but also because I find I can do a
better job with the bonding steps when I have
Figure 31: I have intact tooth structure on all
sides of the carious lesion, so I have a high
degree of confidence about the retention of
this small composite filler I am doing to restore
this (Vertise Flow [Kerr Corp.; Orange, Calif.]).
Vertise Flow is a self-etching flowable composite
that is perfect for small situations like this.
Because it is a self-etching product, there is no
separate etch and bond step. Vertise Flow also
works very well for small Class I restorations,
sealants, preventive resin restorations and quick
little build-ups like this one.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics25
Figure 32: Next, we syringe an initial layer of
Vertise Flow into the preparation. As shown
here, this composite contains a self-etching
bonding agent that is activated by using a
disposable brush to burnish the material into
the dentin for 20 seconds. In reality, you end up
removing most of the first layer from the prep
while doing this, but the point is to get a very
thin layer in close contact with the dentin.
Figure 33: Here we are light-curing the initial
layer of Vertise Flow for 20 seconds. The light
curing actually stops the self-etching of the
dentin that was taking place. Now that we have
that layer bonded to the dentin, we can add 2
mm layers of Vertise Flow, curing for 20 seconds
between each increment. As we are just bonding
composite to composite at this point, there is
no need to use the brush or agitate the material
any more. The process simply is to add some
material, light cure and repeat. Most flowables
won’t support their own weight, so you are
better off placing them in smaller increments.
Figure 34: I always slightly overbuild these
types of small build-ups, or fillers. I want to be
able to prep it back flush against the natural
tooth, so that I don’t leave an undercut in the
tooth. We receive far too many maxillary anterior
impressions at the lab with multiple undercuts
in the teeth where direct composites used to
be. Not only does this cause the impression to
distort, but it also creates weakened dies. It is
my hope that a simplified build-up technique
like this one with Vertise Flow will help more
dentists invest the time needed to place and
charge for these build-ups.
Figure 35: The next step of the Reverse
Preparation Technique is to place the top cord,
the #2E Ultrapak cord (Ultradent). The “2” in the
cord’s name refers to its size, while “E” refers
to it being an epi cord. I know there may be
some controversy with the use of epinephrine,
but my experience has always been that if
a patient can tolerate epinephrine in a local
anesthetic injection, then they can tolerate it in
the retraction cord. If a patient requires a nonepi
vasoconstrictor in their anesthetic, epi cord
would not be an option.
Figure 36: Packing this second cord, or top
cord, is more difficult for a number of reasons.
You can’t floss it into place interproximally like
you can with the first cord because doing so
would disrupt the bottom cord, which we want
to stay firmly planted at the base of the sulcus.
Also, even though this cord is hollow, it can be
hard to pack in certain clinical situations where
there is minimal attached gingiva. Because of
this, on some maxillary bicuspids and lower
anteriors, I will use a smaller #1E cord instead.
In extreme cases, a cordless technique with
Access ® Edge gingival retraction paste (Centrix;
Shelton, Conn.) can be used in place of the
Figure 37: Once the top cord is in place, you
get one last look at your margin. In this case, I
am not entirely happy with what I see because
the shape of my margin does not match the
contour of the gingiva. The margin is not as
smooth as it could be, but keep in mind that it
was prepped with a super coarse 856-025 bur.
This bur is fantastic for quick tooth reduction,
but because of the size of the diamond particles,
it leaves little chips in the margin. At this point,
I switch to my fine grit 856-025 bur with the
red stripe to get rid of that choppiness in the
Photo Essay: The Pursuit of BruxZir Anterior Esthetics27
Figure 38: The margin has now been
recontoured with the 856-025 fine bur. Again,
the speed can be turned down to 2,000 rpm to
avoid overheating the tooth. In my experience, I
can clearly visualize the margin only if I turn the
water off to see what I am doing. Now that I have
dropped the prep margin down to the gingival
margin with both cords in place, the resulting
facial margin will now be approximately 1 mm
subgingival. I typically do this in cases with a
dark prep shade to keep the dark shade from
Figure 39: Now we place two ROEKO
Comprecap Anatomic compression caps
(Coltène/Whaledent) onto the preps, and have
the patient bite down for 8 to 10 minutes. This
time frame is really not negotiable, as these
compression caps work wonders if given
enough time. Because they are “anatomic,”
there is a cutout on the mesial and distal of each
cap to prevent the interproximal papilla from
getting blunted. We moisten the inside of the
Comprecaps before placing them on the teeth
so that when we remove them, we don’t have
cotton fibers sticking to the prep. Comprecaps
are a great way to prevent bleeding during the
Figure 40: After waiting 8 to 10 minutes, we
remove the Comprecaps and then the top cord
from the sulcus. We can expect no bleeding
nearly all of the time thanks to the attention
we have given the gingiva throughout the prep
sequence. When you add in the epi strand in
the top cord and the pressure hemostasis from
the Comprecaps, it should not be surprising
that there is no bleeding at this stage. Quality
restorative dentistry is more dependent on a
great impression than a great preparation, so
this is the moment of truth!
Figure 41: The bottom cord provides the
vertical retraction of the tissue, while the
top cord provides the lateral retraction that
creates the space for the impression material
to flow into. It is imperative that we get a nice
thickness to the marginal impression material,
or it has a tendency to tear when the impression
is removed. Keep in mind that the impression
material is in contact with the #00 cord in the
base of the sulcus, and the cord is preventing
bleeding by remaining in place against the
inflamed base of the sulcus.
Figure 42: Removal of the top cord leaves
behind a wide-open sulcus in which to place
the impression material. It is not the type of
situation where you are racing against gingival
blood flowing into the sulcus. Take your time
and make sure to go around each tooth three
or four times to prevent any pulls or voids in the
material. These pulls and voids are especially
difficult when you get back to the point where
you started expressing the material. I have
watched slow-motion footage of moisture
being pushed around the sulcus in front of the
material and creating a pull when the syringe
tip gets back to the starting point, hence the
recommendation to go around each tooth three
or four times with the tip in the sulcus.
Figure 43: Here I am using a custom impression
tray. I never used a custom tray for two single
anterior crowns in the past, so I admit this
is overkill — perhaps I am a little spoiled by
working within a lab — but I can confidently
say that if you got them for free and they were
always available, you would use them too! In a
case like this, it is perfectly acceptable to use
an anterior double-arch tray for this impression.
The biggest challenge when using anterior
double-arch trays is being able to see whether
the patient is in maximum intercuspation.
Always hold the impression up to the light to
verify that the un-prepped teeth are in contact.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics29
Figure 44: Because I’m not using a double-arch
tray, I have to take a bite registration so that the
lab will be able to articulate the models. With
full upper and lower models, it would be pretty
easy for the lab to hand articulate the models
and verify with wear facets, but the use of a
bite registration does a good job of verifying
the mounting. A properly done bite registration
should only contact the incisal third of the teeth
that have been prepped, and the incisal third of
the opposing teeth. It will be trimmed back in
the lab, but try to keep the registration material
off the soft tissue.
Figure 45: When removing a polyvinyl siloxane
impression from the mouth, do it gently with
a slight rocking motion. This cord technique
gives us a deep subgingival impression of the
root structure, so we want to make sure we give
the material the chance to stretch and pull the
bottom cord off the sulcus if it is attached. This
is the opposite of an alginate impression, which
should be removed with a sudden snapping
motion. One of the benefits of silicon impression
materials is their ability to set in an undercut and
be removed without tearing, so give it a chance
Figure 46: It has been five days, the temps have
been removed, and the preps cleaned with
Consepsis ® (Ultradent). The more I shorten the
time between prepping and seating, the less
adjustments and the lower remakes I have. The
best example of this is same-day restorations
and their almost nonexistent remake rate. My
hope is that as digital impressions continue to
make inroads into more dental offices, threeday
turnarounds will become the standard for
model-less monolithic crowns. The temporary
crown is the biggest source of error and movement
in the crown fabrication timeline, and the
less time that it is in the mouth, the better the
chance the crown will drop into place without
Figure 47: The BruxZir crowns fit well and the
patient has approved them, so it is time to start
the cementation procedure. The more I work with
BruxZir restorations, the more familiar I become
with some of its unique properties, which
hold true for all zirconia-based restorations.
Zirconia crowns are susceptible to salivary
contamination when they are tried in the mouth,
which is something that doesn’t affect other
types of crowns to any great degree. The only
materials that bond reliably to zirconia oxide are
phosphate groups. The phospholipids in saliva
bond to the internal surfaces of zirconia-based
restorations, so if you simply rinse them out
with water as I am doing here, you remove the
visible saliva, but the phosphate groups remain
bonded to the zirconia surface.
Figure 48: Fortunately, Ivoclean (Ivoclar Vivadent)
was released earlier this year, specifically
for the purpose of cleaning out restorations
prior to bonding or cementation. I place a couple
drops in both of the crowns that will stay
in place for 20 seconds. Ivoclean is a concentrated
zirconia oxide solution. When placed in
crowns, it sets up a concentration gradient so
that the salivary phosphate groups bonded to
the inside of the crowns are drawn across the
gradient to the zirconia particles in the Ivoclean,
which can then be rinsed away.
Figure 49: I use a microbrush to ensure that the
Ivoclean is evenly distributed and has come in
contact with all of the internal surfaces of the
crowns, although it is not necessary to agitate it
against the surface as we might do with a selfetching
resin material. We just want to ensure
that the purple Ivoclean material is coating the
entire internal surface of the crown; then, after
20 seconds, it can be rinsed out.
Photo Essay: The Pursuit of BruxZir Anterior Esthetics31
Figure 50: Ironically, perhaps the worst thing
you can do to clean out zirconia-based crowns
after try-in is to use phosphoric acid to clean
them. As you might imagine, phosphoric acid
is full of phosphate groups, and in your attempt
to clean the salivary phosphate groups still
bonded to the zirconia, using phosphoric acid
will flood the area with phosphates and occupy
every receptor site on the zirconia. It is only by
flooding the crowns with zirconia oxide that
we can decontaminate the internal surfaces in
preparation for cementation.
Figure 51: Now that we have freed up the
bonding sites on the zirconia with the Ivoclean,
there is no better way to cement a BruxZir crown
than with a cement that contains the same
phosphate groups that bond to zirconia. That
cement is Ceramir ® (Doxa Dental Inc.; Newport
Beach, Calif.). Doxa Dental recently finished its
clinical trials with the Dental Advisor to
show that Ceramir does in fact bond to BruxZir.
Here I am activating the Ceramir capsule in
the activator by holding the handle down for
Figure 52: It’s a good thing I didn’t get rid of
my triturator! Next, I place the Ceramir capsule
in the 3M ESPE RotoMix capsule mixer for
10 seconds to ensure a complete mix. I know
this method of dispensing this cement seems
a little 1980s compared to modern paste-paste
cements, but I find it to be well worth the little
bit of extra effort. Just the ease of cleanup alone
makes Ceramir a no-brainer for me. Unlike most
resin-modified glass ionomer cements, Ceramir
has a “putty” stage that allows you peel it all off
in one piece. In fact, my dental assistant never
has to call me in anymore to dig out chunks
interproximally that have set rock hard.
