Chairside Magazine Volume 2, Issue 1 - Glidewell Dental Labs

APRIL 2007
Chairside
A Publication of Glidewell Laboratories • Volume 2, Issue 1
No-Prep vs. Minimal-
Prep Veneers
On the Same Patient
One-on-One
With Dr. Michael DiTolla
CHAIRSIDE VOL. 2 ISSUE 1
Is the Wide Range in
Crown Fees Justifiable?
According to
Dr. Gordon Christensen
Lab Management Today’s
Crown Experiment 2007
Does Higher Lab Fee Guarantee Higher Quality?
Dr. Michael DiTolla’s Clinical Tips

Contents
7 Dr. DiTolla’s Clinical Tips
In this month’s Clinical Tips article, Dr. DiTolla
describes two topical anesthetics that he finds extremely
helpful for a number of clinical situations. He also looks
at two new burs that will greatly increase the efficiency
of your clinical dentistry.
11 No-Prep vs. Minimal-Prep Veneers on the
Same Patient
Meet a patient willing to have no-prep veneers placed,
removed with a laser, and then have minimal prep
veneers placed. This fascinating case highlights the
sometimes subtle differences between these two veneer
modalities.
19 Photo Gallery: BioTemps Provisional
Restorations
In this Photo Gallery, we show many examples of the
different clinical problems that can be solved with
BioTemps provisional restorations.
7
24 Is the Wide Range in Crown Fees
Justifiable?
We are privileged to have Dr. Gordon Christensen
weigh in on the topic of crown fees. If you have ever
wondered why one doctor charges $1200 for a crown
and another charges $800 for a crown from the same
lab, you will enjoy this article.
29 Lab Management Today’s
Crown Experiment 2007
This is an experiment many of us always wanted to do
and thanks to LMT, its now been done. They were generous
enough to let us republish this fascinating look
into the relationship between crown fee and crown
quality. As you will see, you may not always get what
you pay for.
11
Cover photo by Kevin Keithley
Illustration by Wolfgang Friebauer, MDT

Editor’s Letter
Publisher
Jim Glidewell, CDT
Contents
Is there anything we do on a daily basis in our offices that is as important to patient
satisfaction and comfort as our injections? Early in my career I learned first hand
how important a painless injection could be. When I graduated from dental school at
the age of 22, I still had all of my hair and looked too young to be a dentist. When
I came back to Southern California after graduation I practiced with my father for
the first 3 years of my career, still one of the most rewarding professional experiences
I have had.
I was surprised how many patients wanted to see my dad instead of me. Many times
I would do the examination and the patient would go to the front desk to schedule
the appointment, and would schedule the two crowns with dad rather than me.
I turned my focus to winning over those patients. Dad only had one chink in his
dental armor: his injections.
My dad hated topical and he could empty a carpule faster than I can load one. The
amount of fast twitch muscles in his thumb were mind-boggling and when he emptied
that carpule in less than 2 seconds, patients would levitate. I saw my chance to
win over the doubters, who were stuck having to have their broken tooth prepped
for a crown on Dad’s golf day. My interests in topical were both academic and
sophomoric: I found it worked as well on patients as it did on my dental school
roommates coffee cup rim. What other dental product opens the door to so many
practical jokes?
I began to brag to patients I could give them a practically painless injection, and it
worked! My crown preps took three times longer than my dad’s, but it would be a
levitation-free procedure. However, painless anesthesia technique does not necessarily
equal profound anesthesia technique, and I believe as dentists we owe it to the
profession and to our patients to continue to search for better techniques to make
dentistry more effective and compassionate.
I hope you enjoy this month’s interview with Dr. Alan Budenz where he makes a
compelling case for all of us to learn the Gow-Gates mandibular block. Just because
we have made it this far in our careers without it does not mean we should stop
striving to provide better dental techniques for our patients. And as I always say, if
you don’t have access to a prison population, you may want to perfect these techniques
on in-laws and staff members. Remember: there is always a price to pay,
especially for free dentistry!
Sincerely,
Associate Publisher
Jim Shuck
Mike Cash, CDT
Creative Director
Rachel Pacillas
Clinical Editor
Michael DiTolla, DDS, FAGD
Coordinator
Lindsey Lauria
Designers
Jamie Austin
Eric Chou
Deb Evans
Phil Nguyen
Gary O’Connell
Rachel Pacillas
Ty Tran
Copy Editors
Lindsey Lauria
Al Lefcourt
Gary O’Connell
Photo Editors
Jamie Austin
Eric Chou
Deb Evans
Phil Nguyen
Rachel Pacillas
Ty Tran
Photographers
Kevin Keithley
James Kwasniewski
Ed Pelissier
Illustrator
Wolfgang Friebauer, MDT
38 Laboratory Portrait: Mikhail Tkachev
Meet Mike Tkachev, an engineer in the Glidewell
Laboratories Research and Development department. He
shares with us his amazing story of how coming from
the former Soviet Union, he landed in Newport Beach,
California and how his previous experience in the
Soviet Army building top secret devices helps him in his
work today.
44 One-on-One with Dr. DiTolla
In this ongoing series, Dr. DiTolla tackles local anesthesia
issues with one of the country’s leading authorities,
Dr. Alan Budenz. Dr. Budenz sheds some light on a
new mandibular block technique that may convince you
to give up your standard inferior alveolar block.
52 Carpe Diem: Now Is the Time to Help
Patients Value the Importance of
Their Dental Office as Their Partner
for Great Health
Gary Takacs explains why now is the perfect time to
inform your patients on how oral heath is related to
overall heath. He provides us with a few examples of
how he thinks this doctor-patient communication can
be easily initiated during your patient’s appointment.
57 Planning the Shade Prescription
One of the country’s leading authorities on esthetic
fixed restorations, Dr. Gerard Chiche, shares with us his
method for shade determination and characterization.
62 Facial Correction without Injection:
Angellift ® Pricing and Technology Update.
The newest addition to the Angellift family of products,
Preview ® , is introduced in this article. This chairside
tool will help to demonstrate the effectiveness of the
Angellift device and to help patients decide if this
product is for them.
38
4
44
Dr. Michael DiTolla
Clinical Editor
chairside@glidewell-lab.com
Editor’s Letter
Contents

Contributors
Gordon J. Christensen, DDS, MSD, PhD
Gordon J. Christensen is Founder and Director of Practical Clinical Courses (PCC) in Utah, and Dean of the
Scottsdale Center for Dentistry (SCD) in Arizona. Both groups are international continuing education organizations
providing courses and videos for all dental professionals. Dr. Christensen has presented over 45,000 hours of
continuing education throughout the world and has published many articles and books. Gordon and Dr. Rella
Christensen are co-founders of the non-profit CRA Foundation (CRA), which Rella directed for many years. Since
1976, CRA has conducted research in all areas of dentistry and published the findings to the profession in the wellknown
CRA Newsletter. Gordon is a practicing prosthodontist in Provo, Utah. Contact PCC at 800-223-6595, or e-mail
info@pccdental.com. For more information, visit www.pccdental.com. Contact Scottsdale Center for Dentistry at
scottsdale@pccdental.com or 866-921-7111.
Gary Takacs
Gary’s seminars, highly acclaimed audio and videotape programs, and in-office consulting services have helped many
dentists develop a more profitable and enjoyable practice. Gary frequently addresses dentists and team members at
national dental meetings, regional seminars, and study club meetings in the United States and internationally. His
seminars are recognized for being both highly educational and entertaining. He has published over 250 articles on
practice management in professional publications. His articles have been published in leading journals including
Dentistry Today and Dental Economics. Gary is the founder of Ride and Learn, and Race and Learn. With Ride and
Learn, Gary leads a small group of dentists on Harley Davidson motorcycle tours through some of the most scenic
parts of the country several times per year. The group convenes each evening for stimulating CE in the lodge. Gary is
a summa cum laude alumnus of the University of Oregon. He can be reached at 480-951-1652 or gary@garytakacs.
com.
Michael DiTolla, DDS, FAGD
Dr. DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, California.
He performs clinical testing on new products in conjunction with the Research & Development department. Dental
technicians who work for Glidewell Laboratories have the privilege of rotating through Dr. DiTolla’s operatory and
experiencing his commitment to excellence through his prepping and placement of their restorations. He is a CRA evaluator
and lectures nationwide on both restorative and cosmetic dentistry. He also teaches hands-on courses on digital
photography and digital-image editing for the entire team. Dr. DiTolla has several clinical programs available on DVD
through Glidewell Laboratories. For information on receiving your free copy of one of Dr. DiTolla’s clinical DVDs,
e-mail him at chairside@glidewell-lab.com or call 800-854-7256.
Gerard J. Chiche, DDS
Dr. Gerard J. Chiche is the Helmer Professor and Chairman of the Prosthodontics Department at Louisiana State
University School of Dentistry. He has given numerous programs nationally and internationally and holds memberships
in the American College of Dentists, the American Academy of Esthetic Dentistry, the American Academy of
Fixed Prosthodontics, the American Academy of Restorative Dentistry and the Omicron Kappa Upsilon Dental Honor
Society. He is a Past President of the American Academy of Esthetic Dentistry and is also, respectively with Alain
Pinault and Hitoshi Aoshima the author of the textbooks Esthetics of Anterior Fixed Restorations and Smile Design:
A Guide for Clinician, Ceramist, and Patient both published by Quintessence Publishing. He serves as adjunct faculty
at the Pankey Institute, he is the recipient of the 2003 LSUSD Alumnus of the Year Award and the recipient of the
2003 Educational Community Achievement Award of the Seattle Study Club for best dental educator of the year.
Alan W. Budenz, MS, DDS, MBA
Dr. Budenz is Professor in the Department of Anatomical Sciences and the Department of Diagnostic and Emergency
Services at the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, California. He also
lectures on Surgical Head & Neck Anatomy and orthognathic surgery to Oral & Maxillofacial Surgery Residents
at Highland General Hospital in Oakland, California and to Orthodontic Residents at Pacific. Dr. Budenz has extensive
experience in head and neck anatomy, dissection, and nerve tract identification, and has lectured nationally on
local anesthesia topics. He has more than twenty years of general practice experience in San Francisco, has served as
clinical Group Practice Administrator, as clinical department chair, and is a clinical floor instructor at Pacific.
Bradley Evans, MD, DDS, MS
Dr. Bradley Evans graduated from Rapid City Central and USD Medical School with highest honors. He became an
eye surgeon and practiced medicine in Hawaii prior to returning to school. He completed his dental and orthodontic
training at the University of the Pacific in San Francisco. Doctor Brad has the unique distinction of having been a
practicing ophthalmologist before entering the field of dentistry and becoming an orthodontic specialist. In his spare
time he enjoys skiing, hiking, biking, scuba diving, jazz music, and family time. He and his wife Brenna have a son
Rowan and a daughter Oona.
Contributors
Contributors

Dr.DiTolla’s
CLINICAL TIPS
PRODUCT.............. Profound Lite
CATEGORY........... Topical Anesthetic
SOURCE................ Steven’s Pharmacy, Costa Mesa, CA
1-800-352-DRUG
Since I switched to Profound Lite, I no longer see the tissue
dehydration I did before, and the patients still don’t feel
the penetration of the needle. It is an incredibly strong
topical anesthetic.
I have written before about how Profound has allowed me to
do lots of gingival recontouring and other soft tissue procedures
without the need for local anesthesia. Profound has also
allowed me to almost entirely eliminate lower blocks from my
day-to-day practice. I noticed that I could squirt it into the
furcation of a lower molar, wait 60 seconds and then slowly
inject one-half to two-thirds of a Septocaine carpule into the
furcation and achieve instant pulpal anesthesia without any
tongue or cheek numbness.
I became a hero to my patients for avoiding painful blocks and
not numbing half of their lower jaw for 3 hours!
Like many dentists, I began to use Profound for many more
clinical uses, as well as in my hygiene rooms. When I began
using it in the vestibule as a pre-injection topical, I noticed
that the patients felt no pain at all! My technique is to leave
the Profound on for 60 seconds, rinse it off, and then pierce
– ARTICLE by Michael DiTolla, DDS, FAGD
– PHOTOS by Kevin Keithley
– ILLUSTRATIONS by AXIS Dental Corporation
the mucosa with the 30-gauge needle as I pull the tissue taut.
They simply do not feel the needle anymore!
However, I also noticed that if I didn’t rinse it off completely,
some patients would experience a dehydration of the tissue
that would result in a white patch on the tissue. I called the
pharmacy to talk about this reaction and they were surprised
to hear that I was using it in the vestibule.
The strength of Profound had been based on doing laser surgery
without a local, not as a pre-injection topical. So with
dentists like me in mind, they formulated Profound Lite. For
those of us who use it more for pre-injections than for laser
surgery, it still has the same powerful combination of prilocaine,
lidocaine and tetracaine as Profound, but the ratios
have been adjusted to make it friendly to all oral tissues.
Since I switched to Profound Lite, I no longer see the tissue
dehydration that I did before, and the patients still don’t
feel the penetration of the needle. I keep a tube of original
Profound in each operatory for the gingival recontouring
touch-ups that seem to pop up in almost all of our esthetic
cases. My dental assistant also uses it on the lingual tissue
when the patient can feel the cord packing since we prefer not
to give palatal injections if we can avoid it.
Profound and Profound Lite are both available in 30 or 45
gram tubes. My staff then dispenses some of the topical into
Ultradent syringes with disposable 18-gauge tips for injecting
into molar furca and gingival sulci. The rest of the topical
stays in the original tube to be dispensed onto cotton-tipped
applicators for use as a pre-injection topical.
Do yourself (and your patients!) a favor by using Profound
Lite to drop the pain from your injection technique! Í
Dr. DiTolla’s Clinical Tips

