PDF Version - Glidewell Dental Labs

Chairside® 

A Publication of Glidewell Laboratories • Volume 8, Issue 1 

Photo Essay 

Another Use for Anterior 

BruxZir ® Restorations 

Page 22 

Small-Diameter Implants: 

Poor to Excellent Function in 

One Day! 

Dr. Ara Nazarian 

Page 14 

Embezzlement and the 

Dental Practice 

An Interview with 

Prosperident CEO David Harris 

Page 44 

The Viability of Prosthetic 

Tooth Repositioning 

Dr. Robert Lowe 

Page 55 

Dr. Michael DiTolla’s 

Clinical Tips 

Page 9 

COVER PHOTO 

Jennifer Folbigg, Customer Service Representative 

Glidewell Laboratories, Newport Beach, Calif.

Contents 

9 Dr. DiTolla’s Clinical Tips 

Showcased in this issue are a cloud-based platform I 

recently demoed from Smile Reminder that offers an 

impressive suite of personalized patient communication 

tools for growing your patient base, and an invaluable 

oral hygiene product from Dental Herb Company to 

aid in your practice’s fight against periodontal disease. 

Also featured are two innovative products designed 

to make your dentistry easier and more efficient: a 

sectional matrix system from Triodent for performing 

high-quality Class II restorations, and an LED curing 

light from Ivoclar Vivadent that features a compact, 

ergonomic shape to fit any dentist’s hands. 

14 Poor to Excellent Function in One Day! 

“Mini” or small-diameter implants offer many benefits 

for patients seeking maxillary and mandibular overdenture 

treatment. Dr. Ara Nazarian presents a case 

report featuring Glidewell’s Inclusive ® Mini Implants 

that demonstrates the protocol for the placement of 

these small-diameter implants, and the subsequent 

beneficial effects they have on the function and retention 

of the patient’s new prostheses. 

22 Photo Essay: Another Use for Anterior 

BruxZir ® Solid Zirconia Restorations 

In this photo essay, I address a difficult situation 

restorative dentists face in clinical practice: treating a 

patient with severe tetracycline staining. The patient 

in this case presented the additional challenges of 

severe bruxism and an edge-to-edge bite. I chose 

BruxZir crowns because I knew these high-strength 

restorations would not only withstand the destructive 

forces generated in his mouth, but would also have a 

better chance than a glass-ceramic material of completely 

blocking out the dark stump shades. 

Visit www.chairsidelive.com to view the latest episode of 

our weekly Web series “Chairside Live.” Also available on 

YouTube and iTunes. 

Contents 1

Contents 

38 Chairside Live Case of the Week: 

Episode 32 — A Disastrous Double-Arch 

Impression Tray 

This new column highlights a Case of the Week from 

a recent episode of our weekly Web series “Chairside 

Live.” The first case comes from Episode 32 and 

addresses one of my dental pet peeves: when our lab 

receives a bridge impression taken in a double-arch 

tray. While double-arch impressions can be suitable for 

a single-unit crown or two single-unit adjacent crowns, 

they are best avoided for multi-unit restorations. 

44 One-on-One with Dr. Michael DiTolla: 

Interview of David Harris 

According to Prosperident CEO and licensed private 

investigator David Harris, embezzlement will strike 

three in five dentists in their careers. While this statistic 

may surprise you, it doesn’t need to discourage you. In 

this issue’s featured interview, the man known in dental 

circles as “the dental fraud guru” shares his expert 

perspective on embezzlement in the dental office. 

Chairside Magazine Digital Edition 

Chairside magazine is now optimized for all popular 

desktop, tablet and smartphone platforms! To try out 

the new beta version of our digital magazine from 

your desktop computer or favorite mobile device, visit 

www.chairsidemagazine.com. 

55 Prosthetic Tooth Repositioning: A Viable 

Treatment Option for Select Cases 

For a select group of patients with minor tooth 

malposition, such as spacing, crowding, minor rotations 

and facial-lingual arch form displacement, esthetic and 

functional correction may be accomplished purely by 

restorative means, claims Dr. Robert Lowe. Three case 

reports demonstrate how prosthetic tooth repositioning 

can be a viable treatment option for these types of 

malocclusions when proper guidelines are followed. 

64 Biologic Shaping from a Restorative 

Perspective 

Dr. Daniel Melker focuses on the concept of biologic 

shaping in this article, outlining the numerous 

differences between this root-reshaping procedure 

and traditional crown lengthening. A case example 

illustrates how this periodontal corrective procedure 

can provide the restorative dentist with a predictable 

and successful method of restoring teeth. 

2 

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Contributors 

Michael C. DiTolla, DDS, FAGD 

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

of clinical education and research at Glidewell Laboratories, he performs clinical testing on new products 

in conjunction with the company’s R&D department. Glidewell dental technicians have the privilege of rotating 

through his operatory and experiencing his commitment to excellence through his prepping and placement of 

their restorations. Dr. DiTolla is a CR evaluator and lectures nationwide on restorative and cosmetic dentistry. 

His clinical programs are available on DVD and online through Glidewell Laboratories. For more info on his 

articles or for a free copy of his clinical presentations, call 888-303-4221 or e-mail mditolla@glidewelldental.com. 

David Harris, MBA, CMA 

David Harris is a licensed private investigator, with a graduate business degree and a professional accounting 

designation. He is CEO of Prosperident, the world’s largest dental embezzlement investigation firm. Prosperident 

is consulted on hundreds of dental embezzlement matters annually, and David has frequently had the pleasure 

of hearing cell doors slam shut on perpetrators. David has lectured at several universities in the faculties of 

dentistry, business and law, and he has been interviewed on embezzlement by virtually every major North 

American dental magazine. David is a member of the Academy of Dental Management Consultants (ADMC) 

and the Speaking Consulting Network. Contact him at 888-398-2327 or www.dentalembezzlement.com. 

Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE, FASDA 

Dr. Robert Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982 and was 

a clinical professor in restorative dentistry at the school until its closure in 1993. Since January 2000, 

Dr. Lowe has maintained a private practice in Charlotte, N.C. He lectures internationally and his work 

is frequently published in well-known dental journals on esthetic and restorative dentistry. Dr. Lowe has 

earned Fellowship in the AGD, ICD, ADI, ACD and American Society for Dental Esthetics (ASDA), and 

received the Gordon Christensen Outstanding Lecturers Award and Diplomat status on the American Board 

of Esthetic Dentistry. Contact Dr. Lowe at 704-450-3321 or boblowedds@aol.com. 

Daniel J. Melker, DDS 

Dr. Daniel Melker graduated from the Boston University School of Graduate Dentistry in 1975 with specialty 

training in periodontics. Since then, he has maintained a private practice in periodontics in Clearwater, 

Fla. Dr. Melker lectures at the University of Florida Periodontic and Prosthodontic graduate programs on 

the periodontic-restorative relationship. He also presents at the University of Alabama at Birmingham, 

University of Houston, Baylor University and Louisiana State University’s graduate periodontal programs. 

Dr. Melker has published several articles in national dental magazines, and he has twice been honored with 

the Florida Academy of Cosmetic Dentistry Gold Medal. Contact him at 727-725-0100. 

Ara Nazarian, DDS, DICOI 

Dr. Ara Nazarian maintains a private practice in Troy, Mich., with an emphasis on comprehensive and 

restorative care. He is the director of the Reconstructive Dentistry Institute, a Diplomate of the ICOI, and has 

conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the U.S., 

Europe, New Zealand and Australia. Dr. Nazarian is also the creator of the DemoDent ® patient education 

model system. His articles have been published in many of today’s popular dental publications. Contact him 

at 248-457-0500 or www.aranazariandds.com. 

4 

www.chairsidemagazine.com

Publisher 

Jim Glidewell, CDT 

Editor-in-Chief and Clinical Editor 

Michael C. DiTolla, DDS, FAGD 

Managing Editors 

Jim Shuck; Mike Cash, CDT 

Creative Director 

Rachel Pacillas 

Copy Editors 

Jennifer Holstein, David Frickman, 

Chris Newcomb, Megan Strong 

Statistical Editor 

Darryl Withrow 

Digital Marketing Manager 

Kevin Keithley 

Graphic Designers 

Jamie Austin, Deb Evans, 

Joel Guerra, Audrey Kame, Phil Nguyen, 

Kelley Pelton, Makara You 

Web Designers 

Jamie Austin, Kevin Greene, 

Allison Newell, Melanie Solis, Ty Tran 

Photographer 

Sharon Dowd 

Videographers 

James Kwasniewski, Sam Lea 

Illustrator 

Wolfgang Friebauer, MDT 

Editor’s Letter 

The crowns & bridges produced at Glidewell Laboratories 

are now made using essentially 100 percent CAD/CAM 

technology, and I really notice the difference in the 

restorations I get back from the lab. The crowns just fit, and 

if I give them enough reduction, I can always get contours 

like a natural tooth. Before we started using CAD/CAM, the 

most frequent complaint we used to hear from dentists was 

about our consistency, so this technology really has been a 

game changer for our lab and our customers. 

More than a decade ago, new customers would tell me that 

they would get three great crowns from us and then two soso 

crowns, then another great one, then one ugly one, and so 

on. We were doing everything we could to fix those issues, 

but the underlying problem went deeper than our lab: there 

simply weren’t enough trained dental technicians available. 

There are currently only 18 accredited dental laboratory 

programs in the U.S. If that number seems shockingly low 

to you, it’s because it is. That number is down 62 percent 

since 1992 — a drastic decrease for that 20-year period. In 

fact, today these programs currently produce only about 300 

graduates annually for the entire U.S. To meet our demand, 

we had to hire people off the street and train them ourselves. 

But it takes time to develop as a technician, just as it does 

as a dentist. 

In 2007, Ivoclar Vivadent’s IPS e.max ® was introduced 

into our lab, and with this first high-strength, monolithic 

restoration came the day where a machine did most of 

the work. Ideal contours were found in CAD libraries, and 

dentists just had to give CAD technicians enough room to 

drop them in. Then in 2009, Glidewell launched BruxZir ® 

Solid Zirconia, signaling the next wave of the monolithic 

revolution. A year later, nearly all of our PFM crowns were 

produced using CAD/CAM as well. 

Coordinator and Ad Representative 

Thanks to our president and CEO’s unwavering commitment 

Teri Arthur 

to technology, we are able to give you, our dentists, the 

(teri.arthur@glidewelldental.com) 

consistency and predictability you’ve always wanted. Dentists 

often tell me that a BruxZir crown fits better than any 

If you have questions, comments or complaints regarding 

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

other crown they have prescribed. It’s a good time to be a 

chairside@glidewelldental.com. Your comments may be 

dentist, and it’s a great time to work with a lab that has fully 

featured in an upcoming issue or on our website: 

embraced the consistency of CAD/CAM dentistry. 

www.chairsidemagazine.com. 

Neither Chairside Magazine nor any employees involved in its publication 

(“publisher”), © makes 2013 any Glidewell warranty, Laboratories 

express implied, or assumes 

any liability or responsibility for the accuracy, completeness, or usefulness 

Chairside of any information, magazine apparatus, nor any employees product, involved or process in its disclosed, publication or 

Neither 

(“publisher”), represents makes that its any use would warranty, not express infringe proprietary or implied, rights. or assumes Reference any 

liability herein or to responsibility any specific for commercial the accuracy, products, completeness, process, or or services usefulness by 

Yours in quality dentistry, 

of trade any name, information, trademark, apparatus, manufacturer product, or otherwise or process does disclosed, not necessarily 

constitute that its or use imply would its endorsement, not infringe recommendation, proprietary rights. or Reference favoring 

or 

represents 

herein by the to publisher. any specific The commercial views and products, opinions of process, authors or expressed services 

by herein trade do name, not necessarily trademark, state manufacturer or reflect those or otherwise of publisher does and not 

necessarily shall not constitute be used for or advertising imply its endorsement, product endorsement recommendation, purposes. or 

favoring CAUTION: by the When publisher. viewing The the views techniques, and opinions procedures, of authors theories expressed and materials 

do that not are necessarily presented, state you or must reflect make those your of own the decisions publisher about and 

herein 

specific treatment for patients and exercise personal professional judgment 

regarding When viewing the need the for further techniques, clinical procedures, testing or education theories and 

Editor-in-Chief, Clinical Editor 

Dr. Michael C. DiTolla 

shall not be used for advertising or product endorsement purposes. 

CAUTION: 

materials your own that clinical are presented, expertise before you must trying make to implement your own new decisions procedures. about 

mditolla@glidewelldental.com 

specific treatment for patients and exercise personal professional 

judgment Chairside regarding ® Magazine the is need a registered for further trademark clinical of testing Glidewell or education Laboratories. and 

your own clinical expertise before trying to implement new procedures. 

5 

Chairside is a registered trademark of Glidewell Laboratories. Editor’s Letter

Letters to the Editor 

Dear Dr. DiTolla, 

Is BruxZir ® Solid Zirconia (Glidewell Laboratories) 

indicated for inlays/onlays as well as 

crowns? I only hear it mentioned for crowns. 

For patients that insist on tooth-colored restorations 

on second molars, what do you 

place, if anything? I love IPS e.max ® (Ivoclar 

Vivadent; Amherst, N.Y.), but I draw the line 

at the first molars forward. 

– Jeffrey L. Schultz, DDS, FAGD 

Bellaire, Texas 

Dear Jeff, 

BruxZir Solid Zirconia can be used for 

inlays and onlays, as well as crowns. 

We have dentists asking us for BruxZir 

veneers as well, which we can do, but I 

am waiting for some bond strength research 

to conclude before we make any 

recommendations. Veneers are essentially 

non-retentive preps, so we need 

to ensure that our cementation/bonding 

protocol is sufficient to retain them. 

For tooth-colored restorations on second 

molars, BruxZir Solid Zirconia is 

the only choice. However, you need 

to have at least 0.5 mm of occlusal reduction. 

I have a 0.6 mm depth-cutting 

bur in my kit that I use for these restorations, 

and by the time I finish the 

6 

www.chairsidemagazine.com 

reduction it will usually be at 0.7 mm. 

At 0.5 mm, you must reduce the opposing 

if the occlusion is high on the 

restoration; otherwise, the BruxZir restoration 

can fail. Cast gold still holds 

the title as the best second molar restoration, 

but you know as well as I do 

that most patients will not accept it. 

Hope that helps! 

– Mike 


I’m totally blown away by “Chairside Live,” 

which I was intrigued to watch for the first 

time when you interviewed Gordon [Christensen] 

— I believe it was Part 3. First, let 

me congratulate you on the entire concept, 

which I found entertaining, informative and 

just plain fun to watch. You and Megan 

remind me of the old Dan Aykroyd-Jane 

Curtin SNL “Point/Counterpoint” parody. In 

any event, great job! I loved your retching 

skit at the end — hilarious! 