Figure 53: I fill the BruxZir crowns with the
Ceramir and seat them simultaneously on the
preps. Because the Ceramir is so moisture
tolerant, I no longer have to vigorously air-dry
the preps prior to cementation. Instead, I often
just place a few cotton rolls around the preps
to remove any pools of moisture. Not having
to blast the preps with air anymore, I find that
I have to anesthetize far fewer patients for
crown seats than before. We use pinewood
sticks to ensure that the crowns stay in place
while the cement sets, in case there is any soft
Figure 54: Due to Ceramir’s tolerance to
moisture, it is OK if the patient’s tongue or saliva
hits the cement while it sets. Many BruxZir
crown preps tend to be slightly shorter clinical
crowns than the ones shown in this case, so
having the Ceramir cement bond to the BruxZir
crown is a good insurance policy without having
to use a silane. As promised, you can see I am
able to remove the entire facial surface of excess
cement in one piece, followed by the lingual. I
then run some Oral-B ® Superfloss ® (Procter &
Gamble; Cincinnati, Ohio) interproximally to
remove those pieces.
Figure 55: Here are the cemented final BruxZir
crowns on tooth #8 and #9. Having an in-house
technician makes it easier for me to match
anterior BruxZir crowns, so I’m not suggesting
that you switch to BruxZir for all of your anterior
crowns. In fact, I’m going to suggest that you
stick with IPS e.max for this type of situation
unless you see that the patient has broken other
restorations or shows higher-than-average wear.
However, it’s becoming clear we are getting
closer to having BruxZir Solid Zirconia become
the go-to anterior crown & bridge material. CM
Photo Essay: The Pursuit of BruxZir Anterior Esthetics33
Interview with Dr. Dan Fischer
– INTERVIEW of Dan E. Fischer, DDS
by Michael C. DiTolla, DDS, FAGD
Dental innovator and Ultradent Products Inc. CEO Dr. Dan
Fischer continues to ensure that his company’s products
play a large role in the clinical techniques of many dentists.
I like to check in with him once a year or so to find out what
his company has been working on, and how his mission to
stamp out dental caries is going. If you are ever in Utah,
you owe it to yourself to visit Ultradent and take a look into
the testing the company does to formulate its products. I
guarantee you will come away impressed.
Interview with Dr. Dan Fischer37
Dr. Michael DiTolla: I’ve always admired Ultradent and what
you guys have done because you’ve brought a lot of common
sense to dentistry. You’ve taken some product categories
and dispensing systems that needed cleaning up and really
made things easier for those of us out there practicing. One
of your newer products that came across my desk the other
day is UltraCem (Ultradent; South Jordan, Utah), your resinreinforced
glass ionomer (RRGI) cement. I’ve always felt like
this was a product category that could use another product
or two in it. It’s far from the sexiest product in dentistry, but
it seemed like there were only two companies dominating the
market. So not only did you come out with a traditional crown
& bridge cement, but you put it into a dispensing system that is
so novel, it could only be from Ultradent. Can you share a little
bit about the development process?
Dr. Dan Fischer: Sure. Most of the credit on that syringe
mixing device for the liquid and powder goes to our young
team in R&D that picked up on the passion of the ease
of use of a syringe. If you think about it, a syringe is one
of the simplest hydraulic devices on the planet. But to be
able to mix a liquid and a powder brings so much to the
equation, on the logic that no paste-paste resin-modified
glass ionomer (RMGI)* can be as strong as a pure liquidpowder
— you just can’t get enough of the glass ionomer
powder into a resin-based system.
MD: So when you guys started development of UltraCem, you
already realized that, in order to have the best physical properties
for this cement, you were essentially going to have to take
*RRGI and RMGI are used interchangeably in this interview.
Ketac-Cem - 3M ESPE
RelyX Luting Plus - 3M ESPE
RelyX Luting - 3M ESPE
GC FujiCEM - GC America
GC Fuji PLUS - GC America
UltraCem - Ultradent
Bond Strengths of Popular Luting Cements
1 2 3 4 5 6 7 8 9 10 11
Metal Button Shear to Dentin
a step back to a powder-liquid and move away from the pastebased
DF: Yep. In fact, if you look at what was the strongest RMGI
out there prior to UltraCem, it was GC’s FujiCEM , and that
is a liquid-powder mix in a capsule. And it’s the same with
3M ESPE RelyX Luting Cement; their strongest RMGI is
still a liquid-powder mix in a capsule. As soon as you have
to go to paste-paste, you lose the opportunity to get the
amount of the glass ionomer silica in there that you’d like
to have for creating a very strong cement.
There was something else we realized, which we feel puts
this product into its own distinctive category, Mike, and
that is: RMGI is so fabulous for bonding to metal, and it
is wonderful for bonding to zirconia, especially with the
zirconia primer. But to really bond well to dentin and enamel,
you need to have a minimal dwell time of the polyacrylic
against the dentin to be able to etch it. That’s why UltraCem
comes only in a regular set. If we were to bring it out in a
fast set, it wouldn’t have that dwell time. But by having that
dwell time, you have the first self-etching, resin-modified
glass ionomer, which gives us a bond strength that more
than doubles GC Fuji’s, which was the strongest heretofore.
MD: You said a couple things there that I want to touch on.
So the paste-paste delivery system, which has kind of become
the norm — I think it’s probably the biggest seller in the
category — it sounds like that was designed more for the
dentist’s convenience than for the quality of the cement that
comes from that mix. Is that right?
Courtesy of Ultradent Products Inc.
DF: Absolutely. It’s been the same
name of the game for 90 percent of
the bonding agents out there: they
have been designed more for the
dentist’s convenience. Tragically, in
that process, we’ve had some great
fourth- and fifth-generation bonding
agents that have kind of been pushed
aside, with the dentist running to
the single bottles and the like, many
of which, Mike, give one-fourth to
one-half the bond strength of what a
non-compromising adhesive can
provide. So you take something like
Clearfil SE (Kuraray America Inc.;
New York, N.Y.) or OptiBond ® (Kerr
Corporation; Orange, Calif.) or our
Peak ® (Ultradent) — these are a handful
of what I call “non-compromising
adhesives” — and these can give an
adhesion to dentin at around 65 to
75 percent of the actual strength of
the dentin. Yet so many adhesives
designed in the sense of speed can
give you one-fourth to one-half that, and it’s really a lost
opportunity. It prevents the dentist from being able to place
larger, direct-bonded restorations.
For the RMGI, it’s succumbed to the same gig: put it in a
double-barrel type device and run it through a static mixer.
When you’re doing that, you’re leaning more toward a resin
cement with a minimal amount of resin-modified glass
ionomer. Doing this was kind of a stepping stone to our resin
cement. The best resin cement today can’t perform as well
as UltraCem RRGI. Additionally, they don’t get the fluoride
release like a RMGI can get. So, all in all, to push the level
of the RMGI to a higher level, you’re getting a great, strong
cement to metal with the self-etching feature, over twice
the bond strength to dentin as what you’d get with the best
out there heretofore, and you’re getting the fluoride release.
You also get a great film thickness that’s around 25 microns.
So we’re kind of passionate about that. Furthermore, to
eliminate the need for that plier that’s required to break the
capsule before you can put it into the Wig-L-Bug ® (Dentsply
Rinn; Elgin, Ill.) to mix it, and to eliminate the Wig-L-Bug
mixing and then to eliminate the little mix device, it brings
about a lot of simplicity in our own office. Our guys have
fallen in love with it because it’s so simplistic. Schools love
it, too. You can probably remember when you had one
Wig-L-Bug mixer between maybe 20 to 40 students, and you
had to leave the patient and travel some distance to get your
little capsule mixed, and then you headed back hoping you
would be able to get everything in place before it set.
MD: Not only that, but I remember mixing about 10 crowns’
worth of cement for every actual dose of cement that I needed to
cement one crown. So, I’m sure that for
the schools it’s also going to eliminate a
lot of waste, in addition to streamlining
the cementation appointment. That
really is amazing that you’ve been able
to have UltraCem be self-etching and
take advantage of those higher bond
strengths, yet still have the fluoride release
and not have to kowtow to going
down the paste-paste route.
Now you mentioned the bonding agents.
I think dentists are probably a little
confused. I think sometimes they see
products that appear too good to be true.
One company releases a product like
this and then the bigger companies, like
the 3Ms, figure it’s selling so well that
they need to release their own one-bottle
system or their own paste-paste cement
to keep up with the Joneses. I guess
when the reputable companies release a
product, the dentist tends to think: this
product must be OK.
DF: Yeah, it’s frustrating. And with your dentist hat on, it’s
doubly frustrating because it’s the patient that loses in the
process. The patient is totally ignorant as to what’s going
on. When you consider that there is somewhere around 100
brands of bonding agents out there now, and you’ve only
got a small handful that are really non-compromising ones,
Every time I’ve lectured over the last year, I share with
dentists that there are two products that have a greater
influence on the quality of your resin restorations than
any other two products, simply based on what you choose
to purchase. One of those is your bonding agent, and the
second is your curing light. There are a number of quality
composites out there, and there are a number of different
matrix systems and the like, but, everything else being equal,
the two factors that have the greatest impact on the quality
of your restorations is the quality of your adhesive and
the quality of your curing light. For posterior composites,
you’ve got to have a curing light that will deliver around
15 to 16 joules entirely into the floor of your Class II box.
You get on a first or second molar with one of these light
guides that has the bend it in, and you just can’t direct
that light directly down into those Class II boxes. So when
I’m lecturing to dentists, I share with them that if you are
using a compromising adhesive down on the gingival floor
of that Class II box, or if you are using a light that just can’t
illuminate the gingival floor of a Class II box then, yes,
there is a much higher potential for recurrent decay in the
next two to three years under that area. It’s sad to say that
our patients, when we notify them of such, just look up at
us and say, “Well, doc, don’t worry, I just have soft teeth.” It
Fluoride Release — One Week
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
• UltraCem - (Ultradent)
• Fuji PLUS - (GC America)
Courtesy of Ultradent Products Inc.
Interview with Dr. Dan Fischer39
just underscores the importance of us really thinking about
the things we don’t think about more. If you envision a
metal matrix wrapping a first or second molar, and you
imagine a mesial-proximal box, with a light guide, the area
that is behind that metal matrix down in the gingival box
is in the shadows to a substantial degree. So, it’s a big deal
to not only have adequate power, but to have a design that
can illuminate the posterior preparations, or restorations,
if you will. These light guides, they work fine for front
teeth, but they sure are not predictable and appropriate for
illuminating in proximal boxes on molars. You take those
big light guides into a child’s mouth and it’s a joke!
