Glidewell Laboratories - Chairside Publication - Vol. 10, Issue I

A Publication of Glidewell Laboratories • Volume 10, Issue 1

Chairside®

Photo EssayEnsuring Sufficient Reduction with the Reverse Preparation Technique 5

One-on-One Interview with Dr. Erin ElliottEvolving a Dental Practice to Compete in a Modern Market Page 40

Buffered Anesthetics and Laser Use

Gaining Control of Day-to-Day Procedures Page 53

Simple Flapless Surgical Overdenture Techniques

Dr. Timothy Kosinski Page 25

Dr. Michael DiTolla’s

Clinical Tips Page 9

COVER PHOTOTiffany Whinery—Human Resources Intern Glidewell Laboratories, Newport Beach, Calif.

ANNIVERSARY EDITION

For more exclusive content, visit www.chairsidemagazine.com Watch Video Presentations • View Clinical Case Photos • Earn CE Credit

Contents

Visit www.chairsidelive.com to view the latest episode of our weekly Web series “Chairside Live.”

9 Dr. DiTolla’s Clinical TipsHighlighted in this issue is a ceramic repair kit from BISCO that contains everything you might ever need for intraoral repair on PFMs and all-ceramics, along with a wedge for matrix systems that becomes an active component in treatment. Also featured are the second edition of a textbook on anesthesia, which has updates beneficial enough that it’s worth showing again in the pages of Chairside®, and a rubber dam from Coltène/Whaledent that places so easily you might actually wind up using it.

15 Photo Essay: Ensuring Sufficient Reduction with the Reverse Preparation TechniqueIn this photo essay, I highlight a straightforward procedure that will ensure you achieve the manda-tory reduction requirements for whichever restorative material you elect to use. Follow along as I prepare a maxillary central incisor using the Reverse Preparation Technique, a handy resource that will have your lab technician eager to come across your next impression.

25 Simple Flapless Surgical Overdenture TechniquesLong-term prognoses of implant-retained overdentures today are largely positive due in part to an increase in the predictability of implant placement during surgery. Dr. Timothy Kosinski shows how computed-tomography diagnostics can contribute to procedures being both more accurate and less invasive, altogether improving the quality of the restoration and the quality of life for patients.

35 Factors Impacting Long-Term Success of Endodontic Post SystemsWhen clinicians treat severely compromised teeth end-odontically, the choice of post system has a significant impact on the overall success and esthetic value of the restorations. Drs. Leendert Boksman, Gildo Coelho Santos Jr., and Manfred Friedman use independent research to showcase the various advantages of the different types of post systems available.

WWW.CHAIRSIDEMAGAZINE.COMChairside magazine is now optimized for all popular desktop, tablet and smartphone platforms! Go online

to view the latest digital edition from your desktop computer or favorite mobile device.

Contents 1

40 One-on-One with Dr. Michael DiTolla: Interview of Dr. Erin ElliottThis issue’s One-on-One features Dr. Erin Elliott, a general dentist who practices in a small Idahoan town just east of the Washington border. With a passion for learning new techniques, Dr. Elliott has continuously evolved her practice by offering new services such as accelerated orthodontics and sleep apnea treatments. Read about how she gets her entire practice involved in educating patients about the available treatment options.

53 Buffered Anesthetics and Laser Use: Efficiency in Scheduling and ProductivityThe wide range of times needed to achieve anesthetic efficacy in patients is one of the most unpredictable variables that dentists face in their daily practices. Drs. Mark Colonna and David Dodrill promote a method for achieving the rapid onset of analgesia that, along with laser dentistry, can substantially increase productivity by expediting procedures and allowing clinicians more control over their schedules.

59 QC Alert: Avoiding Dreaded Remakes — Chairside Live Case of the Week: Episode 85This issue’s featured Case of the Week from Episode 85 of “Chairside Live” takes an in-depth look at how clinicians can immediately improve the results com-ing from their lab by switching to a trusted, proven impression technique. This quick and simple change was more valuable to my practice and skillset than anything I had done in the previous decade.

69 ToothPyk.com: Revolutionizing Dental StaffingFor auxiliary dental staff members who use staffing agencies, difficult job searches often lead to temporary positions that can be ended at a moment’s notice. Andrew Lee, CEO and founder of ToothPyk.com, has created a modern, easy way for job seekers to steer their dental careers toward a staff position, without third-party mediation during the hiring process.

73 Chairside® Magazine: A RetrospectiveIn this article, I reflect on just how far Chairside has come as our magazine enters its 10th year of publica-tion. Marking how the pace of change in dentistry has significantly ramped up in recent years, I am extremely grateful that readers have continued trusting Chairside as a true clinical point of view.

79 Achieving Success with Small-Diameter ImplantsDental implants are no longer a niche corner of den-tistry, as general dentists across the nation adopt the skillset into their practices. Dr. Paresh B. Patel discusses how many of the anatomical and financial challenges associated with the conventional size treatment can be eliminated through the use of small-diameter implants.

90 Top 10 Things to Never Be Without — Part 2Continuing her series, my extremely skilled operatory assistant Jennifer Carpio, RDAEF2, shares two more products that she considers most crucial for registered dental assistants. With more than 18 years in the dental field, Jennifer has certified experience with some of the most demanding cases.

Contents

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Editor’s Letter

I admit I’m a little frustrated right now with dentists who re-fuse to use depth cuts on their crown & bridge preparations. This frustration started when we went 100 percent digital about a year ago, and it’s starting to bother me more lately as I teach more hands-on workshops.

I fully admit that I spent the first 13 years of my career as a dentist being a chronic under-preparer. I switched between 35 different dental laboratories during that time, trying to find one that could give me a crown that resembled human anatomy. One day, I was complaining to my dental assistant about how terrible all 35 of those dental laboratories were, and as the words came out of my mouth, it dawned on me that the only thing those 35 labs had in common was my under-reduced preps and mediocre impressions.

Once I started practicing in the lab, I would get dirty looks from the technicians when I didn’t reduce enough — even if it was on their own teeth! I was forced into using depth cuts in order to guarantee beyond a shadow of a doubt that I had reduced enough for the restorative material I had prescribed.

And that’s when everything changed. The dirty looks stopped. The occlusal anatomy appeared. The anterior crowns started blending in with the surrounding natural dentition, instead of being half a millimeter thicker on the facial surface than the adjacent natural tooth. All because of depth cuts.

We need 0.6 mm minimal reduction for BruxZir® Solid Zirconia, 1.0 mm minimal reduction for IPS e.max®, and 1.5 mm for all bilayer restorations. There should be no guessing here: Make a depth cut, and then prep until you can’t see it anymore. Would you build a tree house for your kids without measuring the wood before cutting it? Would you bake a cake for you significant other by just eyeballing ingredient amounts?

What happened to “measure twice, cut once”? If that saying is to be heeded for lumber, shouldn’t it hold true for hu-man tooth structure, too? Patients deserve crowns that are at the proper thickness to increase both their longevity and esthetic appearance, and I think we owe it to our patients to be as precise as possible when preparing their teeth.

Yours in quality dentistry,

Dr. Michael C. DiTolla Editor-in-Chief, Clinical Editor [email protected]

Neither Chairside Magazine nor any employees involved in its publica-tion (“publisher”), makes any warranty, express or implied, or assumes any liability or responsibility for the accuracy, completeness, or useful-ness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe proprietary rights. Reference herein to any specific commercial products, process, or services by trade name, trademark, manufacturer or otherwise does not necessar-ily constitute or imply its endorsement, recommendation, or favoring by the publisher. The views and opinions of authors expressed herein do not necessarily state or reflect those of the publisher and shall not be used for advertising or product endorsement purposes. CAUTION: When viewing the techniques, procedures, theories and ma-terials that are presented, you must make your own decisions about specific treatment for patients and exercise personal professional judg-ment regarding the need for further clinical testing or education and your own clinical expertise before trying to implement new procedures.

Chairside® Magazine is a registered trademark of Glidewell Laboratories.

PublisherJim Glidewell, CDT

Editor-in-Chief and Clinical EditorMichael C. DiTolla, DDS, FAGD

Managing EditorsJim Shuck; Mike Cash, CDT

Creative DirectorRachel Pacillas

Copy EditorsChris Newcomb, Ethan Perez, Keith Peters,

Neil Thompson, Kiali Wong

Statistical EditorDarryl Withrow

Digital Marketing ManagerKevin Keithley

Graphic DesignersEmily Arata, Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame, Phil Nguyen, Kelley Oh, Makara You

Web DesignersTeri Arthur, Jamie Austin, Jason Jennings,

Allison Newell, Ty Tran

PhotographerSharon Dowd

VideographersJames Kwasniewski, Sam Lea, Crystal Nguonly

IllustratorWolfgang Friebauer, MDT, CDT

Coordinators and Ad RepresentativesJennifer Gutierrez

([email protected]) Mike Martinez

([email protected])

Neither Chairside magazine nor any employees involved in its publication (“publisher”), makes any warranty, express or implied, or assumes any liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe proprietary rights. Reference herein to any specific commercial products, process, or services by trade name, trademark, manufacturer or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring by the publisher. The views and opinions of authors expressed herein do not necessarily state or reflect those of the publisher and shall not be used for advertising or product endorsement purposes. CAUTION: When viewing the techniques, procedures, theories and materials that are presented, you must make your own decisions about specific treatment for patients and exercise personal professional judgment regarding the need for further clinical testing or education and your own clinical expertise before trying to implement new procedures.

Chairside is a registered trademark of Glidewell Laboratories.

If you have questions, comments or complaints regarding this issue, we want to hear from you. Please email us at [email protected]. Your comments may be

featured in an upcoming issue or on our website: www.chairsidemagazine.com.

© 2015 Glidewell Laboratories

Editor's Letter 3

Letters to the Editor

Dear Dr. DiTolla,

My name is Robert McDonald, and I gradu-ated from dental school in May 2013. I’m cur-rently working for the Tennessee Department of Health in rural Dickson County. I try to read dental magazines to stay up to date because, frankly, at a state health department we do not utilize new and exciting techniques or materials due to the state budget and the limited scope of practice.

I just wanted to say that I really enjoyed your article about impressions entitled “The Good, The Bad and The Ugly” (Chairside magazine, Vol. 9, Issue 2). I loved the respect-able shout-out to the Two-Cord Impression Technique. Keep up the good work with your R&D team at Glidewell Laboratories; your contributions to dentistry are great!

– Robert M. McDonald, DDS Dickson, Tennessee

Dear Robert,

Thank you so much for your kind words. I’m glad the magazine makes it out to your corner of the world. Much like how the PFM’s time as the king of indirect restorations has come and passed, I think the Two-Cord Impression Technique will one

day have to turn its crown over, most likely to the inevitable generation of digital impressioning units that will be able to scan through saliva, blood and gingival tissues.

Thanks again,

– Mike

Dear Dr. DiTolla,

I was hoping you could advise me on how you solve extreme sensitivity underneath BruxZir® crowns. I have a 42-year-old male patient with extensive recession and large interproximal spacing. He has good oral hy-giene and is not a perio surgical candidate. Due to extensive facial and palatal erosion, gum recession, and possibly abfraction, I recommended crown coverage to the gin-giva. What would you suggest to alleviate some of his hot/cold sensitivity? Everything he eats or drinks has to be lukewarm.

– Kenneth V. Lee, DDS Auburn, California

Dear Ken,

I have had patients much like the one you mentioned in your letter. Specifically, I have had patients where I have placed onlays on molars in an attempt to be conservative, only to have the tooth structure from the onlay margin to the gingival margin become very sensitive to temperature. As a result, I have ended up turning to full crowns in these situations, with the restorative margin placed slightly subgingival. I use Rella Christensen’s desensitization protocol, which places two one-minute coats of desensitizer on the tooth prior to cementation.

Hope that helps,

– Mike

Dear Dr. DiTolla,

I keep hearing and reading about how the PFM is as good as dead, and I agree.

Occasionally, I have had to perform endo therapy on a previously crowned tooth. Most patients don’t seem to mind the occlusal being repaired with composite material as opposed to paying for an entirely new crown. This is accomplished fairly easily with a PFM. However, my question is: How will a BruxZir or an IPS e.max® (Ivoclar Vivadent; Amherst, N.Y.) crown respond to drilling? Will they crack and shatter? Or will they withstand the insult and continue to be serviceable after patching with composite?

– Jim Blanchard, DDS Berryville, Arkansas

Dear Jim,

Well, concerning PFMs, I would agree that single units are dead, but bridges are not necessarily. Specifically for BruxZir bridges, we have a rule called the Rule of 27 that determines if the prep violates the material’s ability. So even now, there are cases where I might end up doing a PFM bridge.

As for how a BruxZir or e.max crown will respond to drilling? That’s a great question. Actually, Gordon and Rella Christensen at Clinicians Report are in the midst of doing research on this right now. The initial results from the SEMs look fantastic. As neither material has a layered ceramic on the outside of it, they do very well with an endo access hole. With PFMs, the vibration from the bur going through the porcelain causes them to chip and shatter. But with BruxZir Solid Zirconia especially, a zirconia-opti-mized diamond bur with a blue band on the shank goes through and comes out with no chipping whatsoever. IPS e.max has very small chips that are almost unnoticeable, way fewer than the number of fractures that we used to see with some PFMs. So BruxZir and e.max crowns are both easy to use and patch by comparison.

Thanks!

– Mike


Hey Dr. D,

My question is about the Hydraulic & Hydrophobic impression technique. Do you know anything about it? The video from Dentaltown® magazine touts that no cord is necessary and the technique seems extremely easy. I haven’t had the courage to use it on my patients yet. Have you seen dentists use this technique with good success?

– Duy “Dewey” Nguyen, DDS San Francisco, California

Hello Duy,

As far as impression techniques go, the H&H method is about as contro-versial as they come. Having practiced inside of a laboratory for the last 12 years, I can tell you that when the technique is mentioned to any techni-cian or manager out on the floor, they just roll their eyes because they see a higher remake percentage with it. Our remedy for this is to put a couple of extra coats of die spacer on the die, because otherwise they’re undersized.

Dr. Jeffrey Hoos and J. Morita USA came up with the technique to match one of their proprietary impression materials, Blue Velvet® ( J. Morita USA, Inc.; Irvine, Calif.). They say that once it sets, when the impression goes back in the mouth, it will permanently de-form rather than rebounding.

To help you understand the impor-tance of that statement better, here are the steps for the technique: After pre-paring the tooth, you’ll take a double-arch impression tray and put the Blue Velvet material on both sides and have the patient bite down. Essentially, we’re going to get an impression of the opposing arch and most of the preparation down to about the free gingival margin, and register the bite. We pick up the subgingival margins in the second half of this.

After the first material has fully set, we have the patient open again. Making sure the tray stays on the opposing

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arch, rinse and dry the prep and the inside of the impression, and then reline it with the second material, Flexi-Velvet® ( J. Morita USA, Inc.). Express the low-viscosity vinyl poly-siloxane material into the preparation itself, and not along the entire tray. The patient then closes back into that, biting tightly. This motion creates a hydraulic chamber, where the low-viscosity VPS is going to be driven down into the sulcus.

You can see how the original impres-sion material might want to expand a little bit because it already fits snug-gly against the tooth. According to J. Morita, other bite registration materi-als rebound afterward. So if you were going to try it, I’d recommend using the J. Morita impression materials to get off on the right foot.

If you were to ask a dentist about their views on the H&H impression technique, most will say, “Yeah, I use it. I love it. It’s great.” I can tell you, though, from talking to lab techni-cians and lab managers (not just at Glidewell, but at other labs as well) that they somewhat wish dentists wouldn’t do it. And that’s because it typically means higher remakes.

It’s one of those impression techniques where it takes some coordination be-tween you and the lab.

– Mike

Letters to the Editor 5

Contributors

Mark Colonna, DDSDr. Mark Colonna graduated from Loyola University Chicago School of Dentistry in 1983. Holding positions as Assistant Clinical Professor of Radiology and Assistant Clinical Professor of Operative Dentistry, he taught at the university until 1992, at which time he moved to Whitefish, Montana, to open the Montana Center for Laser Dentistry.

Dr. Colonna was the first dentist globally to prepare teeth for full crowns and porcelain veneers utilizing only lasers without local anesthesia, and was a leading pioneer of the technology. He is a member of numerous dental associations and received the Clinician of the Year award from the World Congress of Minimally Invasive Dentistry. Contact him at [email protected].