But you know you and your guest can’t 

spew out data without skeptical Michael 

(that’s me) chiming in. As far as Gordon’s 

claim that various drinks such as lemonade 

are 10-times more damaging to the external 

stain on BruxZir zirconia than Coca-Cola, 

a quick search (Yahoo Answers, NEWTON 

Ask-a-Scientist) found that the pH of Coke 

is 2.5, while lemonade is 3.8. On the other 

hand, another site (21st Century Dental) lists 

Country Time Lemonade as having a pH of 

2.5 and Coke Classic at 2.53. Gordon also 

mentioned energy drinks being worse than 

Coke, but this latter site found that Gatorade 

has a pH of 2.95. Bottom line: It’s very 

hard for me to believe that these drinks are 

worse than Coke when it comes to dissolving 

external ceramic stains, and 10-times 

worse? Nah! Even if pH is not the be-all and 

end-all factor, 10-times worse is still hard 

to believe. 

You also stated that Multilink ® Automix 

(Ivoclar Vivadent) was “self-etching,” but in 

fact, it’s the primers in the kit that are selfetching, 

not the cement itself. Minor point, 

perhaps, but your viewers could possibly 

have come away thinking that Multilink 

Automix is similar to RelyX Unicem (3M 

ESPE; St. Paul, Minn.), which, of course, 

it’s not. 

In any event, you again came up with a terrific 

idea, which I have to admit I’m jealous I 

didn’t think of first! 

– Michael Miller, DDS 

Houston, Texas 

Dear Michael, 

Wow, coming from you that is quite 

an honor! I have such respect for 

what you do at REALITY (www. 

realityesthetics.com), and it means 

a lot when one of my mentors takes 

the time to write a letter like this. You 

might even see your letter read on 

“Chairside Live,” which would earn 

you a signed picture of Megan and 

me. I’ll be sure to mark it with a dotted 

line so you can cut me out of the 

picture. Plus, addressing your letter on 

the show will give me the chance to 

prove I know the difference between 

self-etching resin cements and selfadhesive 

resin cements. 

Gordon was referring to an AGD study 

in their journal, General Dentistry (von 

Fraunhofer JA, Rogers MM. Effects of 

sports drinks and other beverages on 

dental enamel. Gen Dent. 2005 Jan-Feb; 

53(1):28-31). 

After that episode aired, a viewer sent 

me this link, http://fit4maui.com/water/ 

pu/bottled_ph.html, which purports to 

measure the pH of different brands 

of bottled water. Could Aquafina and 

Dasani really have a pH of 4? 

Thanks again for the kind words, 

Michael! They mean the world to me. 

– Mike 


I have followed some of your CE courses online. 

I see that you are a fan of SpeedCEM

(Ivoclar Vivadent). Do you use SpeedCEM 

to cement feldspathic porcelain veneers? 

Would you etch with hydrofluoric acid if the 

lab has already done so? 

– Marea White, DDS 

Bedford, Texas 

Dear Marea, 

Nice to hear from you! I am a fan of 

SpeedCEM, which is a self-adhesive 

resin cement similar to RelyX Unicem 

or Maxcem Elite (Kerr Corp.; Orange, 

Calif.). While these cements are strong 

enough for inlays, retentive onlays and 

retentive crown preps, they are not 

strong enough to bond low-retention 

restorations such as veneers. 

Every veneer manufacturer I have 

spoken with still recommends the 

total-etch (now called etch and rinse) 

technique for luting veneers, including 

higher strength veneers like IPS e.max. 

There is one lecturer I know of, Dr. Jose 

Luis-Ruiz, who mentioned to me in an 

interview for Chairside magazine that 

he is using self-etch to place veneers. 

However, he is doing it using a cement 

with a separate self-etch solution. 

PANAVIA F2.0 (Kuraray America; New 

York, N.Y.) and Multilink Automix are 

two good examples of self-etching 

resin cements with separate self-etch 

primers. 

The standard of care today is to use 

the total-etch (etch and rinse) technique 

with a light-cured resin cement 

to place veneers. 

The research I have seen does not 

show any improvement in bond 

strength if you re-etch the veneers 

with hydrofluoric acid in your office 

after try-in, although it is acceptable 

to clean the veneer with phosphoric 

acid. 

– Mike 


I practice general dentistry in Petaluma, 

Calif. A few months ago, I attended one 

of your CE courses through our local 

dental society, Redwood Empire Dental 

Society (REDS). I enjoyed your lecture and 

your sense of humor. Most importantly, I 

really liked all of your practical tips and 

information. I have been practicing since 

2000, and have taken many CE classes, but 

your lecture has made the biggest impact 

on my practice so far. Your preparation and 

impression techniques have helped me 

achieve perfect impressions and my crown 

cement appointments are so enjoyable now. 

My dental lab technician had always told me 

that my preps and impressions were very 

good, but the small changes I made since 

attending your course have helped me 

achieve excellent and consistent results. I 

wanted to thank you and let you know how 

useful your tips have been to my practice 

and to me. I hope you return to this area to 

lecture again. 

– Nadia Navid, DDS 

Petaluma, Calif. 

Dear Nadia, 

Thank you so much for your kind letter. 

I love hearing stories like yours, 

and I know your lab techs will be 

thrilled with your preps and impressions 

as well. They will love you even 

more if you send a digital photograph 

with all anterior cases! I keep playing 

with new products and techniques, 

looking for ways to help dentists get 

better results in a simple, predictable 

fashion. I will be sure to pass any of 

those your way, and I hope I get a 

chance to make it back to your neck 

of the (red)woods soon! 

– Mike 

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Letters to the Editor 7

Numbers 

by the 

2,827,512 

Total number of BruxZir ® crowns placed 

Source: Glidewell Laboratories internal data 

25 

Number of countries where 

BruxZir ® Solid Zirconia is sold 


10.6 

Dentistry personnel per 10,000 people in the U.S. Dentistry 

Source: Wolfram|Alpha, www.wolframalpha.com 

0.39 

personnel per 10,000 people in China 

Source: Infodent International magazine 

✓ 

5,232 

Number of Glidewell 

Laboratories customers 

in 2012 that had 

ZERO remakes 

(160,939 restorations 

were fabricated for 

these customers) 

Source: Glidewell Laboratories 

internal data 

Unemployment rate of U.S. 

1.5% 

dentists (one of the lowest 

of all U.S. professions) 

Source: U.S. Bureau of Labor Statistics 

8 

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15% 

Percentage of anterior 

restorations fabricated at 

Glidewell Laboratories from 

BruxZir ® Solid Zirconia 


#8 & #9 

BruxZir ® Solid Zirconia is the second most 

requested restorative material at Glidewell 

Laboratories for these upper front teeth 

Source: Glidewell Laboratories internal data

Dr. DiTolla’s 

CLINICAL TIPS 

PRODUCT........ Bluephase ® Style 

SOURCE........... Ivoclar Vivadent Inc. (Amherst, N.Y.) 

800-533-6825, www.ivoclarvivadent.com 

Design matters. Apple has taught me over the last 

few years that, regardless of how well an object 

does something, the look and feel of an item play 

an important role in the user’s personal connection 

to it. The original curing lights were gun-shaped, on 

the clunky side and struggled to reach the molars. 

The Bluephase Style LED curing light from Ivoclar 

Vivadent has won multiple design awards, and it 

is easy to see why. We just hired our first female 

dentist, and her hands are tiny compared to mine. 

Considering that more than 50 percent of dental 

school graduates are women, ergonomics is an 

important issue when we are sharing instruments 

such as electric handpieces and curing lights. 

Bluephase Style’s Polywave ® LED technology provides 

a broadband spectrum of 385–515 nm, and it 

will cure every dental material on the market today. 

The 10 mm light probe tip allows you to cure even 

the largest restorations because it can provide 

continuous curing for more than 10 minutes. 

Dr. DiTolla’s Clinical Tips 9


CLINICAL TIPS 

PRODUCT........ Tooth & Gums Tonic ® 

SOURCE........... Dental Herb Company ® Inc. 

(Lancaster, N.H.) 

800-747-4372, www.dentalherb.com 

I started using Tooth & Gums Tonic more than 10 years 

ago when I started practicing at Glidewell Laboratories. 

Once we began filming all of my dentistry, I realized 

how bad bleeding tissue looked when we were making 

impressions or placing restorations. For some reason, 

I had been willing to tolerate this bleeding for the first 

13 years of my career, but now that I could see it onscreen, 

I was disgusted. While the potent and effective 

formulas of Dental Herb Company products remain unchanged, 

the impact of the company’s new ownership 

is evident. In addition to a fresh, new look, the company 

has vastly improved its customer service, updated its 

packaging and informational materials, and provided a 

more user-friendly Web presence with a “Find a Dentist” 

locator tool that patients can use to search for the nearest 

dental office carrying its products. So while the new 

owners continue to sell Tooth & Gums products through 

dental professionals, the company expects to have online 

ordering ready to go by this summer. It’s clear that 

Dental Herb Company wants to be a valued partner in 

your practice’s fight against periodontal disease, and 

in our lab’s fight against bloody impressions!


CLINICAL TIPS 

PRODUCT........ Triodent V3 Sectional Matrix System 

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

888-230-1420, www.ultradent.com 

Because I practice inside of a dental laboratory, I 

typically only do direct restorations when they are 

adjacent to other indirect restorations I am placing. 

I was introduced to this sectional matrix system while 

I was testing BruxZir ® inlays and found myself doing 

only inlay preps for a month. While I was able to 

rationalize that it was OK when I nicked an adjacent 

tooth while dropping the proximal box and extending 

it buccolingually, a fellow dentist told me about the 

WedgeGuard interproximal tooth shield, which is an 

integral part of the V3 Matrix. WedgeGuard is the 

standard Wave-Wedge interproximal wedge with a 

metal protector attached to it. Place the WedgeGuard 

between the teeth and prep the tooth safely with the 

metal protector in place. After you finish the prep, 

you simply grab the metal protector and pull it out 

with the wedge still in place. Then you place your 

matrix, place the V3 Ring, and place and cure the 

composite. Genius! Go to exclusive U.S. distributor 

Ultradent’s YouTube page to view an animation of 

the system in action. 

Dr. DiTolla’s Clinical Tips11


CLINICAL TIPS 

PRODUCT........ Smile Reminder 

SOURCE........... Solutionreach (Lehi, Utah) 

866-605-6867, http://tinyurl.com/smilereminder 

FREE $10 STARBUCKS GIFT CARD! Yep, that is all 

it took to get me to take the online demo of Smile 

Reminder. Once a month I am asked to fill out an 

online survey for which the soliciting company will 

send me a $5 check. Don’t bother; I don’t want to walk 

it over to the bank. But a $10 Starbucks gift card? 

One of my staff members goes to one of their drivethru 

locations every day on her way to work — well 

played, Smile Reminder! What started off as a demo 

turned into a purchase just 10 minutes later when I 

saw the platform’s mind-boggling suite of features, 

which address everything from reducing no-shows 

with messaging and filling late cancellations, to 

sending targeted e-mail campaigns based on patient 

surveys and giving dentists and staff the ability to 

record custom video birthday greetings that get sent 

to patients. You can even track your online reputation 

by finding positive and negative reviews, as well as 

invite patients to write reviews and post them to the 

sites where your online reputation needs a boost. 

The electronic “recare” feature alone pays for the 

service because it automatically contacts patients 

who don’t have an appointment and are past their 

recall frequency, pulling the data from your practice 

management software. We use Henry Schein’s 

Dentrix ® , and the front office loves that it shows a live 

update of each patient’s pre-approved CareCredit 

amount. The Smile Reminder fixed price guarantee 

is also a refreshing approach I wish others would 

take. The dentists who signed up for Smile Reminder 

years ago are still paying the same price today. I like 

knowing what my monthly flat fee will always be and 

that there will not be any surprises down the road. I 

left out about 50 other functions where this powerful 

software also shines. Yes, you have my permission 

to put down the magazine and go get your Starbucks 

gift card. Go to http://tinyurl.com/smilereminder.

14 www.chairsidemagazine.com

Poor to Excellent 

Function in One Day! 

– ARTICLE by Ara Nazarian, DDS, DICOI 

Introduction 

Minimally invasive devices and procedures are fast becoming the largest growth 

segment of the medical and dental device industry. When compared to traditional 

approaches, they require less anesthesia, shorten surgical and recovery times, 

reduce patient risk, and can offer significant cost savings. Over time, we have 

witnessed the research and development of smaller and smaller components. 

Mini dental implants dramatically improve the quality of the outcomes for patients 

seeking maxillary and mandibular overdenture treatment. 

Small-diameter implants (1.8 mm to 3.0 mm) also differ from their full-sized 

counterparts in several ways. Their configuration allows for a more conservative 

placement protocol without involving tissue flaps or tapping procedures, 

resulting in minimal trauma for the bone and the gingival tissues. Mini dental 

implants’ size also allows the clinician to place them in ridges that might not 

otherwise be suitable for full-sized implants. Once these mini dental implants 

are firmly seated in place in intimate contact with bone, they can be immediately 

loaded with no lengthy waiting period or second-stage surgery. 

The following case report will demonstrate the protocol for the placement of 

small-diameter implants, and the subsequent effects on the new prostheses. 

Poor to Excellent Function in One Day!15

Case Report 

Diagnosis and Treatment Planning 

A male in his late 70s presented to our office; he was 

frustrated with the look and fit of his upper and lower 

dentures (Fig. 1). Most importantly, he complained that his 

lower denture was nonretentive and nonfunctional, always 

falling out when speaking or while eating. He had been a 

denture wearer for the last 25 years, resulting in excessive 

resorption of the mandible. The patient also suffered from 

hypertension, which was controlled with medication. 

The first phase of treatment would consist of having a new 

set of upper and lower dentures (Simply Natural Dentures 

[Glidewell Laboratories]) that would fit properly and occlude 

functionally. Utilizing recorded bases with corresponding 

wax rims, we analyzed the positioning of the teeth and 

proper proportions for an ideal smile. The patient desired 

to have his new set of teeth with shade B1 (VITA Classical 

Shade Guide [Vident; Brea, Calif.]). When the patient viewed 

the wax try-in, he quickly approved them for processing 

(Fig. 2). 

Palpation and radiographic examination revealed a 

moderately narrowed mandibular ridge (Fig. 3). Crestal bone 

and ridge height were sufficient to receive four 3 mm x 13 mm 

Inclusive ® Mini Implants (Glidewell Direct) (Fig. 4). The thread 

pattern and pitch of this implant are purposely designed 

to immediately maximize bone-to-implant thread contact. 

Others like it include: I-Mini (OCO Biomedical; Albuquerque, 

N.M.), I6B (AB Dental USA; Los Angeles, Calif.), HM Implant 

(Hiossen; Fairless Hills, Pa.), MILO ® (Intra-Lock; Boca Raton, 

Fla.), Midi ® (Basic Dental Implants; Albuquerque, N.M.), 

Intermezzo (MegaGen USA; Englewood Cliffs, N.J.) and 

miniMARK (ACE Surgical; Brockton, Mass.). 