MD: Right. There’s no chance of getting down there in those
types of clinical situations. Do you think you face an uphill
battle with this dispensing system? Just in the sense that dentists
are used to and love the fact that you guys have put everything
in a syringe over the years, but this is the first time that we’ve
seen a permanent cement like this that needs to be mixed up
in the syringe. Or do you feel like this is a product that once
dentists get a chance to use it once or twice, they’re going to say
it’s pretty simple to use and that they can sleep better at night
knowing it’s a great cement with no compromises?
DF: The beauty of UltraCem is that the liquid and the powder
are dosed in accurate ways, so you know you’re going to
get a great mix. This is also the case for the capsule with
the Wig-L-Bug; the syringe just eliminates the Wig-L-Bug
and the other apparatus. But, certainly, if they don’t want
to go that way, we offer it in a bottle and a scoop as well,
because we believe in the cement standalone as a quality
self-etching RMGI. But, ideally, they’ll pick up on the beauty
of that syringe just like many other dentists. Many dentists
have found the value of syringes and other dentists prefer
just to bottle. You can’t convince all of them to go down the
MD: That’s really interesting. I think 3M ESPE’s RelyX Luting
Cement, which used to be Vitremer Luting Cement, has
probably been the product category leader for a while. When
it was a powder and liquid, I don’t think a lot of dentists
had complaints about having to mix the cement and put it
in the crown and cement it. I don’t think it was something
that dentists looked at as being overly laborious or technical
or a pain. So when it came out in the paste-paste form and it
was from the same company, I think dentists just thought: all
right, this is the upgrade. This must be version 3.0, instead
of 2.0. This must be the better version of it. It’s really kind of
stunning to hear you talk about the physical properties and
how, clinically, in the patient’s best interest, it was kind of a
step backward. I hope dentists read this and really stop to think
a little more because I think sometimes marketing can lead us
astray in the case of a product like this.
DF: We need marketing and marketing is important, but it’s
the patient in the chair that it’s all about. We can’t afford to
lose sight of that because they’re the ones who ultimately
pay the price if things don’t work out, and they’re the ones
who ultimately benefit if things do work out. From my point
of view, this is just part of being a patient-centered dentist.
MD: I completely agree. And, obviously, as somebody who
practices within a dental laboratory and talks to a lot of
dentists who are cementing restorations, I’m very happy this is
going to be in our magazine that goes out to 125,000 dentists
across the U.S. But I’m especially happy this will go out to our
customers, so they will get an opportunity to see what your
research has proven.
Another thing that I’m passionate about is impressions. One
of the trays I started using awhile back was the Triotray Pro
from Triodent. They came to us as a laboratory and said they
thought we’d like this tray and that our clients would be able
to get better, less-distorted impressions with it. I started using
it and I liked it, and we started promoting it to our customers
who didn’t like the idea of a disposable tray. Then, I woke up
one morning and saw that Ultradent was now distributing the
tray! I thought, “Well, that’s great. Two companies that I really
enjoy are getting along well together.” I’m interested in why,
when you guys seem to develop a lot of things from scratch on
your own and take a new approach to traditional products,
you decided to join up with Triodent, rather than coming up
with your own tray.
DF: There are a couple things that have been at work here
— maybe more than two. Obviously, Triodent’s Dr. Simon
McDonald and his R&D team have been hard at work down
there in New Zealand pushing the envelope with their
fabulous system. We’ve been working for years to push the
envelope where we could. Both companies are driven by
R&D. We’ve probably put more money into R&D for each
dollar of product we sell than any other companies, and
that’s where the first level of our similarity comes.
The next level of our similarity comes in that both of us are
owned and managed by dentists, so we have that dentist’s
need, that necessity-is-the-mother-of-convention drive to
find a better way to skin the cat.
Then, it’s the words that frame the Ultradent brand as determined
by a large, outside marketing entity that surveyed our
customers about six years ago. The two words they found
that were repeated most often by our customers were “progressive”
and “trustworthy.” So when we looked at what the
Triodent guys have done with this matrix — bringing the
ultimate level of finesse, incorporating science and facilitating
virtually 100 percent of the time tight contacts and nice,
anatomically correct broad contacts for the direct-placed
restoration — we thought, “Should we try and reinvent the
wheel on this, or is it logical that we work together?”
Now I bring about the fourth leg of this discussion and that
is, we decided a couple years ago that even if we applied
ourselves darn hard, it’s still not logical to think that we
can invent everything that a dentist needs and have it be
the absolute best product out there. We pride ourselves
on having progressive, trustworthy products. We pride
ourselves on bringing out what is among the best. But to
do that on every front, to be the best at everything, that
gets to be a challenge. And, if you’re not careful, it can
even be a little bit arrogant. So when they approached us
about distributing their matrix system, we studied it and
thought, “You know, this company is aligning pretty good
with our culture. They’re aligning well with our vision to
improve oral health globally. They’re aligning on so many
fronts, so let’s take the leap and for the first time market
and sell another company’s brand of product.” We’re glad
we did that, and I think they’re glad we did it. Certainly,
our sales team focuses not on 20 or 30 different brands of
thousands of different products like the large distributors
do; they focus on a narrower range. We believe if we can
keep that range narrow, even extending beyond our own
brand if an appropriate opportunity presents itself, that we
really can serve the dentist and their needs in much more
knowledgeable, educated, quality, caring ways.
MD: I think you’re right. I think there is a lot of hubris if you
start to go down the road of: we can do everything better than
everybody else. I think, at some point, you do need to realize
that there are a lot of smart people in this industry, and at least
this one team has spent all their time looking at this one thing.
When you sit and look at that impression tray, there are so
many desirable aspects about it: how it’s taller in the anterior
to help you get the impression of the cuspid, and the way the
material locks into it, and how it has the little seal on the back
to keep the extra impression material from running out the
posterior part of the tray. It’s very stiff; it’s hard to squeeze it
laterally and have it bend at all. So, it really is well thought out.
multi-unit bridge, that problem escalates virtually algorithmically.
So, it just made a whole lot of sense to embrace a
quality impression tray such as what Simon and his team
had developed. And I concur with you, when you look at
the finesse, when you look at the details that you described
— higher in the front for cuspids and the like — you can
tell that a lot of thought has gone into it from entities who
are knowledgeable on dental anatomy and dentists’ needs
and patients’ capabilities in the chair and the rest. It all
MD: Even the disposable mesh that goes in the tray, when I
first looked at it I thought there was a mistake in the factory
because the mesh was so loose in the front. But, of course, it
was intentional so that a patient with a deep overbite could
get into maximum intercuspation without tearing the mesh.
So even that little mesh insert has had a lot of thought that’s
gone into it. It’s like you locked seven people in a room and
gave them some quadrant impression trays and told them they
could come out in a year. It looks like that’s the kind of time
that was spent, and it’s pretty ingenious.
I heard you say something that I didn’t know about you.
You started off early in your career doing a lot of full-mouth
reconstruction? I’m surprised because I know you hate crowns
DF: Quite frankly, Mike, I don’t hate crowns. In fact, just
this morning I prepared a crown on a patient. What I say is:
I place fewer crowns than I used to in my younger years. I
don’t plead with my colleagues not to place crowns anymore,
but rather to try and push that more invasive procedure
back in a patient’s life. Not committing them to the invasive
procedure of a full-crown prep in their 20s, 30s and 40s,
When you look at our laboratory statistics, 75 percent of the
impressions we get here are for single-unit crowns, but almost
75 percent of those are still in plastic disposable impression
trays. When you take these disposable trays and you squeeze
them, they distort very easily. We know polyvinyl siloxane
materials already shrink on their own as they cure. Frankly,
it’s amazing that crowns fit as often as they do. Have you done
any research into disposable impression trays? Or do you just
kind of have a feel for how much better these Triotrays work?
DF: We basically believe the same concepts you do. In fact,
my initial passion out of dental school in Loma Linda in the
mid-’70s was full-mouth reconstruction. I ate, drank and
slept that type of dentistry for some time. What you said is
so true: The research that extends for decades shows the
importance of a tray that’s not deformed, that’s rigid, that
holds its shape and supports that impression material to
the best of its ability. And, certainly, when you compound
that with moldable units beyond one unit — boy! With just
a tiny bit of inaccuracy extended out over the length of a
Interview with Dr. Dan Fischer41
ut to try and buy time with less-invasive procedures —
giving the pulp chamber a chance to become smaller,
giving the dentinal tubules a chance to become smaller, and
saving that more invasive procedure for their later years.
When you do so, you minimize the number of root canal
treatments that are required later, you minimize the amount
of replacements that have to occur with crowns and the like.
We will always, within my lifetime, I believe, have the need
for full-coverage crowns. I’ve got one that my daughter put
in my mouth just four years ago. It was an upper second
molar that was a virgin tooth, but it succumbed finally to
the “dental student syndrome.” Namely, when I was a junior,
a senior student had to take out impacted wisdom teeth in
order to graduate, and I became the volunteer. The student
wasn’t the sharpest knife in the drawer and took out some
of the buccal plate over my second molar, and I’m sure he
leaned that elevator on that root. Later, bacteria got in that
crack and it was discovered, much later, probably about
eight years ago, when the tooth abscessed and became a
sinus infection and all the rest. If you’ve got a tooth like
that, or you’ve got a molar that’s taking a heavy load, or a
tooth that’s had root canal treatment — you’ve got to put
crowns on those kinds of things.
MD: Of course! And I know you don’t hate crowns. I know that
what you don’t like is the overuse of full crowns as the easy
way out, or kowtowing to what the patient’s insurance might
pay. Did you go with cast gold on that crown?
DF: It’s solid cast gold on this upper second molar.
MD: Good choice! We like to see that. That’s becoming an
endangered species in the laboratory today. I guess part of
that is gold hitting $1,700 an ounce. It’s also patients giving
some pushback about having gold in their mouth — even on a
second molar — which is kind of crazy, especially after we tell
them it’s the best material we’ve ever had in dentistry.
DF: Well, when you said, “Good choice, that’s what we like
to see,” the truth is at the end of the day, you can’t even
see it, Mike! (I’m teasing you a little based on the meaning
here.) But, yes, it’s true: if nobody is going to see it, you
can’t beat it. That being said, I am impressed with how
zirconia continues to improve. In fact, boy, with the cost of
metals and the like, thank goodness we’ve got materials like
zirconia that are evolving to where they are.
MD: Right. Let me share some numbers with you. In 2007,
66 percent of the crowns that we fabricated here were PFM
crowns and 23 percent were all-ceramic crowns. If you look
at 2011 and the first half of 2012, and PFMs have gone from
66 percent to 20 percent, and all-ceramics have risen from
22 percent to 68 percent of the restorations, and it’s because of
zirconia and lithium disilicate. It’s shocking to me, and even
to us as a laboratory, to see how quickly dentists have changed
their allegiance and have been willing to kind of drop the
PFM. It has been an amazing transformation largely pushed
on by zirconia and dentists being somewhat satisfied with the
material because they continue to order it.
