Chairside - Glidewell Dental Labs

Chairside® 

A Publication of Glidewell Laboratories • Volume 7, Issue 2 

Photo Essay 

Technique for Restoring 

Tetracycline-Stained Teeth 

Page 14 

Repair, Don’t Replace a 

Fractured PFM Bridge 

Dr. Robert Lowe 

Page 19 

One-on-One Interview 

Master Educator Dr. Lee Ann Brady 

Talks Restorative Dentistry 

Page 42 

Dr. Len Boksman and 

Gregg Tousignant, CDT 

Things to Consider When Choosing an 

Impression Material for Your Practice 

Page 35 

Dr. Michael DiTolla’s 

Clinical Tips 

Page 9 

COVER PHOTO 

Mia Gendreau, Digital Support Technical Advisor, All-Ceramic Department 

Glidewell Laboratories, Newport Beach, Calif.

Contents 

9 Dr. DiTolla’s Clinical Tips 

This issue features four new products that are making it 

easier and faster to practice dentistry: the next-generation 

formula of Luxatemp provisional material from DMG 

America; Centrix GripStrip proximal finishing and polishing 

strips; Picasso Lite, an affordable diode laser from AMD 

LASERS; and VOCO America’s easy-to-use Rebilda Post 

System for endodontic post cementation and core build-up. 

14 Photo Essay: Porcelain Veneers for 

Tetracycline Using Blockout Method 

REALITY Publishing’s Dr. Michael Miller illustrates a 

common esthetic challenge we face as dentists: placing 

porcelain veneers on tetracycline-stained teeth. See what 

techniques this leading clinician uses to mask the stains 

and satisfy the patient’s desired tooth color change. 

19 Repair, Don’t Replace – Part 1: 

Resurfacing an Existing Porcelain 

Fused to Metal Restoration with a 

Porcelain Veneer 

What’s the best way to handle a broken porcelain or 

PFM restoration? While the traditional practice is to use 

composite resin to repair the chipped porcelain, find 

out why Dr. Robert Lowe thinks porcelain veneers are 

a better treatment option, especially when dealing with 

multiple-unit fixed bridgework. 

27 Repair, Don’t Replace – Part 2: 

The “Saddle Crown” 

In Part 2 of his series on repairing a fractured porcelain 

bridge, Dr. Robert Lowe presents a second case 

involving a larger fracture exposing the underlying metal 

framework. Discover why cementing a modified crown 

covering only the facial and lingual surfaces can, in some 

cases, be an effective alternative to replacing the entire 

multi-unit restoration. 

Can’t get enough Chairside? Be sure to check out Chairside Live, 

our new Web series featuring dental news, a Case of the Week 

from Dr. Michael DiTolla and more — now available on YouTube, 

iTunes and at www.chairsidemagazine.com! 

Contents 1

Contents 

35 Faster Is Not Always Better When It Comes 

to Impressioning 

When it comes to impression materials, the product 

you use can significantly impact the final fit of your 

restorations. Exploring the pros and cons of fast-setting 

versus standard impression materials on the market today, 

Gregg Tousignant, CDT, and Dr. Len Boksman discuss the 

many things to consider when choosing a new impression 

material for your practice. 

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

Interview of Dr. Lee Ann Brady 

A nationally recognized dental educator who recently reentered 

private practice, Dr. Lee Ann Brady has taught at 

two of the top continuing education centers alongside some 

of the industry’s biggest names. Spend some time with 

this experienced clinician in this lively interview covering 

occlusion, adhesion, preparation, dental photography and 

topics in between. 

57 An Introduction to Dental Photography 

Keeping photographic records of your dental cases can 

be an important part of promoting your dental practice 

and increasing your case acceptance. In this brief tutorial, 

Dr. Carlos Boudet introduces a simple but effective way of 

documenting your cases with dental photography. 

Glidewell Publications for iPad 

iPAD APP Experience Chairside magazine 

on the iPad. Search “Glidewell” in 

the iTunes Store and download the free 

Glidewell Publications app. 

62 Biologic Shaping: An Alternative to 

Extracting a Tooth with a Severe Fracture 

Extraction is a commonly considered treatment when 

dealing with a tooth that fractures subgingivally, 

but it isn’t the only option. Biologic shaping, argues 

Dr. Daniel Melker, is another, more conservative procedure 

that can lead to long-term stability and a successful 

restorative outcome. 