Dr.DiTolla’s
CLINICAL TIPS
Dr.DiTolla’s
CLINICAL TIPS
PRODUCT.............. Cyclone/Cyclone DS
CATEGORY........... Topical Anesthetic
SOURCE................ Steven’s Pharmacy, Costa Mesa, CA
1-800-352-DRUG
PRODUCT.................................Zir-Cut
CATEGORY..............................Carbide Bur
SOURCE...................................AXIS Dental, Coppell,
TX
Zir-Cut burs are absolutely necessary when replacing
zirconia-based restorations.
New from Axis Dental are Zir-Cut burs, filling a need just
recently created. It’s a huge time-saver, too. Zirconia-based
restorations entered the market a few years ago and are now
hitting their strides. Two of the newer systems (LAVA from
3M ESPE and Prismatik CZ from Glidewell Labs) are so strong
that nothing will cut efficiently through their zirconia substructures.
Enter the Zir-Cut burs, absolutely necessary when
replacing these all-ceramic, cementable restorations.
Even if you aren’t placing zirconia restorations (which I now
do routinely), one day you will have to take off a zirconia
crown placed by another dentist, and you’d better have some
Zir-Cut burs on hand!
PRODUCT.................................Razor
CATEGORY..............................Carbide Bur
SOURCE...................................AXIS Dental, Coppell,
TX
This amazing new bur will fly through both porcelain and
metal on any PFM with no problem.
The new Razor carbide bur from Axis Dental is a huge time
saver! This amazing bur will fly through porcelain and metal
on any PFM with no problem. I used to use an old diamond
to cut through the porcelain and then would switch to a 57 or
557 bur to cut through the coping. In addition to having these
burs snap far too often, the chatter they would make as they
cut through the metal was horrible!
In contrast, a new Razor will fly through the porcelain and
continue straight through the metal with no chatter at all. On
certain cases (usually those with semi-precious or high-noble
substructures), I have used the same Razor bur to remove 4 or
5 entire crowns. Just order a couple of them in the 57 size and
shape and you will see what I mean, especially if you have an
electric handpiece like I do.
We offer Cyclone DS to almost anyone having something
done who is not getting local anesthesia.
If you can remember about 10 years ago, there was a
product named Dyclone, which was a topical anesthetic in
liquid form that patients could swish with for one minute
to anesthetize gingival and palatal tissues. It was fantastic
for hygiene patients who need some anesthesia, but don’t
want local infiltrations or blocks. It also worked well for
needle-phobic sensitive hygiene patients, and for patients
who gag during impressions. I searched the FDA database
and found that the company decided to stop producing for
their own reasons. The FDA verified that it had nothing to
do with the safety or efficacy of the product.
Steven’s Pharmacy’s replacement product is called Cyclone
and it is available in the original strength that we used to
use, 0.5%, and also in a double-strength solution called
Cyclone DS that is a 1.0% solution. We have settled on
the Cyclone DS as our choice because we have noticed
no difference between the two solutions, except that the
Cyclone DS works better on most patients.
We use it on anyone who is worried about having impressions
taken, whether it is for Invisalign or bleaching trays
or even just study models. We use it on full arch crowns
and bridge impressions when we are worried about the
patient gagging while we try to capture the detail of multiple
preps. We will even use it prior to taking our digital
x-rays on patients who are worried about gagging.
On the hygiene side, we use it for periodontal probing for
patients with inflammation as well as for gross debridement
patients who are sensitive. We see a lot of patients
who are overdue for hygiene but do not need scaling and
root planing. Since we typically only use local anesthetic
for our root planing patients, Cyclone helps fill the gap by
being an easy-to-use topical that provides peace of mind
for the patients.
The bottom line is that we offer Cyclone to almost anyone
having something done who is not getting local anesthesia.
We do not charge for this service, although there are
dentists who have told me that they charge a small fee for
it (typically $5.00) and that patients are happy to pay it.
We don’t charge for local anesthetic, of course, and we feel
that this falls into the same category.
Dr. DiTolla’s Clinical Tips
Dr. DiTolla’s Clinical Tips

No-Prep vs. Minimal-Prep Veneers on the Same Patient
– ARTICLE by Michael DiTolla, DDS, FAGD
There seems to be a controversy today in the world of esthetic dentistry whether prepped or no-prep veneers are the better
restoration. Typically, this discussion takes place between dentists, from the dentist’s point of view and with little or no input
from the patient’s point of view. I doubt any article can ever settle that debate. My intent in this article is to simply compare
the esthetic results that can be achieved with both types of veneers.
In most articles comparing different restorations, one set is done on one patient and the other set is done on a different patient.
Unfortunately, when you compare the two techniques using two different patients, the comparison is not really significant. Each
patient will have his/her own hard and soft tissue features such as tooth alignment, dentin shade and gingival architecture. Many
times it is these factors that determine which set of restorations look better.
To accurately compare the esthetic potential of two sets of restorations, it is my opinion that both sets of restorations should be
fabricated by the same technician and placed on the same patient. We often do this by trying in both sets of restorations and
taking digital photographs. While this allows us to see the esthetic differences between the restorations, it does not allow us to
evaluate patient feedback about the difference on how the two different sets of restorations look, feel and function.
That’s why I jumped at the opportunity to see the difference between prep and no-prep veneers on the same patient. In this
study, we first placed no-prep veneers on the patient and left them on for six months. The patient loved these veneers from the
day they were placed and had no functional issues with them either. His wife however, who happens to be a dental technician,
thought that they looked too bulky. The patient did say that they initially felt “a little thick to his tongue,” but this feeling went
away within the first few weeks.
As part of our agreement for receiving the veneers for no charge, I removed the no-prep veneers with my Waterlase after
six months. After the veneers popped off, a thin layer of resin cement remained on the enamel surface. I removed the cement
with rubber wheels to get his teeth as close to their preoperative state as I could. This is not to say that I consider no-prep
veneers to be reversible, but if I did ever have to remove a set to return a patient to their pre-op state, I now know that I could
come close.
I then sent a study model to the laboratory in order to do minimal-prep veneers. While the term is somewhat unclear, I define
a minimal-prep case by two conditions: 1) the amount and location of the reduction is determined by the laboratory technician;
and 2) the preparation remains entirely within enamel. By allowing the dental technician to determine the amount and location
of reduction based on the diagnostic wax-up, we ensure we only remove enough tooth structure to achieve the esthetic result
shown by the diagnostic wax-up. By remaining in enamel, we nearly eliminate the potential for post-operative sensitivity while
taking advantage of the highest bond strength in dentistry.
Two weeks later the minimal-prep veneers were bonded into place and again the patient was very happy with them. This
time however, his wife, the dental technician, was also very pleased with the result. The patient did not see much difference
between this set of veneers and the no-prep veneers and commented that he “didn’t feel there was enough of a difference”
between the two sets of veneers to “justify the numbing and drilling.” Please keep in mind that this was not a dental phobic
patient. Had he been a dental phobic, the no-prep veneers would have been the only option and he would have been pleased
with that esthetic result.
I have presented his final pictures side by side so you can compare the results for yourself. While I expect that many dentists
will prefer the minimal-prep set of veneers, I urge you to keep the patient’s response in mind. Is there enough esthetic difference
in the final results to justify the anesthesia and preparation? Only you and your patient can decide. Í
No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient
No-Prep vs. Minimal-Prep Veneers on the Same Patient
Figure 1
Figure 2 Figure 3
Figure 5
Figure 6 Figure 7
Figure 4
Figure 1: Greg’s Pre-Operative Smile
You will notice when he smiles that he does not show the incisal edge of his maxillary anterior teeth. However, you will notice
after his teeth are restored, that his smile becomes more broad and more authentic and the incisal edges of the maxillary anterior
teeth become apparent.
Figure 2: Facial View of Pre-Operative Smile
A close-up view of the maxillary anterior teeth shows numerous esthetic issues, some more dramatic than others. A traumatic
fracture of the incisal edge of tooth #8 has left it 1mm shorter than tooth #9. The gingival levels on teeth #6, 8, 9 & 11 are
roughly in the correct position, but the gingival levels on tooth #7 and especially #10 are too far apical. Short of a gingival graft,
the only way to correct this problem would be to do a gingivectomy on #6, 8, 9 & 11 to match the levels of the lateral incisors,
but that would leave these other teeth with clinical crowns that were too long.
Figure 3: Right Lateral View of Pre-Operative Smile
In addition to the broken incisal edge on tooth #8, it is also apparent that tooth #7 is too short incisally. Teeth #6 & #7 also have
an excessively large incisal embrasure between them in addition to a small diastema.
Figure 4: Left Lateral View of Pre-Operative Smile
From this view, it is apparent that tooth #10 is angled to the facial making it too facially prominent. In a no-prep case like this,
I refer to this as a Facial Limiting Factor (FLF). Since this is a no-prep case by definition, all the teeth are going to get at least
0.3mm thicker on the facial. If the FLF is too noticeable, it will change a case from no-prep to minimal-prep.
Figure 8
Figure 5: Greg’s Smile After No-Prep Veneers
Notice how his smile is now a full smile with his lower lip paralleling the incisal edges of the maxillary anterior teeth. Like many
patients, being happy with their anterior teeth leads to more natural smiles.
Figure 6: Facial View of Post-Operative No-Prep Veneer Smile
I think we can all agree there has been a dramatic improvement from figure 2 to this picture. Essentially, all of the cosmetic
objections the patient originally had have been eliminated by the no-prep veneers. Interestingly, even our FLF has been somewhat
nullified by the no-prep veneer. Because tooth #10 was so short, the ceramist was able to increase its length while bringing
the incisal edge back toward the lingual. This has created an illusion that #10 is not as facially prominent as it actually is. The
only time I see this happen is when the FLF tooth is lengthened by the ceramist.
Figure 7: Right Lateral View of Post-Operative No-Prep Veneer Smile
Compare this picture with figure 3 and note the multiple esthetic improvements. For example, the incisal embrasure between
teeth #6 & #7 that was too far open in figure 3 has been closed in figure 7. The deficient distal-marginal ridge on tooth #6 has
been corrected in figure 7 giving tooth #6 a more pleasing overall shape and appearance. The broken incisal edge on tooth #8
has also been corrected.
Figure 8: Left Lateral View of Post-Operative No-Prep Veneer Smile
Compare this photo with figure 4 and note the multiple esthetic improvements. For example, the insufficient length of tooth
#10 has been corrected. Tooth #9 was a concern to me because the tooth was nearly ideal prior to treatment. Placing a no-prep
veneer on this tooth would not make it look any better, except that the shade will blend in with the adjacent teeth. In figure 8
however, tooth #9 does not appear to be too large. We also dodged a bullet on tooth #10, which was facially prominent prior
to treatment, as it blends in reasonably well. Í
No-Prep vs. Minimal-Prep on the Same Patient
No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient
Figure 9
Figure 10 Figure 11
Figure 9: Facial View of No-Prep Veneer Removal
I set the power on my Waterlase YSGG laser to its maximum (6.0 watts) and held it approximately 2mm away from the surface
of the veneers. Because these were no-prep veneers and extremely thin in most areas, the porcelain began to pop off quickly.
Through my loupes it appeared as though the ceramic fracture was taking place at the level of the silane. In other words, when
the porcelain came off, it left a thin layer of resin cement on the tooth. This was polished off with rubber wheels.
Figure 10: Close-Up View of No-Prep Veneer Removal
The reason I like removing these veneers with the laser is that it pops the porcelain off with much less potential for damaging
the underlying enamel. Because these veneers are so thin, it would be difficult to cut through them with a handpiece and bur
and not cut into the enamel. In areas where the veneers were slightly thicker, I found I could use a diamond bur to slightly thin
the porcelain if the laser was having no effect on it. Once the porcelain was thinned, the laser would pop it right off.
Figure 11: Facial View After Removal of No-Prep Veneers
This is a shot after the no-prep veneers were removed and initial rubber wheel polishing was done. Essentially, we have
taken the patient back to his pre-operative virgin teeth. While I would never tell patients that if they don’t like their no-prep
veneers we can always pop them off and go back to square one, it is nice to know that I do have a way of removing them if I
absolutely had to. Í
No-Prep vs. Minimal-Prep on the Same Patient

