PDF Version - Glidewell Dental Labs

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. 

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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 

www.chairsidemagazine.com 

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 


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 


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 


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. 


– Mike 


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. 


– 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 


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 


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.


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.


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


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. 

12 www.chairsidemagazine.com


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. 

1 

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. 

2 

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.) 

3 

4 


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. 

5 

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. 

6 

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. 

7 


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. 

8 

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. 

9 

10 


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. 

11 

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. 

12 

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. 

13 


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. 

14 

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. 

15 

16 


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. 

17 

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. 

18 

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. 

19 


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. 

20 

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). 

21 

22 


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. 

23 

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. 

24 

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. 

25 


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. 

26 

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. 

27 

28 


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. 

29 

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. 

30 

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. 

31 


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. 

32 

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. 

33 

34 


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. 

35 

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. 

36 

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. 

37 


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. 

38 

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! 

39 

40 


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. 

41 

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. 

42 

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. 

43 


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. 

44 

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. 

45 

46 


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 


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 


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 



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 


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. 


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 


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 


ut to try and buy time with less-invasive procedures — 

giving the pulp chamber a chance to become smaller, 

giving the dentinal tubules a chance to become smaller, and 

saving that more invasive procedure for their later years. 

When you do so, you minimize the number of root canal 

treatments that are required later, you minimize the amount 

of replacements that have to occur with crowns and the like. 

We will always, within my lifetime, I believe, have the need 

for full-coverage crowns. I’ve got one that my daughter put 

in my mouth just four years ago. It was an upper second 

molar that was a virgin tooth, but it succumbed finally to 

the “dental student syndrome.” Namely, when I was a junior, 

a senior student had to take out impacted wisdom teeth in 

order to graduate, and I became the volunteer. The student 

wasn’t the sharpest knife in the drawer and took out some 

of the buccal plate over my second molar, and I’m sure he 

leaned that elevator on that root. Later, bacteria got in that 

crack and it was discovered, much later, probably about 

eight years ago, when the tooth abscessed and became a 

sinus infection and all the rest. If you’ve got a tooth like 

that, or you’ve got a molar that’s taking a heavy load, or a 

tooth that’s had root canal treatment — you’ve got to put 

crowns on those kinds of things. 

MD: Of course! And I know you don’t hate crowns. I know that 

what you don’t like is the overuse of full crowns as the easy 

way out, or kowtowing to what the patient’s insurance might 

pay. Did you go with cast gold on that crown? 

DF: It’s solid cast gold on this upper second molar. 

MD: Good choice! We like to see that. That’s becoming an 

endangered species in the laboratory today. I guess part of 

that is gold hitting $1,700 an ounce. It’s also patients giving 

some pushback about having gold in their mouth — even on a 

second molar — which is kind of crazy, especially after we tell 

them it’s the best material we’ve ever had in dentistry. 

DF: Well, when you said, “Good choice, that’s what we like 

to see,” the truth is at the end of the day, you can’t even 

see it, Mike! (I’m teasing you a little based on the meaning 

here.) But, yes, it’s true: if nobody is going to see it, you 

can’t beat it. That being said, I am impressed with how 

zirconia continues to improve. In fact, boy, with the cost of 

metals and the like, thank goodness we’ve got materials like 

zirconia that are evolving to where they are. 

MD: Right. Let me share some numbers with you. In 2007, 

66 percent of the crowns that we fabricated here were PFM 

crowns and 23 percent were all-ceramic crowns. If you look 

at 2011 and the first half of 2012, and PFMs have gone from 

66 percent to 20 percent, and all-ceramics have risen from 

22 percent to 68 percent of the restorations, and it’s because of 

zirconia and lithium disilicate. It’s shocking to me, and even 

to us as a laboratory, to see how quickly dentists have changed 

their allegiance and have been willing to kind of drop the 

PFM. It has been an amazing transformation largely pushed 

on by zirconia and dentists being somewhat satisfied with the 

material because they continue to order it. 

Let me ask you about one other thing I find fascinating about 

you: your drive to find a cure for dental caries. I don’t think 

there could be a higher mission on the planet, and least in the 

dental world, than to tackle something like this, and I don’t 

hear anybody else really talking about this. In fact, I saw in 

a recent article that the city of Phoenix is thinking about not 

fluoridating their public water supply. Can you tell me how 

your drive to find a cure for dental caries is going? 

DF: The progress has been slow. Not because of the 

technology, but because of regulatory constraints that we’re 

up against with the FDA. We have a technology that we feel 

can go a significant distance on this. We’re being very active 

on it, and we feel like we’re making some good inroads 

relative to explaining the technology to the FDA. It’s a little 

device that in the first human studies — four kids in a lower 

social economic group for which oral hygiene is pretty 

low — was shown to decrease caries 76 percent. If we can 

reduce caries 76 percent, we can reduce the incidence of 

the abscessed tooth 95 percent, which is exciting to me. 

But, yes, we’re still battling that. 

That being said, and I don’t know if I told you this last 

time or not, Mike, but if we could bring about a cure to 

caries today, we’d still need more dentists. I mean, when 

you consider that in our country before the recession, onethird 

of our fellow Americans couldn’t afford to go to the 

dentist except for emergency treatment. When you consider 

that teeth are like tires — they’re good for so many miles, 

and then the treads wear out, the sidewalls give out. When 

you consider the jobs of the Western world, there’s hardly 


one job I can think of in Western countries that makes it 

easy for a patient with a missing central or dark, disfigured 

teeth to get a job. It’s a different world than it used to be. If 

we can bring about a cure for caries today, we’d still need 

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. 