Let me ask you about one other thing I find fascinating about
you: your drive to find a cure for dental caries. I don’t think
there could be a higher mission on the planet, and least in the
dental world, than to tackle something like this, and I don’t
hear anybody else really talking about this. In fact, I saw in
a recent article that the city of Phoenix is thinking about not
fluoridating their public water supply. Can you tell me how
your drive to find a cure for dental caries is going?
DF: The progress has been slow. Not because of the
technology, but because of regulatory constraints that we’re
up against with the FDA. We have a technology that we feel
can go a significant distance on this. We’re being very active
on it, and we feel like we’re making some good inroads
relative to explaining the technology to the FDA. It’s a little
device that in the first human studies — four kids in a lower
social economic group for which oral hygiene is pretty
low — was shown to decrease caries 76 percent. If we can
reduce caries 76 percent, we can reduce the incidence of
the abscessed tooth 95 percent, which is exciting to me.
But, yes, we’re still battling that.
That being said, and I don’t know if I told you this last
time or not, Mike, but if we could bring about a cure to
caries today, we’d still need more dentists. I mean, when
you consider that in our country before the recession, onethird
of our fellow Americans couldn’t afford to go to the
dentist except for emergency treatment. When you consider
that teeth are like tires — they’re good for so many miles,
and then the treads wear out, the sidewalls give out. When
you consider the jobs of the Western world, there’s hardly
one job I can think of in Western countries that makes it
easy for a patient with a missing central or dark, disfigured
teeth to get a job. It’s a different world than it used to be. If
we can bring about a cure for caries today, we’d still need
The most exciting news to me would be the amount of
suffering we could stop for those who can’t afford Western
dentists. Whereas one-third of our fellow Americans can’t
afford treatment, two-thirds of the world doesn’t even
have access to dentists. You’ve got humans who would
jump off a cliff to escape the pain of an abscessed tooth.
You’ve got humans who are known to pick up a boulder
and mash it into the side of their head trying to escape the
pain of an abscessed tooth. In so many parts of the world,
including America, there are 12-, 13-, 14-year-old kids who
are totally edentulous! The magnitude of this infectious
disease is so devastating, when humans don’t have access
to or can’t afford access to our Western-trained dentists. I
believe it’s something we have to be serious about, just out
of humanitarian reasons beyond mastication, chewing and
MD: I thought it was kind of self-evident that we’d still need
dentists, even if we found a cure for caries. Can you clarify
what you mean by that?
DF: What I meant to say is, for sure we’ll need dentists. But
I believe, even if we bring about a cure for caries, we’ll need
MD: Right. But are you saying there’s some pushback from the
dental industry when you talk about curing dental caries?
DF: I say that, quite frankly, just to let the dental industry
know it shouldn’t be afraid of any source that is going to bring
about a cure to caries because, whether it be us, whether
it be NIH, whether it be JNJ, whether it be any company
that comes out with a cure for caries, we’ll still need more
dentists. So in a proactive way I’m saying: dentists shouldn’t
be afraid of that, dental companies shouldn’t be afraid of
that. Teeth being like tires, look at the challenges to the
dentition with people living longer and keeping their teeth
longer. We’d have a shifting demographic. We’d have less
need to be addressing severe, early childhood caries. We
would be working more on older people. But that would be
a good problem, Mike.
MD: I actually think that sounds like a great practice! In fact,
most of the dentists I know who work on adult populations
refer the kids out anyway. They don’t enjoy treating childhood
caries. They prefer doing restorative dentistry on older patients.
For dentists who say they want to do more esthetic dentistry, if
you get rid of caries, a large part of it will be esthetic dentistry.
So that sounds like a very modern, desirable way to practice. I
like your vision of the future.
DF: And if more families, even in lower socioeconomic
groups, didn’t have to spend as much money addressing
caries, they could potentially have more there, including
the insurance companies they align with to help them get
orthodontics for their kids. So you’d have more pediatric
dentists doing more orthodontics, taking more ortho
courses. There’s always going to be the need for it all, we
just will be shifting to somewhat different demographics.
But we’ll still need more dentists, Mike.
MD: I think that’s such a noble effort that you’re putting forth
toward doing that, especially for somebody from a restorative
company — although, as you point out, it’s really not going to
put anybody in dentistry out of business. Business will boom.
It will just be a slightly different treatment modality than we
It’s been fascinating hearing about UltraCem, especially
because when I first looked at the product, honestly, without a
bunch of the literature, I just thought that you had reinvented
the dispensing system. But I really appreciate you informing
me on the difference between the powder-liquid and the pastepaste
cement. It’s nice to hear that you guys decided to go
with the product that was the best clinical product available
and not just chase the easier money and high convenience.
You chose something that’s going to stand the test of time and
ultimately benefit the patient.
DF: That’s right. I think it’s important that the dentist sees
it’s not just a fancy, fun mixer, but that it’s actually a superior
One other quick note on this: You know how frustrating
it is if, say, there’s not adequate retention on a preparation
and the crown comes off, but I’m sure you also know the
most challenging of all cases when that occurs is when you
have compromised retention on one abutment and good
retention on the other and one side of the bridge comes
loose. For dentists who are cementing crowns in which they
have less-than-ideal vertical wall retention capabilities or
any concern over one side of a bridge coming off, they
can take that bond strength — which is a little more than
double GC Fuji’s — and double it again simply by putting
a little of our Peak on the preparation before they cement.
MD: Interesting. That’s certainly an easy way to double the
bond strength. And with the UltraCem, they get all the fluoride
release as well, so they don’t have to make that compromise.
DF: Yes, you are still getting the fluoride release, and you go
from twice the bond strength of a GC Fuji to four times the
bond strength. And the GC Fuji and UltraCem are higher in
bond strength than the self-etching resin cements that are
out there today. CM
For more information on Ultradent, visit www.ultradent.com or call 888-230-1420.
Interview with Dr. Dan Fischer43
Digital Impressions for
Astra Tech, Straumann,
Neoss and Zimmer, as
well as Certain® (BIOMET
3i; Warsaw, Ind.),
Mass.), and Brånemark®
and NobelReplace (Nobel
Biocare; Yorba Linda,
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available for the lab’s
– ARTICLE and PHOTOS by Carlos A. Boudet, DDS, DICOI
Technological advances are making it easier than
ever to practice dentistry in almost every dental
procedure. 1 The purpose of this article is to increase
awareness of a new modality for the restoration
of implants by general practitioners and prosthodontists
utilizing chairside digital impression systems. 2
The conventional protocol for taking an implant impression
for crowns & bridges requires a stock or custom impression
tray loaded with a polyvinyl siloxane or polyether material
that is placed in the mouth to record the position of a
properly seated impression coping. This impression is then
used to pour a stone model from which the laboratory
fabricates the final restoration.
Digital intraoral impressions were first introduced in 1987
by Siemens with the CEREC 1. 3 There are now several wellestablished
systems that offer intraoral scanning and digital
impression capabilities for the construction of crowns &
bridges without the need for impression trays or materials. 4,5
For the dentist who needed an implant impression, however,
this technology was not yet available. In 2004, BIOMET 3i
introduced a coded implant healing abutment that provided
all of the necessary implant information without the need
for impression copings. 6 This was proprietary to 3i and
more costly than a standard impression, but it was a step in
the right direction.
Scannable Abutments: Digital Impressions for Dental Implants45
In late 2010, Straumann introduced a scannable abutment
called a “scanbody,” which allowed for the taking of a digital
implant impression. We needed this option to be available
for most commonly used implant systems, however. At this
time, Straumann only works with iTero (Align Technology
Inc., formerly Cadent Inc.; San Jose, Calif.).
A dental laboratory in Canada, 5 Axis Dental Design Center,
has since taken the concept further by developing scannable
abutments that are compatible with implant systems from
most of the major implant companies, allowing dentists
to submit digital impressions for CAD/CAM design and
milling of implant abutments and fixed restorations.
However, at the time of this writing, they too can only use
the iTero scanner. 7
In February 2012, Glidewell Laboratories introduced intraoral
scanning abutments under its Inclusive ® line of implant
products for implant systems from Astra Tech, Straumann,
Neoss and Zimmer, as well as Certain ® (BIOMET 3i; Warsaw,
Ind.), PrimaConnex ® (Keystone Dental; Burlington, Mass.),
and Brånemark System ® , NobelActive and NobelReplace
(Nobel Biocare; Yorba Linda, Calif.). These Inclusive Scanning
Abutments are also available for the lab’s line of Inclusive
Tapered Implants, and they can be used to create digital
implant impressions with the available, compatible intraoral
scanners, such as iTero, Lava C.O.S. ® (3M ESPE; St. Paul,
Minn.), CEREC ® (Sirona Dental Systems Inc.; Charlotte, N.C.),
IOS FastScan ® (IOS Technologies; San Diego, Calif.) and the
soon-to-be-compatible E4D ® Dentist (D4D Technologies;
Richardson, Texas). Heraeus projects to have a new intraoral
scanner, the cara TRIOS ® , available this year.
This is a rapidly developing field, and I would not be
surprised if in the near future we see a greater number of
compatible implant systems and more dental laboratories
offering this service.
When you compare the
simple steps involved
in capturing digital
digital method is
simpler, easier and
makes you a better,
happier and more
Figure 1: Implant ready to be restored
The following case example demonstrates the simplicity of
capturing a digital implant impression using an Inclusive
Scanning Abutment and CEREC Redcam acquisition unit
with version 3.8 CEREC Connect* software to restore a
Zimmer Screw-Vent ® implant. However, any of the previously
mentioned chairside digital impression systems available
today are compatible and can be used for this technique.
The patient in this case is a 62-year-old male who needed
the restoration of a Zimmer Screw-Vent 4.7 wide implant
in the area of the right mandibular first molar (Fig. 1). The
gingiva had healed around the healing abutment and was
ready for the implant impression (Fig. 2).
Figure 2: Implant with healing abutment
*In April 2012, Sirona renamed its digital impression portal Sirona Connect.
According to the company, the Sirona Connect portal, accessible via www.sironaconnect.net,
is compatible with all existing versions of CEREC Connect.
Figure 3: Inclusive Scanning Abutment finger-tightened on implant
Figure 6: Additional information tab in CEREC Connect software
Figure 4: Scans for digital impression
Figure 7: Fine-tuning the design with Glidewell Laboratories
Figure 5: Digital models correlated with buccal bite
Figure 8: CAD/CAM abutment try-in
Scannable Abutments: Digital Impressions for Dental Implants47
Our last step was to select Glidewell Laboratories as the
dental laboratory in the CEREC Connect software, and
complete the detailed prescription for the simultaneous
fabrication of the CAD/CAM custom abutment and crown
(Fig. 6). I selected a titanium abutment and BruxZir ® Solid
Zirconia crown. Before the lab began the milling process,
the technician called as I had requested, and we fine-tuned
the design (Fig. 7).
The case arrived at my office nicely packaged and organized.
I tried in and verified the fit of the CAD/CAM abutment
(Figs. 8, 9), torqued it to the recommended specifications,
and then cemented the BruxZir ® crown with very minimal
adjustment (Fig. 10).