No-Prep vs. Minimal-Prep Veneers on the Same Patient
No-Prep vs. Minimal-Prep Veneers on the Same Patient
Figure 13 Figure 14
Figure 12
Figure 15
Figure 12: Greg’s Smile After Minimal-Prep Veneers
After the no-prep veneers were removed, a study model was made and sent to the technician. The technician identified the
FLFs he would like removed to enhance the esthetic results for this case. The minimal amount of preparation ensured that all
of the preparations remained entirely in enamel. The minimal-prep veneers were placed with the exact same steps as with the
no-prep veneers. Because the entire preparation is in enamel, we have no fear of post-operative sensitivity or potential loss of
tooth vitality.
Figure 13: Facial View of Post-Operative Minimal-Prep Veneer Smile
Compare this with figure 6 and see which set of veneers you prefer. It should be apparent that the shape and contours of the
veneers in figure 13 are more pleasing and anatomically correct than those in figure 6. The teeth do not appear as bulbous and
the “negative space” in the various embrasures add a depth and vitality to these restorations.
Figure 14: Left Lateral View of Post-Operative Minimal-Prep Veneer Smile
Compare this to figure 8 and see which set of veneers you prefer. Again, the first thing I notice is the lateral incisor, tooth #10.
In the no-prep case in figure 8, the tooth looks bulbous, especially in the cervical third. Note how with the minimal-prep veneers
in figure 13 the cervical third appears much more natural, and the “negative space” surrounding the gingival embrasure makes
it appear more like a tooth and less like a restoration.
Figure 15: Right Lateral View of Post-Operative Minimal-Prep Veneer Smile
Compare this to figure 7 to see which set of veneers you prefer. The first thing that jumps out at me is how natural tooth #7
looks in the minimal-prep case versus the no-prep case. Teeth #6 & #8 also appear more natural, especially the way the incisal
third of tooth #8 is positioned more lingually in the minimal-prep case than in the no-prep case. Í
Figure 16 Figure 17 Figure 18
Figures 16, 17, 18 Retracted Left, Facial and Right Views of Post-operative Minimal-Prep Veneers
These close-up views of the completed minimal-prep veneers highlight the esthetic features that are not possible with no-prep
veneers. Every dentist who has looked at this case prefers the look of the minimal-prep veneers. However, every patient I have
shown this to, including the one the treatment was performed on, had no preference between the two sets of restorations. They
did have a preference for the no-prep procedure over any preparation.
No-prep veneers can solve a lot of esthetic issues in one appointment, without a drill and without anesthetic. For a lot of patients
that is a major benefit, even if the veneers don’t look as nice as if we did a minimal-prep or full-prep procedure. For them, the
main criteria are no drilling, no shots and no removal of tooth structure. These patients are much less concerned about the fact
that their veneers will be slightly bulbous, as they inevitably will be with the no-prep method.
For patients who are insisting on perfection in the shape of their veneers, we need to go to a minimal-prep or full-prep procedure.
It’s important to explain to the patient the advantages and disadvantages of the different kinds of veneers available to
them and then help them to make their own decision.
To watch the video of this entire procedure, visit the Glidewell Online Case Study website at: http://www.glidewell-lab.com/
educational/videos/index.html and click on Online Viewing — Case Studies: Comparative Study of No-prep, Laser Removal, and
Minimal-prep Veneers on the same patient.
No-Prep vs. Minimal-Prep on the Same Patient
No-Prep vs. Minimal-Prep on the Same Patient

Correcting Esthetic and
Functional Problems with the U se of...
BioTemps Provisional Restorations
– ARTICLE by Michael DiTolla, DDS, FAGD
– PHOTOS by Ed Pelissier and Michael DiTolla, DDS, FAGD
In my opinion, BioTemps may be the most versatile restoration available in dentistry today.
This is surprising considering that it is a provisional restoration, but provisionals play such a
big role in managing clinical situations to ensure success with our final restorations. From tissue recontouring
to ovate pontic development, BioTemps are the ideal soft tissue template for shaping gingival
tissues to match your esthetic requirements. From restoring vertical dimension to withstanding months
of periodontal therapy, you won’t find a better long-term provisional on the market. This article looks
at some of the clinical applications I have found for BioTemps, and I welcome your input on any other
uses you may have found for these versatile provisional restorations . Í
Photo Gallery: BioTemps Provisional Restorations

CASE A
CASE D
This 59-year-old female patient presented with a collapsed vertical and anterior bridge that did not show teeth when she smiled. The lack of supporting bone
made implants unfeasible, so BioTemps were placed to overcome the resorbtion and restore a normal vertical dimension. Pink acrylic was used to mask the
resorbed area and permit a smile that would show her teeth.
This 21-year-old male patient would cover his smile with his hand to hide his teeth. This patient has suffered with GERD and has been treated by a physician.
Once under control, treatment could proceed and BioTemps were placed on the upper arch. The patient was visibly moved at seeing his new smile, and the
final restorations matched the size and shape of the BioTemps.
CASE B
CASE E
This 45-year-old male patient had a severe parafunctional habit for all of his adult life. Because of his edge-to-edge bite, he had lost several millimeters of vertical
dimension over the decades. Full upper and lower BioTemps were placed to restore vertical dimension and establish proper overjet and overbite.
This 34-year-old male patient did not like how his PFM bridge from #6-8 looked and the fact that food always got caught underneath. The patient decided to
restore his teeth from #5-12 at the same time. BioTemps were placed from #5-12 to successfully address the patient’s aesthetic and functional concerns.
CASE C
CASE F
This 41-year-old male patient had always smiled with his lips closed because he was embarrassed by the look of his smile. He did not like the spaces between
his teeth, the multiple discolorations or how short the teeth had become from parafunctional activity. BioTemps were used to improve his smile on the same
appointment and to act as a template for final restorations.
This 28-year-old male patient had multiple failing composites with recurrent decay and moderate periodontitis. He was also embarrassed to smile. After completing
his periodontal program, full-arch BioTemps were placed on the upper. The gingival embrasures were intentionally left open so the patient could easily
floss.
Photo Gallery: BioTemps Provisional Restorations
Photo Gallery: BioTemps Provisional Restorations

CASE G
CASE H
This 54-year-old male patient presented with unaesthetic PFMs with exposed metal margins. Upon further examination, it became apparent that teeth #8-
10 were periodontally involved and their prognosis was hopeless. Teeth #8-10 were atraumatically extracted with the use of periotomes. The patient did not
bite down on any 2x2s as this can cause collapse of interdental papilla. Since our goal was to create ovate pontic receptor sites, the BioTemps pontics were
extended into the extraction sites and were allowed to heal, creating a more esthetic result.
Clinical dentistry by Michael DiTolla, DDS, FAGD. BioTemps by Glidewell Laboratories.
This 31-year-old female patient was presented with a PFM bridge from #8-10 with open margins on both abutments. She complained that food constantly got
caught underneath the modified ridge lap pontic. It was decided to place a new PFM bridge with an ovate pontic. When the old bridge was removed, the faciolingual
width of the ridge was measured to see if there was enough space for the ovate pontic, and in this case there was. If the ridge has collapsed on the
facial due to a traumatic extraction, an ovate pontic is often not possible. A color transfer applicator was used to mark the tissue side of the BioTemps pontic,
and the bridge was tried into place, leaving a mark in the correct position for the ovate pontic receptor site. A Waterlase® YSGG laser was used to remove the
marked tissue. The BioTemps bridge was tried in again to continue marking the tissue. When the BioTemps bridge would seat completely, enough tissue had
been removed. The BioTemps were then cemented and the area was allowed to heal for 6-8 weeks.
Photo Gallery: BioTemps Provisional Restorations
Photo Gallery: BioTemps Provisional Restorations

LMT ® ’s Crown Experiment 2007:
“NOT IN MY MOUTH!”
Identical impressions were sent anonymously to nine different laboratories.
The resulting crowns were evaluated by a panel of
highly trained dentists and dental technologists. Every
one of them resoundingly said: “I wouldn’t want
any of these in my mouth.”
Reprinted with permission from LMT ®
Communications, Inc. Copyright © 2007.
Visit www.lmtcommunications.com
T
he evaluators—as well
as LMT—were surprised by the
disappointing quality of the nine crowns in the experiment, which earned an average score of only 4.3
on a scale of 0 to 10. (See The Crowns: A Closer Look on page 32). “These are amateurish crowns with no
natural contours,” said evaluator Fred Hornedo, Jr., MDT, manager of Acqua-Dent Dental Laboratory, Jamesburg, New
Jersey.
The evaluators also criticized the shallow anatomy, gray or too-bright shades and the poor staining and glazing.
However, what concerned them most was that none of these crowns has an acceptable marginal fit
when evaluated on the die. “Every unit is rotating or rocking,” said Dr. Ira Zinner, who maintains a private
practice in New York City and is a clinical professor at New York University College of Dentistry. “None of them have
any bevels or closing angles to keep saliva out and prevent decay.”
The technicians on the panel were especially bothered by what appeared to be a
lack of pride in craftsmanship. “Why are we seeing such sloppy model work and presentations?
It seems as though some of these technicians were just going through the motions,” said
evaluator Gail Broderick, MDT, laboratory director for Jason J. Kim Dental Laboratory, Great Neck, New York.
EXPERIMENT DETAILS
LMT opted to use a Dentoform model as the “patient” so that there could be nine crowns in the
experiment without having to put a live patient through nine impressions. The dentist-consultant
modified the Dentoform so that it appeared more lifelike; he then prepared tooth #14 with a shoulder
preparation. He took nine full-arch impressions of the Dentoform and sent each one to a different
laboratory with a prescription for a low-gold PFM crown with a circumferential metal collar in shade A3.5. He requested
light fissure staining on the occlusal and hand-articulated casts. LMT chose to prescribe a PFM unit since that is still
the bread-and-butter work of most C&B departments and laboratories.
LMT chose six domestic labs (two small, two medium and two large) and three foreign labs. For the
domestic crowns, the goal was to get samples from each of three broad regions of the U.S. LMT also
wanted to cover a wide range of prices, so all of the crowns in the experiment are in the $60 to $190 range. The average
turnaround time was 12 days. Í
nce the crowns arrived at LMT, all the casts, dies and
crowns were marked with coordinating colors and
assigned a letter so that the identities of the laboratories (as well as their size and location) would not be known to
evaluators.
LMT then brought the crowns to two prestigious East Coast
LMT’s Crown Experiment 2007

“NOT IN MY MOUTH!”
Odental schools—New York University (NYU) and the University
of Connecticut (UCONN)—to have them evaluated by a
panel of technicians and dentists; one of the dentists is also
a master dental technician. (See Meet the Evaluators on
page 36.) They were asked to rate each crown in nine
categories: model and die prep, anatomy, contours, contacts/
embrasures, occlusion, shade/vitality/enamel blend, stain and
glaze, metal design/polish and the accuracy of fit on the die.
(Because LMT wanted to eliminate the variable of impressiontaking
and focus solely on laboratory techniques, the fit of
each crown on the Dentoform was not scored.) The scoring
system is based on a 0 to 10 scale, with 0 being “unacceptable”
and 10 being “excellent.”
“Why are we seeing such sloppy model work and
presentations? It seems as though some of these
technicians were just going through the motions.”
-Gail Broderick, MDT
LMT recognizes the limitations of this study and is not
portraying it as a scientific experiment or implying that the
work being evaluated here is necessarily representative of
the entire industry. Rather, the experiment is a rare opportunity
to get an inside look at the work being done in other
laboratories, and to juxtapose it with the fees these labs are
charging for their level of quality.
OBSERVATIONS
1. The lowest scores are for the accuracy of fit on the die. Even
the first-place crown received a 4.0 on the 0 to 10 scale in
that category; the average score for fit for all the crowns is
only 3.5.
Some evaluators commented that the type of shoulder prep
used by the dentist who helped with the experiment may
have inhibited a good fit, but others felt it is a real-world
prep, similar to those often done by general dentists and
that it has nice, clear margins. In the end, though, the real
concern is each laboratory’s inability to make a restoration
that doesn’t rock or rotate on the die. “No matter what the
prep is like, these crowns should fit better than they do,”
said evaluator Mario Zerrillo, MDT, owner of Zerillo Dental
Laboratory, Queens, NY.
2. The crowns that were fabricated outside of the United States
are on par with the ones fabricated inside the country (the
foreign crowns placed 5th, 6th and 7th among the nine restorations).
In fact, the average overall score of the foreign
crowns is 4.2 and the average for the domestic crowns is
4.4. While both of these scores reflect dissatisfaction among
the evaluators, they show that the quality of the foreign
crowns in the experiment is comparable to that of the
domestic ones.
3. What was most surprising about the individual crowns is
that the most expensive one in the group—in the $180
to $190 range—was rated to be the worst. Although the
geographic area in which the laboratory is located tends
to have higher prices, it was still shocking that—even on a
bad day—a crown in this price range would rate 2.8 on a
scale of 0 to 10.
What surprised LMT most about the individual crowns
is that the most expensive one in the group—in the
$180 to $190 range—was rated to be the worst.
4. Overall, the technician-evaluators gave scores that are an
average of one point lower than the dentist-evaluators
(3.6 compared to the average dentist score of 4.5). It’s
LMT opted to use a Dentoform model (below) as the “patient” so that there could
be nine crowns in the experiment without having to put a live patient through
nine impressions. The dentist-consultant modified the Dentoform so that it
appeared more lifelike; he then prepared tooth #14 with a shoulder preparation,
took nine full-arch impressions of the Dentoform and sent each one to a
different laboratory with an identicalprescription.
What concerned the evaluators most was that none of the crowns in the experiment has an acceptable marginal fit when evaluated on the die.
Shown here are three crowns—(from l. to r.): Crown Z, Crown T and Crown R—that were among the worst of the lot.
logical that the technicians—being professionals in dental
prosthetics—would have a more technically critical
perspective. Still, it’s the dentist who is making the final
decision about whether a restoration is suitable to be placed
in a patient’s mouth.
Although all of the dentist-evaluators said they would
reject every crown if it was returned to them, some acknowledged
there are dentists who would consider at least a few
of these units to be clinically acceptable. And that’s the reality:
since quality is so subjective, what constitutes an acceptable
crown is going to differ from one individual to another.
That’s evident even in the context of the experiment: the
scores the evaluators gave Crown U in the stain and glaze
category, for example, range from 1 (from a technicianevaluator)
all the way to 9 (from a dentist-evaluator).
LMT believes that the laboratories involved in the experiment
would be genuinely surprised by the scores they received.
Of course, the evaluators didn’t know the identities of the
laboratories and, therefore, couldn’t be swayed by their
reputations or level of service. Instead, these crowns had to
speak for themselves.
Although in the real world, your marketing, positioning and
value-added service are part of the big picture, how would
your product fare if it was judged on technical merit alone? In
other words, if your work had to speak for itself, what would
it say? Í
LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007