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. 


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. 


– 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 


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. 

REFERENCES 

1. Amenisalehi E. Strength of incisors restored by 

metallic, fiber and ceramic posts. J Dent Res. 

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

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 

of pulpless teeth restored with post-cores. Dent 

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

Mar 28. 

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

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

analysis of endodontically treated anterior teeth 

restored with different types of post material. 

Dent Mater J. 2006 Mar;25(1):145-50. 

5. Piovesan EM, Demarco FF, Cenci MS, Pereira- 

Cenci T. Survival rates of endodontically treated 

teeth restored with fiber-reinforced custom posts 

and cores: a 97 month study. Int J Prosthodont. 

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. 

J Prosthet Dent. 1996 Jul;76(1):94-6. 

23. Pfeiffer P, Grube L. In vitro resistance of reinforced 

interim fixed partial dentures. J Prosthet 

Dent. 2003 Feb;89(2):170-4. 

24. Heymann HO. The Carolina bridge: a novel 

interim all-porcelain bonded prosthesis. J Esthet 

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. 


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. 


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. 


Here are some reliable and generally successful ways 

many dentists have used to increase their speed and begin 

practicing speed dentistry: 

1. Simply think you will do dentistry better and faster. 

Many dentists have never considered this concept, so 

they just continue to work slowly like they did in dental 

school. Once you decide to do your dentistry more 

rapidly, you will. 

One way to check how you are doing is to place a 

timer in each operatory. Time how long it takes you 

to do a procedure. Log the time. Try to do it a bit 

more rapidly the next time, and the next. Experiment. 

Test different ways of doing a procedure or handling 

a patient. Use that timer with every patient and 

every procedure. Keep records and analyze your 

results. Once you are timing yourself, you will begin 

working faster and doing speed dentistry. Remember, 

the true measure of speed dentistry is the amount 

of time the patient is in the chair. It doesn’t help 

much if you quickly do a restoration and then squander 

all the time you saved by telling stories or cracking 

jokes with the now-completed patient. 

2. Identify those procedures that take up most of your time 

and then decide how you will speed up the process. 

Can you do the treatment differently and shave off 

a second or two? Can you use fast-set amalgam or 

a stronger curing light to speed up your restoration 

technique? Will special instruments or preset trays 

increase your speed while maintaining quality? 

For example, use locking pliers with a cotton pellet 

already attached. It is faster than stopping your 

procedure, hunting for a cotton pellet in a capped 

dispenser (requires uncapping and recapping), 

selecting the pellet with your cotton pliers and then 

using the instrument. Save 15 seconds using this 

technique. Now, if you do it 30 times a week, 48 weeks 

a year, you do the math on how much time it saves. 

3. Quit talking so much. Talking sucks time. If you must 

talk — keep in mind, most patients appreciate a 

few words — speak while you are doing something 

productive. Avoid talking about yourself. Instead, talk 

to your patients about their lives. Everyone likes to talk 

about themselves, so let them. If someone needs to be 

calmed down or relaxed, have your dental assistant do 

most of the work. If you save 30 seconds of idle talk 

per patient, and you see 20 patients per day, four days 

a week, 48 weeks a year, you will save 32 hours of 

chairtime per year. Think about how much you make 

in one hour of chairtime. And that’s just 30 seconds. 

Go for more. 

4. Increase the air pressure of your dental handpieces to 

60–80 psi. They run faster, cut faster, and you finish 

faster. My experience is that the handpiece cartridges 

will also last longer, despite the common industry 

recommendations to keep the pressure at 30 psi. 

5. Use sharp instruments. Sharpen the edges of your 

plastic instruments, the tips of your explorers, spoons 

and other hand instruments. Scalers and curettes must 

always be sharp. Do the sharpening before the patient 

is in the chair, not during the visit. 

6. Use topical anesthetics and rapid-induction hypnosis 

anesthesia (waking hypnosis) rather than injecting — and 

waiting — for every little cavity prep or procedure. Using 

fast-acting medications and materials will save you time. 


7. Move faster and have your staff move fast, too. If they 

resist or complain, fire them. A slacker with a mopey 

attitude will never change. You are operating a service 

business, not an employment depot for the low and 

slow of our society. 

8. Analyze each movement during a procedure. Is it necessary? 

Is it needed? Can you do without it or change the 

procedure to omit it entirely? For example, many practitioners 

wipe instruments on the patient’s bib. This 

takes a few seconds to do and then re-establish focus 

on the tooth being treated. Instead, place some gauze 

in the patient’s mouth and wipe your instrument on it 

there. This positions you closer to the action, takes less 

time to do, does not divert focus out of the mouth and 

is probably more sterile. Saves a second — or four. 

9. Have prearranged instrument setups for each procedure. 

This is infinitely faster than picking a multitude of 

instruments out of a chest of dental drawers with the 

patient watching. When the patient is in the chair, do 

dentistry. Don’t waste your time and the patient’s time 

setting up to do dentistry. 

10. Determine if there are simpler treatment methods. For 

example, seventh-generation bonding is an all-in-one 

technique that is considerably faster than a fourthgeneration 

technique of separately etching, separately 

priming and separately bonding a composite. Saves 

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, 


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. 


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. 


– 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). 


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 


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 


• Third-place winners: 39 

dentists found all but two 

differences and will receive 


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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