Figure 9: Radiographic verification of seating of abutment
As I have done many times, I could have handled this
case in-office with good results using soft tissue models, a
prefabricated titanium abutment prepared extraorally and
an IPS e.max ® crown (Ivoclar Vivadent; Amherst, N.Y.), but
why would I want to spend more time doing laboratory
work when I have the option of being more productive
and delivering state-of-the-art dentistry to my patients?
When you compare the simple steps involved in capturing
digital implant impressions using scannable abutments to
conventional impression systems, the digital method is
simpler, easier and makes you a better, happier and more
productive dentist. 8 CM
Dr. Carlos Boudet is in private practice in West Palm Beach, Fla. Contact him at
www.boudetdds.com or 561-968-6022.
Figure 10: Cemented BruxZir crown
After removing the healing abutment, I placed the Inclusive
Scanning Abutment and finger-tightened it over the implant
(Fig 3). If tissue shaping is required for proper emergence
of the final abutment because you did not use a custom
healing abutment, you can do it at this time. This will give
the laboratory a good idea of the desired emergence profile.
The downside is that you will need good hemostasis, as any
bleeding will interfere with the impression.
1. Zweig A. Improving impressions: go digital! Dent Today. 2009 Nov;28(11):100, 102,
2. Patel N. Integrating three-dimensional digital technologies for comprehensive
implant dentistry. J Am Dent Assoc. 2010 Jun;141 Suppl 2:20S-24S.
3. Mörmann WH. The evolution of the CEREC system. J Am Dent Assoc. 2006 Sep;
4. Boudet CA. CEREC Connect: a welcomed upgrade for CEREC users. Chairside.
5. Fuster-Torres MA, et al. CAD/CAM dental systems in implant dentistry: update.
Med Oral Patol Oral Cir Bucal. 2009 Mar 1;14(3):E141-5.
6. Garg AK. Cadent iTero’s digital system for dental impressions: the end of trays and
putty? Dent Implantol Update. 2008 Jan;19(1):1-4.
7. Personal communication between laboratory owner and author.
8. Lee SJ, Gallucci GO. Digital vs. conventional implant impressions: efficiency outcomes.
Clin Oral Implants Res. 2012 Feb 22. Article first published online.
Next, we powdered the scanning abutment and adjacent
teeth, and took the scans for the digital impression (Fig. 4).
I then took the buccal bite and correlated (stitched) the
models (Fig. 5), before replacing the scanning abutment
with the healing abutment.
– ARTICLE and CLINICAL PHOTOS by
Leendert Boksman, DDS, BSc, FADI, FICD and
Robert C. Margeas, DDS
The Creation of a Soft Tissue Emergence Profile
with a Long-Term Ribbond ® -THM Provisional
There is an ever-increasing body of
dental research literature evaluating
the use of fibers to reinforce the clinical
performance of dental composites and
acrylics. Teeth restored with fiber posts
show a significantly higher resistance
to fracture than titanium 1 and stainless
steel posts. 2 Teeth restored with fiber
posts are significantly stronger in
static and fatigue fracture testing than
teeth restored with metallic posts, 3
resulting from an elastic modulus
that more closely approaches dentin,
producing less concentrated stress
on the root. 4 Similarly, custom fiberreinforced
posts (Ribbond ® [Ribbond;
Seattle, Wash.]) fabricated directly
into the root canal space with
composite show that polyethylene
fiber reinforced posts with composite
cores demonstrate high survival rates
and can be recommended for use. 5,6
Additionally, the insertion of Ribbond
inside the cavity has a positive effect
on fracture strength of endodontically
treated molar teeth with MOD cavity
preparation and cuspal fracture, 7 as
well as the ability to reinforce severely
compromised teeth which have been
endodontically treated. 8
The use of fiber reinforcement has
distinct advantages in traditional composite
restorative techniques. The use
of fiber under composite restorations
can save the tooth structure by changing
fracture lines if cusp failure should
occur 9 and significantly increases
fracture strength of MOD composite
restorations, especially if placed in
a buccal to lingual direction. 10 The
fatigue strengths of particulate filler
composite resins is 49–57 MPa, and
those of fiber-reinforced composites is
90–209 MPa, with the strain of UHM-
WPE (ultra-high molecular weight
polyethylene, i.e., Ribbond) being the
highest. 11 Strain energy absorption can
be increased 433 percent over unreinforced
composite, with the leno-weave
reinforced composite having the highest
consistency due to the details of
its architecture, which restricts fabric
shearing and movement during placement.
12 Polyethylene reinforcing fiber,
when used in combination with
a flowable resin in high C-factor
cavity preparations, results in stable
bond strengths and an increase in
the microtensile bond strength to the
dentin floor. 13 Another significant
advantage of using fiber reinforcement
in traditional Class II composite resins
is the significant decrease in gingival
The Creation of a Soft Tissue Emergence Profile with a Long-Term Ribbond-THM Provisional49
Strassler has written
extensively on the benefits
material with dental
resins and has used fiber
reinforcing in single-tooth replacement
techniques, 15 single visit, natural
tooth pontic bridges 16 and periodontal
splinting with thin-high-modulus polyethylene
ribbon. 17 The high molecular
weight polyethylene has a high wear
resistance and high impact strength, 18
with its plasma treatment resulting in
chemical integration with composite
resins. 19 With a locked-stitched lenoweave,
the fibers maintain their orientation
when adapted to the tooth
structure or integrated into temporization
and do not unravel when cut. 20
The addition of fibers to provisional
Figure 1: Initial presentation of patient with
fractured tooth #8 and resorbing tooth #9
resins increases the fracture toughness
and flexural strength, 21 with the clinical
implication of a reduced incidence
of fixed provisional restoration failure 22
due to enhanced fracture resistance. 23
Additional strengthening of the connector
areas can be achieved through the
use of a fiber-reinforcing material such
as Ribbond ® -THM (Ribbond). 24 Polyethylene
bridges can be considered as a permanent
treatment due to their strength 25,26
with selection of appropriate fiber reinforcement
and placement of the fibers
allowing long-term clinical success. 27
A 55-year-old patient presented to
the practice with two failing upper
centrals (Fig. 1). Tooth #8 had a vertical
fracture and tooth #9 had a failing root
canal treatment. Upon presentation
of the various options to restore the
area, the patient opted for placement
of a 4-unit fixed bridge. The centrals
were atraumatically extracted with
minimal trauma to the soft tissues and
alveolar process (Fig. 2). The lateral
incisors were minimally prepared for
the initial long-term temporization so
that the gingival tissues would have an
opportunity to stabilize.
Utilizing a previously fabricated polyvinyl
siloxane matrix, an appropriate
length of Ribbond-THM (thinner
higher modulus) was cut to extend
from lateral to lateral incisor (Fig. 3).
The Ribbond-THM was wetted using
unfilled bonding adhesive, the excess
blotted off with a lint-free gauze and
the saturated Ribbond was placed onto
the lingual surface of the PVS matrix,
followed by injection of Temptation ®
(CLINICIAN’S CHOICE; New Milford,
Conn.) (Fig. 4). A small amount of
Temptation was also placed into the
extraction sockets (Fig. 5), and the PVS
matrix was seated intraorally (Fig. 6).
After polymerization was complete,
the matrix was removed, and the temporary
bridge was removed from the
matrix (Fig. 7). To create the desired
soft tissue emergence profile (ovate
pontic form) for the final restoration,
the temporary bridge was fabricated to
extend 3 mm below the free margin of
the gingival tissue. The over-extension
Figure 2: Atraumatic extraction of centrals
maintaining tissue and bony contours, with initial
minimal full-coverage preparations on lateral
Figure 4: Placement of Temptation over the
Figure 6: Seating of the temporary matrix
Figure 3: Evaluation of the length of Ribbond-
THM required to adapt from lateral to lateral
incisor. Note: Ribbond Triaxial (Ribbond) is used
for larger cases.
Figure 5: Injection of Temptation into the extraction
Figure 7: Temporary removed from the matrix
and flowable added to create initial convex pontic
was removed (Fig. 8), and both pontics
were shaped and contoured to measure
exactly 3 mm from the marked
position of the free margin with flowable
composite (Figs. 9, 10).
Initial shaping of the temporary bridge
was followed by the application of
Tempglaze (CLINICIAN’S CHOICE),
which was cured with a broad
spectrum curing light for 30 seconds
per unit (Fig. 11). The temporary was
cemented with Cling2 ® (CLINICIAN’S
CHOICE), and all temporary cement
was removed (Fig. 12). After 10 weeks,
the soft tissue showed excellent tissue
contours, which will allow for naturallooking
emergence profiles for the
#8 and #9 pontics
clinical cases are
presented in photo format only, to
show the type of tissue response that
can be created with this technique
(Figs. 14–19). CM
Figure 8: Trimming the pontic tissue surface to
create a conically shaped pontic profile, which
will be 3 mm below the tissue margin.
Figure 12: Cementation with Cling2 and excess
Figure 16: Tissue profile after removing temporary
Figure 9: Marking the level of the free margin
to allow for accurate length measurement of
the apical projection.
Figure 13: Tissue profile after removal of
the temporary bridge, which was in place for
Figure 17: Fixed restoration showing excellent
Figure 10: Addition and modification of the tissue
adaptive surface with flowable resin
Figure 14: Six-unit anterior case showing tissue
profile after removing the temporary bridge
Figure 18: Tissue contours after removal of
Figure 11: Application of Tempglaze to the
shaped temporary bridge, which was cured
with a broad band curing light for 30 seconds
Figure 15: Same case final restoration immediately
Figure 19: Final fixed restoration
The Creation of a Soft Tissue Emergence Profile with a Long-Term Ribbond-THM Provisional51
Dr. Len Boksman formerly was director of clinical affairs for Clinical Research Dental and CLINICIAN’S CHOICE. He
currently does freelance consulting and lecturing for the general practitioner. He can be reached at lenboksman@rogers.
Dr. Robert Margeas is an adjunct professor in the department of operative dentistry at the University of Iowa and a clinical
instructor at the Center for Excellence ® in Chicago, Ill. He maintains a private practice devoted to esthetic dentistry in
Des Moines, Iowa.
1. Amenisalehi E. Strength of incisors restored by
metallic, fiber and ceramic posts. J Dent Res.
2005;84 (Spec Issue B), African and Middle East
2. Barjau-Escribano A, Sanho-Bru JL, Forner-
Navarro L, Rodríguez-Cervantes PJ, Pérez-
Gónzález A, Sánchez-Marín FT. Influence of prefabricated
post material on restored teeth: fracture
strength and stress distribution. Oper Dent.
3. Hayashi M, Sugeta A, Takahashi Y, Imazato S,
Ebisu S. Static and fatigue fracture resistance
of pulpless teeth restored with post-cores. Dent
Mater J. 2008 Sep; 24(9):1178-86. Epub 2008
4. Nakamura T, Ohyama T, Waki T, Kinuta S, Wakabayashi
K, Mutobe Y, Takano N, Yatani H. Stress
analysis of endodontically treated anterior teeth
restored with different types of post material.