Erin Elliott, DDSDr. Erin Elliott graduated from Creighton University School of Dentistry in Omaha, Nebraska, and now maintains a private practice in Post Falls, Idaho, focusing on an array of disciplines, including general dentistry, cosmetic dentistry, orthodontics, and obstructive sleep apnea. Dr. Elliott is an active member of the American Academy

of Sleep Medicine and the American Academy of Dental Sleep Medicine, and is a diplomate of the American Sleep and Breathing Academy’s dental division. She is considered a national expert on dental sleep medicine, and has authored several articles and lectured extensively on the growing field and how dentists can incorporate the specialty into their practices. Contact her at [email protected].

David Dodrill, DDSDr. David Dodrill graduated from Virginia Commonwealth University in 2007 and went on to complete an AEGD residency at Idaho State University. In 2013, he completed a master clinician program in implant dentistry under the leadership of Dr. Sascha Jovanovic at the gIDE Institute. Currently, he practices comprehensive laser and implant dentistry at

the Montana Center for Laser Dentistry. In his free time, Dr. Dodrill volunteers with many dental outreach programs including Give Kids a Smile Day, as well as those associated with the Special Olympics.

Manfred Friedman, BDS, BChDDr. Manfred Friedman graduated with a Bachelor of Dental Surgery from the University of the Witwatersrand, Johannesburg, South Africa, in 1971 and went on to earn his Baccalaureus Chirurgiae Dentalis at the University of Pretoria in 1980. He immigrated to Canada in 1987 and took up a full-time faculty position at the University

of Western Ontario, where he later served as the director of the un-dergrad endodontics program. From 1987 to 1994, Dr. Friedman served as the director of dentistry at the Southwestern Regional Centre, a treatment hospital for developmentally disabled adults. He currently maintains a full-time endodontic practice in London, Ontario, and holds a major part-time faculty position in the Operative Dentistry & Endodontics Division at the University of Western Ontario.

Leendert Boksman, DDS, FADI, FICDDr. Len Boksman earned his dental degree from the faculty of dentistry at Western University in Ontario, Canada, in 1972. After practicing in his hometown of Burlington for seven years, he returned to his alma mater as an assistant professor of operative dentistry, and attained tenure as an associate profes-

sor shortly thereafter. Recognized by Dentistry Today as one of the continent’s top dental educators for many years, Dr. Boksman authored more than 100 articles, and was the first international editorial board member for Reality magazine. Having returned to private practice full-time in 1987, Dr. Boksman recently retired, and now volunteers his time teaching at the School of Oral Health Sciences at the University of Technology, Jamaica. Contact him at [email protected].


Michael C. DiTolla, DDS, FAGDDr. Michael DiTolla is a graduate of the University of the Pacific Arthur A. Dugoni School of Dentistry. As director of clinical education and research at Glidewell Laboratories in Newport Beach, California, 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 witnessing firsthand his commitment to excellence as he preps and places their restorations. He is an evaluator for CR (Clinicians Report®) and lectures nationwide on restorative and cosmetic dentistry. Dr. DiTolla has several clinical programs available on DVD and on-demand online 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 email him at [email protected].

Timothy F. Kosinski, DDS, MAGDDr. Timothy Kosinski graduated from the University of Detroit Mercy School of Dentistry and received a Master of Science degree in biochemistry from Wayne State University School of Medicine. An adjunct clinical pro-fessor at UDM School of Dentistry, he serves on the editorial review board of numerous

dental journals. Dr. Kosinski is a Diplomate of the ABOI/ID, ICOI and American Society of Osseointegration, and a Fellow of the AAID, ACD and ICD. He has a Mastership in the AGD, from which he also received the Lifelong Learning and Service Recognition award in 2009 and 2014. Contact him at 248-646-8651, [email protected] or www.smilecreator.net.

Gildo Coelho Santos Jr., DDS, Ph.D.Dr. Gildo Coelho Santos Jr. is an associate professor of restorative dentistry at the University of Western Ontario Schulich School of Medicine, where he serves as the chair of the department. He received his DDS in 1986 from Federal University of Bahia in Brazil, and there served as an associate

professor in the faculty of dentistry from 1992 to 2006. In 2003, he earned a Ph.D. in prosthodontics from University of São Paulo, and now maintains an active prosthodontic practice. He currently trains and mentors graduate students in the area of biomaterials research, and is a consultant to the dental industry. Contact him at [email protected].

Jennifer Carpio, RDAEF2Jennifer Carpio made her first foray into dentistry with a dental assistant course at the local Regional Occupational Program (ROP). Feeding her penchant for the work and passion for self-improvement, she fervently pursued more advanced certifications, com-pleting RDAEF requirements at the University of California Los Angeles and RDAEF2 re-

quirements at the Expanded Functions Dental Assistant Association. With more than 20 years of experience in the dental field, Jennifer is proficient at advanced functions. Today, she is the RDAEF2 at the Clinical Education & Research department at Glidewell Laboratories. Contact her at [email protected].

Paresh B. Patel, DDSDr. Paresh Patel is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/AAID MaxiCourse. He is cofounder of the American Academy of Small Diameter Implants and a clinical instructor at the Reconstructive Dentistry Institute. Dr. Patel has placed more than

2,500 small-diameter implants. He belongs to numerous dental organizations, including the ADA, North Carolina Dental Society and AACD. Dr. Patel is also a member and president of the Iredell County Dental Society in Mooresville, North Carolina. Contact him at [email protected] or www.dentalminiimplant.com.

Contributors 7

NumbersBY THE

Number of BruxZir® Solid Zirconia and IPS e.max® crowns

returned to Glidewell Laboratories due to

allergic reaction out of the last 1 million units prescribed.

Source: Glidewell Laboratories internal data

IPS e.max is a registered trademark of Ivoclar Vivadent.

Total number of BioTemps® Provisionals from Glidewell Laboratories prescribed by dentists.


BioTemps® — We’ll have them there before you even prepare!

Out of the last 1 million PFMs prescribed, number of PFMs returned to Glidewell Laboratories due to allergic reaction.


Year that the bristle toothbrush was invented. The design, crafted in China that year, featured hog hair attached to bamboo or bone.

Source: Library of Congress

1498

2,700Number of years Glidewell Laboratories stores a 3-D digital model of your patient's teeth when you

prescribe Clear-Lock Retainers for Life™.


30Number of miles one in three Pennsylvania dentists chose to send their cases in 2014.

33% of dentists in Pennsylvania used Glidewell Laboratories in

Newport Beach, California, in 2014.


10815

7,000,015


PRODUCT ....... A+Wedge™

SOURCE .......... Garrison Dental Solutions, LLC (Spring Lake, Mich.) 888-437-0032, www.garrisondental.com

Just when you thought you’d seen all the innovations

that are possible in a wedge used with a matrix

system, Garrison Dental Solutions, the company

that brought you WedgeWands® (Garrison Dental

Solutions, LLC), has another trick up its sleeve. In

trying to cure composite in the depths of the proximal

box, the last thing we want to deal with is possible

contamination from bleeding due to nicking the

gingiva or from wedge placement. The A+Wedge™

does more than just seal the gingival margin of

a sectional matrix band; it actually helps prevent

bleeding in that critical area. Because the wedge is

coated with aluminum sulfate (an astringent used

in other dental products), it ceases to be simply a

physical component that keeps composite from

escaping, but rather becomes an active component

that limits bleeding.

CLINICAL TIPSDR. DITOLLA’S

PRODUCT ....... Intraoral Repair Kit

SOURCE .......... BISCO, Inc. (Schaumburg, Ill.) 800-247-3368, www.bisco.com

Even though the amount of traditional ceramic

restorations done by our dentists continues to

decrease, there is still a need to repair existing

restorations when full replacement is not indicated,

or when a patient can’t afford it. The Intraoral

Repair Kit from BISCO now includes Z-PRIME™ Plus

(BISCO, Inc.), meaning it contains everything you

could possibly need to repair any type of ceramic

restoration, including porcelain veneers, PFMs, and

even lithium-disilicate and zirconia restorations. Even

better, it’s one of the most affordable comprehensive

repair systems, costing just less than $100 for the

full kit.



PRODUCT ....... ROEKO Flexi Dam

SOURCE .......... Coltène/Whaledent Inc. (Cuyahoga Falls, Ohio) 330-916-8800, www.coltene.com

Few dentists would try to argue that a rubber dam

does not enhance most restorative and endodontic

procedures; however, many of these procedures are

attempted without rubber dams due to the complexity

of their placement. Nearly all dentists I have asked

say that if they could walk into the operatory with the

dam already placed, they would utilize one for nearly

100 percent of their cases. The ROEKO Flexi Dam

from Coltène/Whaledent is easy enough to place

that most auxiliaries can accomplish placement on

their own. And because it’s nonlatex, it can be used

universally on all patients. Also, the material’s high

tear resistance works especially well in difficult-to-

reach areas that require maximum stretching.


PRODUCT ....... “Local Anesthesia for Dental Professionals, 2nd Edition”

SOURCE .......... Prentice Hall Inc. — A Pearson Education Company (Upper Saddle River, N.J.) 201-236-7000, www.pearsonhighered.com

The second edition of my favorite local anesthesia

book has been released, and it has some great

updates in it. It’s called “Local Anesthesia for Dental

Professionals, 2nd Edition” and is written by Kathy

Bassett, Arthur DiMarco and Doreen Naughton. If you

recall, Kathy is the local anesthesia instructor who

dropped by my operatory to walk me through my first

Gow-Gates injection and my first AMSA injection live

on camera. Due to the fact that I hadn’t been taught

either of these injections in dental school, I never felt

quite comfortable enough to try them on patients

until the day Kathy was here. I’m happy to say that

her book does a great job of walking you through

these injections, just as she did for me.



If you skipped over my Editor’s Letter at the

beginning of this issue, take a peek at it so I

don’t sound like too much of a broken record.

Using a prep technique based on depth cuts not

only ensures that you have given the technician

enough room for whatever restorative material

you have prescribed, but it also fashions the

preparation into the ideal shape without requiring

the sculpting skills of Rodin.

Photo EssayEnsuring Sufficient Reduction with the Reverse Preparation Technique

– ARTICLE by Michael DiTolla, DDS, FAGD

HOW TO WATCH

View a video of this case at www.chairsidemagazine.com

Photo Essay: Ensuring Sufficient Reduction with the Reverse Preparation Technique15

Figure 3: The 30-gauge extra short needle of my STA™ (Single Tooth Anesthesia) System (Milestone Scientific; Livingston, N.J.) is placed in the sulcus, and a few drops of anesthetic are given as I penetrate the base of the sulcus and contact bone (for an in-depth look at this technique, take the free “Rapid Anesthesia Technique” course online at www.glidewelldental.com). While this is a technique I began using for single mandibular molars to avoid blocks, I realized one day that patients hate anterior infiltrations just as much, and I began using single-tooth anesthesia here as well.

Figure 1: I am going to prepare tooth #9 for a BruxZir® Solid Zirconia crown, but I am going to use depth cuts fit for the preparation of a bilayer crown. This amount of reduction works for all restorative materials; there is no such thing as a BruxZir or IPS e.max® crown (Ivoclar Vivadent; Amherst, N.Y.) that is “too thick.” Unfortunately, “too thin” crowns do exist, and this prep technique is an attempt to eliminate those.

Figure 2: Using an Ultradent syringe (Ultradent Products, Inc.; South Jordan, Utah), I place the PFG gel (Steven’s Pharmacy; Costa Mesa, Calif.) into the sulcus. I previously was in the habit of using a cotton-tipped appli-cator, but that made it difficult to get the PFG gel into the sulcus; because I am using single-tooth anesthesia for this case, the needle is going to go into the sulcus, so that’s where the topical needs to go. The tufted tip on the syringe makes it easy to sneak it subgingivally.

1 2

3


Figure 4: The first step of the Reverse Preparation Technique (which is also covered in the aforementioned course) is to break the proximal contacts. We are only preparing tooth #9, so we are going to do this with a thin 056 carbide bur on both the mesial and distal. The goal here is to break contact with the adjacent teeth just enough so we can place our first retraction cord. We need to place this cord now because we are going to create our gingival margin next.

Figure 5: The first cord is Ultrapak® Size 00 Cord from Ultradent. It is a hollow, braided cord that has no epinephrine and has not been soaked in any medicament. The cord is flossed into place on the mesial and distal, and the two loose ends are grabbed on the lingual and pulled until the cord rests against the facial surface of the tooth. A non-serrated cord-packer is used to pack the cord on the facial, and the two ends are cut on the lingual so that they are flush when they are in the lingual sulcus.

Figure 6: Now that the first cord has retracted the tissue about 0.5 mm, it’s time to prep the gingival margin. This is why I call it the Reverse Prep Technique: We prep the gingival margin first, not last like I was taught in dental school. We use an 801-021 bur (Axis Dental; Coppell, Texas) to trace around the gingival margin, taking this bur to nearly half its diameter in depth, about 0.8 mm. It cuts a perfect half-circle into the gingival third.

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Figure 9: With the depth-cut bur perpendicular to the facial surface of the tooth at the junction of the incisal and middle thirds, we make a 1.5 mm axial depth cut. This depth cut should be just gingival to the incisal-edge depth cuts. Ensuring that we get enough facial reduction to have an esthetically pleasing crown that is the same size as the natural tooth next to it is difficult to achieve without using this depth cut.

Figure 7: This gingival depth cut helps ensure we will deliver an esthetic crown, as most crowns look the most fake in the gingival third. Because this depth cut is a perfect half-circle, after we do our axial reduction we will be left with a perfect quarter circle, which is a precision deep chamfer or shallow shoulder. There is no easier way to prep an ideal margin.

Figure 8: Because we are restoring the tooth to its original length, I am preparing a 2 mm depth cut in the incisal edge. I typically place two of these cuts as it helps me quickly reduce the incisal edge while keeping it level. Under-reduction of incisal edges leads to crowns that are facially prominent in the incisal third that tend to look bulky and “bucky.”

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Figure 10: At this point, the depth cuts are all finished. This allows me to really fly through the rest of the prep, because the gingival margin is already essentially done, the incisal edge takes about 15 seconds, and the facial reduction is marked with a depth cut. There is no guessing about how much to reduce. It’s like having a GPS unit to guide you through your prep: When the depth cuts are gone, the prep is essentially done.

Figure 11: The 856-025 bur (Axis Dental) is really the workhorse of this technique. I find it to be such an easy bur to cut with because of its coarse grit and wide surface area. As I move the bur mesiodistally, I am doing the facial reduction based on the axial depth cut. I am really not doing any reduction in the gingival third; the tip of the bur is almost floating in space as I reduce to the facial depth cut and blend it with the gingival.

Figure 12: I turn the 856-025 bur perpendicular to the incisal edge and connect the two 2 mm depth cuts I made earlier. As the bur moves mesio-distally, it is pretty easy to make quick work of reducing the incisal edge. Because the tip of the bur is pointed at the lingual, I roll the tip of the bur about 20 degrees toward the lingual margin.

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Figure 13: With the 379-023 football bur (Axis Dental), I now do the lingual reduction. This is a convex bur, so it cuts a concave surface, which is the shape of the lingual surface of a natural tooth. You don’t really need to place a lingual depth cut because you have the opposing tooth to use as reference, but you could certainly place a depth cut here if you wish. Mark with articulating paper where the opposing incisor contacts the lingual surface, and place the depth cut right in the blue mark to ensure adequate lingual clearance.

Figure 14: This picture shows why I will never switch from an electric handpiece: I am able to turn the speed all the way down to 2,000 rpm, which allows me to turn off the water. Because the bur is only spinning at 2,000 rpm, I will not generate excessive heat, even with the water off. This is the only way I can really dial in and smooth the margins. With the water off, it is simple to see what you are doing. Often, I will use an 856-025F fine-grit bur to smooth out the margin at this point, but in this case I will place the top cord first.

Figure 15: The prep is now essentially done, and it’s time to place the top cord, Ultrapak® Size 2E Cord (Ultradent). The “E” stands for epinephrine. My experience has been that patients who can tolerate epi in the local can tolerate it in the cord as well. The first cord retracts the tissue vertically for margin placement, and the second cord provides all of the lateral retraction to get a great impression. A one-cord technique will not accomplish this.

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Figure 17: With the top cord in place, you get one last opportunity to get a great look at the prep, so I will typically take about 45 seconds to polish the prep, especially the gingival margin. Again turning the handpiece down to 2,000 rpm with the water off, I will use a fine-grit (red stripe) 856-025 bur to give the prep a mirror-like finish.

Figure 18: Here is a look at the finished prep from the incisal view. You can see the top cord in place with just a small tail protruding on the lingual for easy removal. The gingival margin of the preparation is smooth and uniform all around the preparation, due to using the round bur early on in the proce-dure while all the rest of the hard-tissue landmarks are still in place.

Figure 16: The top cord is now fully in, and this cord is the one that dis-places tissue laterally to make room for the impression material. This #2 cord can’t be used in all clinical situations; it is simply too big for many lower anteriors, or upper bicuspids with minimal attached tissue. A smaller top cord, such as a size 1 cord or even a size 0, can be used in these cases. Some retraction is always better than none.

