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Chairside®

A Publication of Glidewell Laboratories • Volume 7, Issue 3

Photo Essay

The Pursuit of Anterior Esthetics for

BruxZir ® Solid Zirconia Restorations

Page 14

How Scanning Abutments and

Digital Impressions Can

Simplify Your Implant Cases

Dr. Carlos Boudet

Page 45

Dr. Ellis Neiburger

25 Guidelines for

Practicing ‘Speed Dentistry’

Page 55

One-on-One Interview

Ultradent’s Dr. Dan Fischer

Discusses the Latest Advancements in

Crown & Bridge Cements

Page 36

Dr. Michael DiTolla’s

Clinical Tips

Page 9

COVER PHOTO

Jordan Semmelmayer, Marketing Department Intern

Glidewell Laboratories, Newport Beach, Calif.


Contents

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

Anterior Esthetics

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.

Contents 1


Contents

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

their practice.

Glidewell Publications iPad App

To experience Chairside magazine on

the iPad, search “Glidewell” in the iTunes

Store and download the free Glidewell

Publications app.

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

2

www.chairsidemagazine.com


Publisher

Jim Glidewell, CDT

Editor-in-Chief and Clinical Editor

Michael C. DiTolla, DDS, FAGD

Managing Editors

Jim Shuck; Mike Cash, CDT

Creative Director

Rachel Pacillas

Copy Editors

Jennifer Holstein,

David Frickman, Megan Strong

Statistical Editor

Darryl Withrow

Digital Marketing Manager

Kevin Keithley

Graphic Designers

Emily Arata, Jamie Austin, Deb Evans,

Joel Guerra, Audrey Kame, Phil Nguyen,

Kelley Pelton, Makara You

Web Designers

Jamie Austin, Melanie Solis, Ty Tran

Photographer

Sharon Dowd

Illustrator

Wolfgang Friebauer, MDT

Coordinator and Ad Representative

Teri Arthur

(teri.arthur@glidewelldental.com)

If you have questions, comments or complaints regarding

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

chairside@glidewelldental.com. Your comments may be

featured in an upcoming issue or on our website:

www.chairsidemagazine.com.

© 2012 Glidewell Laboratories

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Chairside is a registered trademark of Glidewell Laboratories.

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.

Editor’s Letter

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

mditolla@glidewelldental.com

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-

Prep Veneers”:

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

not necessary?

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

“shade-adjustable” porcelain?

– Vincent Johnson, DDS

Bay City, Mich.

Dear Vincent,

Thanks for writing and for the kind

words! Here are some attempts at answering

your questions:

4

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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

the premises.

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!

– Mike

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

Bronxville, N.Y.

Dear Steve,

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.

– Mike

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.

Cordially,

– Alex Zavyalov, DDS

New York, N.Y.

Dear Alex,

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.

– Mike

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

recommendations?

– Dr. Fred Curcio

Ridgefield Park, N.J.

Dear Fred,

Like you, I noticed a good deal of fracturing

of porcelain-fused-to-zirconia

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

much reduction.

Hope that helps!

– Mike

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.

Dear Kevin,

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!

– Mike

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Letters to the Editor 5


Contributors

Michael C. DiTolla, DDS, FAGD

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

Director of Clinical Education and Research at Glidewell Laboratories in Newport Beach, Calif., he performs

clinical testing on new products in conjunction with the company’s R&D department. Glidewell dental

technicians have the privilege of rotating through Dr. DiTolla’s operatory and experiencing his commitment

to excellence through his prepping and placement of their restorations. He is a CR evaluator and lectures

nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has several clinical programs available

on DVD through Glidewell Laboratories. For more information on his articles or to receive a free copy of

Dr. DiTolla’s clinical presentations, call 888-303-4221 or e-mail mditolla@glidewelldental.com.

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 dra@raleighdentalarts.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 lenboksman@rogers.blackberry.net.

Carlos A. Boudet, DDS, DICOI

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

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

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

Fla. Dr. Boudet established his dental practice in West Palm Beach 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.

6

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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 chairside@glidewelldental.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 chairside@glidewelldental.com.

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 eneiburger@comcast.net.

Contributors 7


Numbers

by the

2

26%

Percentage of Brits over

the age of 73 who have

lost all of their teeth

Source: DENTALFAX Weekly,

www.dentalfax.com

Gordon Christensen’s

recommended maximum

number of units for a

quadrant double-arch

impression tray

Source: Gordon J. Christensen

Practical Clinical Courses,

“Predictable Fixed & Removable

Prosthodontic Impressions,”

www.pccdental.com/v1931

33,272

Total number of digital impressions

received at Glidewell Laboratories to date

37%

Percentage of Glidewell

Laboratories’ cases of 3 or

more units that are impressed in

double-arch quadrant trays

#2

BruxZir ® Solid Zirconia is the second-most

prescribed anterior restoration at

Glidewell Laboratories

8

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Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Kick Your Apps ® DDS App

SOURCE........... Kick Your Apps Inc. (Poway, Calif.)

800-631-2021, www.kickyourapps.com

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.


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Practice Booster ® Code Advisor

SOURCE........... Practice Booster (Belmont, N.C.)

866-858-7596, www.practicebooster.com

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.


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ UltraCem RRGI Cement

SOURCE........... Ultradent Products Inc. (South Jordan, Utah)

888-230-1420, www.ultradent.com

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


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ LuxaBite ® Bite Registration Material

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

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

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.

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Photo Essay

The Pursuit of BruxZir ®

Anterior Esthetics

– 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

www.glidewelldental.com.

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.

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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

shades simultaneously.

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

the tooth.

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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.)

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

segment subgingivally.

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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.

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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.

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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

the impression.