Dent Mater J. 2006 Mar;25(1):145-50.
5. Piovesan EM, Demarco FF, Cenci MS, Pereira-
Cenci T. Survival rates of endodontically treated
teeth restored with fiber-reinforced custom posts
and cores: a 97 month study. Int J Prosthodont.
6. Bae JM, Kim MJ, Jung WC, Son DK. Evaluation
of the mechanical properties of experimental
fiber-reinforced composite posts. Abstract #2686
IADR/AADR/CADR 85th General Session 2007
7. Belli S, Cobankara FK, Eraslan O, Eskitascioglu G,
Karbhari V. The effect of fiber insertion on fracture
resistance of endodontically treated molars with
MOD cavity and reattached fractured lingual
cusps. J Biomed Mater Res B Appl Biomater.
8. Kirzioglu Z, Ertürk MS. Reconstruction and
recovery of hemisectioned teeth using direct
fiber-reinforced composite resin: case report.
J Dent Child (Chic). 2008 Jan-Apr;75(1):95-8.
9. Yldirim C, Kahveci O, Akman M, Belli S, Eskitascioglu
G. Effect of fibre on fracture strength of
teeth with MOD cavity. Abstract #0940
IADR/AADR/CADR 85th General Session
10. Belli S, Erdemir A, Yildirim C. Reinforcement
effect of polyethylene fibre in root-filled teeth:
comparison of two restoration techniques.
Int Endod J. 2006 Feb;39(2):136-42.
11. Bae JM, Kim KN, Hattori M, Hasegawa K,
Yoshinari M, Kawada E, Oda Y. Fatigue strengths
of particulate filler composites reinforced with
fibers. Dent Mater J. 2004 Jun;23(2):166-74.
12. Karbhari VM, Strassler H. Effect of fiber architecture
on flexural characteristics and fracture of
fiber-reinforced dental composites. Dent Mater
J. 2007 Aug;23(8):960-8. Epub 2006 Nov 7.
13. Belli S, Dönmez N, Eskitascioglu G. The effect
of c-factor and flowable resin or fiber use at the
interface on microtensile bond strength to dentin.
J Adhes Dent. 2006 Aug;8(4):247-53.
14. El-Mowafy O, El-Badrawy W, Eltanty A, Abbasi K,
Habib N. Gingival microleakage of Class II resin
composite restorations with fiber inserts. Oper
Dent. 2007 May-Jun;32(3):298-305.
15. Strassler HE, Taler D, Sensi LG. Fiber reinforcement
for one-visit single-tooth replacement. Dent
Today. 2007 Jun;26(6):120, 122-125.
16. Strassler H. Single visit natural tooth pontic bridge
with fiber reinforcement ribbon. Tex Dent J. 2007
17. Strassler HE, Brown C. Periodontal splinting
with a thin high-modulus polyethylene ribbon.
Compend Contin Educ Dent. 2001 Aug;22(8):
696-700, 702, 704.
18. Rose RM, Crugnola A, Ries M, Cimino WR, Paul
I, Radin EL. On the origins of high in vivo wear
rates in polyethylene components of total joint
prostheses. Clin Orthop Relat Res. 1979 Nov-
19. Rudo DN, Karbhari VM. Physical behaviors of
fiber reinforcement as applied to tooth stabilization.
Dent Clin North Am. 1999 Jan;43(1):7-35.
20. Strassler HE. Clinical materials review: fiberreinforcing
materials for dental resins. Inside
Dentistry. 2008 May;5(4):76-85.
21. Hamza TA, Rosenstiel SF, Elhosary MM, Ibraheem
RM. The effect of fiber reinforcement on the
fracture toughness and flexural strength of
provisional restorative resins. J Prosthet Dent.
22. Ramos V Jr, Runyan DA, Christensen LC. The
effect of plasma-treated polyethylene fiber on
the fracture strength of polymethyl methacrylate.
J Prosthet Dent. 1996 Jul;76(1):94-6.
23. Pfeiffer P, Grube L. In vitro resistance of reinforced
interim fixed partial dentures. J Prosthet
Dent. 2003 Feb;89(2):170-4.
24. Heymann HO. The Carolina bridge: a novel
interim all-porcelain bonded prosthesis. J Esthet
25. Chafaie A, Portier R. Anterior fiber-reinforced
composite resin bridge: a case report. Pediatr
Dent. 2004 Nov-Dec;26(6):530-4.
26. Karakaya S, Gursel M, Ozer F. Replacement of
natural teeth using fiber-reinforced restoration:
clinical reports. Abstract #0330 IADR 2005
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Reprinted by permission of Oral Health, December
Fast Is Better — Up to a Point
– ARTICLE by Ellis J. Neiburger, DDS
This article will explore the concept of “speed
dentistry,” the practice of doing dental treatments
faster and better. In today’s world, just about
everyone wants things to go faster. This need for
speed extends to many aspects of our lives, including travel,
food, data transmission and services. Time is money, and
slower times cost more money. Many modern businesses
pride themselves on — even advertise — their ability to do
things rapidly and do them “right.” Be it a fast haircut, fast
cost analysis, fast trades or fast dental care, society wants —
even demands — rapid service and high quality. If a
procedure takes less time, the individual has to spend less
time on that project. Any extra time gained can then be used
for doing something else, usually something considered
“more important.” We have all experienced the anguish of
slow food service or post office lines where the operations
are done at a snail’s pace. This can be frustrating and costly,
and dentistry is no exception.
Even before they are seated in the dental chair, patients do
not want to wait. They don’t like spending long minutes with
their mouths open or in uncomfortable situations. Having
an uncomfortable procedure done is more tolerable when
done with speed rather than lethargy. There is no patient
who would rather have a tooth extraction done slowly than
with the utmost speed. Our patients expect speed, comfort
and convenience. They will flock to dentists who provide
these things and shun those who don’t.
TAUGHT TO BE SLOW
Dentists have routinely been associated with slow
procedures. This is in part because a patient experiencing
an emotionally charged procedure (e.g., extraction) is under
stress and experiencing pain or discomfort — physically
and psychologically — so time seems to go slower for the
patient than it would if he were experiencing something
enjoyable. Consequently, the generally held perception is
that dentistry goes slowly.
Modern dentistry, as done by many dentists and their staff,
is often practiced slowly; that is, more slowly than it needs
to be. For example, Dr. Slow is doing an occlusal amalgam.
The dentist slowly sits down, chats a bit with the patient,
then slowly puts on some gloves, slowly adjusts the fit,
then looks at the bracket table, slowly selects a mirror and
explorer, and then slowly focuses on the anxious patient’s
mouth. He then looks at the record, slowly adjusts the chair
Speed Dentistry: Fast Is Better — Up to a Point55
position, lights and his loupes, and then slowly reads the
record again. Then he slowly looks in the patient’s mouth
at the offending caries. He will take his time examining
the tooth, slowly looking at it from several angles, then
glancing at the record, then back at the tooth. He has seen
it several times before, but just to be sure, he looks at it
again — and again.
Talking slowly, Dr. Slow then advises the patient that an
anesthetic is needed and opens a drawer, slowly selects a
syringe, studies a small stack of loose carpules and selects
one. He then slowly takes it in his hands and inserts it into
the syringe, checks the fit and slowly examines the tip of
the needle as solution is slowly expressed. Then he slowly
brings the syringe to the patient’s mouth, elevates the lip,
slowly examines the injection site and then slowly inserts the
needle into the mucosa, slowly injecting as he slowly drives
the needle tip deeper into the tissues. Taking a minute or so,
he then finishes the injection while he painstakingly moves
the syringe from side to side. He then slowly withdraws the
needle and syringe, taking his time to insert the safety cap
back on the instrument. A 5- to 10-minute wait ensues for
what is deemed “good anesthesia.” After asking the patient
several times if he is numb, poking at the gingiva and any
other tissue within range, Dr. Slow lifts his handpiece and
slowly looks at the bur, then looks away and toward his bur
block for an appropriate bur. He might look at several burs,
slowly considering each one before he makes his selection,
and then slowly pick up a chuck tool to loosen the old bur
and slowly insert the new bur. This process can go on and
on for what seems like forever! I’m sure you get the idea.
Instead of taking five minutes, Dr. Slow takes 30 minutes to
do a simple restoration. We are all more or less guilty of this
type of patient abuse.
Why do we do this? Why is practicing dentistry so slow and
methodical? Why must it take so much time when it really
is not necessary? The reason is simple: We were taught to
be slow in dental school. How many times were we told by
instructors, “Take your time and do it right” or “You’re doing
this too fast”?
ADVANTAGES OF SPEED DENTISTRY
The faster you do something, the quicker you will finish.
If you are torturing (treating) a patient, the faster you do
it, the less discomfort the patient will feel over the length
of the visit. If you are being paid for a treatment and you
do it quickly, then you will be making more money, faster.
If you treat 10 patients an hour rather than 10 patients
in four hours, you will be going home earlier and richer.
The patients will be better served because they will not
have to wait for treatment, and they will spend less time
in the chair and experience less stress. Physiologically,
as adrenalin secretion or stress suppresses the immune
system, less patient stress means less adrenalin secretion
and faster healing.
Another advantage is that you pay less for your staff because
they work fewer hours. However, if you choose to spend
the same amount of time in the office as you did doing
slow dentistry (same basic overhead), you will be able to
treat more people and thus increase your income, try new
techniques you previously didn’t have time for, study or
give more to charity. Speed dentistry has its financial as well
as professional advantages.
Many people object to the concept of speed dentistry
because they believe slow is better than fast, equating
reduced speed to precision. This began in 1900 America
with a great surgeon, Dr. William Halsted, who, after
having a stroke, perfected his technique of general surgery
by methodically going slow. Compared to the slip-shod,
microbe-contaminated surgical techniques of the Victorian
era, the new Halsted technique — along with dependable
anesthesia — produced fabulous results. Unfortunately, it
had an effect on dentistry. In most of our dental school
experiences, instructors believed that procedures done
When dental students are first shown a procedure, it is
usually demonstrated slowly to ensure comprehension. It is
then practiced slowly. Rarely, if ever, are we told or taught
to speed up the process. Unfortunately, this dental school
experience transfers over into real life and our dental
practices. Certainly, when we have a crowded schedule
or have to leave the office early, we speed up and push a
bit, but this is an occasional effort, not a continuous one.
We need to be consistently faster because it is good for
our patients, ourselves, our staff and our profession. With
the right training, equipment and mindset, we can all be
practicing speed dentistry.
apidly would lead to more mistakes and lower quality, as
well as potential injury to the patient or the dentist. They
encouraged “slow.” That concept is not held true today,
especially in practice. Doing dentistry rapidly, if you are
adequately trained, can be done safely and with a high level
of quality and patient comfort.