ALSO IN THIS ISSUE 

8 By the Numbers 

65 Figures in Dentistry Spotlight 

68 The Chairside Photo Hunt 

2 

www.chairsidemagazine.com

Publisher 

Jim Glidewell, CDT 

Editor-in-Chief and Clinical Editor 

Michael C. DiTolla, DDS, FAGD 

Managing Editors 

Jim Shuck; Mike Cash, CDT 

Creative Director 

Rachel Pacillas 

Copy Editors 

Jennifer Holstein, 

David Frickman, Megan Strong 

Statistical Editor 

Darryl Withrow 

Digital Marketing Manager 

Kevin Keithley 

Graphic Designers 

Jamie Austin, Deb Evans, Joel Guerra, Audrey Kame, 

Phil Nguyen, Kelley Pelton, Makara You 

Web Designers 

Jamie Austin, Lindsey Lauria, 

Melanie Solis, Ty Tran 

Photographer 

Sharon Dowd 

Illustrator 

Wolfgang Friebauer, MDT 

Coordinator and Ad Representative 

Teri Arthur 

(teri.arthur@glidewelldental.com) 

If you have questions, comments or complaints regarding 

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

chairside@glidewelldental.com. Your comments may be 

featured in an upcoming issue or on our website: 

www.chairsidemagazine.com. 

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Chairside is a registered trademark of Glidewell Laboratories. 

Chairside ® Magazine is a registered trademark of Glidewell Laboratories. 

Editor’s Letter 

I have always thought it would be a good idea to do an 

educational video that focused strictly on restorative 

repairs, but this has proven to be a more difficult program 

to put together than I expected. It’s not as if fractured 

ceramic restorations walk through the door every day, yet 

when they do, it sure is nice to have a good solution. So 

I thought the next best thing would be a pair of articles 

on repairs from Dr. Robert Lowe, a frequent contributor 

to Chairside. 

In Part 1, Bob shows you how he repairs a broken PFM 

restoration with a porcelain veneer, or more specifically, 

how he gives new life to an old PFM by “resurfacing” it with 

a porcelain veneer. This strategy works well when the metal 

substructure is not completely exposed. 

In Part 2, Bob makes use of a “saddle crown” to cover a 

fully exposed metal substructure, which he has prepared to 

give the saddle crown adequate strength and esthetics. This 

technique can be extremely helpful when you have completed 

a large anterior bridge, for example, and something 

chips or breaks within the first year. 

The other thing that made me abandon the idea of putting 

together a video on repairs is the shrinking number of 

repairs I’ve had to do since becoming a predominately 

“monolithic” dentist. In other words, I use a lot of 

IPS e.max ® in the anterior and a lot of BruxZir ® Solid 

Zirconia in the posterior, and I just don’t see either of 

these restorations fracturing. 

Even though I haven’t done a single-unit PFM in years, I 

still use PFMs for bridges. As any bilayered restoration has 

the potential for those layers to separate, Bob’s repair techniques 

will continue to be useful for the foreseeable future. 

Yours in quality dentistry, 

Dr. Michael C. DiTolla 

Editor-in-Chief, Clinical Editor 

mditolla@glidewelldental.com 

Editor’s Letter 3

Letters to the Editor 

Dear Dr. DiTolla, 

Thanks for another great issue of Chairside. 

We were disappointed that we received the 

Fall 2011 issue on Jan. 2 and the contest 

deadline was Dec. 30. 

I am using Capture ® impression material 

now and am very happy with it. I am using 

the green light body. Is there any reason 

why you favor the purple medium body over 

the green? 

I impressed my first no-prep veneer case 

(tooth #8–11, with an implant on tooth #7) 

this week. Your DVD videos are great! To 

prepare, I watched the video online on 

tissue contouring and placement of no-prep 

veneers (“Diagnosis & Placement of No- 

Prep Veneers”), which was very helpful, in 

addition to reading Dr. Robert Lowe’s article 

in the Winter 2012 issue of Chairside. Is there 

a reason why you don’t retract the tissue for 

these no-prep veneers? Dr. Lowe seems to 

make a very strong case to do so. Either 

way, I contoured one area and did pack cord 

(no offense!). 

What cement are you using to cement these 

veneers? 

Once again, thanks for teaching me the 

dentistry I practice with every day! 

– Robert M. Lieder, DDS 

Baltimore, Md. 