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Figure 19: The last step of the preparation sequence is to place the ROEKO Comprecap anatomic (Coltène/Whaledent Inc.; Cuyahoga Falls, Ohio) on the prep. It helps to slightly wet the inside of the Comprecap to keep the tooth moist and the cotton fibrils from sticking to the prep. The Comprecap helps to keep the retraction cord in place and the patient’s tongue from dislodging the cord, but more importantly drives blood from the surrounding capillary bed.

Figure 20: The patient bites down on the anatomically formed Comprecap for 8–10 minutes. This ensures you have plenty of retraction. You should really get up and go finish another procedure during this time; otherwise there is no way you will actually wait the 8–10 minutes needed for optimal results. Go do a hygiene check, go log in to Dentaltown®, or update your Facebook status; just let the patient bite on the Comprecap for the full time.

Figure 21: The result of waiting 8–10 minutes is a sulcus that you cannot miss with your intraoral tip. I am pretty sure I could flip some alginate from the other side of the operatory into the sulcus and get a good impression. When your assistant pulls the top cord, look down from the incisal with a mirror and you will see what I am talking about. You will see the impression material flow ahead of the tip in the sulcus.

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Figure 23: After we try in the BruxZir crown and find the fit to be accept-able, the patient approves the esthetics of the crown and we clean it out prior to cementation. I decided to cement the restoration rather than bond it into place because I had sufficient prep length and it was not over-tapered. I use Ceramir® Crown & Bridge Cement from Doxa Dental (Newport Beach, Calif.) because of its natural bond to zirconia and simple cleanup. A pine-wood stick is used to provide pressure while the cement sets.

Figure 24: Here is the final BruxZir restoration on tooth #9, day of cemen-tation. While it probably won’t be mistaken for a natural tooth, it blends in well with the adjacent natural tooth #8. When I compare it to the existing all-ceramic and PFM crowns in the anterior segment, I think it looks better, although those other crowns are a few years old. With adequate reduction as a result of the Reverse Prep Technique, we allow the technician to give us an optimal esthetic result. CM

Figure 22: The impression has not been contaminated by blood or other gingival fluids because the first (bottom) cord was left in place during im-pression. As a result, you will also get an impression of the 1 mm of tooth structure apical to the gingival margin. This enables dental technicians to precisely see the exact gingival margin and allows them to build a proper emergence profile into the restoration — an important characteristic for whether or not an anterior crown will appear natural.

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redictable dental implant surgical placement today leads to positive long-term prognoses. Precision

prosthetic components that are reasonable in cost pro-vide stable retention and support implant overdentures well. These implant-retained overdentures act as outstanding alternatives to conventional dentures. Creating palateless reconstructions as replacements for full palatal coverage is accepted well by our patients.

Case planning and diagnosis is the critical beginning for consideration for fabrication of implant-retained overden-tures. First, we must consider the desires of our patients for their final restorations. Fixed prostheses versus removable prostheses must be discussed in detail to meet patients’ expectations. Cost factors often play into the final result; however, it is my experience that creating an appliance that is esthetic and functional is a good option for many pa-tients. Also to be considered is the manual dexterity of each patient and his or her ability to clean and maintain the site, not only initially but also in the years to come. Removable implant-retained overdentures are easy to maintain with

little effort and are extremely cost-effective, considering the tremendous advantage they provide in allowing our patients to chew and function much more normally. Having the palate removed from the design allows the taste buds in the palate to function properly. It is a definite improvement in the quality of life of our patients.1

Surgical placement of dental implants in the past was done through radiographic evaluation and intraoral examination. This included manual palpation of the ridges, evaluation of the 2-D panoramic radiograph, use of bone calipers to approximate width of the ridges, digital periapical radio-graphs with bone markers, and measuring study casts. Bone quality, especially in the maxillary region, could only be determined at the time of surgical osteotomy creation. With the advent of computed-tomography (CT) diagnostics, 3-D images are created that allow the practitioner to precisely determine not only vital anatomy, such as the sinuses, but also the height and width of available bone.2 Risks are evaluated prior to any surgical intervention.

– ARTICLE by Timothy F. Kosinski, DDS, MAGD

Simple Flapless Surgical Overdenture Techniques

Simple Flapless Surgical Overdenture Techniques25

When considering implants for maxillary implant-retained overdentures, we will need a minimum of four implants in the maxilla. These implants need to be in positions that allow for proper draw of the chosen attachments. Thus, placement of the implants is a critical factor in achieving ideal final prosthetic reconstruction of the overdenture. Of-ten, improperly placed or angled implants create a hardship for the patient and laboratory technician, as proper draw is not established. This may lead to poorly seating overden-tures or excessive adjustments being made to eliminate sore areas. The use of CT diagnostics and CT guides helps the practitioner to establish proper positioning.3 In addition, the quality of bone can be determined in many instances, thus establishing a platform for success.

CASE REPORTDiagnosis and Treatment Planning

A 46-year-old male presented to our office with an ill-fitting conventional maxillary complete denture that made him gag, decreasing his quality of life physically and emo-tionally (Fig. 1). Furthermore, he felt embarrassed by his appearance. There were no medical contraindications to dental implant therapy. Options were discussed, including the fabrication of another conventional maxillary denture, or placement of implants to retain a fixed hybrid appliance and an implant-retained overdenture. Fabrication of a fixed appliance would require sinus augmentation to allow for more implants to be placed in the posterior region to sup-

Figure 1: Our patient presented with no maxillary teeth. He had a desire to improve his quality of life with an implant-retained overdenture.

When considering implants

for maxillary implant-

retained overdentures, we

will need a minimum of four

implants in the maxilla.

port such a device. Four maxillary implants were consid-ered to secure an implant-retained overdenture using the Locator® attachment system (ZEST Anchors LLC; Escondido, Calif.). This process was determined to be cost-effective to the patient as a means of restoring form and function, and to improve esthetics dramatically.

Conventional radiographs, including panoramic and peri-apical digital radiographs, allowed us to visualize vertical height but not bone angulations or horizontal bone avail-ability (Fig. 2). A CT scan advanced our visual field to a third dimension (Fig. 3). It was clear by the radiographs that placing implants in the very posterior portion of the maxilla would not have been possible without a more invasive surgical intervention because of the large maxil-

lary sinuses.3 Certainly, other techniques (such as sinus elevations) should always be considered. Because of the significant amount of horizontal bone loss (Fig. 4), the pa-tient also lost a good amount of lip support, so fabrication of an overdenture with some facial and lip support was appropriate. When there is bone loss vertically, following long-term resorption after tooth extraction, fabrication of fixed bridgework or hybrids can become challenging (Fig. 5). Teeth would need to be cantilevered to the facial, and they would be extremely long into the gingiva. Lip support is often compromised by such a prosthesis design. Overdentures eliminate the esthetic concerns, are easy to maintain with proper home care, are stable, and are an excellent alternative to conventional techniques.

Figure 2: Preoperative panoramic radiograph illustrating the position of the vital anatomy, including the right and left maxillary sinuses. The premaxilla had adequate bone for dental implant placement, but the posterior maxilla presented with extremely large sinuses.

Figure 3: A CT scan was done to determine the amount of width of available bone in the premaxilla area to accept dental implants. This technique would allow a flapless surgical placement.

Figures 4, 5: Maxillary edentulous ridges seemed to indicate adequate height and width of bone to surgically place four maxillary implants to support an implant-retained overdenture.

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Clinical ProtocolThe surgical process began with making an initial opening with a 2.3-mm-diameter pilot drill (Fig. 6). This drill easily penetrated the cortical plate and allowed proper angula-tion of the implant in front of the maxillary sinus area. Simple digital radiographs allowed us to evaluate not only angulation but also the depth (Fig. 7). Clear markings on the surgical drill helped in visualizing proper depth. This was the only end-cutting bur used in the surgical process; subsequent burs were used to simply widen the osteotomy site. Therefore, it was imperative that proper positioning was determined while using the 2.3-mm pilot drill.

The Inclusive® Tapered Implant System was chosen here because of its high quality, incredible initial stability, and simple prosthetic applications. The Inclusive Tapered Implant design is a minimally invasive, bone-condensing

implant system designed for dual stabilization of the implant in place, providing a true initial mechanical lock.3 The surgi-cal techniques in the placement of this implant are both user-friendly and simple. Chairside efforts are dramatically reduced due to the simple stage surgical drilling. As the cost of implant materials decreases, my ability to provide high-quality dentistry at a reasonable fee increases. Our patients are very responsive to this and appreciative.

Once the angulation of the first osteotomy was determined, we moved forward to the next-diameter bur (a 2.8-mm-diameter drill). The final 3.4-mm-diameter osteotomy drill was used to create a site for the 3.7-mm-diameter implant (Figs. 8, 9), which was then threaded into position using a torque wrench (Figs. 10–13). A torque of 35 Ncm was achieved with the implant system (even in the relatively soft anterior maxillary bone) (Fig. 14).4 Once the first implant

Figures 8, 9: A 3.4-mm-diameter drill was used after the 2.8-mm-diameter drill to create the final osteotomy to accept 3.7 mm x 10 mm Inclusive Tapered Implants. The digital radiograph shows proper depth and angulation. The facial plate of bone was left completely intact for this flapless surgical procedure.

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9

Figures 6, 7: A 2.3-mm pilot drill was used to evaluate proper angulation and availability of bone. Final length was also determined using this drill.

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Figures 10–14: The Inclusive implants were torqued to 35 Ncm (even in the porous maxillary bone). Initial stability was created by the design of the implant body itself.

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Figure 15: The first implant was properly positioned and checked using a radiograph.

Figure 17: Four Inclusive implants were placed using a flapless proce-dure.

Figure 16: Subsequent osteotomies were made for the remaining three dental implants. Parallelism of the dental implants is key to maintain stability of an overdenture.

was deemed to be positioned correctly, the other implants were simply paralleled to the first (Figs. 15, 16). Four maxillary implants were then ideally placed using a flapless technique

(Figs. 17–19). Since a flapless technique was used, healing occurred more promptly (Figs. 20,

21).

Conventional denture fabrication techniques were then used to create the final esthetic contours.

We created an outstanding functional and esthetic result, exceeding the patient’s expectations in func-

tion. The gagging reflex that a full palate conventional denture had previously created was totally eliminated.

Because the implants were properly positioned, Locator attachments were torqued into each implant, and a palateless maxillary overdenture was fabricated. The Locator attachments provided excellent stability and, because the implants were spaced ideally,

Figure 21: Healed tissue cuffs demonstrated attached gingiva around the integrated dental implants.

Figure 20: Following approximately four months of healing, the implants were exposed.

Placement of the implants is a critical factor in achieving

ideal final prosthetic reconstruction of the overdenture.

Often, improperly placed or angled implants create a

hardship for the patient and laboratory technician, as

proper draw is not established.

Figures 18, 19: Digital radiographs and a panoramic radiograph, show-ing parallel positions of the implants.

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excellent retention (Fig. 22). Because of their design, the patient was able to easily align and seat the overdenture. However, it was important that the implants were placed in a parallel position to each other, thus simplifying the prosthetic construction. According to the manufacturer, the attachments resist wear and maintain satisfactory retention for up to 56,000 cycles of function. The male portions can be easily changed chairside with minimal inconvenience to the patient (Figs. 23, 24). The Locators come in a variety of retentions from extra light (blue) to heavy (clear). In this case, the light retention attachments were used. The patient’s chewing function and efficiency, as well as his quality of life, were all dramatically improved using simple,

easy-to-follow, cost-effective dental surgical and prosthetic techniques (Fig. 25). Postoperative oral hygiene instructions were given to the patient. The attachments were easily maintained intraorally with brushing and a simple wipe with a washcloth. The underside of the overdenture can be cleaned with a simple brush.

Closing CommentsWe are fortunate to practice in a time when we can provide our patients with comprehensive, safe and precise surgical techniques. Visualizing the case as finished before starting is helpful in achieving outstanding functional and esthetic

Figure 22: Locator attachments were then torqued into the dental implants so that approximately 1.5 mm of the attachments were supra-gingival, allowing for plenty of room for denture tooth positioning.

Figure 24: The palateless implant-retained overdenture was very stable, providing outstanding functional stability and removing any gag reflex.

Figure 23: The underside of the palateless (horseshoe-shaped) implant-retained overdenture holds the female portions of the Locator attach-ments.

Figure 25: The esthetic, natural-looking maxillary implant-retained overdenture dramatically improved the quality of life of our patient.


final results. CT diagnosis and scanning software make the surgical process simpler for even the less experienced dental implant surgeon.5 Considerations for any and all vital anatomy is easier to assess. However, not every situ-ation warrants CT diagnosis or surgical planning. Because general practitioners are the professionals whom patients consult concerning their dental condition, practitioners must educate themselves with the treatment modalities that may be appropriate. CM

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Reprinted by permission of Dentistry Today, ©2014 Dentistry Today.

REFERENCES

1. Geckili O, Bilhan H, Mumcu E, Dayan C, Yabul A, Tuncer N. Comparison of pa-tient satisfaction, quality of life, and bite force between elderly edentulous patients wearing mandibular two implant-supported overdentures and conventional com-plete dentures after 4 years. Spec Care Dentist. 2012 Jul-Aug;32(4):136-41.

2. Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012 Apr;21(2):78-86.

3. Ganz SD. Restoratively driven implant dentistry utilizing advanced software and CBCT: realistic abutments and virtual teeth. Dent Today. 2008 Jul;27(7):122, 124, 126-7.

4. Abai S. Implant considerations in the esthetic zone. Inclusive. 2013;4:25-8.

5. Amet EM, Ganz SD. Implant treatment planning using a patient acceptance pros-thesis, radiographic record base, and surgical template. Part 1: Presurgical phase. Implant Dent. 1997 Fall;6(3):193-7.

Visualizing the case as

finished before starting

is helpful in achieving

outstanding functional and

esthetic final results.

HOW TO WATCH


In a previous article (“Choosing an Endodontic Post System,” Inside Dentistry®, October 2013, Volume

9, Issue 10), the authors reviewed the different choices clinicians have in restoring severely broken-down teeth with posts. In an attempt to come to a scientifically based decision, the cited literature focused on protecting and preserving dentin, working with tapered and ovoid canals, managing C-factor polymerization contraction stresses, and examining threaded post factors. In this article, however, the au-thors use independent research to ad-dress additional questions that should be asked when assessing the relative

merits, drawbacks and challenges of using currently available endodontic post systems:

➤ Is there any difference in failure mode when comparing metal and fiber posts?

➤ Does modulus of elasticity really play a factor in long-term clinical success?

➤ In highly esthetic cases, do metal posts of any type have a role in the restoration process?

➤ In cyclic fatigue, is there a differ-ence in longevity between metal and fiber posts?

FACTORS IMPACTING LONG-TERM SUCCESS OF ENDODONTIC POST SYSTEMSThe physical characteristics of post materials affect restorations

➤ What is the nature of the relation-ship between round posts and anti-rotational effects?

➤ Does the penetration of the light down the canal change the conversion factor of dual-cured resin cements and dual-cured self-adhesive cements?

Failure ModesIn an extensive 2011 review of post systems, Goracci noted several recur-ring findings in the literature regard-ing failure modes. These include the fact that the risk of vertical root frac-tures was reduced by the biomimetic

– ARTICLE byLeendert Boksman, DDS, FADI, FICD, Gildo Coelho Santos Jr., DDS, Ph.D., and Manfred Friedman, BDS, BChD

Factors Impacting Long-Term Success of Endodontic Post Systems35

behavior of fiber-reinforced composite posts; the risk of vertical root fracture was increased with rigid posts be-cause of the internal transmittance of stress toward the apical (Figs. 1, 2); and root fractures are very rare with less rigid fiber posts.1 If fractures do occur, fiber posts produce favorable tooth fractures, which are retrievable and restorable.2 In one study, the 2-year survival rate was 93.5 percent for glass fiber–reinforced posts and 75.6 percent for metal screw posts, which were also associated with more unfavorable complications — e.g., root fractures.3

Stainless steel is stronger than tita-nium alloy but has the potential for an adverse reaction to the nickel it contains. This fact, combined with concerns about corrosion, contrib-uted to the shift to titanium.4 It is also well documented that non-precious metal posts corrode in the presence of bimetallism or moisture, which leads to decementation and creates unrestorable failures and fractures.5,6 Dissimilar metals used in the fabrica-tion of post and cores create electro-

lytic action, resulting in 72 percent of the failures reported in a study of 468 teeth that failed with oblique or verti-cal fractures.7

Modulus of ElasticityThe elastic modulus, or modulus of elasticity, is the mathematical descrip-tion of the tendency of an object or substance to be deformed elastically (i.e., nonpermanently) when force is applied. When a post has a higher modulus of elasticity than its anchor-ing material (i.e., the tooth), the stress concentration is at the bottom of the post. When the post and tooth have similar moduli, however, the stress is concentrated at the top of the post, where it can be dissipated by the fer-rule.8

The moduli of elasticity of stainless steel and titanium are 20 and 10 times that of dentin, respectively. Stainless steel and titanium posts with a high modulus of elasticity do not flex with teeth under loading and are believed to cause root fracture.2 In discussing low versus high modulus posts, Peutzfeldt says that high-modulus posts are asso-

Figure 1: Radiograph of typical oblique root fracture with metal post.