THE DROP-OFF POINT
The drop-off point is the point in a procedure where your
quality or control suffers. For example, if you are carrying
a tray of filled wine glasses and walking a 40-meter path
over uneven ground, you may spill the drinks if you
a) walk so slowly that you spend an inordinate amount of
time, thus becoming unsteady and fatigued or b) walk so
rapidly that you lose control of the tray or trip, thus shaking
it and spilling the cargo. These points are termed “dropoff
points” because you lose control and quality suffers
catastrophically. The area between the too slow and too fast
drop-off points is where you want to be with your speed
dentistry technique, and the closer you are to the too rapid
drop-off point without reaching it, the faster you will be
giving quality treatment.
Here’s another example: If you drive to a destination on
city streets going 15 mph, it will take you longer to get
there than if you drive at 30 mph. The traffic will pile up
behind you, some cars may pass inappropriately and irate
drivers my become distracted trying to flip you the bird or
honking. Some people may even become confused and hit
your car. You will probably be safer and drive the journey
more efficiently if you go 30 mph. Sixty mph is too fast,
30 mph is not, yet many dentists do their dentistry at 10–15
mph speeds because they believe going slow is good.
DROP-OFF POINT (SLOW)
DROP-OFF POINT (FAST)
Quality and increased speed of doing dentistry are ensured as long as
you stay between the slow and fast drop-off points. Going beyond the
drop-off points reduces treatment quality.
It is important to recognize and not
exceed your slow and fast drop-off
points. As long as you stay in that
range, your treatments will be of
How can you tell when you reach your drop-off point?
You’ve reached it when you start to make errors and
mistakes. When you see this happening, ease off a bit and
slow down. Speed affects different people in different ways,
so you will have to test yourself. No one can tell you how
fast to go.
It is important to recognize and not exceed your slow
and fast drop-off points. As long as you stay in that range,
your treatments will be of high quality. With some practice
and new equipment or techniques, you may even expand
your drop-off point to higher levels. The message is that
slowness is not always good, and speed is not always bad.
Be careful not to confuse slow speed with quality dentistry.
Doing dentistry at a snail’s pace can often be harmful to the
patient and to you, the dentist. For example, slowly doing
a reflected surgical flap procedure in 40 minutes is more
harmful to the tissues than the same flap procedure done in
just 10 minutes. Speed dentistry is beneficial, as long as you
do not exceed your drop-off point.
DOING SPEED DENTISTRY
How does one increase their speed in dentistry? Just doing
a procedure rapidly is not sufficiently beneficial because it
often becomes a hit-or-miss adventure. Carefully planning
how you will increase your speed and repeatedly performing
at that level will yield permanent and controllable results.
You need to think about how you will speed up your
treatment technique. Ask yourself what you are going to
do, what instruments you will need and what materials will
be necessary. Plan what you will do if this or that happens,
such as the enamel breaks or the patient moves. Then have
Every dentist works differently, using his own techniques,
instruments and other customized methods of doing
dentistry. Everyone is unique and produces different results,
even with the same patient, materials and techniques. There
is no one method for speed dentistry. Dentists must identify
a variety of faster techniques, try them out to see what
works and what methods are effective, and then perfect
them. They must execute a little faster here, a little faster
there, until they see substantially improved results.
Speed Dentistry: Fast Is Better — Up to a Point57
Here are some reliable and generally successful ways
many dentists have used to increase their speed and begin
practicing speed dentistry:
1. Simply think you will do dentistry better and faster.
Many dentists have never considered this concept, so
they just continue to work slowly like they did in dental
school. Once you decide to do your dentistry more
rapidly, you will.
One way to check how you are doing is to place a
timer in each operatory. Time how long it takes you
to do a procedure. Log the time. Try to do it a bit
more rapidly the next time, and the next. Experiment.
Test different ways of doing a procedure or handling
a patient. Use that timer with every patient and
every procedure. Keep records and analyze your
results. Once you are timing yourself, you will begin
working faster and doing speed dentistry. Remember,
the true measure of speed dentistry is the amount
of time the patient is in the chair. It doesn’t help
much if you quickly do a restoration and then squander
all the time you saved by telling stories or cracking
jokes with the now-completed patient.
2. Identify those procedures that take up most of your time
and then decide how you will speed up the process.
Can you do the treatment differently and shave off
a second or two? Can you use fast-set amalgam or
a stronger curing light to speed up your restoration
technique? Will special instruments or preset trays
increase your speed while maintaining quality?
For example, use locking pliers with a cotton pellet
already attached. It is faster than stopping your
procedure, hunting for a cotton pellet in a capped
dispenser (requires uncapping and recapping),
selecting the pellet with your cotton pliers and then
using the instrument. Save 15 seconds using this
technique. Now, if you do it 30 times a week, 48 weeks
a year, you do the math on how much time it saves.
3. Quit talking so much. Talking sucks time. If you must
talk — keep in mind, most patients appreciate a
few words — speak while you are doing something
productive. Avoid talking about yourself. Instead, talk
to your patients about their lives. Everyone likes to talk
about themselves, so let them. If someone needs to be
calmed down or relaxed, have your dental assistant do
most of the work. If you save 30 seconds of idle talk
per patient, and you see 20 patients per day, four days
a week, 48 weeks a year, you will save 32 hours of
chairtime per year. Think about how much you make
in one hour of chairtime. And that’s just 30 seconds.
Go for more.
4. Increase the air pressure of your dental handpieces to
60–80 psi. They run faster, cut faster, and you finish
faster. My experience is that the handpiece cartridges
will also last longer, despite the common industry
recommendations to keep the pressure at 30 psi.
5. Use sharp instruments. Sharpen the edges of your
plastic instruments, the tips of your explorers, spoons
and other hand instruments. Scalers and curettes must
always be sharp. Do the sharpening before the patient
is in the chair, not during the visit.
6. Use topical anesthetics and rapid-induction hypnosis
anesthesia (waking hypnosis) rather than injecting — and
waiting — for every little cavity prep or procedure. Using
fast-acting medications and materials will save you time.
7. Move faster and have your staff move fast, too. If they
resist or complain, fire them. A slacker with a mopey
attitude will never change. You are operating a service
business, not an employment depot for the low and
slow of our society.
8. Analyze each movement during a procedure. Is it necessary?
Is it needed? Can you do without it or change the
procedure to omit it entirely? For example, many practitioners
wipe instruments on the patient’s bib. This
takes a few seconds to do and then re-establish focus
on the tooth being treated. Instead, place some gauze
in the patient’s mouth and wipe your instrument on it
there. This positions you closer to the action, takes less
time to do, does not divert focus out of the mouth and
is probably more sterile. Saves a second — or four.
9. Have prearranged instrument setups for each procedure.
This is infinitely faster than picking a multitude of
instruments out of a chest of dental drawers with the
patient watching. When the patient is in the chair, do
dentistry. Don’t waste your time and the patient’s time
setting up to do dentistry.
10. Determine if there are simpler treatment methods. For
example, seventh-generation bonding is an all-in-one
technique that is considerably faster than a fourthgeneration
technique of separately etching, separately
priming and separately bonding a composite. Saves
11. Don’t spend time “making it pretty” if it doesn’t matter to
the patient. Carving secondary anatomy in a composite
or amalgam wastes significant time and will do
nothing to improve the restoration. If you want to be
an “artist,” paint or sculpt during your free time or
off hours. Does amalgam really need to be polished?
How about composites? Do you need frequent recall
appointments for an asymptomatic, healthy patient?
Do you need to do all those adjustments? Can you
place dissolvable sutures instead of using silk sutures
and scheduling an extra and time-consuming sutureremoving
appointment? Don’t waste your time doing
extra, unnecessary work.
12. Look at the treatment area (gingiva, tooth) intently, but
just once. Then treat. Don’t waste time looking, then
relooking, then cleaning off your mirror to look again.
Concentrate and don’t play.
13. Don’t do services that take more time than they are
worth. For example, if maxillary third molar endo on a
difficult patient takes too much time and energy, refer
it out to someone else. If you produce $1,000 an hour
at the chair and take two 50-minute sessions to do
a molar endo for which you are charging $900, then
you are losing big money and not helping the patient.
Refer the patient to someone who can do the job
in 30 minutes. You can’t do it all! Dump the timeconsuming
14. Get rid of difficult patients. Difficult patients take up lots
of time. Spending time to argue, constantly reassure
and repeat slows your work and forces your other
patients to wait and possibly suffer. Send your difficult
patients a note saying, “because of our communication
problems, I cannot continue being your dentist.” You
don’t need them or the time-sucking referrals they may
bring. If a patient wastes your time by often arriving
late or breaking appointments, get rid of them. If you
can’t bear to kick them out of your practice, then
charge them double: they’ll leave. The ones who truly
love you will stay and pay the bill. Another technique
is to have them wait one hour in the reception room
before you see them. They’ll get angry and leave.
15. Prepare a series of information sheets with drawings
or photos on each procedure you will do. Personally
giving an info sheet to a patient as you are going to
another operatory and asking him to “look at this,
Speed Dentistry: Fast Is Better — Up to a Point59
John” saves a lot of non-productive chairtime you
would otherwise spend describing the dental work you
will be doing. Practice discussing dental procedures
or treatment options using the most direct, simplest
way you can communicate. Long-winded lectures are
boring to the patient and wasteful, and they should
be eliminated. For example: “John, we can save your
tooth with root canal treatment costing $700 or pull
it out for $200. Your insurance will pay half. You will
pay the other half.” If the patient dawdles, give him
some speedy direction, “John, if it were my tooth and I
had the $350, I would save it.” Save time by practicing
your role in these situations so you will be prepared to
quickly present yourself when the day comes.
16. Make use of hand signals to your staff. For example,
waving an index finger means to mix the cement. This
saves time, especially when you are communicating
with your patient and need to communicate with your
dental assistant at the same moment.
17. Control phone calls and other non-essential interruptions.
You can call them back at convenient moments.
Grabbing a phone in the middle of an operation is
a time waster, foolish, and insulting to the patient
18. Do as much as you can in one sitting. Try to avoid
wasting time by getting up, walking out, coming back,
re-gloving, re-washing and reappointing. Do it all at
19. Have spare instruments available for quick access. If
you drop a mirror or bend a needle, you should have
a replacement within easy reach. Do not lose time
waiting for your dental assistant to run and get another
instrument in the next room.
20. Always be well stocked with an accurate and dependable
supply of disposables, instruments and other dental
materials. There is no value in running out of widgets
when you need them. Being well stocked is common
sense. Devise an automatic inventory system and
21. Have redundant systems that can quickly be utilized in
case of malfunction. If your compressor or vacuum goes
out, you can simply turn on your spare. If you don’t
have a spare, you will waste time and lose money. Be
sure everything is hooked up and ready to go. Having
a spare compressor in your garage doesn’t help you in
the office. Quick plumbing disconnects and standard
electric plugs/sockets can make it possible to switch
equipment in a few minutes. This converts a timewasting
disaster into a minor inconvenience. It’s going
to happen to you some day, so be prepared.