4 

www.chairsidemagazine.com 

Dear Robert, 

Thanks for the kind words! 

That early due date was a mistake on 

our part, and we will do our best to 

make sure it doesn’t happen again. 

I use the medium body (purple) as 

my syringe material, just to make sure 

it doesn’t tear because I get it to go 

about 1 mm into the sulcus with the 

two-cord technique. Also, it will often 

set in contact with the #00 cord, which 

can increase the chances of it tearing. 

The medium body prevents that 

from happening. 

Because the margins of no-prep/minimal 

prep veneers tend to make a little 

speed bump on the tooth, due to there 

typically being no prep at the margin, 

I prefer to leave that bump at the free 

margin of the gingiva, rather than 

placing it subgingivally. With conventionally 

prepped veneers, I always 

place the margins subgingival. 

As for not retracting the tissue, that’s 

just my personal preference. You 

won’t go wrong following Bob Lowe’s 

method when it comes to any aspect 

of clinical dentistry. He continues to 

be one of my clinical mentors, which 

is why his articles are in nearly every 

issue of Chairside. 

My favorite veneer cement continues 

to be the translucent shade of NX3 

Nexus ® Third Generation from Kerr, 

which is something Bob Lowe and I 

definitely agree on. 

Hope that helps! 

– Mike 


I enjoyed reading the “Figures in Dentistry 

Spotlight” on G.V. Black in the Fall 2011 issue 

of Chairside. Unfortunately, there was no 

mention of his most important contribution 

to dental literature, “The Pathology of the 

Hard Tissues of the Teeth,” first published in 

1906. Most dentists have never heard of this 

book, but as I was studying ways to control 

caries with a medical model, I ran across a 

reference to the book. It took awhile to find 

a copy, but when I finally read it, I was totally 

blown away by the advanced understanding 

that G.V. Black had about the microbiology 

of caries. His chapter on treating children 

is more advanced than any pediatric dental 

text I have ever read, and I have read them 

all. I would encourage you to take a look 

at this classic. Attached is a little paper 

that talks about G.V. Black’s volume in the 

context of advances in cariology. 

Best wishes, 

– Steve Duffin, DDS 

Portland, Ore. 

Dear Steve, 

Thanks for sending me your paper. 

I really enjoyed reading it! With 

your permission, I would love to 

publish your paper in a future issue 

of Chairside. 

– Mike 


First, I want to say how much I enjoyed 

your recent webinar (“State-of-the-Art 

Impression Techniques,” hosted by Catapult 

University). What a great way to learn! 

I hope it becomes a regular occurrence. 

Can you e-mail me about the burs you use 

for your crown preps? What brand do you 

use? I like the whole idea and am looking 

forward to trying the technique. I plan on 

doing a lot more BruxZir crowns. 

Thanks again, 

– Grigg DeWitt, DDS 

Salinas, Calif. 

Dear Grigg, 

Thanks for the kind words! 

The burs I use to prep are from the 

Reverse Preparation Set from Axis 

Dental, available through all dental

dealers. It’s a universal prep technique 

that works for all materials, although 

as the next letter in this section points 

out, the strength of BruxZir ® Solid 

Zirconia is starting to change how 

much we have to reduce, especially at 

the margin. 

– Mike 


First, thank you very much for your 

educational support and updated dental 

market information. The latest issue of 

Chairside (Vol. 7, Issue 1) includes your 

very interesting and helpful article “BruxZir ® 

Solid Zirconia Anterior Esthetic Challenge.” 

I would appreciate it if you could give me 

information about labial and palatal crown 

thickness (Figs. 31–34). I wonder why you 

used a shoulder preparation technique 

when the BruxZir website says that feather 

edge is acceptable? 

Cordially, 

– Alex Zavyalov, DDS 

New York, N.Y. 

Dear Alex, 

Good question! I guess the best 

answer is that having spent the last 

20 years prepping all-ceramic crown 

preps at a certain thickness, old habits 

die hard. My Reverse Preparation 

Technique uses a round bur to ensure 

that I get 1 mm of reduction in the 

gingival third to help the esthetics and 

the emergence profile. As you pointed 

out, BruxZir ® Solid Zirconia is the 

one monolithic material (besides cast 

gold) that can handle a feather-edge 

margin, and we are just getting started 

with a Minimal Prep Crown Project to 

see just how little we can reduce an 

anterior tooth and still have a decentlooking 

BruxZir crown. Imagine if we 

could prep a tooth and stay within the 

enamel, yet be able to cement a highstrength 

all-ceramic crown, rather 

than bonding a veneer. So, yes, even 

though I did not prep conservative 

margins on those teeth, you certainly 

can prep those types of margins with 

BruxZir crowns. Even if you were 

worried about esthetics on the facial, 

you could still prep a conservative 

margin on the lingual. 