Figure 2: Remaining gutta-percha compro-mises success.

Figure 3: Example of the gingival shadowing that can occur when using a metallic post.

ciated with a higher incidence of root fractures when they finally fail; that is, they cause more damage to the remain-ing tooth structure and often result in extraction of the tooth involved.9 If the clinician uses a parallel metal post (threaded or not) and over-prepares the canal for a large (wide) post, forces are transmitted and concentrated at the end of the post due to the high elastic modulus, where there has been needless removal of dentin to create a weakened root structure.4 Horizontal loading of a stainless steel post–re-stored tooth causes a stress that is three times as high as that caused by vertical loading.10 Fiber posts have an elastic modulus that closely mimics the elastic modulus of dentin at 18 GPa, which has been proven to protect teeth from fractures.10

Dietschi states that metal and ceramic isotropic posts prove less effective than fiber posts at stabilizing post-and-cores.11 Metal posts are isotropic in that their elastic modulus is the same at every angle of incidence. Fiber posts are anisotropic and differ from metal in that the modulus of elasticity


Figure 4: Root darkening due to endodontic treatment with metallic post.

varies from angle to angle. Their elas-tic modulus is highest at vertical load and matches dentin when stressed at an angle of 30 to 40 degrees, which is more representative of the forces of mastication.12 Fiber-reinforced posts absorb and dissipate stresses due to their parallel fiber content, and there-fore induce a stress field quite similar to that of the natural tooth.6,13

EstheticsEndodontics in the anterior is often ac-companied by darkening of the tooth structure. In many cases, gingival staining caused by some endodontic sealers and the use of gutta-percha in the canal and pulp affect the ability of the tooth to reflect and transmit light, creating a loss of translucence.14 Us-ing a metallic post further accentuates the gingival shadowing of the tissues, negatively affecting the esthetic re-sults of all anterior restorations (Figs. 3, 4).15 Fiber posts, on the other hand, diffuse light through the restoration, creating natural translucence and im-proving the esthetic result of anterior composites and ceramics (Figs. 5, 6).16

Cyclic FatigueIt is well documented that cyclic fatigue, or repetitive loads below the mechanical resistance limit, is a more common cause of the structural failure of restorations than a single load or force that is over the limit.17 Numer-ous studies have examined the effect of fatigue on different types of posts. Fiber resin posts resist fatigue better than teeth with cast posts, and fiber-reinforced dowels and bonded com-posite cores give significantly stronger crown retention than titanium alloy dowels with composite cores under fatigue loading.18,19 After cyclic fatigue testing, the flexural strength of metal posts and fiber posts decreases by 40 percent and 14 percent, respectively.20 Quartz fiber posts are more than twice as fatigue resistant as stainless steel and titanium alloy posts.21

There is a wide variability in the physical properties and quality of manufacture of fiber posts, however. They can present as dentin-colored, translucent, white, or color-changing translucent, and their capacity for light transmission may be excellent,

good, fair or poor. Different fibers used include zirconia-enriched glass fiber, quartz fiber, or glass and car-bon fiber. Fiber diameters range from 8.2 to 21 µm, with a fiber/matrix ratio ranging from 41 percent to 76 percent.22 In addition, fracture load can range from 60 N to 96 N, and the flexural strength ranges from 565 MPa to 898 MPa. The quality, type and volume of the fibers, the way the fibers are silanated, and the type of resin used all affect the clini-cal performance of fiber posts, with some failing in cyclic fatigue in a few thousand cycles and others surviving for more than two million cycles.17

Anti-Rotational EffectsResistance, or the ability to withstand lateral and rotational forces, is affected by many factors, including the amount of remaining tooth structure, a post’s physical characteristics, and the pres-ence of anti-rotational features (Fig. 7).4

If the clinician uses a restorative post system that allows for integration of the natural shape of the access open-ing, which is typically ovoid, by using

Figure 5: Preoperative view of patient with gingival darkening with metallic post.

Figure 6: Postoperative view shows improved esthetics with use of fiber post.


Figure 7: Multiple fiber posts provide anti-rotational resistance.

the “augmented” approach into the spaces lateral to the “master post,” the addition of multiple posts will provide more anti-rotational stability.

Multiple studies in the dental litera-ture support this restorative approach. Akkayan maintains that when look-ing at a cross-sectional view of the prepared root canal in relation to the form of the post system used, fracture resistance can be improved by using accessory posts to fill the post space, thereby decreasing the cement layer as well.23 Accessory glass fiber posts have been shown to improve the bio-mechanical behavior of flared roots, and glass fiber posts associated with accessory posts have been shown to be the method of choice for restoring structurally weakened roots.24,25 Mac-eri maintains that the multi-post tech-nique increases the bearing capacity and durability of endodontically treat-ed teeth, and that when prefabricated composite posts’ overall cross-section increases, the multi-post solution in-duces a significant reduction of stress levels into the residual dentin.26 There is a lower risk of catastrophic failure

due to better stress distribution when fiber posts are associated with acces-sory fiber posts.27

Penetration of Light and Conversion FactorThere are many luting or cementa-tion materials available to clinicians, including zinc phosphate cement, polycarboxylate cement, glass ionomer cement, resin-modified glass ionomers, and various composite resins. The current shift has been to use a dual-cured composite resin [e.g., CosmeCore™ (Cosmedent, Inc.; Chicago, Ill.), Zircules™ (Clinician’s Choice Dental Products, Inc.; New Milford, Conn.), CoreCem® (RTD; Saint-Égrève, France)] that can be used not only for bonded cementation of the post, but also for fabrication of the bonded core.28 The potential of imme-diate polymerization of the composite allows for simultaneous post inser-tion, fabrication and contouring of the core, and either immediate finishing and polishing of the final restoration, or impressioning, if full coverage is indicated.

A discussion on adhesion using bond-ing agents or self-adhesive cements would require a separate article, but there are a few issues that do need to be discussed here. The preparation of a canal space for a post creates a “secondary smear layer” (sealer, gutta-percha, dentin debris) that is much different from coronal dentin, and thus the bonding values pro-vided by manufacturers mean little when bonding to radicular dentin.1 Radicular dentin is also different mor-phologically and physically, making the creation of a traditional “hybrid layer” more difficult. The current literature suggests that the most reli-able results for adhesive cementation to radicular dentin are attained with the use of etch-and-rinse adhesives and dual-cured resin cements.29 The use of “simplified” systems, such as single-bottle all-in-one self-adhesives and self-adhesive cements, is appeal-ing because the technique is easier with fewer steps involved. However, these systems offer questionable du-rability in bonding to radicular dentin, due to their variability of penetrating the smear layer — especially the

Resistance, or the ability to withstand

lateral and rotational forces, is affected

by many factors, including the amount of

remaining tooth structure, a post’s physical

characteristics, and the presence of

anti-rotational features.


secondary smear layer — and their hydrophilicity, leading to hydrolytic degradation of the bond.30,31

The best physical properties and conversion of single to double bonds of dual-cure systems are attained with sufficient light exposure, even though it is claimed that they polymerize in the absence of light.32 To achieve good bonding to root canal dentin with increased microtensile bond strength and increased hardness, photo-initi-ated polymerization of the adhesive resin and dual-cured resin composite is necessary.33

As mentioned previously, fiber posts do vary considerably in their capacity for light transmission — some do not transmit light at all and, of course, any metal will block the light transmission — and curing lights vary considerably in power and their ability to cure at a distance. It is incumbent upon the clinician when using dual-cured com-posites to find a post that transmits the most light while at the same time combining the best fiber, loading, structure, quality control and research documentation, and to find the curing light that loses the least amount of energy with distance.34

SummaryWhen clinicians treat severely compro-mised teeth endodontically, the choice of post system has a significant impact on the overall success and esthetic val-ue of the restoration. Using indepen-dent research to help understand the physical properties of different posts in terms of their behavior in clinical situations is critically important.

DISCLOSURES

Dr. Leendert Boksman does some writing, lecturing, and consulting on a limited basis for some manufac-turers mentioned in this article. Dr. Gildo Coelho Santos Jr. has received material sup-port from Clinician’s Choice. Dr. Manfred Friedman has no disclosures.Reprinted by permission of Inside Dentistry®, ©2013 AEGIS Communications.

REFERENCES

1. Goracci C, Ferrari M. Current perspectives on post systems: a literature review. Aust Dent J. 2011 Jun;56 Suppl 1:77-83.

2. Dhanavel C, Madhuram K, Naveenkumar V, Anbu R. Fracture resistance of endodontically treated maxil-lary central incisor with five different post and core systems — an in-vitro study. Internet J Dent Sci. 2011;10(1).

3. Schmitter M, Rammelsberg P, Gabbert O, Ohlmann B. Influence of clinical baseline findings on the sur-vival of 2 post systems: a randomized clinical trial. Int J Prosthodont. 2007 Mar;20(2):173-8.

4. Schwartz RS, Robbins JW. Post placement and the restoration of endodontically treated teeth: a litera-ture review. J Endod. 2004 May;30(5)289-301.

5. Fischer DE. Benefits of fiber posts: clinical ap-plication of a new post system. DentToday. 2008 Feb;27(2):138, 140, 142.

6. Fernandes AS, Shetty S, Coutinho I. Factors deter-mining post selection: a literature review. J Prosthet Dent. 2003 Dec;90(6):556-62.

7. Rosenstiel SF, Land MF, Fujimoto J. Restoration of the endodontically treated tooth. In: Contemporary Fixed Prosthodontics. 3rd ed. St Louis, MO: Mos-by;2000:295.

8. Cohen S, Hargreaves KM. Pathways of the Pulp A Mosby 2006 9th Edition, Chapter: Restoration of the Endodontically Treated Tooth: Wagnild G, Mueller K: 796

9. Peutzfeldt A, Sahafi A, Asmussen E. A survey of failed post-retained restorations. Clin Oral Investig. 2008 Mar;12(1):37-44.

10. Song G. Three-dimensional finite element stress analysis of post-core restored endodontically treated teeth [thesis]. Winnipeg, Canada: Univer-sity of Manitoba; 2005.

11. Dietschi D, Ardu S, Rossier-Gerber A, Krejci I. Ad-aptation of adhesive post and cores to dentin after in vitro occlusal loading: evaluation of post mate-rial influence. J Adhes Dent. 2006 Dec;8(6):409-19.

12. Boksman L, Hepburn AB, Kogan E, et al. Fiber post techniques for anatomical variations. Dent Today. 2011 May;30(5):104, 106-11.

13. Boksman L, Friedman M. Ovoid root canals and ovoid fiber posts: a biomimetic and synchronistic approach. Oral Health. May 2009:32-45

14. Milnar FJ. Aesthetic treatment of dark tooth syn-drome. Dent Today. 2010 Sep;29(9):74-6, 78-9.

15. ADA Council on Scientific Affairs. Endodontic Posts: Tips for Securing Restorative Success. www.ada.org/sections/ scienceAndResearch/pdfs/0604_tips_endoposts. pdf. Accessed June 5, 2013.

16. Martelli R. Fourth-generation intraradicular posts for the aesthetic restoration of anterior teeth. Pract Periodontics Aesthet Dent. 2000 Aug;12(6):579-84.

17. Grandini S, Goracci C, Monticelli F, Tay FR, Ferrari M. Fatigue resistance and structural characteristics of fiber posts: three-point bending test and SEM evaluation. Dent Mater. 2005 Feb;21(2):75-82.

18. Felippe LA, Monteiro S, Monteiro SJ, et al. Influ-ence of the use and type of endo posts in the cer-vical stress level of central incisors submitted to the fatigue test. An in vitro study. Paper presented at: IADR 80th General Session; March 6-9, 2002; San Diego, CA; Abstract 0057.

19. Goto Y, Nicholls JI, Phillips KM, Junge T. Fatigue resistance of endodontically treated teeth restored with three dowel-and-core systems. J Prosthet Dent. 2005 Jan;93(1):45-50.

20. Duret B, Duret F, Reynaud M. Long-life physical property preservation and postendodontic reha-bilitation with the Composipost. Compend Contin Educ Dent Suppl. 1996;(20):S50-6.

21. Wiskott HW, Meyer M, Perriard J, Scherrer SS. Rotational fatigue-resistance of seven post types anchored on natural teeth. Dent Mater. 2007 Nov;23(11):1412-9.

22. Seefeld R, Wenz HJ, Ludwig K, Kern M. Resis-tance to fracture and structural characteristics of different fiber reinforced post systems. Dent Mater. 2007 Mar;23(3):265-71.

23. Akkayan B, Gaucher H, Atalay S, Alkumru H. Effect on post geometry on the resistance to fracture of endodontically treated teeth with oval-shaped ca-nals. Can J Restor Dent Prosthodont. 2010 Sum-mer:20-6.

24. Silva GR, Santos-Filho PC, Simamoto-Júnior PC, Martins LR, Mota AS, Soares CJ. Effect of post type and restorative techniques on the strain and fracture resistance of flared incisor roots. Braz Dent J. 2011;22(3):230-7.

25. Braz R, Conceição AAB, Conceição EN, et al. Eval-uation of reinforcement materials used on filling of weakened roots. Paper presented at: IADR 83rd General Session; March 9-12, 2005; Baltimore MD. Abstract 1733.

26. Maceri F, Matignoni M, Vairo G. Mechanical be-havior of endodontic restorations with multiple prefabricated posts: a finite-element approach. J Biomech. 2007 Jan;40(11):2386-98.

27. Raposo LHA, Silva GR, Santos-Filho PC, et al. Ef-fect of posts and materials on flared teeth’s me-chanical behavior. Paper presented at: IADR 86th General Session; July 4, 2008; Toronto, Canada. Abstract 1862.

28. Glassman G, Boksman L. Ensuring endodontic success: tips for clinical predictability. Oral Health. May 2009:18-28.

29. Dietschi D, Duc O, Krejci I, Sadan A. Biomechani-cal considerations for the restoration of endodon-tically treated teeth: a systematic review of the literature — Part I. Composition and micro- and macrostructure alterations. Quintessence Int. 2007 Oct;38(9):733-43.

30. Monticelli F, Osorio R, Mazzitelli C, Ferrari M, Tole-dano M. Limited decalcification/diffusion of self-adhesive cements into dentin. J Dent Res. 2008 Oct;87(10):974-9.

31. Perdigão J. New developments in dental adhesion. Dent Clin North Am. 2007 Apr;51(2):333-57.

32. Peutzfeldt A. Dual-cure resin cements: in vitro wear and effect of quality of remaining double bonds, filler volume, and light curing. Acta Odontol Scand. 1995 Feb;53(1):29-34.

33. Foxton RM, Nakajima M, Tagami J, Miura H. Bond-ing of photo and dual-cure adhesives to root canal dentin. Oper Dent. 2003 Sep-Oct;28(5):543-51.

34. Boksman L, Santos Jr. GC. Principles of light-cur-ing. Inside Dentistry. 2012 Mar;8(3):94-7.


Interview with Dr. Erin Elliott– INTERVIEW of Erin Elliott, DDS

by Michael C. DiTolla, DDS, FAGD

Dr. Erin Elliott practices dentistry in Post Falls, Idaho, a small town just east of the Washington border. Relishing her role as a general practitioner not pigeonholed into a specific subset of the field, Erin continues to grow her practice by learning new areas of dentistry and bringing those treatments to her patients. Discover what this talented clinician has to say about treating snoring and obstructive sleep apnea, and using indirect bonding trays for accelerated orthodontics.

Interview with Dr. Erin Elliott41

Dr. Michael DiTolla: I’m happy to have with us today Dr. Erin Elliott, who I met not too long ago when I was up at the Idaho State Dental Association meeting. I really liked what she had to say about her practice, because I think her two areas of em-phasis are great for any dentist just getting out of school, or for those whose practices are in need of a boost. These two areas that seem to be almost ignored by general dentists are ortho-dontics — specifically, accelerated adult orthodontics — and snoring and sleep apnea. Erin, before we get to that, let’s go back to dental school. Tell me a little bit about what inspired you to become a dentist, and what you did when you got out that got you to where you are today.