The Crowns
A CLOSER LOOK
Crown V Overall score: 6.0 Fabricator: A large, full service lab in the Western U.S. Price range: $170–$180
The “favorite” of both the dentist and technician evaluators,
the first-place crown comes from the largest laboratory in the
experiment and has more than a one-point lead over the
second-place “winner.” It received the highest marks in the stain
and glaze and metal design/polish categories. “This is the best
stain and glaze I’ve seen on any of the crowns so I’m giving it
a ‘9.’ This is a very sellable crown,” said Jason J. Kim Dental
Laboratory’s Gail Broderick, MDT. UCONN’s Dr. Dashti praised
the metal/porcelain margin and metal polish, but felt that the
embrasures were too open, especially on the mesial.
Crown S Overall score: 4.9 Fabricator: A small C&B laboratory in the Central U.S. Price range: $150–$160
This crown earned scores almost as high as the 1st place crown
for its metal design and polish, contacts and embrasures and
occlusion, but some of the evaluators gave it a “0” for
unacceptable model and die work, since the model was returned
to the dentist with chipped centrals. UCONN’s Dr. Squier also
pointed out that the die was overtrimmed, which probably accounts
for this crown’s poor marginal fit. There is also a stress fracture
on the lingual side of the crown, possibly due to metal/porcelain
incompatibility.
Crown T Overall score: 4.8 Fabricator: A medium-sized full service lab in the Western U.S. Price range: $150–$160
Several of the evaluators commented on the impressive-looking
cusp of Carabelli on this crown. However, they were disappointed
with the occlusion. “There’s a ‘hit and slide’ on the occlusion and
it’s not designed in centric occlusion,” said Dr. Grayson of NYU.
UCONN’s Dr. Rungruanganunt agreed, “The crown is only occluding
on the lingual incline of the buccal cusp.” Other judges felt
that the contacts are too wide and too tight, and that the crown is
overcontoured.
Crown WOverall score: 4.7 Fabricator: A large, full service lab in the Eastern U.S. Price range: $120–$130
This crown earned its highest scores in the model work and
occlusion categories, but didn’t do so well with its anatomy
evaluation. “This crown demonstrates a lack of knowledge
of occlusal anatomy,” said Dr. Grayson. Other evaluators
echoed that sentiment and also pointed out that the crown is
overcontoured, especially lingually, and that the contacts are too
wide. Dr. Raghavendra also felt that the crown has excessive external
staining.
Crown Y
Crown Z
Overall score: 4.4 Fabricator: A foreign laboratory Price range: $110–$120
The metal work on this crown concerned the evaluators. “If
you looked at this metal collar under a microscope, it would
look like the texture of concrete...a beautiful home for billions
of bacteria,” said Fred Hornedo, Jr., MDT, manager of Acqua-
Dent Dental Laboratory, Jamesburg, New Jersey. “There are a
lot of fine scratches that should have been polished out with
a red wheel.” The porcelain application is also disappointing.
“The color is uniform from the gingival on up—there’s no natural
coloring, no occlusal staining,” said Dr. Grayson.
Crown X Overall score: 4.3 Fabricator: A foreign laboratory Price range: $80–$90
“My first impression? It’s not good,” said Paul Federico, MDT,
owner of Federico Dental Lab, Staten Island, New York, when
he picked up this crown for evaluation. “It’s overcontoured, the
fit is terrible, the contacts are too tight and the shape is wrong
on the lingual and interproximal.” Other criticism offered by the
evaluators included shallow anatomy, tight contacts and poor
occlusion. UCONN’s Dr. Squier and Dr. Rungruanganunt also commented
that the dies looked worn or mishandled.
Overall score: 3.8 Fabricator: A foreign laboratory Price range: $60–$70
Though overall this crown falls into 7th place, the evaluators at
the University of Connecticut deemed this to be the worst crown
of them all, especially since it was not fabricated with a metal
collar as prescribed.“This is a terrible crown,” said Dr. Squier. “The
prescription wasn’t followed, there’s no contact on the models, no
metal margin on the buccal and the porcelain is overextended.” The
evaluators also pointed out that this crown is overcontoured and out
of occlusion and that the opaque shows through.
Crown U Overall score: 3.4 Fabricator: A medium-sized C&B laboratory in the Central U.S. Price range: $70–$80
This crown received the worst model and die scores of any of
the crowns in the experiment and nearly all of the evaluators
commented on the messy presentation. “Even if the model
work is accurate, it’s ugly. I gave it a ‘1’ for sloppiness,” said
Mario Zerrillo, MDT, owner of Zerrillo Dental Laboratory, Queens,
New York. It was also difficult to remove the die without pulling
off the other parts of the model. The porcelain application
was noted to be inconsistent—thick in some spots and thin in
others—and the crown exhibits bulky contours. “This crown is
unsellable and unacceptable,” said Broderick.
Crown R Overall score: 2.8 Fabricator: A small C&B laboratory in the Eastern U.S. Price range: $180–$190
“Crown ‘R’ is for reject. This is what you get with a $39 crown,”
said NYU’s Dr. Silberg, unaware that this was actually the most
expensive crown in the group. “This crown has no occlusion,
no retention, no contour.” In fact, overall, this crown received
the worst anatomy and occlusion scores of all of the crowns.
And the porcelain application and metal work didn’t fare much
better. “The shade is grayish and the stain doesn’t follow the
anatomy,” said Dr. Dashti. “Also, the metal polish is poor because
there are dark areas.” Í
LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007

LMT Technical Strategies Columnist Bill Mrazek, CDT, asks:
WHERE ARE WE HEADED?
Crown S lost points during evaluation because it was returned
on a broken model (left photo) and because there are cracks in
the porcelain on the buccal and lingual surfaces (right photo).
When the fine folks at LMT asked if I would offer a
“real-world” perspective on the restorations in their
crown experiment, I agreed without hesitation. I felt I
had a pretty good grasp of the “levels” of restorations being
produced in our profession. I’ve been a dental technician
for 30 years and a CDT for almost 28 years. I’ve presented
numerous lectures and clinics and written articles for over
15 years. Many of us have looked to Willi Geller, Asami
Tanaka, Lee Culp and others for inspiration, guidance and
education—and continue to learn from them—in an attempt to
continually raise the level of our restorations.
As we know, there remains a range of acceptability in what
we produce. That is not to say that high quality restorations
are not being delivered on a daily basis; they certainly are.
There are also restorations being delivered that are not as
detailed; as accurately fitting; or as anatomically, functionally,
gnathologically or esthetically correct that still fall within that
range of acceptability. Then there are those that should not
be delivered at all. But, in most businesses, there is a market
for everything. Unfortunately, as evidenced from this study,
restorative dentistry is no exception.
First, let me say that my comments are not directed at
specific laboratories, since I do not know where the
restorations were fabricated. I evaluated each crown in the
same categories used by the other dentist- and technicianevaluators
(see Meet the Evaluators on page 36) and used
the same 0 to 10 scale. I looked at each crown three times,
on three different days, to make sure that I was being fair
and consistent. I’ve arranged my observations based on the
judging categories:
Model and die prep (my scores range from 0 to 7.5): Crown
S received a zero because the model was returned badly
broken, as if dropped from a second-floor window (see photo
on page 32). Crown T received the highest score because it
uses one-piece double pins and the model work is neat and
clean. Most of the cases use simple plastic articulators, which
are common, but they allow no protrusive movement and only
limited excursive movements.
In most businesses, there’s a market for everything.
Unfortunately, as evidenced from this study,
restorative dentistry is no exception.
Anatomy (my scores range from 2 to 8): Only Crown T
includes a Cusp of Carabelli, even though there clearly is one
on the 1st molar on the opposite side of the arch.
Contours (my scores range from 5 to 7.5): Almost all units
exhibit a square, boxy, overcontoured shape.
Contacts/embrasures (my scores range from 0 to 8): I gave
two crowns a zero—Crown W and Crown Z—because they
have both mesial and distal open contacts. Crown R and
Crown V have one open contact; the others have varying
degrees of contact, from point to concave design.
Occlusion (my scores range from 2 to 8): Crown R was
totally out of occlusion; the others exhibited good centric
contact, but most had lateral interferences.
Shade/vitality/enamel blend (my scores range from 0 to 9):
Most of the samples are too high in value, the chroma varies
from crown to crown and, the lower scoring units—such as
Crown S and Crown Z—don’t represent the requested A3.5
shade at all.
Stain and glaze (my scores range from 0 to 9): Most of the
restorations have a poor and unrealistic-appearing application
of occlusal stain, and some appear overglazed. I gave a
‘0’ to Crown S because it has cracks in the buccal and lingual
surfaces of the porcelain (see photo on opposite page). Crown
W earned a ‘9’ because it is the only one with surface texture.
Metal design/polish (my scores range from 0 to 9): Crown
Z earned the ‘0’ since it did not follow the Rx request for a
metal collar. The highest scores were given to those crowns
that exhibit the narrowest collar at the buccal margin (such as
Crown U).
Accuracy of fit on die (my scores range from 0 to 9): I gave
seven of the nine crowns scores of 2 or less; four of them
received a ‘0’! (The two that fit the best—Crown X and Crown
Y—earned a 9 and 7.5, respectively). To me, this is the most
amazing aspect of the experiment, as the prep is ideal and has
margins that could be read in the dark. Some of the crowns
fit very loosely on the die, others have open margins, short
margins, or over-extended margins that could be easily seen
without any form of magnification!
Final analysis: In my estimation, the clinical acceptability of
Crown X and Crown Y is questionable; the remaining crowns
are, without a doubt, undeliverable.
In all fairness, nine samples don’t constitute an accurate
representation of the work being done by the entire dental
laboratory profession. But doesn’t it seem reasonable to
expect that there would be at least some higher scores than
we see here? Obviously, the laboratories in this experiment
Nine samples don’t constitute an accurate
representation of the work being done by the entire
profession. But doesn’t it seem reasonable to expect
that there would be at least some higher scores?
sent back a product that they felt was an acceptable
restoration. If these restorations are accurate representations
of what they produce on a regular basis, it means their
products are being accepted and delivered on a regular
basis.
My greatest concern is not directed at those laboratories in
the experiment, but actually at the level of acceptance that
apparently exists in our profession—a level of acceptance
that is a shared responsibility between the dentist and the
laboratory.
Crown
Model &
Die Prep
Anatomy Contours Contacts/
Embrasures
I truly hope that restorative dentistry can remain a respectable
profession rather than becoming strictly a “business
arrangement” between the dentist and laboratory, primarily
based on price and turnaround time. Once we reach that point,
our restorations are nothing more than a manufactured commodity.
Ultimately, it is up to each of us to determine where
we are headed. In what direction do you want to go? Í
Occlusion
Shade/
Vitality
Bill Mrazek, CDT, is the owner of Mrazek
Prosthodontics, Ltd. and Mrazek Consulting
Services in Naperville, Illinois. LMT is grateful
to Bill for lending his creative input during
brainstorming for this experiment, as well as
for his technical expertise during its planning
and execution.
AVERAGE SCORES RECEIVED BY EACH CROWN IN ALL CATEGORIES
Stain &
Glaze
Metal
Design/
Polish
Accuracy
of Fit
on Die
CROWN R 3.9 1.5 2.9 2.0 1.8 2.8 3.6 4.5 1.5
CROWN S 3.5 4.9 4.5 6.0 5.7 5.1 5.6 6.6 2.6
CROWN T 4.5 5.1 5.0 4.6 4.7 5.4 6.2 6.3 1.5
CROWN U 2.3 2.7 3.0 4.7 3.9 3.6 5.1 3.6 1.9
CROWN V 5.9 5.7 6.0 6.4 5.8 7.0 6.6 6.7 4.0
CROWN W 5.9 4.6 4.5 4.3 5.2 4.4 4.4 5.0 4.3
CROWN X 5.2 3.5 3.1 3.9 3.6 4.0 4.1 5.0 6.7
CROWN Y 4.6 4.5 3.6 3.7 3.2 4.3 4.6 5.0 6.2
CROWN Z 3.4 4.2 4.1 2.7 4.2 4.8 5.6 2.5 3.2
LMT’s Crown Experiment 2007 LMT’s Crown Experiment 2007