– Mike 


Regarding Dr. Ellis Neiburger’s article 

in the last issue of Chairside, “Is It Time 

to Do Routine Adult Pulpotomies?” 

(Vol. 7, Issue 1), there should have been 

more discussion about using lasers to sterilize 

the pulp instead of formocresol, and 

other options instead of IRM, like MTA. 

– Brian Danielsson, DDS 

Ridgecrest, Calif. 

Response from Dr. Neiburger: 

Dear Brian, 

The article focused on time-tested 

pulpotomy techniques that, in light of 

the world’s poor economic situation, 

can be done easily, quickly and 

inexpensively. Laser sterilization of 

the pulp chamber is relatively new, 

has only a small amount of research 

to establish efficacy and requires laser 

equipment more costly than a $10 

bottle of formocresol. It holds promise 

and should be further investigated. 

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Letters to the Editor 5

Contributors 

Michael C. DiTolla, DDS, FAGD 

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

director of clinical education and research at Glidewell Laboratories in Newport Beach, Calif., he performs 

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

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

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

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

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

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

Leendert Boksman, DDS, BSc, FADI, FICD 

Dr. Leendert “Len” Boksman is a former tenured associate professor and adjunct professor at the Schulich 

School of Medicine and Dentistry in London, Ontario, Canada, and former director of clinical affairs for 

Clinical Research Dental/CLINICIAN’S CHOICE. He retired from practice at the end of 2011, and currently 

does freelance consulting and lecturing. He also authors articles of interest to the general practitioner. 

Contact him at lenboksman@rogers.blackberry.net. 

Carlos A. Boudet, DDS, DICOI 

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

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

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

Fla. Dr. Boudet established his dental practice in West Palm Beach. Fla., in 1983 and has been in the same 

location for 26 years. He is a Diplomate of the International Congress of Oral Implantologists, a member of 

the Central Palm Beach County Dental Society and sits in the board of directors of the Atlantic Coast Dental 

Research Clinic. Contact him at www.boudetdds.com or 561-968-6022. 

Lee Ann Brady, DMD 

Dr. Lee Ann Brady is a privately practicing dentist and nationally recognized educator and writer. She has 

worked in practice models ranging from small fee-for-service offices to large insurance-dependent practices, 

as an associate and practice owner. From 2005 to 2008, Dr. Brady held the positions of resident faculty and 

clinical director for the Pankey Institute. In 2008, she moved to Scottsdale, Ariz., to join Dr. Frank Spear in 

the formation of Spear Education, where she served as executive VP of clinical education until June 2011. 

As director of education and president of Lee Ann Brady LLC, she offers daily clinical and practice content 

through her website, www.leeannbrady.com, as well as innovative online and live education programs. 

Contact her at lee@leeannbrady.com. 

6 


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

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 dental journals on esthetic and restorative dentistry. Dr. Lowe received fellowships in 

the Academy of General Dentistry, International and American Colleges of Dentists, Academy of Dentistry 

International and the International Academy for Dental-Facial Esthetics, and in 2005, Diplomat status on 

the American Board of Esthetic Dentistry. He was also awarded the 2004 Gordon Christensen Outstanding 

Lecturers Award. Contact Dr. Lowe at 704-364-4711 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 program. 

Dr. Melker has published several articles in national dental magazines, as well as The International Journal 

of Periodontics & Restorative Dentistry, and has twice been honored with the Florida Academy of Cosmetic 

Dentistry Gold Medal. Contact him at 727-725-0100. 

Michael B. Miller, DDS 

Dr. Michael Miller is the co-founder, president and editor-in-chief of REALITY, and maintains a dental 

practice in Houston, Texas. He is a Fellow of the Academy of General Dentistry, as well as a founding and 

accredited member and Fellow of the American Academy of Cosmetic Dentistry, for which he created its 

acclaimed accreditation program. Dr. Miller has contributed to several texts and authors regular columns 

for General Dentistry, the AGD’s peer-reviewed journal. He is also a founding board member of the National 

Children’s Oral Health Foundation. He can be reached at mm@realityesthetics.com. 