After reviewing the patient’s panoramic radiograph, the 

mental foramina were also located, and it was confirmed 

that the four mini dental implants could be safely placed 

within the cuspid-to-cuspid area. 

Figure 1: Existing dentures were approximately 17 years old. 

Figure 2: New upper and lower dentures. 

Figure 3: Lower edentulous ridge, in preparation for mini dental 

implant placement. 

Outline of Clinical Treatment 

Before starting treatment, all the risks, benefits and 

alternatives were reviewed with the patient. A clean 

operating environment was established, the patient was 

draped and local anesthetic was administered. Then, an 

indelible marker was used to designate landmarks and 

areas of insertion. 

Keeping correct alignment, a 1.5 mm pilot drill from the 

Inclusive ® Surgical Kit (Glidewell Direct) was placed into 

the sites and advanced to a depth of 15 mm, measuring 

from the tissue surface using a surgical motor (AEU-7000E 

[Aseptico; Woodinville, Wash.]) with generous amounts of 

Figure 4: Inclusive Mini Implants (Glidewell Direct) in packages and 

ready for placement. 


sterile water. This additional 2 mm was the same depth 

of the tissue height to bone. In other words, 13 mm for 

the osteotomy in bone and 2 mm for tissue thickness was 

created to place a 13 mm long implant. Paralleling pins 

(Salvin Dental; Charlotte, N.C.) were placed in the sites 

of the osteotomies and an X-ray was taken to check the 

angulations to ensure proper orientation among the implant 

sites. Using a rotary tissue punch, a 3.0 mm outline was 

created over the initial osteotomies and the tissue plugs 

removed with a serrated curette (Zoll Dental; Niles, Ill.). The 

osteotomies were completed with the final drill (2.4 mm) 

included in the Inclusive Surgical Kit. Once the osteotomies 

were completed, four 3 mm x 13 mm Inclusive Mini Implants 

were placed in the osteotomies, using an implant finger 

driver (Fig. 5) until increased torque became necessary. The 

ratchet wrench was then connected to the adapter and the 

implants were torqued to final depth, reaching a torque 

level of 65 Ncm (Fig. 6). A postoperative radiograph was 

taken of the implants before initiating the prosthetic phase 

of treatment. 

At that point, the location of each implant was transferred 

to the denture using bite registration material (Take 1 ® 

Advance [Kerr Corp.; Orange, Calif.]). These areas were 

relieved to a diameter of 5.0 mm, and the denture was then 

reseated passively, confirming adequate relief had been 

properly established. 

A covering silicone (Fit Test C&B [VOCO America; Briarcliff 

Manor, N.Y.]) was used to cover any undercuts or interface 

of the implants, allowing only the O-ball of the implant 

to be exposed. This step prevented problems of the pickup 

material locking around the implants. A female O-ring 

keeper cap (Inclusive) was then fitted over each implant. 

Retentive fit and mobility were again verified. Each O-ring 

would create a retentiveness of approximately 5 lbs. Since 

there were four implants with corresponding housings, 

the total amount of force needed to remove the prosthesis 

would be about 20 lbs. 

The cleaned and dried recesses in the lower denture were 

filled with cold-cure acrylic (Quick Up [VOCO America]) 

(Fig. 7) and seated onto the implants, allowing it to 

polymerize. Upon setting, the lower denture was relieved of 

any excess flash, and the flange areas were relieved (Fig. 8). 

Finally, postoperative instructions were reviewed with the 

patient regarding denture placement, removal and oral 

hygiene. The patient was extremely excited and pleased that 

his new dentures were now very retentive and functional. 

Figure 5: The mini dental implant on the plastic insertion driver. 

Figure 6: Four mini dental implants in place in the mandible. 

Figure 7: Quick Up (VOCO America) was placed in recesses for 

housing pick-up. 

Figure 8: Retentive housings, as picked up in the lower denture. 

Poor to Excellent Function in One Day!17

Implants Are Easy to Code: The Question Is the Final Appliance! 

Tom M. Limoli, Jr. 

Gaining in rapid popularity are these so-called “mini 

implants.” They are sometimes referred to as “small” or 

“narrow diameter” depending on the precise dimensions as 

well as the specific manufacturer. From the coding, billing 

and reimbursement perspective, let’s separate the global 

procedure into its two major subcomponents. They are the 

implant and the existing denture that is now being modified 

to become an overdenture. 

Procedure code D6010 identifies the surgical placement 

of the implant body. In reviewing thousands of claims for 

multiple implant placements during the same surgical 

series, it is not uncommon to find documentation and 

billing based upon the premise of the “single incision 

rule.” This type of billing generally results in the first 

implant being billed at 100 percent of the fee, while each 

additional at the same surgical visit being billed at some 

variation of 80 percent, 60 percent, all the way down to 

40 percent of the fee for the first surgically placed implant. 

Implant Codes and Fees 

When the technique involved is the modification of an 

existing removable denture to one becoming an implantretained 

overdenture, they are globally identified with 

procedure code D5875. This code would only be applicable 

if we were simply going to be using the patient’s existing 

appliance with modifications. A weakness in the existing 

coding sequence is that code D5875 does not specify if 

the original removable appliance replaces either a partial 

or completely edentulous arch. Also the fact that this code, 

by ADA definition, does not require a “by report” clinical 

narrative makes the claim delay the inevitable. That is why 

I recommend that the code always be submitted with a 

description of the prosthetic modification along with the 

original date of placement and anticipated longevity. 

As concerns Dr. Nazarian’s specific technique and 

treatment plan for this individual patient code, D5875 would 

not apply since the completed “global” procedure is in fact 

an implant-retained overdenture identified by code D6053. 

Code Description Low Medium High 

National 

Average 

National 

RV 

D5875 

Modification of removable 

prosthesis following implant surgery 

$250 $324 $577 $334 6.68 

D6010 Surgical placement of implant body $1,532 $1,745 $2,398 $2,012 40.24 

D6053 

Implant/abutment-supported 

removable denture 

$2,117 $2,514 $3,500 $2,650 53.00 

CDT-2011/2012 copyright American Dental Association. All rights reserved. Fee data copyright Limoli and Associates/Atlanta Dental Consultants. This data 

represents 100 percent of the 90 th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. 

The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office 

is available for a charge from Limoli and Associates/Atlanta Dental Consultants at 800-344-2633 or www.limoli.com. 

Closing Comments 

The advent of the mini dental implant has given general 

dentists an efficient and more affordable way of solving 

many of the challenges associated with complete dentures. 

In providing mini dental implants that immediately improve 

denture function and retention, the clinician can rapidly 

restore a patient’s confidence and also yield positive economic 

benefits for the practice. In addition, the simplified protocols, 

conservative procedures and elimination of gingival surgery 

make mini dental implants ideal for medically, anatomically 

and financially compromised patients. 

It has been estimated that more than 36 million patients in 

the United States have lost their teeth; however, 0.5 percent 

have received implant therapy. This striking disparity signifies 

a huge untapped market for implants and dentures! CM 

Dr. Nazarian maintains a private practice in Troy, Mich., with an emphasis on 

comprehensive and restorative care. He can be reached at 248-457-0500 or at 

www.aranazariandds.com. 

Disclosure: Dr. Nazarian reports no disclosures. 

Reprinted by permission of Dentistry Today, © 2012 Dentistry Today. 



Photo Essay 

Another Use for ANTERIOR 

BruxZir ® Solid Zirconia Restorations 

– ARTICLE by Michael C. DiTolla, DDS, FAGD 

One of the most difficult clinical situations restorative dentists face in 

clinical practice is treating a patient with severe tetracycline staining. 

I treated one of these patients a few years ago with a set of veneers 

that were conservative but an esthetic compromise. The tetracycline stains 

showing through the veneers were still visible enough to bother the patient. 

When we removed the veneers six months later, I prepped 0.6 mm deeper to 

make the veneers thicker. But at the try-in appointment, it was clear that the 

esthetics hadn’t improved much from the first set. We ended up using lithium 

disilicate crowns, which provided an improved result, but there was still some 

minor show-through in the gingival third. 

Not long ago, the patient’s brother came to see me. He was already prepared 

to do crowns, so I wanted to see if BruxZir ® Solid Zirconia crowns (Glidewell 

Laboratories) could block out the prep shade. While not as esthetic as lithium 

disilicate crowns, I hoped to get a more esthetic overall result by entirely 

blocking out the stump shade. Unlike his sister, this patient had fractured nearly 

every PFM in his mouth, and the wear in his mouth and his edge-to-edge 

bite clearly revealed a severe bruxing habit. Taking this into consideration, 

I knew BruxZir Solid Zirconia was the only ceramic material that would stand 

a chance of surviving in this hostile oral environment. 

Another Use for Anterior BruxZir Solid Zirconia Restorations23

Figure 2: With retractors, we get a much better picture of the challenge 

we are up against. When a young patient takes tetracycline 

while their primary or permanent teeth are forming, the tetracycline 

chelates, or binds, to calcium ions present on the hydroxyapatite 

crystals in the dentin and, to a lesser degree, in the enamel. 

Figure 1: My experience with tetracycline patients is that they have 

spent most of their lives trying not to smile. Even though smiling is 

an involuntary reaction to something that strikes us as funny, the 

majority of these patients become adept at smiling with stiff lips to 

cover as much of their teeth as possible. 

Figure 3: This view of the maxillary arch reveals the abuse that 

goes on in this patient’s mouth. The effect of his edge-to-edge 

bite is clear from the wear on the unrestored teeth. The strength 

of this patient’s musculature is also clear from the broken PFMs. 

Kudos to the dentist who put the cast metal crown on tooth #15; 

it’s doing fine! 


Figure 4: This view of the mandibular arch shows the same type of 

destruction evident in the maxillary arch. The patient said no dentist 

had ever told him that he needed a nightguard, which surprised 

me. (Keep in mind, I’ve found patients to be wrong more than they 

are right when relaying clinical facts.) Again, the cast metal crown 

on the lower right is the only tooth — natural or restored — that is 

doing well in this oral environment. 

Figure 5: Just for fun, I take out my VITA Easyshade ® Compact 

(Vident; Brea, Calif.) and attempt to get a reading on the current 

shade of the patient’s teeth. I have to admit that I half expected 

smoke to come pouring out of the device as it attempted to match 

this shade. The device is programmed to give the closest shade 

as opposed to the exact shade, so it indicated a C4 as you might 

have guessed. 

Figure 6: When I place the C4 tab next to the teeth, it’s clear that 

the hue and the chroma are more intense, and the value is much 

lower. As the tetracycline staining is technically in the dentin, what 

we are seeing is the stains showing through the enamel. You know 

as well as I do that when we prep into the enamel, this discoloration 

will only intensify. 

Figure 7: A SeeMORE 4-way retractor (Discus Dental; Los Angeles, 

Calif.) is placed. I used to use these retractors only when filming, 

but then I realized they freed up a hand each for my assistant and 

me. The company stopped making them for a while, but rumor has 

it they are starting to again. Here I am placing PFG Light topical 

anesthetic (Steven’s Pharmacy; Costa Mesa, Calif.) onto moist 

mucosal tissue. (NOTE: Don’t dry the tissue beforehand.) We leave 

it in place for 45–60 seconds before rinsing. I love this topical gel 

because it is the only one I have found that keeps the patient from 

feeling the needle insertion. 


Figure 8: Next, I use my Wand ® STA ® device (Aseptico; Woodinville, 

Wash.) to give anesthetic. This anesthesia system has removed so 

much stress from my time spent in the operatory, especially when 

it comes to giving anterior infiltrations — a simple injection to give 

in a very sensitive area of the patient’s mouth. It never occurred to 

me that I was tensing up during these injections and concentrating 

on giving the anesthetic as slowly as possible. With the STA, I can 

set it to the slow speed and tell my assistant jokes, creating a lowstress 

environment for the patient. 

Figure 9: The first step in the Reverse Preparation Technique is to 

break the proximal contacts. We will be prepping all of the patient’s 

anterior teeth, so we start by simultaneously breaking the contact 

between tooth #8 & #9. Usually we use a #56 bur for this; however, 

by using an 856-025 bur (Axis Dental; Coppell, Texas), we not only 

break the contact, but we also begin to form our interproximal margins 

at the same time. 

Figure 10: Here we are starting to break through the contact, 

pushing the bur toward the palatal. With my KaVo ELECTROtorque 

handpiece (KaVo Dental; Charlotte, N.C.) spinning at 40,000 rpm, 

this big bur easily makes its way through the contact. The one thing 

to watch out for is nicking the gingival papilla. We also go to great 

lengths not to go subgingival, unless the existing crown has subgingival 

margins. 

Figure 11: I then move on to the rest of the interproximal contacts 

using the 856-025 bur to create separation and begin the formation 

of the interproximal margins. When I reach the most distal tooth I 

am going to prepare, I can still use the 856-025 bur on the mesial, 

but I must switch to the 856-016 bur (Axis Dental) on the distal 

to avoid over-preparing the tooth or damaging the adjacent tooth. 


Figure 12: This is the Razor ® Carbide bur from Axis Dental, my 

favorite bur for cutting through PFM crowns. The Razor even cuts 

well on those metal substructures we see on patients who went 

to Mexico to have their dentistry done. It feels like you are cutting 

through a 1950’s Chevy bumper when replacing those types of restorations. 

The Razor cuts through porcelain as well, so it’s the only 

bur I ever need to get through a PFM. 

Figure 13: What’s not to love about the 90-degree angle of the 

Christensen Crown Remover (Hu-Friedy; Chicago, Ill.)? I’ve owned 

this one for at least 15 years and it still looks like it did the first time 

I used it. It’s a good thing Hu-Friedy’s scalers and explorers need to 

be replaced, otherwise they might put themselves out of business! 

Figure 14: This is a better shot of the Razor Carbide bur going 

though the porcelain of a PFM we are replacing. I used to use a 

diamond bur to cut through the porcelain and would then switch to 

a carbide to cut through the metal coping. But with the Razor, it’s 

one and done. It even has a reinforced shank to prevent breakage. 

Figure 15: Sometimes when I use the Christensen Crown Remover 

to open a crown, it still won’t come off because of the contacts. 

Rather than cutting through the lingual portion, I try to grab the 

coping with my hemostats and do my best to wiggle it off. Having 

cut off many high-strength, all-ceramic crowns, I will never again 

complain about cutting off a PFM. 


Figure 16: The next step of the Reverse Preparation Technique is 

to prepare the gingival margin. Unlike in dental school where I was 

taught to prep the margin as the last step of the preparation, I now 

do it as the second step. In my experience, doing it at the end feels 

10 times harder than doing it at this point. In fact, most dentists 

who try this never go back to placing the margin at the end of 

the procedure. 

Figure 17: The 801-021 bur (Axis Dental) is a round diamond, and 

when used parallel to the tooth, it cuts a half-circle into the gingival 

third. This ensures we have enough reduction in the gingival third 

for an esthetic restoration that won’t have an over-contoured 

emergence profile. An ugly gingival third is almost always the cause 

of ugly anterior crowns. 