Dr. Erin Elliott: Well, my dad is a dentist. He practiced in Long Beach, California, and I grew up in Orange County, but I didn’t grow up hanging out at his office or anything. I went away to college in upstate New York, always figuring I’d have a career in health care. I never had expectations of becoming a dentist myself; but as it turned out, dentistry was for me, and I absolutely fell in love with it.

MD: My dad was a dentist, too. His practice was 3 miles from the house, but I didn’t spend any time there, either. I went when I needed to borrow money. Well, it wasn’t really borrowing. I had no intention of paying it back. What was your experience like in dental school?

EE: I went to Creighton University School of Dentistry, and I absolutely loved it because there were no spe-cialties. If I wanted to go place an implant, if I wanted to do third molar extractions, I got to do it. A part of me always felt like they held me back, though. I thought, “You know, it’s not going to take three hours to do a Class II amalgam.” When I graduated, 11 years ago now, I felt like I was ready to go.

MD: I know you’re not going to brag, but I happen to know you did very well and placed very highly in your class — much higher than I did — so maybe they were holding you back in many differ-ent ways. When you got out, did you just start doing the regular day-in-day-out, bread-and-butter general dentistry? Or were you immediately attracted to some of these other areas?

EE: I loved doing bread-and-butter den-tistry. I still do. One of my professors pulled me aside once and said, “Elliott, I didn’t know you were smart. Why aren’t you specializing?” The reason I didn’t specialize was because I like to

do everything, and I knew I could pick and choose what I wanted to do.

MD: It’s funny to hear an instructor say, “You’re smart. Why don’t you go into a specialty?” That’s quite an insult to GPs.

EE: I think so.

MD: Right? Like they’ll pull somebody to the side and say, “You’re dumb. Just be a GP.” Honestly, do you have to be smart-er to do nine different things, or to do nothing but endo all day? You know what I mean?

EE: Yeah, I don’t envy endodontists at all.

MD: Right. The great part of being a GP is getting to do lots of different things.

EE: It was probably about five years ago that I discovered that dentists could be a part of sleep apnea treatment, and I started in that because I really like to sleep myself.

MD: That was the attraction? You love to sleep, and you want to help other people sleep as well? We make a lot of snoring and sleep apnea appliances here. For a dentist’s first case, we tend to see the doctor and patient names are matching. So they’re probably making one for themselves.

Dr. Erin Elliott's in-house dental sleep medicine coordinator, Bri, and other assistants are well trained in screening patients for snoring and sleep apnea appliances.


EE: The guinea pig.

MD: As I got involved with it, I noticed that it was kind of this weird area of health care, where doctors didn’t really learn anything about it in medical school, and dentists didn’t really learn anything about it in dental school, and these poor people suffering from obstructive sleep apnea are kind of caught in between the professions. Dentists stepping in with oral appli-ances is a great solution for tackling this problem and treating mild to moderate obstructive sleep apnea. When you first got involved, what were your very first steps? Did you make your-self an appliance?

EE: I think my husband wished I would make myself an ap-pliance; there are a couple of videos floating around social media right now of me snoring. I knew there was more to it than taking impressions and handing over an appliance. I knew that we were treating a medical condition, so I didn’t want to mess around with appliances before I understood sleep apnea. I started out with Kent Smith’s course down in Dallas. My dad came with me. He had retired, but he just loved dentistry so much that he decided to come with me. I was like, “OK, as long as we don’t share a room.” But I’m cheap, so we did. It was miserable, because he snores. He had snored his whole life. So as part of the course, we

did a home sleep test. He ended up having severe sleep apnea. The scariest part was seeing his heart racing all night long. He got up to 139 beats per minute. That’s a heart rate you’d see during a workout. It scared me because he was supposed to be resting, but his body was working overtime. He was running a marathon without the benefits of running a marathon.

MD: What did your mom say? They had always thought it was just snoring.

EE: Yeah. “It’s normal. Dad makes noise.” We’d go camping in the summers, and it was miserable. I like my sleep, and he’d interrupt it. As part of the course, there was an appli-ance made, and he didn’t know what the heck he was doing when he set it. It wasn’t necessarily in the proper position, but even that first night, his heart was resting and he was quiet. My mom actually thought he was dead the first night because, for the first time ever, he was quiet.

MD: She was calling the paramedics over every night for the first week or two and checking his pulse?

EE: Well, she’s a nurse, so she’d be able to resuscitate him.


tions, acid reflux medications. We check blood pressures all the time. There are a lot of dental clues, too: high-arch pal-ates, mouth breathing, acid erosion, scalloped tongue, and small airways. You could also change your health history form to ask if a patient has had sleep apnea, but patients aren’t always as in-tune with their health as they should be. We do ask if they snore, and a lot of patients will say, “Uh, no, I don’t, but my wife says I do.” Or we’ll ask, “Do you feel refreshed when you wake up?” And they’ll look at us like, “Are you supposed to?” Well yeah, you are. What I really like are the faxed-over referrals because the patients have usually met their deductible, they’re diagnosed, and they’re desperate for help.

MD: Where are they coming from?

EE: Physicians, primary care, nurse practitioners, sleep physicians. As soon as you get in front of physicians, or even treat some of them, it’s amazing how many referrals you can get.

MD: Did you actively go out and kind of court these different groups in order to educate them?

EE: I like that word: “Court.” As soon as you can get face to face with them, they see that they really don’t know a whole lot about sleep apnea, or how to screen for it. They don’t ask those questions. They put their patients on medications for high blood pressure or Type 2 diabetes and send them on their way, when a sleep study should be a part of the diagnosis. Making doctors aware of that has been really fun. You do have to hit the pavement, but it’s fun for me. I put my handpiece down and put my stethoscope on.

MD: When I was practicing with Todd Morgan at Scripps En-

Dentists aren’t just

tooth mechanics

anymore. Oral health is

tantamount to total

body health. Sleep

appliances are just

another tool in our kit

to help people.

MD: Of the tens of thousands of sleep appliances that Glidewell Laboratories made last year, I would guess that the vast majority were prescribed without a sleep study. I think it’s one of the things that holds dentists back, this idea of hav-ing to send patients to a sleep lab or send them home with a device to wear. But it’s really not that big a deal, sending people home to wear one of these at-home sleep tests.

EE: It’s really not, and the potential for the average practice is huge. I get at least two consults a day just out of hygiene appointments. There was a study of a hundred people sent for sleep studies where 30 percent of them didn’t go. The whole reason they didn’t go was because they didn’t want to wear a mask, or because they didn’t want to sleep overnight. Well guess what? If you remove those hurdles, your patients are all of a sudden like, “OK.”

MD: Yeah, it’s not a big hurdle to send them home with that because it’s such a comfortable way to do it. If you’re able to get two referrals out of hygiene a day, your hygienists must be familiar with what to look for in these patients?

EE: Yeah, screening is paramount. The hygienists know what medications to look for: high blood pressure medica-


cinitas, there was a monthly sleep meeting at the hospital where everybody involved with sleep medicine would get together and watch some of the surgeons show slides of their UPPP surgeries and be shocked. It was kind of funny how it would start with CPAP, and then it would go through various levels of surgery and Pillar® implants (Pillar Palatal; Dallas, Texas) and all kinds of things; and then, when everything else had failed, after the doctors had hacked and cut this person all apart, a dentist might be asked to do the “super aggressive” treatment of tak-ing two alginates to make a sleep appliance. Starting with the dental treatment is really doing patients a favor. I don’t think anybody disputes CPAP as the gold standard of treatment, as long as the patient can tolerate wearing it. Have you ever tried sleeping for a night with a CPAP mask on just for fun?

EE: I tried for about five minutes.

MD: You made it that long? That’s good.

EE: I have one here at the office. I’ve had my staff try it and I tell them it’s the alternative to sleep appliances. Everyone reading this knows that dentists aren’t just tooth mechanics anymore. Oral health is tantamount to total body health. Sleep appliances are just another tool in our kit to help

people. Dentists might be worried that they’re not 100 per-cent successful, but they’re thinking like a dentist. Do you think the ENT lost sleep by charging for a $10,000 surgery that didn’t work at all? A surgery that put the patient in all of this pain? You’re not putting your patients in pain, and you’re not charging that much, so you can sleep at night. See? I’m all about good sleep.

MD: It just seems logical to me to start with the most conserva-tive, least invasive treatment first. You could make a good ar-gument that the least invasive treatment is CPAP, if you can tol-erate this air being blown through your airway all night long; and then the second-least invasive would be an oral appliance; and then work your way up if those two don’t work. Roughly how many appliances are you making a month now?

EE: We’re probably averaging about 30 appliances a month. That’s in addition to general dentistry.

MD: What are your favorite appliances?

EE: I’ve really been using a lot of the dorsal fin appliance from SomnoMed (Frisco, Texas), as well as Narval™ CC (ResMed Corp.; San Diego, Calif.), which is a CAD/CAM-

milled, biocompatible, laser-sintered nylon; virtually indestructible, very comfortable. And of course Medicare doesn’t cover those, so I love the Herbst® (SomnoMed) for my Medicare patients.

MD: What is the Medicare rule for cover-ing an appliance? What does it need to have?

EE: Telescoping hinges.

MD: Telescoping hinges. That’s right! That’s the exact term.

EE: Yeah, what’s interesting is there is a guy out of Utah that sends patients an impression kit, has the patients take their own impressions, and deliv-ers what is basically two bleach trays with a fabric fastener and telescoping hinges on the side. And that’s Medi-care approved.

MD: If you put some lines on there, you can use the fabric fastener to titrate it, I guess. Yeah, that Narval appliance is fantastic. It’s really well thought-out. It’s probably the most expensive one out of all the ones you order, I would guess.

EE: Hey, I’ve got good taste. But we’re


getting medical insurance coverage for it. To me, it’s not my bottom line; it’s what the patients are going to wear and have a good experience with. It’s been really fun integrating this into my practice and having some good months because of it.

MD: It’s interesting, I’ve been hugged by more men as a result of this than any-thing else. They say things like: “I’m not falling asleep every day driving home from work”; “I now believe I’m going to be alive to see my two daughters get married”; “I forgot what it felt like to feel good. I felt like crap for the last 15 years, and I thought that’s how everybody felt.”

EE: Yeah, they just lived with it.

MD: You’ve seen that same kind of reac-tion?

EE: Oh yeah. Again, I’m in a small community, so we’ll go to a restaurant, and I’ll get hugs from a wife and husband, and they’ll tell all the friends they’re sitting with that I saved their life and saved their marriage. My husband will see this from a distance, and as soon as I come back to the table, he goes, “That was a sleep apnea patient, wasn’t it?” Your regular dental patients love you, but it’s just not the same.

MD: Yeah, it’s not the same. Do you feel like this aspect of den-tistry — treating OSA — could be good for a doctor who suf-fers from back pain caused by routine procedures like prepping teeth or endo?

EE: I sure do. I have all sleep apnea on certain days, and I come back home just refreshed and rejuvenated. There are definitely a lot of hoops to jump through with medical insurance and all that, but it’s worth it for me because I love it.

MD: It just seems like lower stress as well, even though there’s complicated paperwork. Your staff has probably been well trained on how to get medical insurance reimbursement for these appliances.

EE: I’m all about delegation.

MD: Did you have any exposure to OSA or snoring treatment at Creighton?

EE: Not at all. I keep hoping that maybe they’ll get it in there at least a little bit.

MD: It just seems like a real disservice to patients. I feel that we are well-qualified, especially since we’re going to be seeing them twice a year anyway if they’re already dental patients. So

out of all your patients over the last five years that did a home sleep test, what percentage do you think would end up benefit-ing from an appliance?

EE: That’s hard to guess. We know the average is one in four men and one in 10 women have sleep apnea. And then there are primary snorers, because when they include pri-mary snorers in studies with oral appliances, their fatigue has gone down quite a bit. When you get over the age of 50, it’s up to 50 percent, and we have a pretty aged population here. So it’s hard to judge, but I have quite a few patients.

MD: What’s your favorite OSA appliance for an edentulous pa-tient?

EE: I do make a Herbst, usually acrylic. My partner places implants, so if their dentures aren’t fitting well and we want to get a better-stabilized appliance, we can do implants for them.

MD: The other area of dentistry that I know you’re very in-volved with is orthodontics. I know that you love doing Six Month Smiles® (Six Month Smiles LLC; Scottsville, N.Y.). Tell me a little bit about how you originally got interested in doing Six Month Smiles.

EE: I think I got about as much ortho education as I did sleep apnea education in dental school. I did Invisalign® (Align Technology, Inc.; San Jose, Calif.) for a while, but it was very frustrating. It wasn’t until I became my own Invisalign patient that I realized that I needed to do something different. I was never really satisfied with the results or the process; even on myself, I just took them out. I’m the most noncompliant patient you could ever meet. Do as I say, not as I do.


MD: I did it in the opposite order. I did the traditional ortho first and then the aligners after that. In America — even in Idaho — there’s such an instant-gratification mindset. It’s re-ally difficult to get adults to commit to something for two years. Kids do it because they don’t have a choice. They do what their parents say.

EE: And because their peers are all doing it. So I went and took the Six Month Smiles course and absolutely fell in love with it because you can control the teeth so much more. You can move them faster, and patients don’t mind them. I’ve gotten some spectacular results. A lot of patients will say they like their smile if I ask; but if I ask about a specific tooth, they’ll say they hate that tooth, and it’s because they think they need to go get metal braces for two years to fix it. They’ll just shut it out of their mind. I just fixed a diastema on a 62-year-old man with the biggest Idaho beard — you hardly see his teeth — who wanted to fix the space. His wife said she never realized how much it bugged him, and was really glad that he finally did something about it.

MD: When you’ve had your eyes opened to this type of adult or-thodontics, you begin looking at teeth in a slightly different way. You begin noticing that almost every adult has lower anterior crowding and other small issues. So how did you get started? Where was your first training class, and when was it?

EE: It was in Chicago with Tony Feck. And I’ll tell you what; it’s perfect for general dentists and easy to do with assistants. I can’t sit down for an hour and place brackets. I just don’t have the time, and that’s not profitable. So it’s just a great system in which they give you the trays with the preset brackets, and you can bond the brackets indirectly. The wires are white, and the “donuts” are clear, so they don’t catch your eye like traditional braces. Patients really love

that. I have at least one member of my staff in Six Month Smiles at all times.

MD: Whether they need it or not, you’ve got one of them in it?

EE: Pretty much.

MD: When I was doing ortho, we were placing brackets on teeth manually us-ing measurements and a positioner to line them up with the long axis of the tooth and get them properly centered. To a large extent, that placement deter-mines how successful your result is go-ing to be. It’s an indirect method with Six Month Smiles. You have somebody — a trained technician — putting the brackets on a study model out of the mouth without any lips, tongues or sa-liva getting in the way, and then doing a thermoformed tray over that and send-

ing it to you. All you need to do is be able to get acid-etch in the middle of the tooth, rinse it off, apply bonding agent, put it down with the cement, cure it, and peel it off, and instantly everything’s in the right position.

EE: And everything is esthetic.

MD: And six months for them is not a huge commitment. Do you guarantee that?

A lot of patients will say

they like their smile if I ask;

but if I ask about a specific

tooth, they’ll say they hate

that tooth, and it’s because

they think they need to go get

metal braces for two years

to fix it. They’ll just shut it

out of their mind.


EE: We say, “Would you like to have straight teeth by your next clean-ing?” Which is a good way to put it. Sometimes they’re stubborn teeth, sometimes it’s a more advanced case, and if it is more advanced, then I’ll let them know. But for the most part, it’s ortho relapse or some crowding that someone’s always hated, and it’s just unraveling those teeth and get-ting the nice arch forms that the wire provides you. So we always say about six months.

MD: Are you doing anything for reten-tion at the end of these cases? Remov-able? Fixed? What do you find most adults like?

EE: Yes, the patients all need to sign off on the retention knowing that it’s vitally important when we’re done. We have a new braided wire system from Six Month Smiles called Ortho FlexTech® (Reliance Orthodontic Products, Inc.; Itasca, Ill.) that I place on the maxillary if I can, or if not, at least on the anteriors of the mandible; and then clear Essix® (DENTSPLY Raintree Essix; Sarasota, Fla.) retainers that I make in-house. You can also do an indirect lingual wire that the lab at Six Month Smiles makes and places for you with the trays. Again, it’s a no-brainer — you just place it. But I don’t like to wait. I just

want to take them off and get my patients smiling again. You can get tears occasionally with that, which is really rewarding.

MD: The day the hardware comes off is such a great day.

EE: Actually, I have a photographer across the street, and he does a free photo session for them afterwards.