MEET THE EVALUATORS
Dr. Allan Grayson
Dr. Sangeetha Raghavendra
Fred Hornedo, MDT, ATACP,
Dr. Steven Silberg
New York University
LMT went to two prestigious East Coast dental
schools to have the crowns evaluated: New
York University (NYU) and the University of
Connecticut (UCONN). The panel includes
laboratory owners and managers, practicing
dentists and educators:
Gail Broderick, MDT, is the Laboratory Director of
Jason J. Kim Dental Lab, Great Neck, New York. She
is on the board of the Dental Laboratory Association
of New York, and is affiliated with the American
Society of Master Dental Technicians, International
Congress of Oral Implantologists, Alpha Omega
International Dental Fraternity, Northeastern
Gnathological Society, Dawson Center, Occlusal
Concepts Study Club and Six Sigma Greenbelt.
Dr. Buthaina Dashti is an Assistant Clinical
Professor in the Department of Oral Rehabilitation
at UCONN Dental School, where she teaches dental
students and prosthodontic residents. She received
her dental degree in the U.K. and her prosthodontic
degree from the University of Southern California.
Paul Federico, AAS, BS, MDT, owns Federico
Dental Lab, Staten Island, New York, a full service
lab specializing in full mouth rehabilitation. He
is on the faculty of NYU College of Dentistry and
president of the American Society of Master Dental
Technologists. Federico is also the director of
Predictable Restorative Dentistry Seminars and
a member of the Dr. Richard Tucker cast gold
study club.
Dr. Allan Grayson is Clinical Professor of fixed
and removable prosthodontics at NYU College of
Dentistry and maintains a private practice in New
York City. He’s been an educator for 28 years
and this summer will complete the Master Dental
Technologist program.
Fred Hornedo, MDT, ATACP, AAOP, has 28 years’
experience in all phases of laboratory work and is
the manager of Acqua-Dent Dental Laboratory,
Jamesburg, New Jersey. He is an alliance technician
for the American College of Prosthodontists, and
a member of American Society of Master Dental
Technicians and the American Academy of Oral
Facial Pain.
Dr. Sangeetha Raghavendra is an Assistant Clinical
Professor in the Department of Oral Rehabilitation,
Biomaterials and Skeletal Development at
LMT’s Crown Experiment 2007
UCONN School of Dental
Medicine. She also practices
in Chicopee, Massachusetts and is
a Diplomate of the American Board
of Prosthodontics and a Fellow of the
American College of Prosthodontists.
Dr. Patchanee Rungruanganunt is a faculty
member at UCONN Health Center and course director
for the fixed prosthodontics program. She practices
in University Dentists, the dental school’s multidisciplinary
faculty group practice.
Dr. Buthaina Dashti
Dr. Steven Silberg is a Clinical Associate Professor at
NYU College of Dentistry and practices in East Rockaway,
New York. Also a Master Dental Technologist, Dr. Silberg is a
member of the American Dental Association, American
Academy of Fixed Prosthodontics, American Society of Master
Dental Technologists, Academy of General Dentistry (Fellow),
Northeastern Gnathological Society and the Consensus for
Dental Excellence.
Dr. Rachel Squier is an Assistant Professor in the Department
of Oral Rehabilitation, Biomaterials and Skeletal Development at
the UCONN School of Dental Medicine. She practices in University
Dentists, the dental school’s multi-disciplinary faculty group
practice. She is a Diplomate of the American Board of Prosthodontics,
a Fellow of the American College of Prosthodontists and a member
of the International Team for Implantology and the Academy of
Osseointegration.
Mario Zerillo, CDT, MDT, is the owner of Zerillo Dental Laboratory,
a one-person ceramic lab in Queens, New York and a member of the
American Society of Master Dental Technologists. He got his start in
the industry 20 years ago when studying dental technology at the
George Westinghouse High School in New York and the New York
City Technical College.
Dr. Ira Zinner is a clinical professor at NYU College of Dentistry
and director of its Full Mouth Rehabilitation Program and Masters
of Dental Technology Program. He has a prosthodontics practice
in New York City and is a Diplomate of the American Board of
Prosthodontists; a Fellow of the American College of Prosthodontists,
Greater New York Academy of Prosthodontists and Academy of
Osseointegration; and an honorary Fellow of the New York Academy
of Oral Rehabilitation.
Dr. Rachel Squier
University of Connecticut
Dr. Ira Zinner
Paul Federico, AAS, BS, MDT
Dr. Patchanne Rungruanganunt
Gail Broderick, MDT
Mario Zerillo, CDT, MDT
Title of Article

Laboratory
PORTRAIT
Mikhail Tkachev
Engineer, Research and Development
Glidewell Laboratories
It must have been something about that visit from the Soviet secret police. Even his top-secret military
clearance couldn’t keep Mikhail Tkachev from coming under suspicion for the simple act of request
ing permission to visit his friend in Poland, and when the men in black suits came to interrogate him
at his Vladikovkas apartment, he knew it was time to take leave of his Mother Russia.
It was a country Mikhail knew well, perhaps too well, having been the second of eight children born to a
father who moved 13 times, by Mikhail’s count, before he was old enough to join the army. There he was
first assigned to a tank unit, but his aptitude with electronics recommended him to special duty building
top-secret devices in a Soviet weapons lab. He soon learned to reverse engineer, repair and improve any
electronic device in the world, a skill that would ironically be put to a positive use, at last, years later at
Glidewell Laboratories.
That journey, from a small town just 15 miles from the now war-torn Chechnya to Orange County,
California, is truly the stuff of Hollywood films.
It took two years from that fateful visit from the secret police, and two major upheavals in the Russian
government, for Mikhail’s desire to emigrate to the U.S. to come to fruition. Now, in 1991, a married man
with a three-year-old daughter and a six-year-old son, he jumped at the opportunity offered by Mikhail
Gorbachev’s bold open-border policy. Mikhail Tkachev (pronounced T’Kah-chow) brought his family to
the U.S. with no money and no English, bearing only the phone number of a friend in Sacramento whose
simple promise of assistance was enough hope for someone seeking a new start in a land of freedom.
But something went awry the moment he and his family set foot in the promised land. A clerical error at
the immigration office in the airport in New York rerouted them to St. Louis, Mo., instead of to Sacramento
where their friend awaited. There they were placed in a boarding house in a rough section of St, Louis,
a town where they knew no one and, indeed, weren’t even quite sure where they were. But a couple of
noisy nights marked by the sounds of nearby fights and robberies quickly told them it was a place they
didn’t want to be.
Amazingly, Mikhail found someone who spoke enough Russian to help him get in touch with his
Sacramento friend, Victor. Victor had driven to the Los Angeles airport
to pick up the Tkachev family only to be left there helplessly
wondering what had happened to them when their plane landed
and they weren’t on it. On receiving the call from his stranded
Russian friends, Victor was stunned by what had happened Í
– ARTICLE by Al Lefcourt
– PHOTOS by Ed Pelissier and Kevin Keithley
Mikhail Tkachev, far left on both photos, the early years (personal collection).
Title of Article
Laboratory Portrait

to them, but having preceded the Tkachevs to America by only three months, he hadn’t enough money
to fly them to California.
Mikhail, ever resourceful, went through his little black book of phone numbers he’d been collecting all
though his immigration process, and called a friend of his brother’s, also from the Russian military and
now in the U.S., and he immediately agreed to loan them some travel money. But the money was just
enough to get them to Los Angeles; someone would still have to drive down to pick them up.
But again fate had other plans. Mikhail’s son, Sergei, got ill on the flight to LA, causing the plane to land in
Phoenix. There the airport medical emergency team flew into a panic; they spoke no Russian, the Tkachevs
spoke no English, and they had on their hands a little boy turning bluer every minute. They called over
the airport PA system for anyone who spoke Russian, and only one person stepped forward: another boy,
a brave little fourth grader who was just beginning to study Russian.
Language turned out to be just one barrier they faced. Mikhail had no knowledge of the American systems
of health care, insurance and credit, and the fourth-grader’s language skills were clearly not up to the task
of explaining it all. Thinking he would have to pay cash for the hospital cash he didn’t have, Mikhail made
a difficult decision. He waited a bit for his son to feel better and asked to resume the flight.
At this point, of course, the airline was concerned about liability for the sick child and made the Tkachevs
sign a medical release form they really didn’t understand. But for them, it was California or bust, so they
were happy just to finally arrive at LAX.
Where yet another disappointment awaited. Their friend Victor’s car had broken down on the way
from Sacramento to Los Angeles, and this time it was the Tkachevs who were left alone and wondering
at the airport.
Mikhail again pulled out his little black book and found a phone number with a Russian name but no
record of who it was or where the number had come from. But, it was a local number and he called it. It
turned out to be a generous and helpful fellow named Peter who’d lived in the U.S. since the age of three
but who spoke fluent Russian. They asked Peter only for help in contacting Victor, but ties to Russia and
the Tkachev’s absurd predicament opened Peter’s heart to house them for two weeks, then bring them to
a place they could rent, and even to loan them enough money to get them started in their new home.
And as unlikely a series of events as this might be, it turned out to be nothing short of miraculous for
Glidewell Laboratories. If Mikhail had managed to get to Sacramento on either of his attempts, he may not
have settled in Los Angeles and may have never brought his considerable talents to the company. And that
would certainly have been a loss not just for Glidewell, but for the dental industry at large.
Mikhail’s first job in America was one of the few things one could do where the boss had only to point
and motion for you to understand what was expected of you: breaking rocks with a sledgehammer at
construction sites. Not the place one would normally expect to find a man with a degree in electrical
engineering. Unwilling to accept a long-term career in rock breakage, Mikhail enrolled in English classes
so he could better his lot.
The teacher was demanding, but hardly as demanding as Mikhail was of himself. He worked and he
schooled, both full-time, determined to get ahead in America. But he wasn’t earning enough to support
his family and his debts, so he started dental technician classes at Pasadena City College (7 a.m. to 5 p.m.,
Mon.-Fri.!) and, on the side, taking in auto transmissions for repair. It was something he could do, and do
well, for much less than a repair shop would charge, because he didn’t have the overhead of a garage.
Which also meant…he didn’t have a garage overhead.
So Mikhail rented workspace when he could, but often he actually had to carry transmission up the stairs
to his apartment to tear them apart and rebuild them. A grueling task he did for five years while he continued
to perfect his English and his dental tech skills, and he now bears the back pain to prove it.
As with everything Mikhail undertakes, he was so good at it, his customers nearly prevented him from
quitting when he was offered a job as an R&D dental technician at Glidewell Laboratories. But he eventually
was able to devote himself full-time to Glidewell, where his new English skills and his old Russian Í
Custom Plastic Injection Mold
This plastic injection mold was needed to make stump sticks inhouse,
rather than purchase them at high cost from dental dealers.
Technicians place an all-ceramic restoration onto the top of the stump
stick, which is colored to imitate the shade of the preparation in
the mouth.
Jar Rolling Mill
This simple Jar Rolling Mill is used during the zirconium oxide ball
milling process. The device can be utilized when the particle size of
zirconium oxide powder needs to be reduced.
Laboratory Portrait
Laboratory Portrait