Figure 18: With the gingival margin prepped on all teeth, we are 

now going to place incisal edge depth cuts. The three rings that 

are visible on the shank indicate that this is a 1.5 mm depth cutter, 

which will provide an adequate amount of reduction for the dental 

technician to build the desired incisal edge. This is especially true 

when working with IPS e.max ® crowns (Ivoclar Vivadent; Amherst, 

N.Y.), because they can be cut-back and layered for the best 

esthetic result. 

Figure 19: The benefit of using a self-limiting depth cutter is not 

having to guess like you do when using a #330 bur as a depth cutter. 

The shank is much wider than the cutting surface of the bur, 

making it impossible to go too deep. Once the shoulder of this bur 

is on the incisal edge, I can move the bur to the lingual to complete 

the depth cut. 


Figure 20: On posterior teeth, this depth cutter is also used to 

establish reduction, which is typically 2 mm for bilayered restorations 

such as PFMs or Lava crowns (3M ESPE; St. Paul, Minn.). 

For lithium disilicate crowns, I prefer 1.5 mm of occlusal reduction. 

I prefer 1 mm for BruxZir crowns, but this material can be prepped 

as thin as 0.6 mm. On this cuspid, we are reducing the incisal edge 

1.5 mm, like we did for the other anterior teeth. 

Figure 21: I am now placing a 1 mm depth cut on the facial surface 

of the teeth to be prepped. I prefer to do this at the height 

of contour, or incisal to the height of contour, to ensure that I reduce 

enough in that area. One of the most frequent mistakes I used 

to make was under-reducing in this area, which leads to bulky, 

opaque, ugly crowns. 

Figure 22: This image shows the payoff of spending a little extra 

time up front to make these depth cuts. Now we can grab our 856- 

025 bur again and go to town, secure in the knowledge that we 

know exactly where we are going. These depth cuts are a road map 

that keeps us from under-prepping or over-prepping these teeth, 

allowing us to fly through this part of the prep sequence. 

Figure 23: Typically, I start this part of the prep sequence by reducing 

the incisal edges. I intentionally use the middle third of the bur 

to do this reduction because I want to save the tip of the bur for 

finishing the gingival margin. There is little chance that the tip will 

be dulled by then, but I’m prepping multiple teeth and I want it as 

new and as sharp as possible. 


Figure 24: Here I am using the 856-016 bur to do the occlusal 

reduction on the bicuspid. I use the bigger 856-025 bur on molars, 

but it is a little too big to use on bicuspids without accidentally 

nicking the adjacent teeth. You could also use a football bur to 

do this reduction (the convex shape of the bur will give you some 

“bonus” reduction). 

Figure 25: The 856-025 bur does a great job on the facial surface of 

anterior teeth as well. You can see that I already finished the facial 

reduction on tooth #10 as I reduce tooth #9 here. Notice how dark 

the staining is on tooth #10 compared to tooth #8. Tooth #9 is right 

in the middle in terms of shade because we have removed about 

half of the enamel. You can already see that the margin looks good 

on tooth #10 — that’s the beauty of the round bur. 

Figure 26: I use the 379-023 football bur (Axis Dental) to reduce 

the lingual surfaces of the anterior teeth. The convex shape of 

the bur helps to prepare a concave shape that will allow room 

for the incisal edges of the lower anteriors. Unlike other allceramic 

materials that require at least 1 mm of reduction, we 

can reduce just 0.6 mm on the lingual for a BruxZir crown. 

I have a 0.6 mm depth cutter in my bur kit to measure this precisely. 

Figure 27: Toward the end of the prep sequence, I like to start 

rounding things over, especially the junctions of the facial surfaces 

and the incisal edges. I also try to avoid leaving sharp corners on 

the mesial and distal corners of the incisal edges. While BruxZir 

crowns are strong enough to be placed on these sharp angles, 

CAD/CAM mills are not able to replicate those sharp angles with 

their round burs. 


Figure 28: Even though we know we reduced the proper amount 

on the incisal, facial and gingival surfaces, there are interproximal 

areas where it is impossible to place depth cuts. This makes it 

prudent at this point to try on the BioTemps ® prep stent (Glidewell 

Laboratories) for the BioTemps Provisionals we will be placing 

to make sure we have reduced enough in all dimensions. The 

BioTemps are prepped as thin as possible, so there should be 

plenty of clearance, except maybe interproximally. 

Figure 29: You can also try on the stent that was made with the 

BioTemps on the model. While the first prep stent serves to check 

interproximal reduction, this one shows your preps in relation to 

the BioTemps, which act as the proposed final restorations. Just 

as important, this stent can save you if something goes wrong 

with the BioTemps; simply fill this stent with Luxatemp ® Ultra 

(DMG America; Englewood, N.J.) and place it on the teeth for a 

direct temporary. 

Figure 30: The rubber really meets the road when you try in the 

BioTemps for the first time. If you have followed every step detailed 

so far, 9 times out of 10 the BioTemps will drop into place passively. 

This is our objective. If you skip the first stent that was made on 

the BioTemps prep model, the BioTemps may not passively seat. 

(For BioTemps techniques and troubleshooting tips, view the video 

“BioTemps Techniques for Indirect Temporization,” available in the 

Video Gallery at www.glidewelldental.com.) 

Figure 31: Here we have placed the Luxatemp Ultra into the 

BioTemps and are seating them on the preps. I insist on Luxatemp 

Ultra because it is the only bis-acryl temporary material that goes 

through a doughy stage, which allows me to pump the BioTemps up 

and down in it as though it were methyl methacrylate — other bisacryl 

materials go from soft to hard too quickly for this technique, 

potentially locking the BioTemps into place too soon. 


Figure 32: My assistant has trimmed the BioTemps with a thin, 

perforated diamond disc, taking extra care to make sure she 

opens the gingival embrasures. If anything, she will intentionally 

create black triangles on the temps so the patient can swish Tooth 

& Gums Tonic ® (Dental Herb Company; Lancaster, N.H.) through 

the spaces. This also avoids blunting the papilla with the temps, 

which can lead to real black triangles when we try in the permanent 

crowns. I have made that mistake too many times in the past and 

have had to drop the prep margins and re-impress. 

Figure 33: The BioTemps are now cemented with TempBond ® 

(Kerr Corp.; Orange, Calif.) and the temporary cement is cleaned 

up with an explorer and Thornton 3-in-1 Floss (Thornton International; 

Norwalk, Conn.). The proper overjet and overbite relationship 

has been re-established with the BioTemps, and the next two 

weeks will give us a good chance to see if the patient has any 

issues with this change. My assistant did a good job with the embrasures, 

but she over-trimmed the gingival margin on tooth #9. If 

I were concerned about gingival overgrowth on the margin, I could 

place some flowable composite, but I feel confident it will stay put. 

Figure 34: Two weeks later the patient returns, reporting no functional 

or phonetic issues with the BioTemps, so we can ask the 

dental technician assigned to the case to fabricate the final BruxZir 

crowns based on the digital scan of the BioTemps. Thanks to digital 

technology, we can now duplicate BioTemps in the contours of 

the final restorations by scanning them, storing the digital information 

and then using the stored digital file to mill the final crowns to 

match. (To request this “scan & save” service, simply note this preference 

on your BioTemps prescription.) Things look pretty good 

when we remove the BioTemps, and there are just a few spots of 

minor gingival irritation. It’s now time to take the final impression. 

Figure 35: Not taking the impression during the prep appointment 

for large anterior cases was a difficult lesson to learn, but now I 

won’t do it any other way. I have had too many cases of crowns 

having to be remade because the temps blunted the papilla. The 

first thing my assistant does is place a #00 Ultrapak ® cord (Ultradent; 

South Jordan, Utah). This cord does not have any hemostatic 

agent or epinephrine on it. Its purpose is to create vertical retraction 

of the tissue and sit against the inflamed base of the sulcus to 

prevent bleeding when I pull the top cord. 


Figure 36: I prefer to use straight, non-serrated cord packers when 

placing the #00 cord. In this shot, you can see that this cord is 

braided and hollow. Its hollowness makes it easier to pack into the 

sulcus; however, even #00 solid cords are fairly easy to pack. Because 

it is braided, the #00 cord starts to expand once it is placed 

in the sulcus, absorbing any crevicular fluids. Trying to pack a #00 

cord when it is wet is frustrating, so we try to dry the sulcus as 

much as possible first, especially at the gingival margin. 

Figure 37: Now that the #00 cords are all in place, we can inspect 

the margins and see if any of them need to be dropped subgingivally. 

Our goal is to have slightly subgingival margins without taking 

a bur subgingival. We are able to achieve this because the #00 cord 

has vertically retracted the tissue approximately 0.5 mm. I typically 

drop the margins with the 856-025 bur, and most times I turn the 

water off and my electric handpiece down to 3,000 rpm. This way, 

I can clearly see what I’m doing. 

Figure 38: Even though I am a huge fan of the two-cord impression 

technique, I continue to try every non-cord retraction technique 

that comes on the market, hoping that one day I can stop packing 

cord. So far I haven’t found anything that works as well as cord, 

but the search continues. My common complaint about the paste 

retraction systems has been the difficulty in getting retraction 

material into the sulcus, so I ordered the 3M ESPE Retraction 

Capsule after seeing an ad about its narrow tip that the company 

claims fits directly in the sulcus. You can see us trying it out here. 

Figure 39: The retraction paste is left in place for a minimum 

of two minutes, but typically closer to eight minutes. Just 

like we do with the two-cord technique, we place ROEKO 

Comprecap Anatomic compression caps (Coltène/Whaledent; 

Cuyahoga Falls, Ohio) over the preps to help keep the retraction 

paste in place and the patient’s tongue away. The pressure 

also drives blood out of the capillaries, providing us with additional 

temporary hemostasis. 


Figure 40: I find that the 3M ESPE retraction paste rinses 

out more easily than other retraction pastes — another common 

complaint I have with them. As I examine the final impression, 

I am impressed with how good it looks. I still think I would 

have had more retraction with a second cord on top of the #00 

cord, but it might be the best cord-free impression I have taken. 

I’m not switching from retraction cord just yet, but this new 

product is a step in the right direction. 

Figure 41: Having practiced around dental technicians for the last 

12 years, I always hear them talking about what they want to see 

in a bite registration. They want the bite registration material to be 

only on the hard tissue. They also want the material to be between 

only the prepped and the opposing teeth; they don’t want any 

material between the unprepared teeth. It simply needs to capture 

the incisal thirds of the prepped teeth and the incisal thirds of the 

opposing teeth. After taking the bite registration, we put the temps 

back on and schedule the patient to come back one week later. 

Figure 42: Seven days later we remove the temps. To clean up the 

preps, I know no better way than with my KaVo SONICflex ® scaler 

(KaVo Dental). This scaler will blast any temporary cement — even 

Durelon ® (3M ESPE) — off the preps, leaving behind no trace of 

cement that could interfere with seating. The scaler doesn’t spin, 

so even if you accidently bump the tissue, it won’t cause bleeding. 

Figure 43: After trying in the crowns and getting the patient’s 

approval, we place two one-minute coats of G5 All-Purpose 

Desensitizer (CLINICIAN’S CHOICE; New Milford, Conn.) on the 

preps. We are going to use Ceramir ® Crown & Bridge cement 

(Doxa Dental; Newport Beach, Calif.) to place the BruxZir crowns, 

so we don’t need to use the Ivoclean ® solution (Ivoclar Vivadent) 

or Z-PRIME Plus (Bisco Inc.; Schaumburg, Ill.). Because Ceramir 

doesn’t rely on phosphates to bond to the zirconia, the salivary 

phosphates do not affect it, so there is no need to use a zirconia 

primer. As always, we place tooth #8 & #9 first to ensure proper 

seating, applying pressure apically with pinewood sticks. 


Figure 44: Retracted facial view of the cemented BruxZir crowns. In 

addition to being the only permanent cement that bonds to BruxZir 

restorations without the use of a zirconia primer, Ceramir is also 

a breeze to clean up due to its gel state during set-up that allows 

for any excess cement to be peeled off in one piece. While these 

crowns likely won’t be mistaken for IPS Empress ® (Ivoclar Vivadent) 

or IPS e.max in terms of esthetics, these glass-ceramic materials 

would have resulted in show-through due to the dark stump shade 

color. This is definitely one case where the lower translucency of 

BruxZir Solid Zirconia is advantageous. 

Figure 45: Retracted left lateral view of the cemented BruxZir 

crowns. An interesting thing to note is the visible broken PFM in the 

lower left quadrant. We prescribed BruxZir Solid Zirconia for this 

case because we wanted to use a material that would completely 

mask the dark underlying stump shade. It’s just a coincidence that 

we can see a broken PFM, but broken restorations typically are 

my primary reason for prescribing BruxZir crowns. I don’t give a 

patient more than one chance to break restorations. 

Figure 46: Retracted right lateral view of the cemented BruxZir 

crowns. Here we see another broken PFM in lower right quadrant. 

My point in noting these broken PFMs is that, even if this patient 

didn’t have tetracycline staining and instead required replacement 

of all of these anterior crowns due to old, leaky composites and 

recurrent decay, BruxZir Solid Zirconia still would have been my 

restorative material of choice. PFMs have a pretty good track 

record over the last 50 years, but when I see a patient who breaks 

them, their two choices in my mind are cast gold and BruxZir 

Solid Zirconia. 

Figure 47: Occlusal view of the cemented BruxZir crowns. How are 

these restorations going to hold up against this patient’s difficult 

occlusal situation? There are no guarantees in dentistry, but singleunit 

BruxZir crowns have the lowest fracture rate of any restoration 

in our lab, with the exception of cast gold, but that material really 

wasn’t an option in this case. Because BruxZir Solid Zirconia is a 

monolithic material (solid zirconia with no porcelain overlay), I have 

a high degree of confidence that these crowns will be intact for 

years to come. 


GENERAL REFERENCES 

• Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to 

zirconia: clinical and experimental considerations. Dent Mater. 2011 

Jan;27(1):83-96. 

• Holt LR, Boksman L. Monolithic zirconia: minimizing adjustments. 

Dent Today. 2012 Dec;31(12):78, 80-1. 

• Janyavula S, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO. 

The wear of polished and glazed zirconia against enamel. J Prosthet 

Dent. 2013 Jan;109(1):22-9. 

• Rinke S, Schäfer S, Lange K, Gersdorff N, Roediger M. Practicebased 

clinical evaluation of metal-ceramic and zirconia molar 

crowns: 3-year results. J Oral Rehabil. 2013 Mar;40(3):228-37. 

• Shahin R, Kern M. Effect of air-abrasion on the retention of zirconia 

ceramic crowns luted with different cements before and after artificial 

aging. Dent Mater. 2010 Sep;26(9):922-8. 

• Kern M, Swift EJ Jr. Bonding to zirconia. J Esthet Restor Dent. 2011 

Apr;23(2):71-2. 

• Sasse M, Eschbach S, Kern M. Randomized clinical trial on single 

retainer all-ceramic resin-bonded fixed partial dentures: Influence 

of the bonding system after up to 55 months. J Dent. 2012 Sep; 

40(9):783-6. 