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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.

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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

(Axis Dental).

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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

of space.

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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.

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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.

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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.

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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

with that.

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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

electric handpieces.

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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

better access.

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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.

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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.

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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.

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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.

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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

top cord.

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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

marginal surface.

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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

showing through.

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

impression process.

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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!

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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.

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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.

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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.

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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

to release.

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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

any adjustments.

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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.

47

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.

48

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.

49

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

three seconds.

50

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.

51

52

32 www.chairsidemagazine.com


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

tissue rebound.

53

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.

54

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

55

Photo Essay: The Pursuit of BruxZir Anterior Esthetics33


36 www.chairsidemagazine.com


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

3.65 MPa

4.36 MPa

5.25 MPa

5.12 MPa

4.76 MPa

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

systems?

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?

10.89 MPa

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

38 www.chairsidemagazine.com


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

25

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

20

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.

PPM

15

10

5

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,

that’s disconcerting.

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

same path.

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

40 www.chairsidemagazine.com


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

comes together.

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

now. (laughs)

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

42 www.chairsidemagazine.com


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

more dentists.

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

the like.

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

more dentists.

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

practice today.

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

cement.

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


Scannable Abutments:

Digital Impressions for

Dental Implants

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.). They are also

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

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.

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.

Case Presentation

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.

46 www.chairsidemagazine.com


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

Conclusion

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.

References

1. Zweig A. Improving impressions: go digital! Dent Today. 2009 Nov;28(11):100, 102,

104.

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;

137 Suppl:7S-13S.

4. Boudet CA. CEREC Connect: a welcomed upgrade for CEREC users. Chairside.

Spring 2011;V6I2:38-44.

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.

48 www.chairsidemagazine.com


– ARTICLE and CLINICAL PHOTOS by

Leendert Boksman, DDS, BSc, FADI, FICD and

Robert C. Margeas, DDS

Case Report

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

microleakage. 14

The Creation of a Soft Tissue Emergence Profile with a Long-Term Ribbond-THM Provisional49


Strassler has written

extensively on the benefits

of fiber-reinforcing

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

fiber-reinforced composite

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

CASE PRESENTATION

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

incisors

Figure 4: Placement of Temptation over the

wetted Ribbond-THM

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

sockets

Figure 7: Temporary removed from the matrix

and flowable added to create initial convex pontic

form

50 www.chairsidemagazine.com


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

(Fig. 13).

Three additional

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

cement removed.

Figure 16: Tissue profile after removing temporary

bridge

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

10 weeks

Figure 17: Fixed restoration showing excellent

tissue profile

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

temporization

Figure 11: Application of Tempglaze to the

shaped temporary bridge, which was cured

with a broad band curing light for 30 seconds

per unit

Figure 15: Same case final restoration immediately

post cementation

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.

blackberry.net.

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.

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metallic, fiber and ceramic posts. J Dent Res.

2005;84 (Spec Issue B), African and Middle East

section (www.dentalresearch.org).

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.

2006 Jan-Feb;31(1):47-54.

3. Hayashi M, Sugeta A, Takahashi Y, Imazato S,

Ebisu S. Static and fatigue fracture resistance

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Mater J. 2008 Sep; 24(9):1178-86. Epub 2008

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4. Nakamura T, Ohyama T, Waki T, Kinuta S, Wakabayashi

K, Mutobe Y, Takano N, Yatani H. Stress

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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.

2007 Nov-Dec;20(6):633-9.

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

(http://iadr.confex.com/iadr/2007orleans/

techprogram/abstract_91891.htm).

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.

2006 Oct;79(1):35-41.

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

(http://iadr.confex.com/iadr/2007orleans/tech

program/abstract_89686.htm).

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

Jan;124(1):110-3.

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-

Dec;(145):277-86.

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.

2004 Mar;91(3):258-64.

22. Ramos V Jr, Runyan DA, Christensen LC. The

effect of plasma-treated polyethylene fiber on

the fracture strength of polymethyl methacrylate.

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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

Dent. 2006;18(2):81-92.

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

(http://iadr.confex. com/iadr/eur05/techprogram/

abstract_68611.htm).

27. Trushkowsky R. Fiber-reinforced composite

bridge and splint. Replacing congenitally missing

teeth. NYS Dent J. 2004 May-Jun;70(5):34-8.

Reprinted by permission of Oral Health, December

2008.

52 www.chairsidemagazine.com


SSS


SPEED

DENTISTRY

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.

56 www.chairsidemagazine.com


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.

QUALITY

DROP-OFF POINT (SLOW)

DROP-OFF POINT (FAST)

SPEED (TIME)

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

high quality.

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

everything ready.

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.

58 www.chairsidemagazine.com


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

two minutes.

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

procedures.

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

and staff.

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

one time.

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

implement it.

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.

60 www.chairsidemagazine.com


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.

BE HUMANE

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.

PROBLEMS

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

lazy dentist.

START NOW

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

at www.andent.net.

Dr. Ellis Neiburger is a general practitioner in Waukegan, Ill. Contact him at 847-244-

0292 or eneiburger@comcast.net.

© 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

Digital

Imaging:

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).

Case Presentation

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

tooth #9

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

place

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

diastema

Clinical Technique

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

vital result.

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).

64 www.chairsidemagazine.com


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

Conclusion

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

approval

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 dra@raleighdentalarts.com or visit http://raleighdentalarts.com.

Figure 17: Final restorations immediately after bonding

Figure 18: Postoperative close-up photo showing esthetic integration of

feldspathic veneers

66 www.chairsidemagazine.com


Congratulations, Chairside ® PHOT

A

Hunt Winners!

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

Technology Center.

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:

B

• 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.

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