Pressure Vessel
This is a Pressure Vessel for silicone material injection. Using the
vessel, we create rubber molds, which are then used in the fabrication
of pressable ceramics. This device uses air pressure to force the
otherwise viscous silicone material into a chamber to create the mold.
Today, 40% of the ceramic restorations we fabricate in the laboratory
are pressables, and that number is expected to eventually double.
X, Y Table
This adjustable X,Y Table has a spindle mounted on the top for zirconium
oxide sample preparation.
military engineering training combined to make him an integral part of one of the dental lab industry’s
most advanced commercial R&D departments.
One of the first episodes that brought Mikhail’s talents to Jim Glidewell’s personal attention was the failure
of a critical $30,000 piece of intricate equipment from Germany that would have slowed production of
restorations to a crawl, something that would have been unacceptable to Glidewell, its customers and to
countless patients around the country.
The problem was that the machine’s manufacturer in Germany would take two weeks to get a technician
to California with the proper replacement parts. Not good. Enter Mr. Tkachev with an offer to take
the thing apart, figure out what makes it tick and do whatever it takes to get it back online. Needless
to say, there were those who questioned the advisability of such a course of action, but Mike knew he
could do it-all those years of military training weren’t wasted on him and Jim Glidewell opted to give him
the chance.
Mike worked into the night, eventually isolating the problem to a certain sector of the main motherboard,
which he took home to test with his own special electronic diagnostic equipment. (Best not to ask.) By 4
a.m. he’d tracked the problem to a single chip that he was sure was the culprit.
When businesses opened later that morning, he rushed to an electrical supply shop to get a replacement
chip. “No such thing” he was told by the man behind the counter. “Not in this country.” Turns out he was
right. There was no U.S. equivalent for the German chip used in the machine.
Not to be deterred, Mikhail asked for the catalog to leaf through himself to find something, anything, that
he could use to replace the faulty chip. Finally he found an item that was close enough in function and
size to the original that with some ingenuity and a hot soldering iron he could make it work, whether it
wanted to or not.
Sure enough, before noon that very day, just as Glidewell managers were filing into a meeting where
they’d decide what to do about the calamitous equipment failure, Mikhail was able to send the message
up to the brass: ”The machine is put back together, and it works. It works!”
Mikhail has gone on to devise dozens of ingenious solutions to problems, and new ways to accomplish
old tasks in smarter, more efficient and more economical ways. He’s an important reason Glidewell is the
competitive powerhouse it is, constantly offering its customers new products and better prices.
One such example is the magnetic articulator system marketed by Glidewell Direct. It’s an elegantly simple
solution for dental technicians’ desire to hold impressions securely in place and then remove them quickly,
without having to make a huge investment in a competing system. Yes, it was Jim Glidewell’s idea to
develop such a tool, but it’s Mikhail’s creation, right down to the details of tooling and die-casting.
Of course, being the gentleman he is, Mikhail breaks into his typical bright-eyed, boyish grin when
he discusses the articulator and credits his co-workers and especially Wolfgang Friebauer, the head of
Glidewell’s R&D department, for bringing it into being. He even asked that Chairside deflect credit to his
machinist, Viktor Khivrenko.
Need proof of the Tkachevs’ success in America? Both of their children graduated college at the age of
18. Daughter Alona is now studying nursing at Long Beach State, and son Sergei, who earned a BA from
UCLA at age 21, works at KPMG and is halfway though his CPA exams.
Meanwhile, Vladikavkas remains a small but technically advanced town in the Caucasus Mountains, now
home to the Polymer Research Institute of Electronic Materials, a place Mikhail may have found employment
had he stayed. And had the secret police approved.
Laboratory Portrait
Laboratory Portrait

– INTERVIEW of Alan Budenz, MS, DDS, MBA
by Michael DiTolla, DDS, FAGD
– PHOTOS by Kevin Keithley
After missing a mandibular block a few weeks back, I decided it was time to interview one of my
instructors from dental school who has gone on to become one of the country’s leading authorities
on local anesthesia. Dr. Alan Budenz is an Associate Professor in the Department of Anatomic
Sciences and Chair of the Department of Diagnosis and Management at the University of the Pacific
in San Francisco, CA. By the end of the interview, Dr. Budenz had inspired me to learn at least one
new injection that I wasn’t taught in dental school: the Gow-Gates. As you read the interview you
may find yourself wondering, just as I was, why you are not using this injection on a daily basis. I am
taking a hands-on anesthesia class with cadavers next month with Dr. Budenz and I look forward to
giving my first Gow-Gates on a cadaver and then moving on to live patients the next morning.
20 Questions with Dr. Alan Budenz

Question 1: What’s the most exciting thing to happen in local
anesthesia in the last 5-10 years?
Alan Budenz: There’s been a lot certainly with the advent
of the CompuDent Wand and the Dentsply Comfort Control
syringe. Both are computer controlled devices and more than
ten years old, but still relatively new to the field. I have both
of these devices and they don’t necessarily allow me to do
anything I couldn’t do with a traditional syringe, but what
they do is make the process less taxing, and they let me
administer the anesthetic more consistently, time
after time.
The more slowly it gives the injection
-- particularly if it’s an anes-
t h e t i c
with a vasoconstrictor, because
those are more
acidic and would tend to cause the patient a little more
burning sensation -- and with consistent control, the patient
feels virtually nothing. It’s all about making it more comfortable
for the patient, and it doesn’t hurt that it makes it more
comfortable for yourself as well.
Another exciting development recently is the VibraJect. At first
I doubted it was worth $230 for a little vibrator so I don’t have
to shake the cheek anymore to distract the patient. I thought
there had to be more to it, and I discovered that it’s actually
a very clever device. It gives you a very low level of stimulation
going down to the tip of the needle, and if the needle
is in close proximity to the nerve tissue it will stimulate that
nerve at a low level, which will open up more of the sodium
channels. And it’s the sodium channel opening that allows
the anesthetic to flow in and bind to the receptor sites in the
sodium channels.
Q2: So it’s really more than a comfort and distraction device, it
actually improves the quality of the injection?
AB: Yeah, it’s really not a distraction device at all. It’s not
vibrating where it’s going to distract the patient from the
penetration, particularly. Really, what it is all about is getting
that stimulation to open up the sodium channels. It’ll tend to
give you a more profound anesthesia and potentially less of
that problem where you start to drill on a mandibular molar
and the patient feels it even though when you check with an
explorer, everything appears to be numb. But the patient still
feels it when you root plane or drill because you don’t have
enough of those sodium channels blocked. This device will
reduce the incidence of that. I bring this up not because it’s
the greatest thing in anesthetics, but because it’s a very simple
device with a very brilliant idea behind it – and it works!
But bottom line, the best thing that’s happened in local anesthesia
in the last 5–10 years is Septocaine coming on the U.S.
market in 2000. It’s a really good anesthetic but there are
drawbacks to it. The simple fact that there’s so much controversy
about it has stimulated people to ask so many more
questions about anesthetics and how they give them, that
overall, I think it’s beneficial because people aren’t just taking
everything for granted anymore. Typically people would say “I
use lidocaine for everything except when I can’t use epi, then
I use mepivocaine plain and for long-acting, I use Marcaine.”
It’s made people think about what’s out there, what’s appropriate
to use, what’s safe to use and what technique should
be used with it.
Q3: As a 4% anesthetic, do you avoid giving blocks with it? There’s
some literature about a possible increase rate of parasthesia with
Septocaine.
AB: All of the reports I’ve seen are anecdotal. There’s no real
scientific study that shows that absolutely the 4% anesthetics
are the cause of paresthesia, but there’s enough anecdotal
material out there to make me think there is a greater risk of
parasthesia using the 4% solutions, both articaine and prilocaine.
I’m not hesitant to use Septocaine for blocks, when it’s
indicated, except for the inferior alveolar block. I’m extremely
hesitant about Septocaine for that one because we’ve seen
numerous reports that the greatest incidence of paresthesia is
with that injection technique and the 4% anesthetics.
But personally, I don’t choose to give inferior alveolar nerve
blocks the conventional way. I prefer the Gow-Gates technique,
which from all the evidence I can gather is a safer injection
with any solution. I use it on a regular basis.
Q4: Say someone’s been practicing for 15–20 years and has been
giving lower blocks and knows there’s something better but is just
a little nervous about shooting that high with the Gow-Gates versus
the typical target point, what do you think is the best way for a
GP to learn how to do the Gow-Gates technique comfortably?
AB: The ideal way is to go to a hands-on course. Mostly you’ll
find this in a dental school setting, occasionally at a larger
meeting, but that’s pretty rare. Another alterative is to find a
practitioner in your area who knows the technique. A lot of
oral surgeons are familiar with the technique. More recent
dental school grads are more likely to have been taught the
technique. Watch them do it and have them observe you
doing it to give you feedback as you do it. A “study club” setting
like that is the ideal way to do it outside of a dental school
course/CE course. Í
20 Questions with Dr. Alan Budenz

Q 5 : I have seen numbers published on the
mandibular block stating that up to 20% of
blocks are missed on the first attempt. Do you agree
with that?
AB: Yes, but it always seems to go in spurts.
Practitioners tell me, “I can’t miss a block for weeks
and all of a sudden I’m missing every one.” I published
a literature review paper some time ago and the range
I saw was 63% to 86%, with some studies reporting it
into the 90% range. Now that’s with the first injection. But
most of us get it with the second attempt. I think the true
incidence of failed anesthesia is well below 1%. But on the first
attempt, I’d say 15%, plus or minus 5%, is about average.
Q6: One of the most frustrating experiences most of us GP’s have
are with “hot teeth”. Any tips you can give us on accessory innervation
and how to anesthetize these patients?
AB: On a mandible, of course, the number one nerve to anesthetize
is the inferior alveolar nerve, number two is the long
buccal nerve. The long buccal has been shown to have a lot
of accessory innervation to the teeth, particularly the molars.
When you look at the retromolar pad area, there are a lot of
accessory foramina there. You may wonder are they there for
blood vessels, are they for nerves, or are they just air holes?
You cannot tell just by looking at the bone. But there are a
lot of holes there. By doing micro-dissection, the long buccal
nerve is seen to send little branches into the bone. It’s not
just the main pathway like we instructors have always taught.
There are a lot of accessory nerve branches coming off all
along the long buccal pathway.
The number three nerve to anesthetize is the mylohyoid
nerve. In anatomy, we teach that this is a motor nerve to
the mylohyoid muscle at the floor of the mouth and also
out to the anterior belly of the digastric under the chin. What
is not taught from the anatomy literature, is that there are
also pain and temperature fibers in that nerve. And those
pain fibers have been tracked through micro-dissection into
teeth. So yes, it is an accessory nerve pathway. All along
the pathway to the mylohyoid, it is giving off little branches
into the bone and many of those branches are accessory
innervation to teeth.
Q7: I recall being taught that the long buccal just innervated
buccal tissue and for crown preps it was necessary, but only
for soft tissue anesthesia. With all these nerves branching off, it
sounds like nature is not as simple and straightforward as we
want it to be.
AB: Exactly. That is a great summary. We teach the basic nerve
pathways, but we probably don’t do a decent enough job of
teaching that any nerve that exists in the neighborhood of a
tooth is likely to be carrying some accessory innervation to
that tooth. No nerve is purely sensory or purely motor. They
all have a mixture. Some of those fibers are proprioceptive,
but some of those are also primary pain fibers and going to
tooth structures. Unfortunately for us, as dentists and dental
hygienists, we have to be aware of all of the possible nerve
pathways in the oral cavity.
Q8: Say I come to your office and I need crowns on #18, #19 and
#20. Walk us through exactly what you’re going to do in terms of
local anesthesia.
AB: I would start with a Gow-Gates injection. It has the best
likelihood of anesthetizing the inferior alveolar, the lingual,
the long buccal and the mylohyoid nerves all with one injection.
I’ll use a 27-gauge long needle and I’m going to drop
a full cartridge of lidocaine. I could use Prilocaine or
Septocaine if I felt that you were a person who expressed
to me that you were very hard to get numb or you had a
history of getting numb but not staying numb very long, or
had a history of drug abuse. Then I might use one of the
“big boys,” the 4% solutions. Ideally, I’d just use lidocaine
because it’s pretty safe. I find that with the Gow-Gates
technique, I have a good success rate using one cartridge of
lidocaine, in the upper 80s to mid-90% range. Occasionally, I
will need to chase it with a full second cartridge in the same
location. The one nerve that is hardest to get consistently is
the long buccal. So I may sometimes have to inject that separately.
With a Gow-Gates injection, I’ve never had to give a
separate mylohyoid.
If you have a hot tooth, a tooth you’re going to extract or
that you need to do a root canal procedure on because it’s
abcessed, that’s a lot harder to get numb. I’m still going to do
the Gow-Gates and then I might use an intraosseous around
the tooth, or PDL injections to get it. But the Gow-Gates works
well because you’re so high up on the innervation pathway.
You target the anterior-medial aspect of the neck of the condyle.
With the mouth wide open, the condyle translates out
just immediately lateral to the foramen ovale. So you’re right
next to where this whole big nerve trunk is coming in to the
infratemporal fossa. If you drop your anesthetic bolus there
and keep the patient’s mouth wide open – Dr. Gow-Gates recommended
for a full 90 seconds after you finish the injection
— you keep that bolus right there next to the nerve. If there
are any accessory branches coming off of anywhere along the
trigeminal nerve pathways, you’re still catching them right at
the source.
Q9: How long do you wait after a Gow-Gates injection to test
for anesthesia?
AB: Gow-Gates has a slower onset because you’re approaching
such a large nerve trunk. The most peripheral fibers are
going to the back of the mouth. The fibers at the center of
that big nerve bundle are coming out to the tip of the tongue
and the lip, and so you must wait at least five minutes. The
study I like to quote, shows that it’s at ten minutes when the
Gow-Gates injection is really going to give you the absolute
best result. Within the five minute window I should be getting
some signs that the anesthesia has taken effect, and if so
I’m going to wait a little longer and double-check it for signs
of full anesthesia. If I’m not getting signs after 5 minutes,
I may conclude that I’ve missed it and give a second Gow-
Gates injection.
Q10: Some esthetic clinicians are advocating the use of the
Anterior Middle Superior Alveolar injection, the AMSA, because it
numbs all the maxillary anterior teeth. Do you use this injection
if you are working on 8 anterior teeth rather than going around
and giving numerous infiltrations? It seems counter-intuitive,
being a palatal injection. Tell us a little about it.
AB: There are actually two AMSA techniques, a facial approach
and a palatal approach. The palatal injection technique is
actually one that was first described in the 1920s. When
the Wand first came out they really pushed this palatal AMSA
technique but it has never really caught on. The whole principle
of this technique is that rather than doing the standard
facial approach AMSA injection, which is properly called the
infraorbital block injection given on the face just below the
eye, which is a true block, when you do the palatal approach
you’re further down on the pathway of the anterior and middle
superior alveolar nerves, at the junction where the vertical
process of the maxilla meets the horizontal hard palate.
If you take a line perpendicular to the midline palatal raphe
and extend it out to where it meets the two bicuspids halfway
along that line, you’ll be at that junction. Drop your anesthetic
there, a small amount, very slow injection, and you’ll
get anterior and middle superior alveolar anesthesia. Now the
beauty of this injection is that you don’t get lip anesthesia
like you do with the infraorbital, but you do get buccal soft
tissue anesthesia around the teeth. You get palatal, pulpal
and buccal anesthesia so you can do work from the second
bicuspid forward. It might be a little fuzzy at the second
bicuspid because you’re getting a little innervation coming in
from the posterior, the PSA, so I always give a little infiltration
behind there as well. By the way, infiltrations on the maxilla,
pretty much the only thing I’m giving these days is Septocaine.
Lots of times it gives me palatal anesthesia as well buccal.
Not on everybody, but most of the time.
Q11: You’re absolutely right about the Septocaine. It seems as
though I can pack cord on the lingual on nearly everybody without
any problems. Maybe once or twice every couple of months I
am not able to and need to give a little palatal soft tissue anesthesia.
So you like the AMSA injection?
AB: Well, with the palatal AMSA, you’ve got maxillary anterior
anesthesia without having the lip numb, which is helpful
for esthetic dentistry. But there are two drawbacks with it.
One, it’s a palatal injection, so you have to give it real slow
and #2 it doesn’t have as good duration because it’s not a true
block. It’s in between a block and an infiltration. For veneer
cases, where you want to keep the smile line and you’re not
going to be in there very long, it’s a real efficient way to do it.
But if you’re going to be doing crown preps from bicuspid Í
to bicuspid, in my opinion, I’d rather use the infraorbital and
the nasopalatine.
20 Questions with Dr. Alan Budenz