Figure 48: The final result — not a bad smile for a guy who told 

me he hasn’t smiled for the last 30 years. This type of patient really 

does need some coaching to learn to smile again, and I encourage 

them to practice in front of the mirror, as silly as that sounds. To me, 

it’s not that different from physical therapy, where a patient needs 

to re-learn a physical skill that they haven’t been able to do for an 

extended period of time. With this patient, I am already wondering 

what I will do if he wants to do the lower arch as well. I’m not a big 

fan of doing full crowns on lower anterior teeth and typically prefer 

veneers, but I’m not sure whether BruxZir veneers will block out 

the dark shades. If he opts for this treatment, you will see it here. 

Stay tuned! CM 



CASE OF THE WEEK: Episode 32 

A Disastrous Double-Arch Impression Tray 

– ARTICLE by Michael C. DiTolla, DDS, FAGD 

When dentists attend my lectures, they are often fascinated by the clinical cases I show of what other dentists 

are sending in to Glidewell Laboratories. “Chairside Live,” our weekly Web series, is a great opportunity for 

me to share these cases with dentists on an ongoing basis. Episodes can be viewed online and on demand at 

www.chairsidelive.com, or on YouTube and iTunes. If you aren’t already a viewer, I encourage you to start watching now 

for informative case examples from our lab and intriguing dentistry-related news stories. 

The video stills that follow highlight an interesting Case of the Week from Episode 32 that addresses what is probably 

my biggest dental pet peeve: when a double-arch tray is used for a bridge impression. While double-arch impressions 

can be suitable for one single-unit crown or two single-unit adjacent restorations, they should never be used for a bridge. 

A closer look at the case illustrates why. 

Figure 1: When walking through Glidewell’s crown & bridge department 

the other day, I stopped to ask a technician what one thing dentists do in 

cases they send to the lab that drives him crazy. “I’m glad you asked!” he 

said, and handed me this impression. 

Figure 2: Looking closer at this impression, we can see that it is for a 4-unit 

bridge, but it was taken in a double-arch tray. I learned from Dr. Gordon Christensen 

many years ago that this is a no-no, and now this technician wants me 

to know that he dislikes this technique just as much as Gordon does. 

A Disastrous Double-Arch Impression Tray39

Figure 3: Turning the impression, we can see that the prep was in contact 

with the tray — another no-no. As hard as it may be to believe, all it takes 

is one point of contact like this between tray and prep to prevent the entire 

bridge from seating properly. 

Figure 4: The impression itself around the splinted abutments is so-so; 

tooth #29 appears to have a void on the facial and the lingual margins, 

while tooth #28 has some very thin material on the facial and distolingual 

margins. This always makes me nervous as we pour the die stone because 

the material is heavy enough to bend those margins. 

Figure 5: The margins on tooth #31 also appear thin and friable, and it’s 

hard to tell definitively whether tissue retraction took place. Using the twocord 

impression technique, or to a lesser degree by using a diode laser, we 

can create enough lateral retraction to end up with a big, thick margin on 

the impression that won’t distort. 

Figure 6: As I flip the impression over, notice that we are missing the second 

molar opposing the bridge and that the first molar is the most distal 

tooth. You may recall that we are missing the first molar on the lower arch 

as well, which is going to make it more difficult to verify a correct bite. 

Figure 7: Here is the poured model of the impression. It looks like we have 

enough reduction for the BruxZir ® bridge (Glidewell Laboratories) the doctor 

prescribed, except for on tooth #28 perhaps. I would have prescribed 

a PFM bridge, but that is another story. I am still concerned about the bite 

because there aren’t any stops distal to the bridge. 

Figure 8: When I spin the articulator around and view the case from the 

anterior, my fears are confirmed. I have a hard time believing that the bite 

from the impression is correct. I cannot believe that the patient only bites 

on that cuspid. Without any unprepped teeth on the opposite side to hand 

articulate, the situation looks dicey. 


Figure 9: As I look at the lower anterior teeth, I realize the bite problems 

are getting bigger because this patient spends some serious time with 

these teeth in contact with the uppers. Every once in awhile you will see a 

case like this with an anterior open bite, but if this isn’t one of these cases, 

this bite will drive the patient crazy. 

Figure 10: A little twist of the articulator brings the other two anterior 

teeth into contact, but now there is a huge gap between the posterior 

teeth. Again, there is no way to verify where the bite is correct. If only we 

had a full-arch impression on the upper and the lower, we could take an 

educated guess. 

Figure 11: Look at all these wonderful wear facets; usually, these make it a 

no-brainer for us to hand articulate a case. Even a separate bite registration 

over the preps could have saved this impression — if you ignore the fact 

that many bridges made from double-arch trays don’t fit. Bottom line: This 

case needs to go back to the doctor for new, full-arch impressions. 

Figure 12: As I was leaving the technician’s workstation, he also handed 

me these full-arch impressions. I was instantly suspicious when I saw the 

trays the dentist used. Do you recognize them? You do if you do Invisalign ® 

(Align Technology Inc.; San Jose, Calif.). These are the plastic trays you 

have to take Invisalign impressions in so that the company’s X-ray scanner 

can read through the trays. 

While double-arch impressions can be suitable for one 

single-unit crown or two single-unit adjacent restorations, 

they should never be used for a bridge. 

A Disastrous Double-Arch Impression Tray41

Impression errors are especially important to avoid when 

dealing with multiple-unit impressions because any mistakes 

will be multiplied across the entire length of the bridge. 

Figure 13: I thought we had seen it all when it comes to impressions, but 

this may be a first. It’s a 3-unit bridge impression on the lower, but the dentist 

took what looks like a half-arch impression with a full-arch tray. There 

is also some material placed on the other side of the tray to impress two 

molars and a bicuspid. Was this done purposely? 

Figure 14: Apparently, this was done intentionally. Even on the opposing 

model the doctor put a large amount of impression material on the side 

opposing the bridge — impressive! He then put some material on the other 

side to impress four additional teeth. How much money did the dentist 

save by not impressing that lateral and cuspid? Twelve cents? Pouring 

these impressions is going be a challenge and make excursions tougher 

to accurately replicate. 

Conclusion 

Using a double-arch tray looks so easy and seems so 

tempting when taking an impression on just one side of the 

mouth, but it very rarely makes for an accurate multiple-unit 

impression. Impression errors are especially important to 

avoid when dealing with multiple-unit impressions because 

any mistakes will be multiplied across the entire length of 

the bridge. Even if the bridge still fits the patient’s teeth, 

the bite will likely be off, which does not make for a happy 

patient. For any bridge case like this, you, the lab and your 

patient will be better served if you use a full-arch lower 

impression tray and a full-arch upper impression tray, as 

well as a bite registration between the opposing teeth and 

the preps. CM 

How to Watch 

To view past and current 

episodes visit 

www.chairsidelive.com. 

Also available on iTunes and YouTube. 

For clinical technique tips on taking a bridge impression, watch “Chairside Live 

Episode 36: The Do’s and Don’ts of Taking an Impression for a Bridge.” 



Interview with David Harris 

– INTERVIEW of David Harris, MBA, CMA 

by Michael C. DiTolla, DDS, FAGD 

David Harris is a licensed private investigator and the CEO of Prosperident, a 

company that specializes in the investigation of frauds and embezzlements 

committed against dentists. I first heard about David when I came across his 

seminar “How to Steal from a Dentist” listed in the program for a dental meeting 

where I was lecturing. The title of his lecture captured my fascination, especially 

when I saw that it was a course designed to help dentists detect and protect 

against dental-practice embezzlement. I wasn’t able to attend his lecture during 

the dental meeting, so I thought the next best thing would be to ask him to share 

his expertise on the subject in Chairside magazine. 

Interview with David Harris45

Dr. Michael DiTolla: For those of our readers who haven’t had 

the opportunity to see your lecture on dental-practice fraud yet, 

can you tell me a little bit about your background and how you 

got involved in dental embezzlement investigation? 

David Harris: I’ve been investigating dental embezzlement 

for about 22 years. Before that I did various things. I was 

in the Army for a while; I did investigation for a bank. After 

retiring from working for the bank, I was sitting at home 

not doing a whole lot when I got a call from a friend of 

mine who happened to be a dentist. He said, “I think my 

front-desk person is stealing from me, and you’re the only 

guy who I can think of to turn to on this.” So I went to his 

office that night, we found the fraudulent employee and we 

got rid of her. I went back to watching TV and really didn’t 

give it another thought. 

It was a coincidence when about three weeks later I went to 

my own dentist for a hygiene appointment and saw through 

the glass of the office door the same person who we had 

terminated from the other office three weeks earlier! So I 

ran away quickly hoping that she didn’t see me, went to 

the nearest pay phone — this story pre-dates me having 

a cell phone in my pocket — and phoned the dentist. I 

got put through to him on some pretext and I said, “I’m 

not coming in for my appointment today, but when I tell 

you why you’ll probably forgive me.” I told him about the 

time bomb he had sitting at the front desk, and he asked 

me what he should do next. Halfway through my second 

sentence he hired me. Things have changed a lot since then 

in a whole bunch of ways. I was doing this on my own then, 

and now I have a decent-sized company that helps me with 

investigations, but the basics haven’t changed. 

MD: That’s an amazing story. In terms of dentistry, I guess it’s 

not that surprising in the sense that in most of our communities, 

and even nationally, dentistry is a very tight-knit group where 

you know and see a lot of the same people. Even in corporate 

dentistry, with the dental product manufacturers, you’ll see 

somebody leave one company and then a new CEO gets hired 

at another company. It seems like the same people are shifting 

slots and moving around. So I guess it’s not shocking that 

somebody who gets fired from one dental office job turns up at 

another dental office. 

DH: It’s what they know. In the case of this particular 

woman, it was lucrative because she was getting paid her 

official salary and then her, shall we say, “unofficial” salary. 

MD: It’s not like when she got fired from the first practice 

that there was a scarlet letter put on her forehead to identify 

her as an embezzler on any interview she might go on after 

that, right? 

DH: Thieves are pretty good at doctoring their résumés 

enough to hide their backgrounds. One of the most common 

lines is simply telling the new employer that they’re still 

working at the previous place and saying, “My old employer 

doesn’t know I’m leaving, so please don’t call him.” 

MD: That’s an interesting line. I get the feeling that we’re going 

to hear about some slightly ingenious — albeit evil — things 

like that today. I guess these people have figured out how best to 

cover their tracks. 

DH: Thieves are pretty clever. One of the most interesting 

parts of my job is witnessing the sheer creativity that some 

of these folks show. I will now have to disappoint your 

readers a little bit because our policy in an uncontrolled 

forum like this one is not to talk specifics. My recurrent 

nightmare is to turn thieves into better thieves. We do talk 

about specifics in closed seminars, but in this interview, 

I feel a little bit constrained. Some of the stuff we see is 

almost spectacular in its ingenuity. You can’t help thinking 

“ 

The serial embezzlers ... cater to what I sometimes call the ‘wet-fingered fantasy’ 

some dentists have. A fantasy where they get into their office every 

morning, do high-quality dentistry on a relatively small number 

of patients and then go home, without having to 

get dragged into the messiness of 

managing their practice. 

”

about what these folks could accomplish if they put their 

minds to honest labor. 

MD: I guess what they’re doing on a small scale is what happens 

in big Wall Street firms when there is embezzlement. I don’t 

know if you have come across any studies or surveys on this, but 

what percent of dentists would you say will have embezzlement 

be an issue in their office at some point in their career? 

DH: In the published statistics, there are two or three 

surveys saying that somewhere between 50 and 60 percent 

of dentists will be victims. But there is a confounding factor 

to this because there is a fair amount of embezzlement that 

never gets detected by anybody and therefore won’t be in 

the statistics. So the true number is probably higher, but I 

think it’s safe to tell your audience that at least three in five 

dentists will be victims at some point in their careers. 

MD: Wow, that seems like a pretty high number. I wonder 

how much of that is from repeat offenders like the person you 

referenced in your first story where she goes from one office to 

another. Is that a common occurrence? 

DH: It definitely happens. We call them serial embezzlers. 

There was one woman who was working in the Toronto, 

Canada, area. Over a period of four years, she worked in 

13 different practices and stole from all of them. She was 

really good at getting hired, but as a thief — despite a fair 

amount of practice — she wasn’t all that skilled. So she 

would get caught fairly quickly and get terminated, then 

move to the next office. 

MD: If these so-called serial embezzlers can come up with 

creative schemes that continue to impress you, I would guess 

that they have decent verbal skills when it comes to lying. 

So couldn’t they show up at an office and seem to be a 

dream employee? 

DH: Absolutely. The serial embezzlers are very much takecharge 

people. They cater to what I sometimes call the 

“wet-fingered fantasy” some dentists have. A fantasy where 

they get into their office every morning, do high-quality 

dentistry on a relatively small number of patients and then 

go home, without having to get dragged into the messiness 

of managing their practice. The serial embezzlers cater to 

that. They know the computer systems really well; they’re 

organized and efficient. They look like they are working 

hard. It’s what every dentist wants. So it’s easy for them to 

get hired because when they’re in the door, they cater to 

this idea. They’re the people who will run personal errands 

for you on their lunch hours. 

MD: To back up the impression that they are somebody who 

would take a bullet for you, so how could they ever embezzle? 

DH: That’s right. Now, having said all that, the vast majority 

of embezzlement is not carried on by the serial embezzlers. 

It’s done by long-time employees. The big stuff that we 

investigate is usually from employees who have been in 

your office for 3, 5 or 12 years. Generally speaking, we think 

that these people had no plan to embezzle from you when 

they were hired. But then something happened to them 

that put their backs to the wall financially, and they decided 

that instead of going downtown and stealing people’s 

wallets, just sitting at the same desk where they work every 

day and handling the paperwork a little differently was a 

better answer. 

MD: Wow, so it’s often somebody who started off as a trusted 

employee and probably has a well-deserved good reputation? 

DH: Clean employment record, no blemishes on it at all. 

One morning they just woke up and said, “Today is the day 

I’m going to steal from my employer.” 

MD: Yeah, or something happens. Maybe they lose their house, 

a spouse loses a job, or they get divorced. There might be a 

situation that makes them desperate enough to steal from a 

person they might have previously held a lot of affection and 

trust for. 

DH: What I’ll suggest is that there are different definitions 

of desperation. There are some real hardship cases like 

the examples you mentioned; you know, somebody who 

is three months behind on their mortgage payment and is 

about to lose their house. We also find people who steal 

to get things that you and I probably wouldn’t consider 

necessities. We’re wrapping up an investigation now where 

the woman who was stealing was spending $800 a month 

on a personal trainer, and she also belonged to something 

called the Shoe of the Month Club. I wouldn’t consider her 

to be desperate. But of course what I think doesn’t matter; 

it’s her perception that governs her behavior. 

MD: Exactly. Do you think dentists are more prone to this type 

of embezzlement than other small businesses? 