MD: Oh, that’s a great idea. How many cases did it take before you really started to feel comfortable with it?

EE: I did my first 10 cases on patients that I knew personally. I treated them at a discounted rate because during training you can buy a pack of 10 or so and get a discounted lab fee. But after that, there’s so much support on the forum for those new to it; in fact, I’m a mentor on the forum now. They really do help you through it, and it’s a really nice system.

MD: Can you compare the learning curves of Six Month Smiles and getting involved with snoring and obstructive sleep apnea?

EE: For snoring and sleep apnea, it’s a matter of learning all of the information that’s out there; for Six Month Smiles, it came down to my assistant and I getting familiar with the protocol. It really doesn’t take a whole lot of time. The learning curve would be more treatment planning and knowing what cases you can and can’t do, and what to tell your patients to expect.

MD: I’m sure in the course, there’s equal emphasis on what cases to treat and what cases not to treat.

EE: And which patients — as far as personalities — to treat.

It really doesn’t take a

whole lot of time. The

learning curve would be

more treatment planning and

knowing what cases you can

and can’t do, and what to tell

your patients to expect.

With the benefit of being virtually indestructible and comfortable, the Narval™ CC is among the sleep appliances that Dr. Erin Elliott prescribes.


Do you really want to be married to them for the next six months?

MD: Ah, well six months. I used to do it for two years. It’s really nice to be able to do it in six months, so you can see the goal and at least have an idea of when the treatment is going to end.

I think you have a real willingness to jump in and learn some-thing new. And if you don’t like it, then you just don’t do it any-more, right? It’s not a lifelong commitment that you’re making.

EE: Well, yeah. You should never do anything if profit is your only motivation. And these areas are ones that I abso-lutely love doing, so I don’t mind the learning curves. I love doing braces, and changing smiles and changing lives.

MD: Would you also classify the Six Month Smiles treatment as being less backbreaking than, say, typical general dentistry?

EE: Definitely. I sit down, look at it, and do an overview. I’m not putting in the wires or the “donuts.” So yeah, I’m not bending over my patients all day.

MD: That’s the experience I think most of us had when we were kids going through ortho. When I visit my orthodontist friends, I see the staff doing pretty much everything after the diagnosis and treatment planning. It makes me jealous of orthodontists. And then I get just flat-out angry with orthodontists when they want four bicuspids extracted, and they don’t even have the technical fortitude to do the extraction themselves.

EE: They probably don’t even have anesthetic.

MD: I’ll be happy to ship some over to them along with some

forceps. They’re going to charge $5,500 for an ortho case where their assistants are going to do 95 percent of the work, and they want me to take out four perfectly healthy teeth on a 15-year-old for $150 each?

EE: Without breaking off the palatal root tip.

MD: Yeah, exactly. No, I refuse. They can do it themselves. Do you have Six Month Smile-only days, kind of the same way that you have obstructive sleep apnea-only days?

EE: Yeah. I tend to do them on the same days because I can have my assistants line it up, and I can go back and forth.

MD: So after that first Six Month Smiles course you took, did you come right back and start treating patients?

EE: I did. I had patients lined up before I even went. Once I got all the information and informed consents and all that, I was out the gate, ready to go. I did go back to check my notes a few times, but I felt prepared.

MD: It’s amazing to see how easy it is to move teeth. Do you have any advice for dentists who have thought about getting involved with either of these areas of dentistry, but have been nervous to do it?

EE: There are a lot of great courses out there for sleep apnea, and I think they are a great place to start. There’s a lot to learn; it’s a lot more than just making an impression and giving your patient a piece of plastic. I’d be more than willing to email those that might want more information on where to go and how to get started. For Six Month Smiles, there are a ton of courses with great instructors all

over the country. I’ll be attending one in Vegas this year. My favorite part is that all of my colleagues offering this service are in the same boat. No one is competing against each other, so it’s a great community.

MD: It’s all about making things eas-ier on the patient and the dentist. And the more dentists in your community who do this, the more legitimacy it gets. It’s kind of like how CEREC® (Sirona Dental Systems, Inc.; Charlotte, N.C.) was the only chairside CAD/CAM system for decades, but now that there’s four or five other commercially available ones, they don’t seem like such crazy rene-gades anymore. You going out and shar-ing this raises the water for everybody.

EE: Well, that’s why I loved your lecture at the Idaho State Dental Association meeting about digital impressions and

The SomnoDent Fusion™ is one of Dr. Erin Elliott’s favorite appliances to prescribe for treating sleep apnea and snoring.


how it made you a better dentist. I’m kind of disappointed you showed some of my preps and impressions that I sent down to Glidewell, but that’s OK.

MD: I spared you by not saying your name. Usually, I do that. I show a bunch of bad impressions, and then say, “Now, the interesting thing is all of these impressions are from dentists sitting in this room.” And the room goes totally quiet. Everyone who was talking or chatting on their phone just stops because they’re all terrified of seeing their own bad impressions. At which point I let them know that I’m just kidding.

I think it’s fantastic that you’ve embraced these two areas of dentistry and really incorporated them into your practice to help make it more successful. I speak with a lot of dentists who say their practices are down and they’re looking for a way to bring it up. I know you’re up, and a big part of the reason you’re up — besides your personality — is the ability to of-fer patients what they want. They want to feel good when they wake up in the morning. They don’t want to fall asleep when they’re driving home. They don’t want to hear their husbands snore anymore. They’d like to have straight teeth and then bleach them afterwards. And these are all things that are more appealing than scaling and root-planing and some of the other things that we have to do. These are things that people want, and that’s part of the genius of it all.

You mentioned if someone wanted to email you, you’d be happy to email back and forth. Can you give your email address for anybody who wants some more information?

EE: Sure! It’s [email protected].

MD: Well, Erin, thank you so much for your time today. It was a pleasure getting to spend some time with you up in Idaho and then speaking again with you today. Hopefully, you’ll be an inspi-ration to dentists interested in these areas. Thanks so much. CM

HOW TO WATCH

View this one-on-one interview at www.chairsidemagazine.com


Buffered Anesthetics

Rapid-onset buffering of local anesthetic saves time and offers predictable pain control, allowing the practice to take charge

Efficiency in Scheduling and Productivity

and Laser Use:

– ARTICLE by Mark Colonna, DDS and David Dodrill, DDS

One of the biggest challenges most practitio-ners face in dentistry is the unpredictability that comes out of anesthetic latency. The inability to predict anesthetic onset time impacts clinicians’ schedules every day. The authors have been using lasers in their respective practices since 2001 with great success. For restorative procedures and some selective surgeries, the erbium laser allows them to work without the limitations of local anesthetic in almost 85 percent of these cases. Another advantage of laser use is the ability to start the procedure immediately, which is efficient for the office and demonstrates good cus-tomer service. Despite finding the laser to be very effective, the authors still occasionally encounter breakthrough pain, resulting in the need for local anesthetic. They also use local anesthetics for extractions, implant placement, endodontics and other more invasive surgeries. They are now seeking the advantage of being able to immediately begin work without leaving the patient when procedures require local anesthetic. They believe if they could combine laser dentistry and more rapid onset of analgesia, they could be more efficient, have more control over their schedules and potentially see more patients in a day — all of which would substantially increase their productivity.

BUFFERED ANESTHETICS BACKGROUNDWhile Dr. Colonna was teaching a laser class at his office in Whitefish, Montana, in the summer of 2010, one of the participants, Mic Falkel, DDS, from Monterey, California, asked to share the science of the technology he was work-ing on regarding buffered anesthetic. He explained the chemistry, pharmacology and indications, which are rapid onset of analgesia and less injection pain. Dr. Colonna was very impressed, but skeptical.

Figure 1: The Onset technology offers the means to buffer the anesthetic ex vivo immediately before the injection, rather than the in vivo process that relies on the patient’s physiology to buffer the anesthetic.

Buffered Anesthetics and Laser Use: Efficiency in Scheduling and Productivity53

The authors’ first experience with the technology, The Onset® Approach (Onpharma; Los Gatos, Calif.), was dur-ing that class. As part of their laser training, the authors’ students work on live patients and perform surgical peri-odontics with the laser, which requires local anesthesia. They were impressed with the results of using Onset with lidocaine on patients — profound anesthesia in just one and a half minutes in most cases. During a demonstration of the product, one of the doctors who was skeptical ex-pressed the desire to have an incisive foramen block just to see if the product worked as advertised. His eyes were closed in anticipation as the injection was administered. Afterward, he wanted to know when it would be done but, in fact, he was already numb. Needless to say, the skeptic became a believer, along with the authors.

HOW IT WORKSHow does buffering local anesthetic actually work? Com-mercial local anesthetic cartridges are formulated as acidic solutions (compared with the physiologic pH of 7.4) to enhance the solubility of the anesthetic salts and to prolong shelf life.1 Typically, commercial lidocaine solutions have a pH of about 3.9.2-4 The pH of the solution is important because it affects the way anesthetic works. Like most other injectable local anesthetics, lidocaine with epinephrine solution contains two forms of the anesthetic salt: the un-charged and deionized, or “active” free base, form, which is lipid-soluble; and the charged or ionized cationic form, which is not lipid-soluble.5-7

The deionized form more readily penetrates the nerve membrane to enter the nerve axon, where the anesthetic attaches to receptors on the sodium channels, resulting in a

Figures 2, 3: The patient’s chief complaint concerned an upper front tooth. Radiographs found generalized moderate-to-severe horizontal bone loss with no signs of pathology or decay.

Figure 4: Slow advancement of the 30-gauge needle was made through the tissue while expressing small amounts of lidocaine to the desired depth.

Figure 5: Treatment was initiated 90 seconds after the injection was com-pleted with an erbium laser to dissect the periodontal ligaments.

2 3


blockade of nerve conduction.8,9 This biochemical process makes the relative availability of deionized anesthetic im-portant in creating clinical analgesia.

Normally, the body buffers the local anesthetic after injec-tion toward physiologic pH, which eventually increases the availability of deionized anesthetic.10 Over time, as this in vivo buffering process continues, more and more of the deionized (active) form of the anesthetic is available. This ultimately leads to nerve blockade. The Onset technol-ogy (Fig. 1) offers the means to buffer the anesthetic ex vivo (outside the body) immediately before the injection, rather than the status quo in vivo buffering process, which relies on the patient’s physiology to buffer the anesthetic. Bringing the pH of the anesthetic toward physiologic levels before injection results in rapid onset of analgesia and less injection pain.

CASE PRESENTATIONA 77-year-old woman presented with a need for a full set of implants with dentures. This patient was in fair health, with diagnosed hypertension and depression. Her medications included amlodipine (calcium channel blocker), losartan (angiotensin II receptor antagonist), simvastatin (antilipemic agent, HMG-CoA reductase inhibitor), 80 mg of aspirin, and amitriptyline (tricyclic antidepressant). Her chief complaint concerned an upper front tooth (Figs. 2, 3).

Radiographs found generalized moderate-to-severe horizontal bone loss with no signs of pathology or decay. Clinically, the patient had a large chronic periodontal abscess in tooth #8, which was magenta in color with Miller Class III mobility. Peri-odontal probing found 9-mm to 10-mm pockets with bleeding on probing on all sites. The authors’ assessment was general-ized moderate periodontitis with localized severe chronic periodontitis. Tooth #8 was not salvageable and needed to be

removed. Colleagues at Vista Dental Technologies fabricated an interim removable partial denture in less than a day, as the patient was concerned about having no front tooth.

Written and verbal consent were obtained from the patient, and all questions were answered before beginning the pro-cedure. Laser protective eyewear was placed, and 1.7 mL of 2 percent lidocaine with 1:100,000 epinephrine was buffered with 0.18 mL of Onset sodium bicarbonate neutralizing addi-tive solution. A bolus of lidocaine was expressed to the needle tip and was allowed to disseminate onto tautly held gingival tissues. The liquid was allowed to have topical contact for three to five seconds, allowing the liquid carbon dioxide to act as a topical agent prior to advancing the injection. Contact was then made with the gingival tissue, and slow advancement of the 30-gauge needle was made through the tissue while expressing small amounts of lidocaine to the desired depth (Fig. 4). Approximately one-half of a cartridge of lidocaine was deposited as a buccal infiltration, and approximately one-fourth of the remaining cartridge was deposited using the same procedure on the lingual.

The patient reported a 1 on the pain scale, with 10 being the worst pain she has ever felt. Treatment was initiated 90 seconds after the injection was completed with an erbium laser11 to dissect the periodontal ligaments (Fig. 5).

Atraumatic extraction of the tooth was completed approxi-mately four minutes after injection. The Nd:YAG (neodym-ium-doped yttrium aluminium garnet) laser was used to complete photobiomodulation12-14 of the extraction site and aid in clot formation. The interim partial denture was then placed (Fig. 6), the occlusion was adjusted, and postopera-tive instructions were reviewed. Upon dismissal, the patient provided the best possible feedback on the experience with the following testimonial: “This has been the most pleasant dental experience of my life. I mean that, and I’ve had a lot of teeth pulled, as you can see.” The authors attribute the efficacy of Onset with much of the success in this case.

Figure 6: The interim partial denture was placed, occlusion was adjusted, and postoperative instructions were reviewed.

Bringing the pH of the

anesthetic toward physiologic

levels before injection results

in rapid onset of analgesia and

less injection pain.

Buffered Anesthetics and Laser Use: Efficiency in Scheduling and Productivity55

CONCLUSIONLike many clinicians, the authors have at times deferred treatment for patients with an abscessed tooth or infection until the patients had been started on antibiotics to allow for more efficient local anesthesia. The authors have expe-rienced a much higher incidence of successful profound anesthesia while using Onset buffered lidocaine, even on abscessed teeth. This provides more efficient patient

REFERENCES

1. Ruegg TA, Curran CR, Lamb TL. Use of buffered lidocaine in bone marrow bi-opsies: a randomized, controlled trial. Oncol Nurs Forum. 2009 Jan;36(1):52-60.

2. Masters JE. Randomised control trial of pH buffered lignocaine with adrenaline in outpatient operations. Br J Plast Surg. 1998 Jul;51(5):385-7.

3. Hinshaw KD, Fiscella R, Sugar J. Preparation of pH-adjusted local anesthetics. Ophthalmic Surg. 1995 May-Jun;26(3):194-9.

4. Kennedy RM, Luhman JD. The “ouchless emergency department.” Getting closer: advances in decreasing distress during painful procedures in the emergency de-partment. Pediatr Clin North Am. 1999 Dec;46(6):1215-47.

5. Bartfield JM, Homer PJ, Ford DT, Sternklar P. Buffered lidocaine as a local anes-thetic: an investigation of shelf life. Ann Emerg Med. 1992 Jan;21(1):16-9.

6. Gupta RP, Kapoor G. Safety and efficacy of sodium bicarbonate versus hyaluroni-dase in peribulbar anesthesia. Medical Journal Armed Forces India. 2006;(62):116.

7. Hille B. The pH dependent rate of action of local anesthetics on the node of Ran-vier. J Gen Physiol. 1977 Apr;69(4):475-96.

care, allowing the dental professional to directly address the source of the patient’s infection in a single visit, pro-vided there is sufficient time. The combination of lasers and Onset enables dentists to treat every case exactly the same way. The clinicians are able to be more efficient and can maintain control of their schedules, which contributes to practice productivity and patient satisfaction. CM

8. Mehta R, Verma DD, Gupta V, Gurwara AK. The effect of alkalinization of lignocaine hydrochloride on brachial plexus block. Indian J Anaesth. 2003;47(4).

9. Gardner JH, Semb J. The relation of pH and surface tension to the activity of local anesthetics. J Pharmacol Exp Ther. 1935;54:309.

10. Stübinger S, von Rechenberg B, Zeilhofer HF, et al. Er:YAG laser osteotomy for removal of impacted teeth: clinical comparison of two techniques. Lasers Surg Med. 2007;39(7):583-8.

11. Ross G, Ross A. Photobiomodulation: an invaluable tool for all dental specialties. J Laser Dent. 2011;19(3):289-96.

12. Lins RD, Dantas EM, Lucena KC, et al. Biostimulation effects of low-power laser in the repair process. [Article in English, Portuguese] An Bras Dermatol. 2010 Nov-Dec;85(6):849-55.

13. Grzesiak-Janas G, Kobos J. Influence of laser radiation on acceleration of postex-traction wound healing. Proc. SPIE. 1997;3188:142-6.

14. Takeda Y. Irradiation effect of low-energy laser on alveolar bone after tooth extrac-tion: Experimental study in rats. Int J Oral Maxillofac Surg. 1988 Dec;17(6):388-91.