Q12: So you’re going to be giving an infraorbital and a nasopalatine
if you are doing crowns from second bicuspid to second
bicuspid? As opposed to giving 8 infiltrations over those teeth?
AB: Yes. I want blocks. As a rule of thumb a block will give
you twice as long a duration of anesthesia as an infiltration.
That’ll depend a little bit on your anesthetic and other
variables. But if you want hemostasis, if you’re gong to be
doing root planing or surgery or subgingival preps, anything
where you know you’ll be getting some bleeding, I will do
local infiltration using ideally Lidocaine with 1 to 50,000
epinephrine. That one little infiltration will give me a great
deal of hemostasis in a localized site. If I use 1 to 50,000, for
an I.A. block, my anesthesia will be about the same duration
as 1 to 100,000 but it won’t give me good hemostasis. So for
blocks, I want to use as low a concentration of vasoconstrictor
as I can. For example, Septocaine now has the 1 to 200,000
epi solution available and there are a number of studies
now, which are all quite similar, that there is no significant
difference in duration. It’s a little bit shorter duration with
1 to 200,000 than 1 to 100,000, but clinically it’s not really
significant. So why not use the safest one with the lowest
concentration? But if I am going to use it for hemostasis as a
local infiltration, I am going to use the highest one I can get
my hands on.
Q13: I have to tell you that I don’t know any of my friends who
are giving infraorbital injections with a nasopalatine for anterior
crowns like that, I think most of them are still giving 8 infiltrations.
Do you think there are a lot of GP’s using your technique?
AB: No
14: Can you explain to me how exactly you do it? Or do you even
recommend that the average GP does this?
AB: Absolutely, I have no hesitation. So what you do is feel
the lower rim of the orbit. You feel for the lowest part of the
rim, but it’s not right in the center. It is actually more towards
the base of the nose. Drop your finger down 1cm below that
rim and your finger is right over the foramen. And with many
people, if they’re a little bit thin there, you can press and they
can feel a little bit of nerve tingling. So you are right over
the foramen. Keep one fingertip there and I take my other
fingertip, usually my thumb and slide it up into the top of the
maxillary vestibule in the area of the cuspid to bicuspid. That
distance between those two fingertips is going to be the depth
of my penetration of the needle.
Q15: I am doing it on myself as you talk, and it doesn’t feel very
deep. It feels like a quarter inch or a half-inch to me.
AB: Yeah, for most people it’s less than 10mm, less than a
centimeter. So it’s not a big deal. So then I’m going to insert
a needle up into the top of the vestibule paralleling the slope
of the maxillary bone there until I feel that needle right up
underneath my fingertip that’s outside over the foramen.
Q16: So where’s the puncture point in relation to the crowns on
the teeth?
AB: I’m coming in really more over the bicuspids. I use a little
more posterior approach because it’s more comfortable, you
know, away from the midline. The technique I was taught in
school you came in over the lateral to cuspids and that brought
you in close to the base of the nose and patients always feel
that, so you go further posterior and it’s not as sensitive. I’m
coming into the vestibule over the bicuspids and paralleling
the bone until my needle is in about a centimeter so it’s right
up underneath my fingertip. I stop, aspirate, drop my bolus of
anesthetic and then with that same finger that’s been outside
the mouth the whole time, I just massage the bolus into the
foramen. I give the injection with the patient lying down and
I keep the patient lying down. Then that anesthetic is either
going to dissipate into the soft tissue or it’s going to flow
down into that foramen.
Q17: How often do you get a positive aspiration on that infraorbital
injection?
AB: Not very often. There are little blood vessels there but
they’re small enough to be of little consequence. And I give it
slowly. I give all my injections very slowly. To me it’s all about
patient comfort, but it’s also about safety. If I see any blanching
there, I’m giving it too fast. I shouldn’t see that.
Q18: So when you successfully give the infraorbital block, what
gets anesthetized?
AB: It’ll anesthetize the lip, the buccal soft tissue, and the
pulps of the anterior teeth cuspid to central. It won’t get
palatal soft tissues and it may or may not get the pulps of the
bicuspids. So I may have to infiltrate over the bicuspids in
some cases, maybe 25% of the time.
Q19: Do you think it’s safe to say that in dental school fifty years
from now or in general practices fifty years from now that the
Gow-Gates might be the routine and the IA blocks kind of the
thing of the past?
AB: It could be, but I honestly don’t think of it in those
terms, Mike, because to me, I want to know as many tricks
as possible, if “tricks” is the right word. No two people are
put together the same and there are always these oddball
situations where it helps to know different techniques. The
conventional IA technique has been around since the 1880’s,
it’s got a good track record. You know, I started using the
Gow-Gates initially because when my regular lower block
didn’t work I wanted a back up technique. And the Gow-Gates
technique usually worked. Then I started reading about it and
I was seeing the higher success rates in the literature and I
thought, if this is so successful, then why don’t I do this all
the time and use the other one, the conventional technique,
just when I need to for an alternative. And so now I almost
exclusively use the Gow-Gates. But I think it’s good to know
all the techniques. That’s my opinion.
And another troubleshooting tip is that, I advocate caution
giving additional inferior alveolar injections if the first one
doesn’t work. If I give an inferior alveolar nerve block conventional
technique, I was taught if you didn’t get it the first time,
to go a little higher and little deeper the second time, and, you
know, it usually worked.
Q20: By higher, by deeper, do you mean to the hub or do you
mean medially versus laterally? What do you mean by deeper?
AB: Well, that’s a great question because you are never quite
sure what people are referring to when they say that’s what
they do. By going a little bit higher I’m talking about a quarter
of an inch at the most higher up on my thumbnail at the
anterior border of the mandible. As far as deeper, what I’m
referring to is a slightly more posterior injection site, not necessarily
going in deeper with the needle because the bone
should still be in the same place, so it’s just that my injection
site is slightly more posterior than my initial one.
But what I’ve found reading the literature is that that higher
and deeper technique also led to increased incidents of positive
aspirations. I don’t really want to be more successful with
anesthesia at the risk of causing more bleeding. And that again
is what led me to look more closely at the Gow-Gates.
I didn’t start out using the Gow-Gates, I started out using
it only for back up and the more I used it the more I got
comfortable with it. Everything points to it being safer, being
more effective, being more efficient, and that’s why I’m a big
believer in it now.
Michael DiTolla: I’ve learned some great stuff today and if we
just inspire one or two people to take a look at their local anesthetic
procedures, and they can add a new technique that will
keep a patient comfortable while they are having dentistry done,
I think we’ve done our job. I look forward to taking
your cadaver course at the CDA meeting,
and thank you so much
for your time today.
AB: My pleasure
Mike,
I enjoyed talking
with you.
20 Questions with Dr. Alan Budenz

Carpe Diem!
NOW
is the time to help patients value the importance of their dental office as their partner for great health
– ARTICLE by Gary Takacs
– PHOTO by Ed Pelissier
Perhaps the biggest challenge we have in the dental
profession is creating value in our patients’ minds for the
services we provide. In the most simplistic sense, patients
accept treatment recommendations and keep their appointments
because they value the care we provide. In the not-sodistant
past, many patients seemed to disconnect their dental
health from their overall body health. That situation is changing
dramatically.
Today, good health is a valued commodity and the great news
is that there is a growing body of evidence that links good
dental health to good overall body health. While this link is
hardy new, what is new is that the general public is beginning
to understand how oral health has a dramatic impact on general
health. As a result, we have a wonderful window of opportunity
to help our patients place greater value on the care we
provide.
Let me present some proof of how the public is being educated
about the link between daily. Some of this information is from
the scientific community and some comes from the media.
Recently, I saw a segment on the ABC television show Good
Morning America discussing the link between periodontal
disease and pancreatic cancer. In this segment, Diane Sawyer
and Dr. Timothy Johnson discussed some recent research that
demonstrated a possible connection between perio disease
and pancreatic cancer. At the end of the segment, Dr. Johnson
looked directly into the camera as if he was talking to a
particular person in the audience and said, “So, what does this
mean to you as a viewer. Well, what it means is that if you are
not going to the dentist you need to be under the care of
a dentist because today going to the dentist is not just about
your teeth, it’s about oral health and general health. New
information on the oral-systemic link emerges almost your
total body health.”
I wanted to stand up and cheer!! What a great message for
the public and it was right there on the screen stated by a
respected authority.
Here’s more proof of how this message is spreading to the
public. Colgate-Palmolive is currently running an advertising
campaign with Christie Brinkley as spokesperson, focusing
on educating the public about the link between perio disease
and systemic health. In the ads, she talks about how perio
disease has been linked to heart disease, diabetes, pancreatic
cancer, pre-term low birth weight and other systemic concerns.
On the Colgate website, Brooke Shields is also featured in a
segment discussing the link between dental health and overall
body health.
As another example, the magazine Scientific American recently
published an entire special issue entitled “Oral and Whole
Body Health” with an absolute wealth of information designed
for health care professionals and patients alike.
In the spirit of Dr. Timothy Johnson from Good Morning
America, I’ll ask the question, “So, what does all this mean
to you?” In my opinion, it can be nothing but good news
when we have Diane Sawyer, Christie Brinkley, Dr. Timothy
Johnson, Brooke Shields, at least one major magazine, and
countless other media channels educating the public that
indeed, good oral health may be connected to overall health!
All of this exposure presents a wonderful opportunity to build
value for our role in helping patients become as healthy as
possible.
However, I would not suggest sitting passively by and hoping
your patients become educated about the link between oral
health and systemic health. Rather, I’d recommend a proactive
approach where you take the lead in helping your patients make
this connection. Following are three specific recommendations
that will help your office take this proactive approach.
The first recommendation is a very simple one
to initiate, namely, take a blood pressure reading at the beginning
of all exams in your practice. In addition to the value of
the information that you and your patient receive by taking
a blood pressure measurement, this simple step has the
wonderful effect of symbolically connecting the dental visit
with overall health. This simple step will create lasting benefits
in your practice.
The second recommendation is to create a system
for oral cancer screening in your practice. Each year, more
than 30,000 Americans are diagnosed with oral cancer and
Practice Management