DH: Probably. There is one differentiating characteristic 

between the way dentistry operates compared to, say, a 

plumbing business. The differentiation has nothing to do 

with the amount of business knowledge that each owner 

has, or the amount of attention that each spends on 

business versus the other things in their trade. What sets 

dentistry apart is that a lot of it is paid for by third parties. 

So we have this unstable situation where patients, for the 

most part, really don’t understand a whole lot about what 

just happened in their mouth, and somebody else is paying 

for it anyway. So the amount of attention that patients pay 

when leaving your office is minimal. If there is an extra 

charge in there or something that shouldn’t be, very few 

patients are going to notice it and object. 

MD: Especially if it’s an extra charge that is billed to the 

insurance company, right? 


DH: That’s right. So somebody gets extra soft tissue work 

done today, and it’s billed to their insurance company. Most 

of the time the patient won’t notice. 

MD: My original perception was that most of the embezzlement 

taking place in the dental office was from the cash patients as 

opposed to the insurance patients. The latter seems like a more 

difficult embezzlement because of the paper trail that is left 

with the insurance company. But you’re saying that it is just as 

likely to happen with the insurance people as the cash people? 

DH: Yes, it is. In fact, most embezzlers do both simultaneously. 

Dentists look at an insurance claim as a clinical document. 

To me, it’s a check requisition. 

MD: That’s a good point. Without giving too much away, are 

you saying that if a crown is done on a patient and the frontoffice 

person adds an extra buildup that wasn’t done, for 

example, that the employee is able to skim that amount off the 

top when the whole thing gets deposited? 

DH: That’s exactly right. 

MD: Interesting. Have you found that the vast majority of 

employees who embezzle are front-office staff? This seems like 

something that would be much more difficult for a hygienist or 

a chairside assistant to pull off. 

DH: I don’t think it’s more difficult; they just have to be a 

little bit more creative. We all know what has happened in the 

past three or four years to the price of gold. A lot of dentists I 

know have what they call a “gold jar” in the back of their lab. 

This is where they put the crowns they pull out of people’s 

mouths for various reasons. A lot of dentists jokingly refer to 

this as their retirement. Well, I’ve had a number of them say 

to me that since the price of gold has doubled, the gold jars 

don’t seem to fill up as quickly as they used to. 

MD: Wow, that’s an interesting one, but it seems a little 

tougher to prove. Are you able to catch people in those kinds of 

situations? Or is that just something that gives dentists a feeling 

that something funny may be going on in their offices? 

DH: You can catch them if you install cameras. And there 

are indicator powders that you can put in places that will 

turn people’s fingers purple if they touch it. If you want to 

catch them, you can. 

MD: I was noticing the other day that cameras seem to be 

everywhere. Almost everything we do is being recorded. You 

see cameras out on the street, you see them inside stores — you 

even see them on the air train that takes you from the airport 

terminal to the rental car lot. Do you suggest that dentists start 

putting cameras in their offices as well? 

DH: I’m trying to make up my mind about that, the 

usefulness of cameras with respect to embezzlement. In 

terms of catching most embezzlement, I think cameras are 

useless. Because you’d have to be the dumbest of thieves to 

visibly steal in front of a camera that you know is there. Let’s 

say you have four cameras in your office and your office 

is open 30 hours a week, your cameras are capturing 120 

hours of video a week. The practical issue is: When are you 

going to watch the footage? On the other hand, there have 

been dentists who have been accused of groping a sedated 

patient and things like that, and to me a camera would be 

a marvelous way for the dentist to defend against that kind 

of thing. So I can see the necessity of cameras in the clinical 

area perhaps more than in the administrative areas of the 

practice. But even with that, there are a lot of questions. 

Placement of the camera is critical to avoid ever being 

accused of placing it in a bad place, say in an area where 

you could look up women’s dresses or something like that. 

MD: With most of the embezzlement that goes on, do you get the 

feeling that it happens during working hours while everyone is 

there? Or does it happen during off-hours? 

DH: A lot of it happens off-hours. One of the things we 

frequently see with embezzlers is that they come and go at 

weird times. It does happen during office hours, but a lot of 

embezzlers want to be alone when they’re doing their stuff. 

MD: That also seems to tie in with what you said about the longterm 

employees. I would guess that if there are a few employees 

who have keys to the dental office that they are probably the 

longer-term employees versus the new employees. 

DH: Sure, and it will also be the ones who appear to be the 

hardest working. They’re the ones who are going to go to 

the dentist and say, “There’s some stuff I want to clean up 

on Saturdays, can I please have a key?” And then the dentist 

is going to think: “This is great, I’ve got a staff member who 

is super dedicated. I should give them an outlet for that.” 

MD: When you listen to practice management speakers, almost 

all of them emphasize that one of the key traits to having a very 

successful dental office is your ability to attract and retain longterm 

staff members and not have a lot of turnover. This really is 

the first time I’ve considered that long-term employees might be 

the ones who embezzle more often than the new employee who 

is the serial embezzler. Do you find that dentists are conflicted 

about this notion? 

DH: We can’t lose sight of the fact that the vast majority of 

dental office staff members are honest people who got into 

dentistry out of a genuine desire to help people. The bad 

apples are relatively few in number, but over the course of a 

30-year dental career, you’ll go through a lot of employees, 

so the chances of getting one of those bad apples at some 

point is high. That doesn’t mean that the vast majority of 

dental staff members are dishonest. I agree completely 

with the practice management consultants when they say 

long-term employees are part of your success. They don’t 


steal because they’ve been there for a long time. If they 

act dishonestly, it’s their longevity that enables them to get 

away with it. Because they know the dentist, his habits, and 

what the dentist looks at and what he doesn’t, they can craft 

their fraud in a way that bypasses scrutiny. For example, if 

you’re a dentist who checks your day sheet every day — I 

think every dentist should do that — then someone who 

is going to embezzle from you knows that. So they’re not 

going to do something that leaves a mess on your day sheet. 

They’ll have to find a different way to steal. 

MD: I know we have a lot of staff members who read our 

magazine, so I’m glad you brought that up. Maybe a better way 

to state the practice management message is to say that a lot 

of a dental practice’s success comes from the dentist’s ability 

to find and retain honest, long-term employees. The long-term, 

dishonest employee is a counterintuitive thought, and I think 

most dentists would be flabbergasted to find out that a longterm 

employee is the one embezzling from them. But I think 

it’s a good point to make just because of the fact that those 

employees would probably be the last people a dentist would 

suspect in a situation like that. 

DH: A lot of dentists go through a period of disbelief. They’ll 

see some signs that somebody is stealing from them, and 

then they think about their employees and they’ll sort of 

rule everybody out — even those who they think have an 

opportunity to embezzle. They’ll convince themselves that 

the theft isn’t happening, and then they’ll go back to work. 

At some point the noise gets a little bit louder and something 

happens that they just can’t categorize as an innocent mistake 

anymore, and then they realize they have a problem. A lot of 

times there is a denial period that dentists go through when 

they have long-term employees because they have a lot of 

trust in those employees, whether it’s misplaced or not. 

MD: Have you come across instances of a family member working 

at the office and being responsible for the embezzlement? 

DH: Yes, we have. One scenario is when you have one 

spouse who is the dentist and one spouse who is the office 

manager. The office manager has decided to get divorced 

from the dentist, but hasn’t told the dentist that yet. So they 

need to build up a war chest in order to pay their attorney 

and find a place to live because their only source of 

income is employment income from their spouse, which is 

presumably going to be cut off when they drop the divorce 

bomb. The spouse knows they will need money under the 

mattress and that’s how they get it. 

MD: I was thinking more about kids coming to work in the 

office, or maybe an in-law. But that’s a great example that 

never occurred to me. Do you have a list of potential warning 

signs that dentists might see happening in their practice that 

could warrant an investigation? 

DH: We do. This is maybe where I have a slightly different 

view than a lot of people who write and speak about 

embezzlement. Many of them try to turn dentists into what 

I would call untrained, ill-equipped auditors in their own 

practices. These advisors give the dentists lists of things to 

“ 

We see everything from stealing toilet paper at 

the office to frauds that exceed a million dollars. 

The average we see these days is probably a 

little over $100,000. I think last time we did the 

calculation, it came out to about $105,000. 

”

check for and to look at in order to stop embezzlement, 

or to find out if it’s happening. My approach is a little 

bit different. What I tell dentists is that there might be a 

thousand different ways to embezzle from their practice, 

but regardless of which of those thousand the thief is 

using, the way these thieves behave is very predictable. We 

already mentioned the people who are in the office alone 

at unusual times. You also might consider that employees 

who are reluctant to take vacations might have their finger 

in the till. So we have what we call the “Embezzlement Risk 

Assessment Questionnaire,” which is a scored questionnaire. 

If you score at a certain level, it tells you that you either 

have very little risk or, conceivably, that you are at high risk 

of embezzlement going on in your office. 

MD: So are you saying that one type of employee who might be 

suspicious is someone who gets two weeks’ paid vacation from 

the dentist but never uses it and cashes it out? Or maybe it’s the 

person who wants to stay in the office even when everybody else 

goes on vacation? 

DH: Yes, that’s a symptom. Whether they get cash for their 

vacation or not is irrelevant. To me, the real issue is that 

they do not want the office open when they are not there. 

MD: I see, so they want to be able to cover their trail at any 

moment if something irregular is discovered. They probably 

worry that if they are gone for a week and somebody starts 

digging through the computer that any irregularities could 

be noticed. 

DH: What uncovers a lot of fraud is patients asking questions 

about things. A very common scenario is when a patient 

says, “I was in two weeks ago and I paid by cash, but I just 

got my statement and it showed that I paid by check.” If that 

call comes to the thief, they can squelch it by saying: “Yes, 

I know. We just upgraded our computer system and there 

are a couple of bugs. The software vendor is working on 

it. We’re very sorry it happened.” It doesn’t matter whether 

there is one of those calls a day or a hundred, the thief can 

make them go away. On the other hand, if the thief is not 

in the office and there is someone else getting these calls, 

sooner or later that person is going to say to the doctor that 

something funny is going on. And then it unfolds. It’s about 

control of information in the practice, and the thief can only 

exert that control by being there. 

MD: That makes sense. They’d probably even insist on taking 

all phone calls, right? 

DH: That’s right. They’re often the ones who almost lunge for 

the phone when it rings. For a dentist who doesn’t suspect 

fraud, this looks like a very motivated, committed employee. 

MD: Might this employee work on having the best phone skills in 

the office, so it only makes sense to have them answer all calls? 

“ 

You’ll see hand instruments and 

all kinds of consumables that are 

for sale online at a lower price 

than you can buy them from 

a supplier. Theoretically, 

I guess some of this stuff is 

gray market that somebody 

bought in some other country 

and imported. But I think a 

vast majority of it just kind of 

‘fell off the truck’ in one way 

or another. 

”

DH: Definitely. 

MD: From the different cases you’ve seen over the years, what 

would you say is the range or average of how much money is 

usually taken? 

DH: We see everything from stealing toilet paper at the office 

to frauds that exceed a million dollars. The average we see 

these days is probably a little over $100,000. I think last 

time we did the calculation it came out to about $105,000. 

MD: Have you actually caught somebody who was just stealing 

toilet paper? 

DH: It’s not one that we normally chase. But it certainly 

happens, and we do have dentists complaining to us about 

it. Sometimes it’s the tip of a bigger iceberg. But, yes, we 

do have lots of dentists who complain about things going 

missing when the staff members are probably the only 

people with the opportunity to steal. Another thing is, if 

you look on eBay, you’ll see all kinds of dental gear for sale. 

MD: Interesting. To my knowledge, I have never been embezzled 

from. But in preparing for this interview, I was trying to think 

like the criminal mind, and ask myself what I would do if I 

had the opportunity. A chairside assistant could maybe sell 

bleaching kits on eBay, the kind that don’t need custom trays, 

like the pre-made ones from Ultradent. Those could be sold on 

eBay directly to patients for a markup. Is that the kind of thing 

you’re talking about, or do you mean actual equipment? 

DH: Both. If a compressor is for sale on eBay, I highly doubt 

the dental assistant snuck it out of the office while nobody 

was watching. But you’ll see hand instruments and all kinds 

of consumables that are for sale online at a lower price than 

you can buy them from a supplier. Theoretically, I guess some 

of this stuff is gray market that somebody bought in some 

other country and imported. But I think the vast majority of 

it just kind of “fell off the truck” in one way or another. 

MD: Wow, and that’s not really something that anyone polices, 

or could even. It seems like a difficult thing to try to get a 

handle on. 

DH: I hate to say it, but I think most of the purchasers of 

this stuff aren’t end consumers buying bleach kits, but other 

dentists saying, “Wow, this stuff is really cheap on eBay.” 

MD: In a dental office where the dentist doesn’t pay a lot of 

attention to what arrives in the boxes from Patterson Dental or 

Henry Schein, you might have somebody ordering things at full 

price and then putting them on eBay. Three days later when it 

disappears, no one misses it because the dentist didn’t really 

need it or even order it in the first place, right? 

DH: Yes. Unless it’s enough to distort the ratio of consumables 

to productivity, which would have to be a whole lot of stuff 

going out the back door, nobody is ever going to notice. 

MD: I’ve heard stories about dental assistants, for example, 

coming into the office on a Saturday and making bleaching 

trays for people and charging for it. Obviously it’s illegal, but is 

that considered embezzlement as well? 

DH: I’m not sure it meets the formal definition of 

embezzlement, but it’s some kind of stealing, yes. What it 

really amounts to is practicing unlicensed dentistry. I saw 

something the other day about a dental assistant who would 

bring her friends in on Saturdays and do fillings on them. 

MD: The very first story you told was about a woman who 

was fired from one practice for embezzling, who you then ran 

into at another practice. Then you told me about the woman 

in Toronto who stole from 13 practices. It seems like at some 

point they would be prosecuted. Is it up to the dentist to decide 

whether they want to prosecute these employees? 

DH: Prosecution is the responsibility of the government, 

not the individual dentist. So when people say, “I’d like to 

press charges,” or “I’d like to not press charges,” they’re 

assuming a privilege that they really don’t have. It is the 

government that carries that responsibility and the financial 

and evidentiary burden that goes with it. Having said that, 

what a dentist can do is either communicate their interest in 

having somebody charged, or communicate that they really 

don’t want a person charged. Most of the time law enforcement 

and prosecuting agencies will give some weight to 

that. Also, if somebody hires us to investigate and we gather 

a fair amount of evidence, they can instruct us whether to 

share it with law enforcement. If we don’t share that evidence 

with law enforcement, in most cases they will have 

no interest in prosecuting because they don’t have the realistic 

means of gathering the same information themselves. 

MD: Have you seen any cases where it was not a full-time 

employee doing the embezzlement, but instead the dentist’s 

accountant or somebody who only comes in once a month, an 

auxiliary position like that? 