Dr. DiTolla’s Weekly Web Video Series

We’ve got a great Case of the Week for you from Episode 85 of “Chairside Live.” It’s from a dentist who is actually a pretty big account here at Glidewell Laboratories, and she’s a really good dentist. She had been frustrated with some of her results, and I think they have to do with the impressions. I wanted to take some time to present

alternative methods that might give her better results. They might be a little more time-consuming than those you’re doing now, but they’re completely worth it if you can eliminate remakes and adjustments in your office, and avoid having to send things back to the lab. So, let’s take a look.

– ARTICLE by Michael C. DiTolla, DDS, FAGD

QC Alert: Avoiding Dreaded RemakesCASE OF THE WEEK: Episode 85

.com

Dr. DiTolla’s Weekly Web Video Series

QC Alert: Avoiding Dreaded Remakes59

Figure 3: I was OK with my impressions at the time because it appeared that I had gotten the margin, but now I know that unless you can see im-pression material beyond the margin, you haven’t quite gotten it. This dip right here is a good example. It’s hard to tell whether that’s what the actual margin does, or if in fact that’s short of the margin, because we don’t have any material beyond that point.

Figure 2: This impression for a BruxZir® Solid Zirconia crown on a second molar was taken in a double-arch plastic tray, which has got pretty good stiffness to it. The prep gets a little close to the plastic, but it’s really more about the look of the margin on the impression. Trust me, every impression I took for the first 15 years of my career looked exactly like this one.

Figure 1: I was walking through the lab the other day and I saw my favorite sticker. That’s right: “QC Alert.” This means somebody from quality control needs to take a closer look at this case. And coincidentally, this is a dentist I know personally. She’s been working with us for a number of years and started to experience more remakes, and I think it really comes down to the impression more than the prep. Regardless of the quality of the prep, if the information is not properly picked up in the impression, there is a chance of recurrent decay because the resulting restoration is going to match the bad impression and not the actual prep. If a prep is not reduced enough on the lingual, there’s reduction copings and other things. The prep can always be fixed at the seat appointment, while the impression cannot.

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Figure 4: I used to think an impression like this was OK to be sent to the lab, but I don’t feel that way anymore. My time at the lab has made my eyes better at recognizing what a good impression is supposed to look like. The result of that enlightenment is the Two-Cord Technique that I blab on about all the time; the technique that allows me to get great results with my very average set of hands.

Figures 5a, 5b: When you take an impression like this and the very edge of it is also the margin, what happens is once we pour it up in the lab, the prep goes down and then it just stops right against the stone. There’s no real way for us to tell if that is in fact the end of the margin. We have to trim it there and hope for the best. Even if it’s not a perfect prep in some other areas, if it’s a great impression, it can probably be worked with.

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Figure 8: It was clear when I looked at her impression that it was just a one-cord impression; I’ve taken so many one-cord impressions, I know what they look like. When you see a margin like the one the arrow points to, this is what a two-cord impression looks like. The only other way to get a margin like this is by using a diode laser. Getting the thickness we see here is important because it won’t bend back and forth as we’re pouring in the die-stone. The thickness of this margin material is actually due to the bottom #00 cord that stays in the sulcus during impression. Keeping that cord there gives us that margin and prevents any bleeding that might occur with a one-cord impression.

Figure 7: I talked to this dentist and sent her a few photos of what I feel are exemplary impressions. This is a picture of an impression I took where I used the Two-Cord Technique alongside my Reverse Preparation Technique. That’s what gives you this kind of result. It’s this wall of material around the perimeter of the prep that lets the technician know the margin is right there. It’s clear as a bell where it is. This is the kind of case you give to somebody who’s been out of dental technician school for two weeks, because it’s simple enough that you could teach one of your kids to do it.

Figure 6: This impression is far from being the worst. When I show a really bad impression in a lecture, everybody “oohs” and “ahhs” because they know there’s something wrong with it, but they can’t specifically say what it is. Once it’s poured up, though, you go, “Oh, that’s what’s going on there. That’s what the problem is.” As dentists, we don’t always get to see the poured-up model, so we need to get good at looking at the impression, and knowing when it’s going to create a good model.

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Figures 9a, 9b: Here’s a more detailed example of a two-cord impression. You can see exactly where the bur marks are on the margin, and exactly where it transitions to the root surface. Giving the technician an impression with 1 mm of root surface lets them really dial in the emergence profile. Whether it’s digitally or by wax, they can really blend the gingival third of the crown with the contours of this root surface here. In fact, if you’re taking impressions like this and not getting stunning crowns back from your lab, whether it’s us or somebody else, you have a right to be angry and should probably switch because this is as good as it gets. And again, you can really only get these results with the Two-Cord Technique or with the diode laser. For me, the two-cord is the more useful of the two because that’s the one I’m going to be using on anterior teeth. With diode lasers I have a tendency to lose tissue-height on anterior teeth, and that’s worrisome.

Figure 10: Here’s the Two-Cord Technique. We’ve just teased out the top #02 cord, and you can see there is a line there in the sulcus; that’s the #00 cord. Because that cord is in place, there won’t be any bleeding. As soon as that cord comes out, just like with the One-Cord Technique, there will be blood. Any time you put one cord in and take it out, it bleeds. If you put two cords in and then take the top one out, the gingiva don’t bleed because the bottom cord is the one that’s in contact with the inflamed base of the sulcus. When you pull it out, it’s like ripping off a bandage.

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Figure 13: When the impression is taken out four minutes later, it gives us that same two-cord impression look where we can see the margin and then a thick, meaty band of impression material beyond the margin. I always describe it as “a Great Wall of China.” It should not look thin. Mine used to look thin with the One-Cord Technique, because I’d rip the cord out and then I’d try to squirt the impression material in before the sulcus filled with blood, and that’s kind of a hacky way to do it. This picture shows the prototypical, iconic look for the Two-Cord Impression Technique.

Figure 12: After we completely remove the top cord, you can see that the syringe tip fits nicely into the sulcus. The material just flows right into that sulcus, giving us an impression of the margin by creating a distinct line where the margin stops. It’s also going to give us an impression of this 1 mm of root structure apical to the margin, so the technician will be able to blend the crown with the shape and contour of that root surface.

Figure 11: The other problem with the One-Cord Technique is that when you put the cord in, it drops underneath this gingival cuff down to the base of the sulcus, so while it provides vertical retraction of the tissue away from the margin, it’s not until you put the second cord in that you move the tis-sue laterally away from the margin. In fact, when you take that second cord all the way out, you can see there’s just a moat around these teeth. It’d be almost impossible to miss this impression. I don’t even know if you need to syringe material into place. You could probably mix up some alginate and just flick it at the preps and then seat a tray on top of it and still have it work.

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Figures 14a, 14b: Here’s another case. We didn’t replace any existing restorations here, so we don’t have many subgingival margins to speak of. I used a diode laser around these teeth just to expose the margins a little bit more, and then I placed retraction paste on top of it; not to retract, really, because we used a diode laser — the tissue is not going to grow back that quickly. I’m using this specific retraction paste because it has aluminum chloride, an astringent material that’s going to stop any bleeding that might occur because of what I did with the laser, or any seepage that might happen afterward.

Figure 15: When we rinse the retraction paste off, you can see that we’ve got a nice-looking margin. You can see some of the remaining little tissue tags caused by the diode laser that we tried to clean up with the Ultradent brush (Ultradent Products, Inc.; South Jordan, Utah) and some hydrogen peroxide. We have the type of moat around the preparation that we want, but because of the thickness of the tip of the diode laser, we did lose a little bit of tissue height. Not a big deal here on these molars, but a much bigger deal on anterior teeth, when losing tissue height could really end up being a mess.

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Figure 17: Commit this picture to memory, where we don’t have that mate-rial beyond the margin, and try to not make that mistake. If you look at an impression in your office and can see that material beyond the margin, you know it’s not going to end up with a “QC Alert” sticker. It’s going to end up with a sticker with a big happy face on it and a high-five because our technicians are going to have a much easier time fabricating a quality restoration for you and your patient. CM

Figure 16: If we compare the impression the doctor sent in against the second example I sent her, you can see the striking difference caused by having that excess material beyond the margin. Having that 1 mm of root structure is crucial, and on my list of what’s required for an ideal impres-sion. Getting an accurate margin is equally as important, and the only two ways I know of that can get these results are the Two-Cord Technique and using a diode laser. Honestly, I’m much more likely to do that type of troughing with the diode laser in the posterior. In the anterior, I use my diode laser all the time for re-contouring gingiva to level out gingival levels on tooth #7 through #10, for example (you could also use an electrosurge; I just say diode laser because that’s become my instrument of choice, mainly because it can be used around implants and other metals, whereas the electrosurge cannot).

HOW TO WATCH


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Fling a toothbrush in any direction, and you’re likely to hit somebody ready to regale you with commiserative stories of stressful job-hunting. No matter which side of the desk you find yourself on, the search for that perfect employer-employee fit can be a nerve-wracking ordeal that drives even the most promising candidates into the arms of a third-party agency pledging to alleviate the pain while si-multaneously introducing all new obstacles to hurdle. With such a pervasive shared experience, one can be forgiven for surrendering to the process under the assumption that

it’s an inescapable part of modern life. But wandering the floor of the 2014 CDA Presents convention in San Francisco, I encountered someone who has sparked a plan to combat the status quo and executed it with deft precision, inciting in me a bittersweet mixed reaction of “Sweet! What a great concept!” and “Blast! Why didn’t I think of that?” That per-son was Andrew Lee, CEO and founder of ToothPyk.com.

Andrew tells an all-too-familiar story. After graduating from a dental hygienist program, the scarcity of local opportuni-

Revolutionizing Dental Staffing

– ARTICLE by Jennifer Carpio, RDAEF2

ToothPyk.com: Revolutionizing Dental Staffing69

ties compelled him to sign with a local staffing agency specializing in dental careers. Unfortunately, for someone seeking full-time employment, the blade was double-edged: The agency, like many others, bound its constitu-ents with contracts that disallowed them from accepting an employment position unless the hiring dentist paid a contract buy-out fee to the agency. With these buy-outs priced well into the four-figures, Andrew’s skills and rapport with the dentist of the day did little to tip the scales of a cost-benefit analysis when pitted against another candidate unbound by the same contract. Additionally, while the hourly wage paid by the dentist was commensurate to industry standard, Andrew would see only a percentage of that wage after the agency garnished the gross for its fees.

Over eight years in the industry, he earned his Master of Business Administration with a focus on health care man-agement. Once armed with both an MBA and an RDH, Andrew created ToothPyk.com, an Internet startup company designed to establish a system that puts the power back into the hands of the dentist and the auxiliary staff member, and removes the third-party self-interest from the equation. “The motivation came from a need to help the dental industry recover from an employment issue that has challenged dental professionals for decades,” he told RDH magazine in a September 2014 interview. “I was able to amalgam-ate the education and experience from both dentistry and business to design and create an easy-to-use tool that helps job-seeking dental professionals enhance their visibility to hiring dentists, while helping these dentists find us without the additional fees and contracts.”

For those proficient with business-related social media, the site will be a familiar affair. Candidates create a professional profile complete with qualifications and license informa-tion, days and times available to work, and the ability to attach a resume and a picture. The profile also stores the candidate’s location of residence, which lies at the heart of ToothPyk.com’s user-friendly conceit: Hiring doctors, for a nominal membership fee, can perform searches custom-ized to the specific needs of their practice, with the results displayed on a GPS-driven map that shows the location of all auxiliaries fitting the criteria within a 60-mile radius. The clinician can then peruse the candidates and contact them directly, without the need for any third-party mediation.

As an RDAEF2 who’s done her time on the headhunting circuit, I would have been grateful for the opportunity to present myself directly to potential employers, rather than

go through the hand-wringing stress of a job interview knowing that the immediate outcome would be little more than a low-priority spot in a candidate pool. With no pref-erential treatment given for generating revenue or unwit-tingly meeting criteria an agent finds personally appealing, candidates at ToothPyk.com can enjoy enhanced visibility constrained only by proximity, and be confident that their depiction to hiring dentists is exactly as they wish to be represented. Likewise, since no one knows the needs of the practice better than the dentist, ToothPyk.com provides the tools necessary to locate the ideal employee for his or her unique business. Through well-defined, thorough profiles, clinicians can find candidates available on the days needed and licensed in the disciplines required. Doctors can even get a sense of candidates’ personalities, all while resting assured that the potential auxiliary resides within the dis-tance of a reasonable commute. And with no staffing fees or additional costs, a temporary or temp-to-hire position can be made permanent with the straightforward dignity of a one-to-one offer. Candidates will see the monetary rewards of their labor in their entirety during trial staffing, and den-tists pleased with the fit can offer a staff position with no penalty incurred for removing themselves from the market.

The digital age has brought with it a litany of advances that have increased economy, convenience, and communication, and the advent of social media has removed many of the third-party barriers that once stubbornly separated people. With ToothPyk.com, Andrew has tailored these technolo-gies to the distinct staffing needs of the dental industry, providing a user-friendly framework for auxiliary and clinician alike. Placing the power into the hands of those most affected by the outcome, ToothPyk.com removes the hoops imposed by intermediaries, allowing each side of the equation to control its own variables and increasing the likelihood that the expended effort will be rewarded by the perfect match. CM


Chairside® MagazineA R E T R O S P E C T I V E

Chairside® Magazine: A Retrospective73

As we move into 2015, Chairside® magazine is entering its 10th year of publication.

My mission for the magazine has been simple: to offer tips and techniques from my unique perspective as a dentist who practices inside the nation’s largest laboratory. As a self-professed average dentist, seeing my somewhat embarrassing preps and impressions on the big screen 14 years ago forced me to learn how to do better dentistry using the same average hands I’ve always been stuck with. I wanted to share the perspectives of dentists, consultants and mentors who helped me get above-average results, with the goal of doing the same for others. Looking back on the magazine’s history and hearing from many of you, I feel like we’ve accomplished that goal more often than not.

In the decade since the first issue of Chairside was published, an extraordinary amount of change has taken place in our once low-tech industry. The biggest leap has been the rapid advancement of restorative materials. All-ceramics have largely toppled PFMs, ending their half-century reign as the go-to solution. In 2007, PFMs accounted for 65 percent of the crowns we made at Glidewell Laboratories. Today, they’re under 10 percent. Such an extreme shift in prescribing habits suggests that these new monolithic materials are passing muster for general dentists. Today, dentists are finally able to provide a solution that satisfies both their requirements for strength and the esthetic needs of their patients.

CAD/CAM technology has swept across the industry. I’ve seen firsthand how digital tools are helping both doctors and labs treatment plan and design restorations with more precision and speed than most of us ever thought possible. While intraoral chairside scanners aren’t yet the norm in offices nationwide, you’d be hard-pressed to find a dentist who hasn’t at least considered using the technology. Prices for digital radiography have dropped substantially, and hopefully cone-beam scanners will soon follow suit, helping dentists visualize cases in astonishing detail. Guided surgery has given many dentists, including me, the confidence they need to place their first implant. These technologies are no longer in their infancy and, as they become more affordable, are well on their way to becoming the norm.

Ten years ago, we were still trying to figure out how to integrate these tools into our daily work-flow. Our only successful attempt at the time was the digital design of PFM copings. Now, all of our fixed restorations have at least one substantial phase of CAD/CAM technology involved in their


production, with most of them completely manufactured using digital processes. While it’s true that a majority of doctors continue to favor conventional VPS impressions, once we pour the models they are all scanned and entered into a digital workflow.

For the last several years, the buzzwords for im-proving your practice have been “social media.” Dentists are more or less required to have a Web presence today to maintain relevancy. Many feel compelled to update Facebook pages or Twitter accounts daily. Not many dentists entered dental school thinking they would have to worry about negative Yelp reviews from dissatisfied patients. Internet-savvy patients can now tell the world how their visit to your office went, and, if it didn’t go exactly as they hoped, you might end up seeing a heated review that blames you by name for “what went wrong.” For those dentists who just want to focus on delivering quality restorative dentistry, social media is an exhausting new addition.

In short, the last 10 years have produced more change than any decade I have witnessed. New technologies, protocols and product innovations are hitting dentists from every angle, and Chairside will continue to do its best to explain how average practitioners (and their patients) can benefit from these changes. We’ll explore technology that can improve the clinical aspects of your

practice, and feature practice-management professionals who offer advice on which advancements might signifi-cantly help your bottom line. Our aim is not to spotlight change simply for change’s sake, but to advocate for clini-cally tested and lab-proven techniques and technologies, with the goal of improving quality and satisfaction for both doctor and patient.

While I am extremely grateful to our guest contributors, I’d also like to thank the Chairside team. When we started back in 2006, we had a staff of just 11, with most employees taking on multiple roles. We now have a staff of more than 30 individuals carefully putting together each issue, including dedicated photogra-phers, videographers, illustrators, writers, project coordinators, and graphic designers, as well as a Web team that carefully transitions all of that work into a digital-friendly format.