some 9,000 people die of this dreaded disease. Early detection
and treatment of oral cancer can reduce the mortality
rate Í dramatically and the dental office should be the first
line of defense in early detection. Most hygienists and dentists
conduct an oral cancer exam as part of the patient visit, yet
many patients have absolutely no idea that they have received
an oral cancer exam.
I have routinely conducted exit interviews with patients and
asked them for their feedback so we can improve the practice.
Among other questions, I ask if they received an oral cancer
screening exam today, knowing full well that one was done.
Many patients respond with an outright, “no” or “I really don’t
know.” If you did the screening and the patient is not aware
of it then you have lost an important opportunity to create
value. Tell your patients you are doing an oral cancer exam;
they will appreciate it and it will reinforce the dental/systemic
health connection.
You should also review the manner in which you do this exam
to be certain it is as thorough as possible. In addition to your
visual and palpitative exam, I would also recommend installing
a system such as the VisiLite process to further enhance
the oral cancer screening system in your practice. Also, let’s
not forget that initiating a system for oral cancer screening in
your office may well result in saving lives.
The third recommendation I have is to revisit
your system for conservative perio therapy and update it to
21st century standards. If you do not have a state-of-the-art
system in your practice for perio diagnosis and treatment,
now is the time to develop one. There have been significant
advances in the science of the diagnosis and treatment of
perio disease in the last few years and most offices could
benefit significantly by reviewing protocols here.
For example, science now provides us with the capability of
conducting a very simple DNA test resulting in the identification
of the specific bacteria causing that patient’s perio disease.
With the identification of the specific bacteria, a proven treatment
regimen can be provided targeting those bacteria. (Visit
www.addx.us for more information about this DNA testing
process). This science provides a level of exactness that will
result in improved clinical results in the treatment of perio
disease. As part of your improved system for perio diagnosis
and treatment, set up very specific probing and exam protocols
for all patients and educate the entire team on great verbal
skills to use to educate your patients about perio disease and
how modern treatment can help them become as healthy as
possible. With all the news and coverage about the link
between perio disease and overall body health, you will find
that your patients are more receptive than ever to your education
and treatment recommendations.
Now is an absolutely incredible time to be in the dental
profession! There has never been a better time to educate your
patients and the general public about the importance of how
good oral health is connected to good general health. You are
getting a huge “assist” from the media today about this link
and it is important that you leverage this opportunity to full
advantage. Consider the three recommendations in this article
as a way to take a proactive approach that demonstrates your
interest and commitment to helping your patients become as
healthy as possible. The end result will be that your patients
will place increased value on the importance of their dental
office as a partner in achieving great health.
Author Credit: Gary’s life work and passion is helping dentists and their team members
develop a more profitable and enjoyable practice. He is a sought-after speaker at national
and international dental meetings where his informational courses are often recognized
as the most fun and entertaining courses that attendees have ever experienced.
Gary is also the founder of Ride and Learn, and Race and Learn, perhaps the most
unique continuing education programs in dentistry today. Ride and Learn combines a
Harley Davidson motorcycle tour with dental CE and Race and Learn combines high
Practice Management

Planning the
PRESCRIPTION
– ARTICLE by Gerard J. Chiche, DDS
– COVER PHOTO by Kevin Keithley
When the a patient comes to consult for Esthetic Treatment, the consultation
appointment is divided into 1) a conventional evaluation with charting, periodontal,
occlusal and radiographic surveys; 2) diagnostic models and photographs; 3) an
esthetic evaluation involving an esthetic analysis and a focus on the patient’s esthetic
requests.
The media image displayed in many advertisements has a very strong influence
in contemporary dental treatment. Increasingly, today’s smile is part of a youthful
dynamic appearance characterized by whiter teeth which often fall beyond the
range of traditional shade guides. To that extent it is possible to identify two types
of patients: “perfect-minded,” and “natural-minded.” Í
Planning the Shade Prescription

Figure 1: Right lateral view of an ideal smile for a
“perfect minded” patient.
Figure 2: Right lateral view of an ideal smile for
a“natural-minded” patient. (In collaboration with
Dr. Basil Mizrahi).
Figure 3: Left lateral view of an ideal smile for a
“natural-minded” patient. (In collaboration with
Dr. Basil Mizrahi).
CATEGORY 1
Patients in the first category will typically
expect maximum regularity and
alignment along with maximum brightness
and a “generally sparkling effect.”.
It will be critical to provide for these
patients a straight dental midline, a
regular smile line, often flatter than the
curvature of the lower lip, symmetric
central incisors, lateral incisors and
canines, along with symmetric gingival
margins. (Fig. 1, right lateral view of an
ideal smile for a “perfect minded” patient).
CATEGORY 2
Natural-minded patients will typically
expect a general sense of regularity and
alignment along with definite brightness,
but do not wish their teeth to be
noticed at every turn. In any pleasant
smile, pleasing tooth symmetry is found
close to the midline, therefore the central
incisors must be mostly symmetric
with only minor irregularities (a central
incisor may be more mesially inclined
than the other, and the distal incisal
angle of the central incisors may be
bilaterally asymmetric). The main asymmetry
will be provided between the lateral
incisors. The canines will also provide
minor asymmetry as their gingival
margins and their cusp tips do not need
to be leveled horizontally. The depth
of the incisal embrasures should be of
a natural depth in addition to providing
a natural progression (Figs. 2 and 3).
These pictures also illustrate the need to
provide these patients with subtle polychromatic
effects: incisal halo, streaks
and increased cervical saturation.
When planning the shade prescription, one must bear in mind that the most frequent
shade variation from the basic shade of an anterior tooth is observed in nature at
the incisal third. The next most frequent category observed is when the shade distribution
is nearly uniform, resulting in a monochromatic appearance. In the third
category, the color deviation from the basic shade is observed at the cervical third
mostly, and finally in the fourth group, the shade variation involves the middle
aspect of the tooth.
In order to give the patient an idea of what incisal effects are possible, the incisal
aspect of the shade tab is discussed with the patient after the basic shade is selected.
The patients’ reaction usually is to prefer incisal effects similar to the shade tab if
they are natural- driven, and to attenuate the effects to the maximum if they are
perfect-driven.
There are three typical scenarios that may be transmitted to the dental ceramist:
SCENARIO 1
Lightly Monochromatic
Figure 4
Shade Design
Figure 5
It is very common to find patients who are so displeased by the dark appearance
of their teeth that they end up requesting very monochromatic and high brightness
restorations (Fig. 4, 5). The shade prescription is accordingly straightforward and
uncomplicated and the dental ceramist will assume that the incisal effects are very
tenuous and hardly noticed. Í
Planning the Shade Prescription
Planning the Shade Prescription

2SCENARIO 2
Lightly Polychromatic
Shade Design
Figure 6
Figure 7
SCENARIO 3
Lightly Monochromatic
Shade Design with
Effects
Figure 8
Figure 9
There are situations where several shades and various degrees of discolorations
coexist in the same mouth. Also, there are situations where different ceramic systems
are present and do not perfectly match with one another.
In such situations, the rule is to assure for maximum patient’s acceptance of the
restorations that by keeping the central incisors at a slightly higher value than the
other anterior teeth. If the value of the central incisors ends up a slightly lower
value due to some excessive translucency for example, then it is very likely that the
patient will reject the final result, even with the best designed proportions, display
and length. Therefore, in situations where the patient desires a natural appearance
or when several different colors or ceramic systems are expected in the final outcome,
a lightly polychromatic system should be considered.
Typically, a mild transition in shades will be produced whereas the central incisors
have the highest value, followed by the lateral incisors and finally the canines.
Whenever possible, this effect should be very soft. However, it allows for an easy
transitions from a light central incisor to a dark canine which was not bleached (Figs.
6 and 7). It is very important in such transitions to keep the value of the lateral incisor
closest to the central incisor even if the canine is of a much lower value.
The typical incisal effects found on unworn incisors include: 1. Halo effect;
2. Transparent incisal Border; 3. Dentin Streaks or mamelons; and 4. Proximal
translucency (Figs. 8 & 9). These are the typical shading effects young unworn
incisors have, imparting a very pleasing effect to the tooth shade overall. The
incorporation of these effects for the natural-driven patients yields the above shade
prescription. It is recommended that the clinician provides in such situations the
same template each time so that nuances and variations recorded from patient to
patient may be more easily interpreted.
Fig. 2, 3, 6, 7, 8, and 9 are reproduced from the textbook by Chiche G., Aoshima H.: Smile Design. Quintessence Pub.
Co. Inc. Chicago 2005.
REFERENCES
1. Mc Lean, JW.: The Science and Art of Dental Ceramics. Louisiana State University School of Dentistry, Monographs
I and II, (1974) III and IV (1976)
2. McLean JW.: The science and art of dental ceramics. Quintessence Pub. Co. Inc. Chicago 1980.
3. Sproull R.C.: Color matching in dentistry. Practical applications of the organization of color. J. Prosthet. Dent.
29:556;1973.
4. Jinoian V.: The importance of proper light source in metal Ceramics. In: Preston J.D.: Perspectives in Dental ceramics.
Proceedings of the Fourth International Symposium on Ceramics. pp 229. Quintessence Pub. Co. Inc. 1988,
Chicago.
5. Hegenbarth E.A.: The Creative Color System. Quintessence Pub. Co. Inc. 1989, Chicago.
6. Miller L.L.: Scientific approach to shade matching. In: Preston J.D.: Perspectives in Dental ceramics. Proceedings
of the Fourth International Symposium on Ceramics. pp 193. Quintessence Pub. Co. Inc. 1988, Chicago.
7. Nakagawa Y. at al.: Analysis of natural tooth color. Shikai Tenbo 46;527;1975
8. Sekine M. et al.: Translucent effects of porcelain jacket crowns. 1. Study of translucent patterns in the natural teeth.
Shika Giko 3:49;1975.
9. Chiche G., Pinault A.: Esthetics of Anterior Fixed Restorations. Quintessence Pub. Co. Inc. Chicago 1994.
10. Chiche G., Aoshima H..: Smile Design. Quintessence Pub. Co. Inc. Chicago 2005. Consultant Noritake co.
Planning the Shade Prescription
Planning the Shade Prescription

Lip Lines and
Spider Lines
– ARTICLE by Bradley Evans, MD, DDS, MS
– Images courtesy of Medical Matrix, LLC
Facial Correction without Injection:
Angellift ® Pricing and Technology Update
Lower Lip
Recession
Deep Nasolabial
Folds
Laugh Lines
Smoker Lines and
Chin Depression
In June of 2006, Angellift was introduced to the dental industry as a technique and device to remove lower facial wrinkles.
Within 6 months Angellift was featured on NBC, FOX, CBS, CW and appeared throughout the Canadian press. Consumer
response to our media coverage has been extraordinarily enthusiastic and deeply gratifying. Clearly the dental industry now
has an effective, comprehensive tool in the competition for the consumers’ anti-aging dollar.
Last year, Americans spent 2.2 billion dollars fighting facial wrinkles with injectable materials. Until the introduction of Angellift,
most dentists could not offer comparable alternative anti-aging services to this booming industry as it was considered to be
practicing beyond the legal scope of general dentistry.
Extraordinary consumer demand for the Angellift device throughout North America, has enabled us to REMOVE THE PRICING
CEILING in order to charge an appropriate fee for their professional services. The new pricing structure enables additional profits
where demand is highest without negatively impacting sales in areas where Angellift consumer awareness is relatively new.
In addition to the new retail pricing flexibility, Angellift is introducing the Preview ® , a soft, flexible strip which allows you to
promote and evaluate a patient for Angellift within seconds. The Preview is a patented, flexible, surgical silicone based strip
with an imbedded titanium wire that allows you or your staff too safely, comfortably and quickly demonstrate to a patient the
effectiveness of the Angellift without the need for an impression or
timely consultation. The
Previw can be placed in the mouth for a quick cosmetic pre-
view, during a
routine exam, cleaning or even front desk consultation. This
could never be done with Botox ® or dermal fillers.
Women spend more money on skin care and cosmetic products
and services than the combined total spent on porcelain veneers,
teeth whitening and orthodontics. The combination of our new
pricing flexibility and ease of the Preview puts your practice
in the sweet spot of this extraordinarily profitable market.
Unlike any shot or injectable dermal filler, Angellift is hypoal- l e r -
genic, removable and doesn’t pose any of the inherent dangers related to
injections, chemical peels, fillers or surgery. Combining these benefits
with the new
Preview and our revised retail pricing policy, Angellift can bring you new
patients, expand
the scope of your practice and make your practice even more profitable.
Upper Lip
Depression
Angellift and Preview are registered trademarks of Medical Matrix, LLC, San Diego, CA.
Botox is a registered trademark of Allergan, Inc. Irvine, CA.
Angellift: Facial Correction without Injection
Angellift: Facial Correction without Injection

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