DH: The only cases where we’ve seen an appreciable amount 

of theft is with some kind of bookkeeper or accountant; 

somebody who has some level of control over the banking 

function, such as writing checks. A part-time bookkeeper 

is the only bookkeeper there, so even if that person only 

comes in three days a month, there is nobody else doing the 

job when they’re not there. So they can probably succeed 

there on a part-time basis. With somebody like a part-time 

receptionist, however, we really see very little stealing. 

Somebody who mans the front desk on Fridays is going to 

have a tough time getting away with much. 

MD: Might another warning sign be an employee who insists 

on doing all the insurance claims herself? 


DH: Yes, refusal to delegate is one thing. Another sort of 

related symptom is refusal to cross-train. A lot of these 

people come off as perfectionists. They tell the dentists 

that if somebody else does it and messes it up, then they 

have to fix it. In the meantime, your cash flow suffers 

because all these claims have been sent to the wrong 

place. The employee convinces the dentist that he or she 

is a perfectionist, which generally we consider a positive 

with employees rather than a negative characteristic. So the 

dentist tends to be receptive to this argument and the thief 

gets away with it. 

MD: It has to be even more confounding for a dentist to have an 

employee with all these fantastic traits that they wish all their 

employees had, and then to find a knife in their back with that 

employee’s fingerprints on it. Are you aware of some dentists 

who have been embezzled from multiple times? 

DH: Definitely. In fact, once you’ve been embezzled from 

once, the probability of you being a repeat victim is actually 

higher than the general dental population. About two-thirds 

of recorded embezzlement is from people who have already 

been a victim. The probability goes up from 50 to 60 percent 

to something closer to 70 percent. 

MD: How do you explain that? 

DH: I think the short answer is that some dentists are 

probably easier to steal from than others. What makes them 

easier to steal from could be anything from personality to 

how they run their office to who else is working in the 

office. There could be a lot of factors. Again, the chances 

of hiring a bad apple in your career are pretty good. The 

chances of hiring two are also pretty good. 

MD: Once somebody in the office is caught and nothing about 

the way the office is run changes, do you think it gives other 

people in the office the idea to do the same thing? 

DH: I don’t think that is what happens. I think five years 

goes by, somebody else gets hired and that person steals. 

The not checking the day sheet thing is a little bit of a red 

herring. But if I’m a nice, easygoing dentist, for example, 

the staff might get the idea that they can steal from me 

without me really doing anything, because I’m just way too 

nice. So I think if one staff member can form that opinion 

about a dentist, so can two or three more. 

MD: Let’s say I think I’m having an issue in my office and I give 

you a call. Can you tell me a little bit about what the process is 

like after that? 

DH: Sure. The first thing we do is have somebody reasonably 

senior at my company interview the dentist to see what the 

dentist is seeing, and just try to validate that there could 

be a problem. Sometimes we get dentists who don’t really 

think there is a problem, but they have an employee who 

did one thing to them once three years prior that they 

think could be symptomatic of stealing. We usually tell that 

doctor that if this person is embezzling, they’re going to see 

more manifestations than one instance three years ago. We 

try to help the dentist sort out what the employee is doing 

“ 

One message I’ll give 

your readers is that it is 

really important to have 

individual logins for your 

practice management 

soft ware. Some offices 

have what I call the 

‘unicode,’ a single code 

that everybody uses to 

log in with, which makes 

it very tough for us to 

track who is doing the 

dirty stuff. 

”

that should give them concern. We probably have a better 

knowledge than the dentist of what embezzling behavior 

looks like. 

Once we mutually decide that an investigation should 

happen, the next thing we do is obtain their computer data. 

We don’t like to work on the dentists’ computers because 

they’re live systems and stuff is constantly changing. Plus, 

if we’re connected remotely to a dentist’s computer, there 

is a reasonable possibility that the staff member might 

realize what we are doing. One thing that we emphasize 

to every dentist we deal with is that an investigation has 

to be stealthy. The staff cannot know that you are doing an 

investigation until the process is complete and you have 

an answer. Because if you think there is fraud when there 

isn’t and you let the employees know that, you’ve destroyed 

the employment bond and rebuilding it will be close to 

impossible. On the other hand, if there is embezzlement 

going on, you want to spring a trap on the thief as opposed 

to the other way around. So stealth is important. What 

we do is we get a complete copy of someone’s practice 

management software data. So if you’re using Dentrix ® 

(Henry Schein; American Fork, Utah), for example, there 

is a folder on your server that has all the data. We get it 

and bring it into our computer lab, where we analyze it 

using our copy of Dentrix and look for patterns that are 

consistent with embezzlement. 

MD: Once you’ve identified that there might be some embezzlement 

going on, do you set the trap at that point? Or do you 

have to have another occasion or two to be able to make a 

strong case? 

DH: No, most of the time at that point we can see what 

has gone on. A lot of times we’re helped by third parties. 

For example, if we see a situation where there was money 

billed to an insurance company but the money didn’t come 

to the practice. Then we can go back to the insurance 

company and ask where the check went. If it went into the 

receptionist’s bank account, then we know. 

We also look at login names on the computer and who 

is logged into the practice management software. We also 

check if someone is coming and going at strange hours and 

if there is either an alarm system in the office or if there 

is some kind of building log that tracks access. If we can 

correlate transactions to a specific person’s access, then we 

have them. One message I’ll give your readers is that it is 

really important to have individual logins for your practice 

management software. Some offices have what I call the 

“unicode,” a single code that everybody uses to log in with, 

which makes it very tough for us to track who is doing the 

dirty stuff. 

DH: I highly doubt it will stop anybody from stealing, but 

it will make the job of pinning their hide to the wall far 

easier afterward. I’ll say the same thing about alarm systems 

in the office. I go into a lot of offices where there is one 

code that everybody in the office uses, including the office 

cleaners that were fired who used to work there three years 

ago. It’s important that everybody has their own unique 

login code for the alarm system, and that they are changed 

periodically. Because it stops employees from scooping up 

someone else’s code by watching over their shoulder when 

they’re entering it. 

MD: That is another great tip. I love your example about the 

office cleaners who were fired three years ago. I would present 

individual login codes to the staff as a protection measure 

against outside theft more than internal theft, but also suggest 

that they keep the codes to themselves regardless. That way 

people aren’t looking at one another wondering who is stealing 

from the office or thinking that is why the practice is going 

through all the security trouble. 

So if a dentist does think something funny is going on in their 

office and they want to give your company a call, what is the 

best way for them to contact you? 

DH: We have one e-mail address that we refer to as the 

“embezzlement hotline.” The e-mail address is emergency@ 

dentalembezzlement.com. We have an on-duty fraud 

investigator 365 days a year, and that e-mail address 

is monitored by whoever is on duty. So if you send an 

e-mail to that address on a Sunday, you will typically get 

a response the same day from an investigator who will 

say, “Let’s find a time when you are able to speak freely, 

and go from there.” We also have a phone number and 

other e-mail addresses, but the absolute best way to get 

in touch with us if you have embezzlement concerns is 

emergency@dentalembezzlement.com. 

MD: Any tips about where they should be sending that e-mail 

from, just in case the embezzler is going through their e-mail? 

DH: If they’re not sure about their e-mail security, the best 

advice I can give your readers is to set up a new Hotmail 

or Gmail account and send it from there. Just because we’ll 

know that one is secure. CM 

For more information, contact David Harris at 888-398-2327 or by visiting 

www.dentalembezzlement.com. For immediate concerns about potential dental 

fraud being committed in your office, e-mail emergency@dentalembezzlement.com. 

MD: Individual logins seem like a good preemptive thing to 

have in place, so employees know that anything they do on the 

computer is going to be able to be traced back to them. 


Prosthetic Tooth Repositioning: 

A Viable Treatment Option for Select Cases 

– ARTICLE by Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE, FASDA 

Introduction 

For many years, patients with esthetic and functional problems 

due to tooth malposition have had few treatment 

options. Orthodontics is the first option to correct tooth 

malposition; however, not all patients are willing to follow 

through due to the length of time it takes to complete treatment. 

In a certain percentage of these cases, orthognathic 

surgery is also suggested to correct maxillary and mandibular 

jaw position prior to orthodontic therapy. Often, the 

patient is still faced with the prospect of restorative dentistry 

when these therapies are completed to gain a full esthetic and 

functional correction. Therefore, many patients never have 

the opportunity to receive the treatment they seek unless 

they agree to this lengthy regimen. 

With the advent of dentin bonding and advancements in 

dental porcelains, elective esthetic dentistry has never before 

been in such high demand. For a select group of these 

patients with minor tooth malposition, such as spacing (diastemata), 

crowding (mesial and distal overlapping), minor 

rotations and facial-lingual arch form displacement, esthetic 

and functional correction may be accomplished purely by 

restorative means. The patient, however, must understand that 

correction of these malpositions will require a more aggressive 

preparation of the teeth involved to align the arch form. 

A diagnostic wax-up is absolutely necessary to help determine 

the amount of tooth preparation that will be required. 

A silicone or plastic preparation guide, or stent, is fabricated 

from the diagnostic wax-up that is approved by the 

patient. In some cases, intentional endodontics is required 

to gain the proper space for the correction of tooth position. 

It is imperative that the patient be aware of this possibility 

before any treatment is started. However, as long as the 

patient is fully informed of all treatment options, the patient 

should have the opportunity to pursue this type of elective 

treatment, if that is what the patient desires. 

Case Preparation 

In order to determine if a patient is a candidate for prosthetic 

tooth repositioning, mounted study casts are 

required. It is recommended to duplicate the models so a 

preoperative model can be kept as part of the permanent 

record. The second model is prepared to assess how much 

tooth reduction is required to gain an optimal result. Depth 

cuts and preparation dimensions can be recorded for use 

during the operative phase of treatment. Once the teeth are 

prepared, a wax-up is done to correct tooth contour and 

position. Keep in mind proper tooth length and width when 

designing the esthetics, or “Golden Proportion,” of the case. 

When preparing crowded dentition, the first step is to 

perform an enameloplasty on teeth that are outside of the 

proposed arch form to bring them into better alignment. Next, 

the proximal contacts between the teeth are broken. Crowded 

or overlapped teeth will require wrap-around veneers 

Prosthetic Tooth Repositioning: A Viable Treatment Option for Select Cases55

or full-coverage crowns. It is recommended to use a very thin 

diamond instrument, such as a 30-micron interproximal composite 

finishing diamond, or mosquito diamond, to shape 

opposing proximal surfaces and vertically break the contact 

between the roots. These surfaces can later be highly polished 

with 50-micron finishing burs, discs and fine curettes. 

One key to achieving good results is having adequate 

interradicular space for development of a healthy gingival 

papilla that can easily be cleaned by the patient. Teeth 

that are out of line in the buccolingual dimension must be 

corrected by over-preparing the side of the tooth that is out 

of alignment. The opposite side of the tooth, in most cases, 

will only need slight preparation in the marginal area. It is 

important to mention that so-called “no-prep techniques” 

cannot possibly correct misalignment of functional surfaces 

without adding thickness to the tooth form, resulting in 

overcontoured teeth. 

Figure 1: A preoperative, full-arch, retracted view showing the amount 

of crowding present in this Class II Division 1 patient. 

Figure 2: A preoperative incisal view of the maxillary arch showing the 

rotation and crowding of the maxillary anterior segment. 

Figure 3: This incisal view of the preoperative cast shows the areas 

in black that need to be reduced to create proper arch form before 

reducing for the restorative material. 

Figure 4: The completed maxillary and mandibular composite mockup 

for the patient. 

Case Report #1 

The patient in this case has a Class II Division 1 malocclusion 

with normal overjet and crowding of the maxillary 

and mandibular anterior segments (Figs. 1, 2). The areas of 

tooth structure outside the proposed arch form are marked 

on the preoperative study model (Fig. 3). For labiolingual 

malpositions, the proposed arch form will be positioned 

halfway between the most facially positioned tooth and the 

most lingually positioned tooth. This will allow for more 

conservation of tooth structure by avoiding a full correction 

on any one malpositioned tooth. 

It is important to inform the patient that this type of case 

may require correction of both arches because, with normal 

overjet, the mandibular malpositioned teeth will get in the 

way of correcting the maxillary teeth in the lingual direction 

if only a maxillary arch alignment correction is attempted. 

This must first be verified by preoperative cast preparation 

and composite mock-up (Fig. 4). 


Figure 5: The areas that need to be reshaped as determined on the 

preoperative cast are marked prior to preparation. 

Figure 6: The provisional stents in place to be used as preparation 

guides to evaluate for proper tooth reduction. 

Figure 7: A maxillary arch incisal view of the completed case. Compare 

the postoperative arch form to the preoperative view shown in Figure 1. 

Figure 8: A retracted facial view of the completed case. 

Figure 9: An eight-year postoperative view of the completed case. 

For a select group of 

patients with minor tooth 

malposition … esthetic and 

functional correction may 

be accomplished purely by 

restorative means. 

If the case is determined to be reasonable to perform, the 

patient must then approve the mock-up to ensure that the 

proposed correction will meet his or her expectations. If desired, 

the actual teeth can be marked in the same fashion as 

the study models using a sterile marker to show where the 

teeth need to be reshaped prior to depth-cut placement and 

tooth preparation for the restorative material (Fig. 5). Clear 

provisional stents made from the composite mock-ups can 

also serve as three-dimensional preparation guides to verify 

proper tooth reduction (Fig. 6). 

A completed incisal view and full-smile retracted view are 

shown in Figures 7 and 8. Compare these to the preoperative 

views (Figs. 1, 2) to visualize prosthetic corrections. 

Figure 9 is an eight-year postoperative, full-arch, retracted 

facial view. This case has been esthetically and functionally 

stable over this period of time. 


Figure 10: A full-arch retracted preoperative view of a patient in 

centric relation with no posterior tooth contact. He has no TMJ 

symptoms at this time. 

Figure 11: As the incisal edges of teeth #7–10 are reduced out of 

contact, the posterior teeth begin to come into contact. 

Figure 12: Following the incisal reduction of teeth #7–10, contacts of 

the posterior maxillary teeth can be seen from this maxillary arch view. 

Figure 13: Tooth preparation of the maxillary incisors completed for 

all-ceramic restorations. 


The patient shown in a preoperative, retracted view in 

Figure 10 is positioned in centric relation. It is evident 

that this patient is occluding on the anterior only and has 

no posterior tooth contact. He has been told that his only 

option is to have jaw surgery followed by orthodontics and 

restorative therapy. After mounting the preoperative study 

models in centric relation on a semi-adjustable articulator, 

it was determined that if the maxillary anterior arch form 

could be slightly expanded facially (increasing the overjet), 

it would likely allow the mandible to close and the posterior 

teeth to contact. 

When the maxillary teeth #7–10 are reduced incisally, the 

posterior teeth will come into contact. Therefore, the operative 

plan will be to prepare teeth #7–10 and place 360-degree 

ceramic restorations to correct the arch form in the facial 

direction and tilt the long axis of the crowns slightly toward 

the facial aspect, creating overbite and overjet. As the incisal 

edges are shortened, the posterior teeth come into contact 

(Figs. 11, 12). Once this occurs, the teeth must then be depth 

cut on the facial and palatal aspects to allow for the thickness 

of the ceramic material (Fig. 13). 