You might not be reading every article word for word, but I’m hoping that our clinical photos are attractive enough to hold your interest. Blurry, out-of-focus photos are no longer acceptable in dentistry when the average cell phone has a cam-era chip more powerful than a 1960s NASA su-percomputer. Our photographers, videographers

Chairside® Magazine: A Retrospective75

and illustrators do their best to help present cases and products with clinical integrity. My goal has been to share with you what I see in the lab and the operatory in the highest available quality.

Finally, all of this would be impossible without Jim Glidewell, who truly believes in giving back to the dental community that has given him so much. He’s provided all of the resources, tools, equipment and technologies needed to send out more than 125,000 copies of each issue to every dentist across the United States. Publishing a mag-azine like this brings in far fewer new customers than if that money was spent directly on full-page ads in dental journals. I want to thank Jim for his commitment to helping dentists improve their prac-tices through Chairside magazine’s common-sense approach to dentistry.

The team at Chairside wants to sincerely thank you for reading over the last nine volumes. We hope that you’ve enjoyed our publication and perhaps even learned a thing or two. CM


It is without question that dental implants are one of the most successful additions to modern dentistry. With a success rate of greater than 95 percent, the root-form

implant should be considered to restore any edentulous area. However, when we are presented with the need to manage a highly resorbed ridge, significant issues for the surgeon and restorative team arise if only the use of a stan-dard body implant (3.7 mm or larger) is considered. These issues can be anatomical, medical, financial or restorative.

Achieving Success with Small-Diameter Implants

Anatomical challenges are closely associated with how much residual alveolar ridge remains (quantity) and also its density (quality). These can sometimes be overcome with additional surgical procedures such as ridge expansion, block grafting, and other hard- and soft-tissue procedures. If these solutions are not accepted, the use of a much less invasive procedure should be considered, such as the small-diameter implant (SDI), also referred to as the mini implant.

– ARTICLE by Paresh B. Patel, DDS

Achieving Success with Small-Diameter Implants79

Figure 1: Pre-op maxillary ridge. Figure 2: Pre-op mandibular ridge.

SDIs have been around in their FDA-approved form since 1997 and share surface texture, coatings and titanium grade similar to their larger counterparts. Most implant manufac-turers now have added SDIs to their systems. These SDIs now are available in one- and two-piece versions as well as crown & bridge prosthetic options.

Medical challenges should be addressed by utilizing the most minimally invasive surgical plan. The incorporation of 3-D cone-beam computed tomography is rapidly increasing and can allow for presurgical planning to avoid mandatory grafting. A CBCT surgical guide can be created to deliver the implant into the bone with a flapless technique reducing surgical trauma. This may be a prudent solution for patients with systemic conditions who are unable to tolerate lengthy healing times. It is important to note that a CBCT-based surgical guide is much different than a prosthetic guide that is based on a panoramic X-ray and a stone model.

Restorative challenges are usually the management of restricted restorative space in the mesial-distal or buccal-lingual direction. This has always posed a high-risk prob-lem in the esthetic area. Too wide of an implant will create potential for bone and soft-tissue loss. Convergent roots can also preclude the use of a standard body implant. In these cases, an SDI may allow for the placement of the implant and still allow proper bone support, soft-tissue space and proper spacing from adjacent tooth roots.

SDIs can be used to retain maxillary or mandibular den-tures. Due to reduced surface area, it is recommended to utilize four SDIs in the mandible and six SDIs in the maxilla.

The residual ridge should be of Misch Type I or II to en-sure a successful case. If the SDI selected is of a one-piece design, then immediate loading must be addressed. Primary stability should be at a minimum of 30 Ncm on all of the implants, and a stable tissue-supported denture should be delivered. The implants should also be placed as parallel as possible to minimize off-axis loads.

CASE REPORTSCase 1: Multiple-Unit Fixed Restorations

Diagnosis and Treatment Planning — A 54-year-old female presented in general good health with a history of diabetes. She had progressively lost her teeth during the previous 15 years, with the last of them being extracted about five years earlier. She was unhappy with her existing dentures due to poor retention and difficulty with eating. Both ridges were examined and found to be moderately atrophic (Figs. 1, 2). A CBCT scan was taken (i-CAT® FLX [Imaging Sciences In-ternational, LLC; Hatfield, Pa.]) with the dual-scan protocol to facilitate a prosthetically driven treatment plan (Figs. 3, 4).

Due to the height and width of the remaining bone, six SDIs would be placed in the maxilla and four SDIs in the mandible to support overdentures. The SDIs selected for this case were of a two-piece design with a Locator® at-tachment (ZEST Anchors LLC; Escondido, Calif.). The low profile of the attachment would allow for a less obtrusive denture and a variety of retentive inserts. After the treat-ment plan was approved by the patient, surgical guides (Anatomage; San Jose, Calif.) were ordered (Figs. 5, 6).


Figure 3: i-CAT FLX scan of the maxilla. Figure 4: i-CAT FLX scan of the mandible.

Figure 5: Mandibular surgical guide. Figure 6: Maxillary surgical guide.

A CBCT surgical guide can be created to deliver the implant into

the bone with a flapless technique reducing surgical trauma.

This may be a prudent solution for patients with systemic

conditions who are unable to tolerate lengthy healing times.


Clinical Protocol — On the day of surgery, the surgical guides were tried in to verify stability and fit (Figs. 7, 8). A single 1.6-mm pilot bit was used to create the osteotomies through the surgical guide in the maxilla using an implant motor (Aseptico AEU-7000 [Aseptico, Inc.; Woodinville, Wash.]) with copious irrigation (Fig. 9). The pilot guide was removed, and the implants were inserted and carried to depth (Fig. 10). All six SDIs were confirmed to have at least 30 Ncm of torque, and the Locator attachments

Figure 7: Maxillary surgical guide seated. Figure 8: Mandibular surgical guide seated.

Figure 9: Implant motor and pilot drill. Figure 10: Locator Overdenture Implant System fully seated.

were secured (Fig. 11). This protocol was duplicated on the lower arch (Fig. 12). To ensure that the existing dentures would fit passively over the SDIs, Fit Test (VOCO America, Inc.; Indian Land, S.C.) material was placed and allowed to set, showing where relief areas would need to be created (Figs. 13, 14). Once the relief was complete, the process was repeated until a verified passive denture could be obtained (Figs. 15, 16). The dentures could then be soft-relined (Ufi Gel SC [VOCO America]). A final CBCT scan was taken to


All six SDIs were confirmed to have at

least 30 Ncm of torque, and the Locator

attachments were secured.

Figure 11: The Locator attachments were secured on the upper arch. Figure 12: Locator attachments on the lower arch.

Figure 13: Fit Test materials were placed. Figure 14: Fit Test was allowed to set and show the relief areas to be created.


ensure that all of the SDIs were fully encased in bone and no vital anatomical structures were violated (Fig. 17).

Case 2: Single-Unit Fixed Prosthetics

SDIs can be an excellent solution to support a single crown in areas of reduced interdental space (less than 5 mm between adjacent teeth) where it would be impossible to place a larger implant. These areas could be maxillary lateral and mandibular incisors. Case selection should have a bone type of Misch I or II, and off-axis occlusal forces should be minimized by designing the single-unit crown to have implant-protected occlusion. The use of a single SDI to support a crown much larger than a maxillary lateral is still quite controversial.

Diagnosis and Treatment Planning — An 18-year-old presented to our office after completion of orthodontics several months prior. He had lost his retainer/flipper that

Figure 15: Relief wells in maxillary prosthesis. Figure 16: Relief wells in mandibular prosthesis.

SDIs can be an excellent solution to support a single crown in areas

of reduced interdental space (less than 5 mm between adjacent

teeth) where it would be impossible to place a larger implant.

also replaced his missing upper lateral #7 (Fig. 18). A digital radiograph (DEXIS Platinum Sensor [DEXIS, LLC; Hatfield, Pa.]) was taken to see the position of adjacent roots, and it confirmed an extremely narrow mesiodistal space (Fig. 19). It was decided to utilize a one-piece, 3.0-mm-diameter crown and bridge SDI (I-Mini™ One-Piece Implant System [OCO Biomedical Inc.; Albuquerque, N.M.]). The decision to use this brand was due to the I-Mini’s aggressive thread design that allows for compression and fixation of the implant in Type II bone.

Clinical Protocol — A 1.8-mm pilot bit in the Aseptico handpiece was used to carefully create the initial osteotomy (Fig. 20) and another digital radiograph was taken to confirm a parallel path between the adjacent roots (Fig. 21). A final 2.4-mm osseoformer was used to prepare the bone, and the one-piece SDI was inserted (Fig. 22). After final depth was reached, the prosthetic head of the implant was shaped for


Figure 17: i-CAT FLX post scan. Figure 18: Pre-op photo showing missing lateral.

Figure 19: Digital periapical for mesiodistal width. Figure 20: A 1.8-mm pilot bit.

Figure 21: Digital periapical at initial placement. Figure 22: Initial placement.


interarch space with a high-speed handpiece (KaVo Dental; Charlotte, N.C.) and a titanium abutment prep bur (Komet USA LLC; Rock Hill, S.C.) (Fig. 23). A conventional vinyl polysiloxane (VPS) impression (Take 1™ Advanced [Kerr Corporation; Orange, Calif.]) was taken using light- and heavy-body materials. The case was then sent to our dental laboratory team for the fabrication of a monolithic zirconia crown (BruxZir® Solid Zirconia) (Fig. 24).

Case 3: Multiple-Unit Fixed Restorations

Many of the same principles of utilizing an SDI for single-unit fixed restorations should be embodied when applying their use for multiple-unit fixed restorations. All fixed units should be splinted together to help dissipate force and minimize any micro-movement. In function, the occlusal loads can be distributed over the multiple splinted SDIs. This reduces the functional load on any one SDI and in-creases the bone-to-implant contact. For full-arch cases, it is prudent to increase the number of SDIs in order to reach the desired surface area to prevent implant overload.

Diagnosis and Treatment Planning — A 62-year-old female presented with the chief complaint of difficulty chewing and keeping her dentures in place. The patient stated she had been wearing the full upper and lower dentures for 15 years. The clinical exam revealed the edentulous tissue to have a healthy appearance (Fig. 25). The patient stated that her experience with dentures had made her unhappy and self-conscious with her overall appearance, so much so that she wanted to have “fixed teeth.” A medical history review

Figure 23: Komet titanium abutment bur. Figure 24: Monolithic BruxZir Solid Zirconia restoration.

revealed the patient had had a previous heart attack and continued the use of Plavix® (Sanofi US; Bridgewater, N.J.), an anticoagulant medication. The patient also had diabetes controlled with medication.

To minimize surgical trauma and to increase the efficiency of implant-guided surgery, a flapless technique was to be employed for implant placement. A CBCT scan was taken for treatment planning and fabrication of a surgical guide. Upon completion of the CT scan, it was evident that the residual ridges were highly resorbed and would require the use of SDIs or additional surgical procedures to accommo-date standard body implants. To keep within our concept of minimally invasive dentistry, multiple SDIs were prescribed to support the full-arch restorations.

The treatment plan options were discussed with the pa-tient and the final decision was made and approved by the patient. CBCT surgical guides (Materialise NV; Plymouth, Mich.) were made for upper and lower full-arch implant placement.

Clinical Protocol — The patient presented on her appointed day with no changes made to her daily medication regimen. Infiltration with local anesthetic was administered. The surgical guides were tried in to ensure proper fit and stabil-ity (Figs. 26, 27). The surgical guides were retained, and a 1.8-mm pilot drill was used in each site to full length. The guides were then removed, and an immediate photograph was taken to illustrate the minimal amount of trauma to the implant surgical sites (Fig. 28). Each SDI (3.25-mm ERI


Figure 25: Pre-op maxillary ridge.

Figure 27: Mandibular surgical guide. Figure 28: Initial osteotomy.

Figure 26: Maxillary surgical guide.

In function, the occlusal loads can be distributed over the

multiple splinted SDIs. This reduces the functional load on any

one SDI and increases the bone-to-implant contact.


[OCO Biomedical Inc.]) was started by hand to half depth (Fig. 29), and then taken to full depth using the Aseptico surgical motor. With the exception of the posterior upper right site, all sites accepted a two-piece 3.25 x 12 mm in the maxilla and 3.25 x 10 mm in the mandible (Fig. 30). A post-implant placement CT scan was taken; it demonstrated parallel placement in the panoramic view very closely resembling what was treatment planned (Fig. 31). In addi-tion, the 3-D slice view showed that the implants were fully encased in bone, away from the nerve canal and engaging the cortical plate for maximum stability (Fig. 32). Solid abut-ments (OCO Biomedical Inc.) were placed and torqued to 30 Ncm. Full-arch impressions of the duplicated dentures were taken with Take 1 Advanced. The impressions were then delivered to the lab team, and full-arch fixed bridges were fabricated for final cementation (Figs. 33, 34).

Figure 29: Hand-insertion of an OCO Biomedical implant. Figure 30: OCO Biomedical SDIs fully inserted on the upper arch.

Figure 32: i-CAT slice.Figure 31: Final i-CAT FLX scan.

CLOSING COMMENTSWith the use of guided surgery and SDIs, more patients can undergo implant surgery to achieve their desired goals to have teeth. SDIs, along with minimally invasive dentistry, are an ideal treatment solution to consider when standard-body implants are not feasible without additional procedures. CM

Dr. Patel is a graduate of University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/American Academy of Implant Dentistry Maxi Course. He is the cofounder of the American Academy of Small Diameter Implants and is a clinical instructor at the Reconstructive Dentistry Institute. He has placed more than 2,500 mini implants and has worked as a lecturer and clinical consultant on mini implants for various companies. He can be reached at [email protected] or via the website dentalminiimplant.com.

Disclosure: Dr. Patel reports no disclosures.

Reprinted by permission of Dentistry Today, ©2014 Dentistry Today


Figure 34: Final full-arch upper and lower prostheses.Figure 33: Final upper full-arch Prosthesis.


For any case in restorative dentistry, a successful outcome is largely contingent on the quality and quantity of intraoral information that a clinician can communicate to the laboratory. As an RDAEF2 working in the R&D and marketing operatory of one such laboratory, where any qualified patient who comes in for a cleaning is screened for his or her potential as a research candidate, the ability to obtain and transfer a patient’s compre-hensive biological situation quickly and accurately is of paramount importance. In this second installment of

my top 10 things, I wanted to share two excellent tools I use to deliver the greatest amount of structural data with the least amount of chairside stress.

Part 2Top 10 Things To Never Be Without –

Adjust-a-Tray®

Much of what makes impression trays a stumbling block in a dental of-fice workflow is the constant guesswork involved in figuring out which tray fits to what patient anatomy. Does the patient’s arch fit a medium or a large tray design? With high or low buccal walls? Narrow width? Wide width? A decent estimation can be made with the eyeball, to be sure; but landing on the right tray often involves auditioning multiple try-ins, with the unsuccessful apparatuses relegated to time-consuming sterilization. The Adjust-a-Tray® (www.adjustatray.com) alleviates this process of trial and error by introducing breakaway buccal and facial walls, perforations at the rear of the tray to control mesial-distal depth, and a system of indexed tabs that allow arch width to be tailored to each patient’s unique anatomy. With four widths, three lengths, and two heights available in a single tray, the Adjust-a-Tray finally delivers the advantages of a one-size-fits-all solution to the conventional dental impression. CM

PhotoMed Universal Mirror Handle KitWhen presenting a potential research case to Dr. Michael DiTolla, I take full advantage of the benefits afforded by the Universal Mirror Handle Kit from PhotoMed (Van Nuys, Calif.). Plated with a coat of highly reflective, durable titanium, PhotoMed’s line of intraoral mirrors capture the full force of a camera’s flash without ghosting the image, delivering a single detailed shot that, provided the camera is correctly calibrated, ensures a robust repository of data about the patient’s condi-tion. Each mirror is specifically shaped to reach a particular region in the mouth, relieving concerns about hard corners irritating the patient or insufficient surface area to capture the intended site; additionally, with a handle that attaches easily and at any angulation to one of the three location-specific mir-rors packaged with the kit, a willing patient can hold the mir-ror in place while the assistant’s hands remain free to keep the camera steady and true to capture the perfect oral snapshot. There’s no quicker way to improve one’s dental photography skills than implementing these PhotoMed miracles.

– Article by Jennifer Carpio, RDAEF2

Top 10 Things To Never Be Without — Part 291

Glidewell Laboratories - Chairside Publication - Vol. 10, Issue I

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Transcript of Glidewell Laboratories - Chairside Publication - Vol. 10, Issue I