22. If it takes too much time to learn or use, you don’t need it.
Our lives are filled with “labor-saving” gadgets, which
we buy only to find out that they take too much time
to use. “Modern” and “new” is not always the best.
Software is a prime culprit. Beware of the time-wasting
learning curve. Keyboard entry may be considerably
slower than quickly scribbling on a record sheet. If you
have to computerize, let your staff transfer the patient’s
written records to the computer.
23. Keep appointments to a minimum. If the patient has four
restorations to do, do them all in one appointment, if
practical. Don’t schedule another appointment if you
don’t have to. Reappointing takes up considerable
time: greeting the patient at the door, seating the
patient in the dental chair, looking at the patient’s
record, chatting with the patient, etc. With your speed
dentistry technique, you can do more work in less
time. Your patients will appreciate it.
24. Inject anesthetics rapidly. Some dental instructors say it
is better to inject slowly, but they are wrong. Why do
it rapidly? Because it takes less time. Patients may feel
a bit more pressure, but they will suffer less emotional
trauma if you inject in 15 seconds instead of giving a
slow, torturous 65-second injection. If you are going to
inflict pain, the faster you do it, the less net discomfort
there will be.
25. Move with a sense of purpose. Avoid wasted movement.
There is no one method for speed dentistry. Dentists must identify a variety
of faster techniques, try them out to see what works and what methods are
effective, and then perfect them. They must execute a little faster here, a little
faster there, until they see substantially improved results.
Let’s face it: Everything in dentistry is not about time and
money. You may confront a situation in which you must
take more time to do a procedure or talk to a patient. If
necessary, you must sacrifice cold efficiency for good
humanity. However, you must keep these time sinks to a
minimum or direct them to that portion of the day when
you can take a little more time. Sometimes a lonely elderly
patient wants to tell you a joke that goes on forever, or
worse, talk about their divorce or operation. Do your best
without insulting the patient. Devise techniques for such
situations. Just keep it controlled.
Speed dentistry, like any endeavor, has advantages and
disadvantages. If you are going to speed up, you will use
more energy. If you speed up gradually, your stamina will
increase, but you may be more tired by the end of the day.
That is the cost of speed dentistry. Of course, if you do two
days’ worth of patients in one day, you can take another day
off to rest and recover with no net financial loss. Decide
what you are going to do with that extra time and money.
If the way you decide to use it is productive — great. If it is
self-absorbed and abusive, such as spending your newfound
time at the local bar, then perhaps you should go back to
the office. Think about it. Speed dentistry is not for the
So where do you start? As previously suggested, start by
realizing how speed dentistry will help you, your patients
and your practice. Get some idea of how long it takes to do
a procedure or see a patient. Start with exams, cleanings
and restorative procedures. Using a timer (or a group of
timers), identify how long it takes to do a procedure. Make
some changes. Time yourself again. See if you can shave off
some seconds or maybe even a minute or two. Use quicker
materials and techniques. Keep track of the time. Perfect
your technique. Watch for your drop-off point. You may
become a fast dentist or a good dentist, but what you really
want to strive for is being a fast, good dentist. This is an art
form. Try it and good luck! CM
Sections of this article come from the book “Speed Dentistry,” by E.J. Neiburger,
DDS. Andent Publishing, 1000 North Ave., Waukegan, IL 60085. Copies are available
Dr. Ellis Neiburger is a general practitioner in Waukegan, Ill. Contact him at 847-244-
0292 or firstname.lastname@example.org.
© 2012 by E. Neiburger. First publication rights granted to Chairside magazine.
Speed Dentistry: Fast Is Better — Up to a Point61
– ARTICLE and CLINICAL PHOTOS by
Tarun Agarwal, DDS, PA
An Important Visual Aid in
Treatment Planning and Case Acceptance
Photographic imaging has been available in dentistry
for many years. Typically, it has been used for full-smile
makeover simulations. Full-smile simulations can be very
difficult and time consuming, however, and can often create
unrealistic expectations or outcomes. This challenge, added
to the expense of investing in traditional dental imaging
software, leads many clinicians to completely avoid the use
of digital imaging in their practice.
For anterior cases, digital imaging can and should play a
vital role in patient education and decision-making. In fact,
in situations where a few teeth are being treated, its use
may be even more important than for full-smile restorations.
This case study will demonstrate how digital imaging can be
used to communicate different treatment possibilities and
assist in patient treatment acceptance. It will also detail the
clinical technique used for achieving the patient’s desired
final result (Figs. 1, 2).
A 34-year-old male presented to our office for cosmetic
consultation at the urging of his girlfriend. His major
concern was to fix the chip on the mesial-incisal corner
of tooth #8 and a broken tooth #9 (Figs. 3, 4). During our
consultation, I inquired about his overall treatment goals.
He said he wasn’t sure what he wanted and that he hadn’t
given the matter much thought.
This particular case was not cut and dry, and there were
multiple treatment options and things to consider. Do
we close the diastema or leave it open? Do we keep the
Figure 1: “Before” photo
Figure 2: “After” photo
Figure 3: Preoperative photo showing chipped tooth #8 and fractured
Figure 4: Close-up photo of tooth #8 and #9
Digital Imaging: An Important Visual Aid in Treatment Planning and Case Acceptance63
centrals at the current length or shorten them? Do we
use direct composite in-office or send the case out to
the lab for porcelain restorations? Does the patient want
teeth whitening? These were all appropriate options, and
the suitable treatment depended on the patient’s desires.
Deciding on these factors would not only impact the
cosmetic outcome, but also influence the clinical treatment.
Figure 5: Simulated photo showing treatment with the diastema left in
At this point, I decided visual communication using digital
imaging would simplify the decision-making process.
Using Adobe ® Photoshop ® Elements (Adobe Systems; San
Jose, Calif.), an off-the-shelf photo manipulation software,
I completed several simulations of the various treatment
options. The first simulation showed repairs made to tooth
#8 and #9 using direct bonding, leaving the diastema in
place (Figs. 5, 6). The second simulation showed porcelain
veneers being used to repair tooth #8 and #9 and close the
diastema (Figs. 7, 8). The final simulation showed the patient
what his teeth would look like if he whitened them (Fig. 9).
After seeing all treatment possibilities, the patient decided
to whiten his teeth followed by having porcelain veneers
placed on tooth #8 and #9 that would close the diastema.
The patient whitened his teeth for about two weeks and
then allowed two weeks for rebound (Fig. 10).
Figure 6: Close-up simulated photo of first treatment option
Figure 7: Simulated photo showing second treatment option, closing the
The decision was made to utilize feldspathic porcelain
veneers. Feldspathic veneers require only 0.5 mm of facial
reduction and 1 mm of incisal reduction for adequate
strength and beauty. Feldspathic veneers are layered and
allow the characterizations and color to be built deep within
the restoration. This combination yields a conservative, yet
After achieving adequate anesthesia, the teeth were
prepared using the “connect-the-dots” approach. First, a
0.5 mm depth-cutting bur (LVS1 [Brasseler USA; Savannah,
Ga.]) was used to ensure minimum thickness on the facial
surface (Fig. 11), and incisal depth cuts were placed to ensure
minimal incisal reduction (Fig. 12). Incisal depth cuts were
not necessary on tooth #9 because it was being lengthened.
Next, preparations were made for closing the diastema.
When closing a diastema, the preparation margins must
be placed subgingival interproximally and carried to the
lingual to allow for a proper emergence profile. A twogrit
diamond bur (LVS3, Brasseler USA) was used for final
margination (Fig. 13).
Figure 8: Close-up simulated photo of second treatment option
Porcelain restorations require rounded preparations that
are free of sharp angles and unsupported enamel. A coarse
polishing disk (EP2, Brasseler USA) was used to round
all line angles and sharp edges to ensure a smooth final
preparation (Fig. 14).
Figure 9: Simulated photo showing tooth whitening
Figure 10: Preoperative photo after patient completes at-home whitening
Figure 11: Facial depth cuts
Figure 12: Incisal depth cuts
Figure 13: Two-grit diamond finalizing the preparations
Figure 14: Diamond disc smoothing the preparations
For anterior cases, digital imaging can and should play a vital role in
patient education and decision-making. In fact, in situations where
a few teeth are being treated, its use may be even more important
than for full-smile restorations.
Digital Imaging: An Important Visual Aid in Treatment Planning and Case Acceptance65
Retraction cord was used to gently displace the soft tissue
to assist in capturing the final preparation details (Fig. 15).
Impressions were then taken and sent to the laboratory
along with digital pictures to communicate tooth length,
form, color and characteristics.
Once the restorations were received from the lab, they
were verified on the solid models and then tried in the
mouth with appropriate try-in gels (Fig. 16). After receiving
patient approval, the restorations were bonded into place
using the total-etch technique. The final result successfully
accomplished the treatment goals of closing the diastema,
correcting the fractures and looking natural (Figs. 17, 18).
Figure 15: Final preparations
Digital imaging is a powerful tool for helping patients
decide which treatment option is best for them when
multiple alternatives exist. It allows the dentist to visually
communicate realistic results to the patient and involves the
patient in the treatment decision-making process. Giving
patients an active role in their treatment breaks down
barriers between clinicians and their patients, leading to
increased treatment acceptance.
By using an off-the-shelf digital imaging solution, the
clinician can significantly lower the cost of adding this
technology to their practice. This type of software is widely
available, and many community colleges conveniently offer
inexpensive user training courses. CM
Figure 16: Porcelain restorations in place with try-in gel for patient
Dr. Tarun Agarwal maintains a full-time private practice in Raleigh, N.C.,
emphasizing esthetic, restorative and implant dentistry. Contact him via e-mail
at email@example.com or visit http://raleighdentalarts.com.
Figure 17: Final restorations immediately after bonding
Figure 18: Postoperative close-up photo showing esthetic integration of
Congratulations, Chairside ® PHOT
This must have been an especially
challenging edition of
the Chairside Photo Hunt because
only three of you found
all 20 differences. Maybe you
were too distracted by the
cutting-edge digital impression
technology you see me
demonstrating in the photo,
which was taken during one
of the courses I teach on the
subject at the Glidewell International
If you’re looking to pick up
some continuing education
credits or your interest is
piqued by what’s going on
in the photo, you may want
to visit www.glidewellce.com
for info on upcoming courses.
Thanks for playing!
Here are the results:
• First-place winners:
3 dentists found all 20
differences and will receive
$500 in lab credit each.
• Second-place winners: 15
dentists found all but one
difference and will receive
$100 in lab credit each.
• Third-place winners: 39
dentists found all but two
differences and will receive
$100 in lab credit each.
Not sure what to use your
lab credit for? Why not help
your patients who have had
orthodontic treatment protect
their investment by prescribing
them Clear-Lock Retainers
for Life . This convenient lifetime
replacement service for
retainers includes digital file
storage of the patient’s models
for easy reordering when
retainers are broken or lost.
Chairside Photo Hunt Contest entries were
individually scored after being sent to the
lab via e-mail and standard mail. Prize winners
were notified by standard mail and/or
phone. In total, 57 prizes were awarded.