Figure 14 shows the case completed after the four maxillary 

incisor restorations are delivered. Note the functional 

contact that now exists in centric occlusion for the patient. 

Although the crossbite cannot be addressed without restoration 

of the posterior teeth and a full-mouth reconstruction, 

the patient has gained a stable occlusal situation by the restoration 

of four teeth without invasive orthognathic surgery. 


Figure 14: After placement of the ceramic restorations, contacts in 

the posterior region can now be seen back to the first molar region, 

giving this patient a more stable intercuspation in centric occlusion. 

Figure 15: A preoperative smile view of a dentally compensated 

Class II malocclusion. 

Figure 16: From this preoperative incisal/occlusal view, there is a 

great deal of crowding and rotation because the teeth are tipped lingually, 

constricting the arch form and pushing teeth out of the arch. 

Figure 17: An incisal view of teeth #5–8 after breaking the proximal 

contacts and separating the teeth (interproximal reduction, or IPR). It 

is important to separate the root forms at the gingival crest interproximally 

with a mosquito diamond, allowing retraction cord to be placed. 

This will ensure proper space for the emergence profiles and healthy 

interproximal gingival tissue. 


The patient shown in Figure 15 presented with a dentally 

compensated Class II malocclusion. He had never pursued 

esthetic dental treatment because he was consistently told 

that his functional and esthetic dental problems could not 

be corrected without orthognathic surgery and orthodontics 

prior to restorative therapy. In his opinion, the cure was 

worse than the disease. 

After working up the case on study models as previously described, 

it was determined that this patient could be helped 

prosthetically without surgical intervention. Figure 16 is an 

occlusal/incisal view of the preoperative maxillary arch. The 

orthodontic approach to unraveling this crowded arch would 

be expansion, or tipping the teeth in the labial direction. This 

would increase the arch length and allow for proper tooth 

alignment. It would also increase the overjet, resulting in a 

more Class II-like appearance. 

When planning to orthodontically prepare these teeth, it is 

important to note that correcting the lingual inclination of 

the clinical crowns will have the same effect in gaining arch 

length. There will be very little need to prepare these teeth 

on the facial surfaces. The majority of the tooth reduction 

will be on the proximal and lingual surfaces to orthodontically 

correct the clinical crown angulation with the bur 

(“diamond-driven orthodontics”). 


Figure 18: A facial view of teeth #5–8 after selective reduction on the 

facial and lingual surfaces to remove excess tooth structure outside 

the proposed arch form. 

Figure 19: An incisal view of the preparations for teeth #5–8 after 

depth cutting and two-plane reduction. This process is referred to as 

“orthodontic tooth preparation.” Note that the prepared incisal edges 

now follow a nice arch form that will be followed in the definitive restorations. 

Compare this to the varied directions of the incisal edges in 

the preoperative condition in Figure 16. 

Figure 20: A facial view of the completed preparations. These 

orthodontically prepared teeth are now ready to accept restorations 

that will not only correct the clinical crown positions, but will also 

be structurally sound and esthetic due to the space created for the 

proper thickness of restorative material. 

Figure 21: A facial view of the correction of the maxillary arch after 

provisionalization with a rubberized urethane provisional material 

(Tuff-Temp [Pulpdent Corporation; Watertown, Mass.]). 

Interproximal reduction, or IPR, is performed in a similar 

fashion to that of conventional orthodontics. The goal is to 

separate the prepared teeth at the free gingival crest (Fig. 17). 

The facial surfaces of the rotated teeth are reshaped in areas 

that are facial to the proposed completed arch form (Fig. 18). 

Lastly, depth cutting and two-plane reduction is performed 

to allow for the proper positioning and thickness of the 

definitive restorations (Fig. 19). 

Figure 20 shows the completed preparations from the facial 

view. Looking only at the final shape of the final preparations 

of the teeth prior to master impression-making, one 

would be hard-pressed to know how severe the preoperative 

crowding and rotations were. 

After making the master impression, taking a facebow 

transfer and making interocclusal records, the preparations 


Figure 22: The delivered maxillary restorations and the provisionalized 

mandibular arch. 

Figure 23: An incisal/occlusal view of the definitive restorations on 

the maxillary arch after delivery. Compare this to the preoperative 

view in Figure 16. Note that the crown forms have normal anatomic 

contours and incisal edge thickness even after prosthetic correction 

of the original misalignment. 

Figure 24: An incisal/occlusal view of the definitive restorations on 

the mandibular arch after delivery. 

Figure 25: A postoperative smile view of the completed case. This 

patient chose A1 as the final shade of the ceramics (IPS e.max ® 

[Ivoclar Vivadent; Amherst N.Y.]). Compare this to the preoperative 

smile view in Figure 15. An amazing transformation in esthetics and 

arch form accomplished without surgery or braces was achieved for 

this patient with careful planning and precise clinical execution from 

preparation and provisionalization to delivery. 

are provisionalized using a rubberized urethane provisional 

material and a clear plastic stent made from a diagnostic 

mock-up of the case (Fig. 21). 

At the following appointment, the maxillary restorations are 

delivered and the mandibular arch is prepared in the same 

fashion as previously described, and then provisionalized 

(Fig. 22). Figure 23 shows the completed maxillary arch 

from the occlusal/incisal view after delivery of the definitive 

restorations on teeth #5–13. Figure 24 shows the completed 

mandibular restoration from the occlusal/incisal. The completed 

smile view is shown in Figure 25. Compare this final 

result to the preoperative smile view in Figure 15 to see the 

remarkable transformation! 


Conclusion 

Prosthetic tooth repositioning is a viable treatment option 

for select malocclusions that require esthetic and functional 

correction. The stability of these cases has been shown 

clinically when proper guidelines have been followed. Some 

specialists have editorialized that this type of treatment is a 

“quick-fix cop-out,” arguing that patients should be talked 

into the ortho/surgical approach for these types of cases. It 

is important to note that crowded dentition is very difficult 

to clean, which can pose a challenge to maintaining proper 

periodontal health, so it is very common to see these patients 

with chronic marginal and interproximal gingivitis and, in 

later years, full-blown periodontitis when these problems 

are not addressed and corrected. Therefore, it is important 

to emphasize to patients that these corrections, no matter 

how they are accomplished, are needed for dental health 

reasons as much as they are for esthetic correction. Just ask 

these patients if the sacrifice of a little more tooth structure 

versus the more “conservative” surgical approach was worth 

it for them. It is always best to present all of the treatment 

options and let patients help decide the course of treatment 

that best suits their needs. CM 

Prosthetic tooth 

repositioning is a viable 

treatment option for select 

malocclusions that require 

esthetic and functional 

correction. The stability 

of these cases has been 

shown clinically when 

proper guidelines have 

been followed. 

Dr. Robert Lowe is in private practice in Charlotte, N.C. He also lectures internationally 

and publishes on esthetic and restorative dentistry. Contact him at 

boblowedds@aol.com or 704-450-3321. 

Acknowledgement 

The author would like to acknowledge the ceramic artistry of William “CK” 

Kim, CDT, of Yes Dental Lab in Case #1; Mike Felgenhauer, CDT, of Dental Arts 

Precision Laboratory in Case #2; and Nadar Hedeshi, CDT, in Case #3. 


Biologic Shaping from a 

Restorative Perspective 

– ARTICLE by Daniel J. Melker, DDS 


In today’s world of advanced dental procedures and 

technology, traditional or classic dental principles can 

easily be lost. This may especially be true with the 

decision-making process of saving teeth. Implants are 

wonderful options when appropriate, but they should not 

be selected when a tooth can be saved using a predictable 

perio or restorative protocol that yields excellent long-term 

prognoses. Too often today, good teeth are being removed 

in favor of implant placement that is occurring in a clinical 

environment of inadequate bone and soft tissue, as well 

as biomechanical compromise. Biologic shaping and soft 

tissue grafting offer a classic, proven methodology for 

treating teeth with absolute predictability. 

Often our restorative treatment plans lead us to subgingival 

margins, furcation involvement, root flutes and concavities, 

in addition to a multitude of complex issues. Many of the 

issues we face are in the subgingival environment and require 

periodontal corrective procedures to return the foundation 

to a healthy state. Traditionally, crown lengthening was 

indicated for deep subgingival margins, not only to facilitate 

impression making but also to correct biologic width 

infringements. Biologic shaping is a periodontal corrective 

procedure reported in the literature 1 that may complement 

traditional crown lengthening, yet it differs from traditional 

crown lengthening in the following ways: 

5. 

6. 

calculus and caries formation. Biologic shaping 

leaves the subgingival area as smooth as glass; there 

are no areas for plaque, calculus or caries to hide. 

Traditional crown lengthening worsens crown-toroot 

ratio. Biologic shaping maintains crown-to-root 

ratio. 

Traditional perio is about pockets and probing. Biologic 

shaping is about preserving bone, smoothing 

out the rough spots, and making restorative dentistry 

predictable and a joy to perform. 

The concept of biologic shaping is presented in the case 

that follows. The procedure stresses a 360-degree removal 

of tooth surface irregularities as well as all cementoenamel 

junctions (CEJs) and existing margins. An important aspect 

of the procedure is to remove any concavities or furcation 

involvements. Once the root surfaces are perfectly smooth, 

the flap is placed just coronal to the osseous surface and 

sutured in place. After 12 to 14 weeks of healing, the 

restorative dentist simply places a new margin just coronal 

to the gingival collar, which allows for a perfect impression 

to be taken. This case also features the specific correction of 

a mesial concavity on an upper first bicuspid. 

1. 

2. 

3. 

4. 

Traditional crown lengthening moves the bone away 

from the margin. Biologic shaping moves the margin 

away from the bone. 

Traditional crown lengthening requires osseous 

surgery to re-establish the biologic width. Biologic 

shaping may require minor osseous surgery, but 

it generally avoids major osseous surgery and still 

re-establishes biologic width because you have the 

choice to locate your restorative margin coronal to 

the old restorative margin (0.5 mm apical to the core 

is the coronal extent). 

Traditional crown lengthening may open furcations 

and render a poor prognosis. Biologic shaping 

preserves the integrity of the furcation because 

aggressive osseous surgery was not needed. 

Traditional crown lengthening does not eliminate 

flutes, concavities or root clefts, leaving the 

postoperative lengthened crown at risk for disease 

recurrence due to increased susceptibility for plaque, 

Case Presentation 

Figure 1: This patient will undergo a maxillary full-arch restoration to 

correct occlusal issues and mild periodontal disease. When performing 

definitive restorative procedures, it is critical to have an ideal periodontal 

foundation to restore. There was an initial discussion on whether to restore 

the bicuspids. After review of occlusal issues, it was decided to include the 

bicuspids in the provisional phase of treatment. 

Biologic Shaping from a Restorative Perspective65

Figure 2: Upon reflection of the tissue with a full-thickness flap due to 

the existing thick bone, the tooth surfaces exhibited calculus located in 

concavities. 

Figure 3: From a slightly different angle, the irregular contours of the bone 

can be seen. Osseous contouring will be necessary to create contours that 

will be compatible with the soft tissue when it is replaced. Once the flap is 

reflected, a split-thickness dissection is used to preserve the periosteum 

for suturing of the flap and for stability. 

Figure 4: Using a C847-016 diamond bur (Axis Dental; Coppell, Texas), the 

tooth surface is gently smoothed to remove any irregularities of the root 

surface, as well as all CEJs. The concavity on the upper first bicuspid is also 

removed by gently blending the line angles approximating the concavity. 

Removal of the middle tooth surface of the bicuspid was avoided so as 

not to deepen the concavity. 

Figure 5: Once the gross removal of tooth structure is completed, an 

F847-016 diamond bur (Axis Dental) is used to smooth the root surface. 

Biologic shaping and soft tissue grafting offer a ... proven 

methodology for treating teeth with absolute predictability. 


Figure 6: A C801L-023 diamond round bur (Axis Dental) is then used to 

properly contour the bone to mimic the soft tissue. The term for this procedure 

is “creating a parabolic architecture,” and it is the key to forming an 

ideal interface between bone, tooth and tissue. This phase of the surgery 

helps to avoid the formation of pockets between the bone and soft tissue 

when the tissue is replaced. 

Figure 7: Upon completion of the biologic shaping and osseous contouring, 

an ideal foundation is created over which the soft tissue can be sutured 

in place. 

Figure 8: 5-0 chromic gut suture material is used to replace the flap just 

coronal to the osseous underlying foundation. An important aspect of 

suturing the flap is to involve the periosteum as an attachment apparatus 

for the suture. The suture grabs the periosteum apically to allow for perfect 

placement of the flap so that no movement or displacement of the flap can 

occur. There is no need for any dressing to be placed. 

Figure 9: An occlusal view showing as much primary closure of the flaps 

as possible. This allows for decreased discomfort in the healing phase. 

Also note that no CEJs are present on any of the teeth. A recent article 

by Rapley and Cobb, et al. 2 demonstrated with electron microscopy that 

the CEJs tend to hold biofilm and that these areas can be a source of 

periodontal breakdown. It is the belief of the author that by removing the 

CEJs, we are treating a cause of future breakdown, thus changing the 

environment for long-term maintenance. 

The procedure stresses a 360-degree removal of tooth 

surface irregularities ... all CEJs and existing margins. 

Biologic Shaping from a Restorative Perspective67

Biologic shaping is about preserving bone, 

smoothing out the rough spots, and making 

restorative dentistry predictable and a joy to perform. 

Figure 10: The day of the reline appointment after four weeks of healing. 

The provisionals will be closed to fit the teeth, leaving 1 mm of space 

between the provisional and the tooth surface to allow for future biologic 

width growth in a coronal direction. No prepping of the tooth surface is 

done at this appointment. 

Figure 11: Impressions day, 12 weeks post-op. All margins are placed 

just coronal to the gingival collars. A size 7/00 SilTrax ® cord (Pascal 

International; Bellevue, Wash.) is placed in the sulcus to allow for the lab 

technicians to trim the dies. 

Figures 12–14: Final restorations placed. All are IPS e.max ® crowns 

(Ivoclar Vivadent; Amherst, N.Y.) with the exception of full-coverage gold 

on the second molars. All margins are supragingival. Ideal health exists 

between the crowns and the soft tissue with no inflammation present. 

(Restorations courtesy of Dr. Howard Chasolen of Sarasota, Fla.) CM 

Dr. Daniel Melker is in private practice in Clearwater, Fla., and lectures nationwide 

on periodontics and prosthodontics. Contact him at 727-725-0100. 

REFERENCES 

1. Melker DJ, Richardson CR. Root reshaping: an integral component of periodontal 

surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296-304. 

2. Satheesh K, MacNeill SR, Rapley JW, Cobb CM. The CEJ: a biofilm and calculus 

trap. Compend Contin Educ Dent. 2011 Mar;32(2):30, 32-7.

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