Gregg Tousignant, CDT 

Gregg Tousignant graduated from George Brown College with a dental technology degree in 1992. Two 

years later, he earned CDT designation from the National Board for Certification in Dental Laboratory 

Technology. He lectures and teaches hands-on courses for the general and cosmetic dentist and at dental 

and hygiene schools across Canada on tooth whitening, impressioning, temporization, adhesives, and 

direct anterior and posterior composites. Gregg currently serves as manager of technical support for 

Clinical Research Dental, where he provides continuing education programs consistent with the company’s 

philosophy, “Teaching Better Dentistry.” Contact him at gtousignant@clinicalresearchdental.com. 

Contributors 7

Numbers 

by the 

52% 

Percentage of dentists in 

Virginia who sent cases to 

Glidewell Laboratories in 2011 

50,000 

Number of case evaluation 

slips filled out by Glidewell 

customers in 2011 

96% MARGINS 

Percentage of those 

slips marked as 

“GOOD” 

57% 

Percentage of Americans over the 

age of 65 who wear either full or 

partial removable dentures 

Source: www.orawave.com 

856,250 

Total number of full 

or partial removable 

dentures fabricated by 


since 1993 

Percentage of 

80% 

metal-based (PFM and 

28% 

cast gold) vs. all-ceramic 

crowns & bridges 

fabricated by Glidewell 

Laboratories in 1997 

Percentage of 

metal-based (PFM and 

cast gold) vs. all-ceramic 

crowns & bridges 

fabricated by Glidewell 

Laboratories in 2012 

8 


Dr. DiTolla’s 

CLINICAL TIPS 

PRODUCT........ Rebilda ® Post System 

SOURCE........... VOCO America Inc. (Briarcliff Manor, N.Y.) 

888-658-2584, www.vocoamerica.com 

Considering that placing posts and cores isn’t an everyday procedure 

for most dentists, it’s surprising how many e-mails I get asking which 

post-and-core system I prefer. I continue to try different systems on an 

ongoing basis, but it’s a niche filled with me-too products for the most 

part. I recently ordered the Rebilda Post System from VOCO America 

and was pleasantly surprised from the moment I opened the box and 

found the directions on the lid — the rest of the industry could learn a 

thing or two from VOCO about directions! Beyond that, the fiber posts 

are highly translucent, while being more radiopaque than the posts I was 

using before, and the drill sizes are well-matched to the post sizes. The 

kit also includes VOCO’s bonding agent and dual-cure build-up material 

to ensure the chemistry will work to provide maximum retention. 

Dr. DiTolla’s Clinical Tips 9


CLINICAL TIPS 

PRODUCT........ GripStrip 

SOURCE........... Centrix (Shelton, Conn.) 

800-235-5862, www.centrixdental.com 

It would be impossible to practice modern adhesive dentistry without finishing strips, yet I haven’t seen many 

products to get excited about in the last few years. Enter GripStrip diamond-coated strips. Someone really 

smart over at Centrix realized how much easier it would be for dental professionals to control the use of metal 

finishing strips if there was a better way to hold onto them, and the perforated tabs at either end of these 

finishing and polishing strips solve that problem. There is an uncoated zone in the middle of each strip where 

there is no abrasive, allowing you to pull it through tight interproximal areas. Each strip also has a 40-micron 

grit side for finishing and a 15-micron grit side for polishing. It’s pretty much the perfect interproximal strip. 

Here’s hoping they come out with a serrated version for breaking through inadvertently fused contacts. 

10 www.chairsidemagazine.com


CLINICAL TIPS 

PRODUCT........ Luxatemp ® Ultra 

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

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

Has it really been two decades since Luxatemp was introduced? Much like when your oldest child turns 

21, this is one of those times when you ask, “Where did the time go?” Maybe it’s because Luxatemp 

has been my only chairside temporary material for 20 years, except when using BioTemps ® provisionals. 

In the past, I hated not being able to reline BioTemps with Luxatemp, due to its quick-setting reaction. 

It was the only time I would have to break out the stinky methyl methacrylate. The new Luxatemp Ultra 

has an elastic phase, so you can pump the BioTemps up and down on the preps to ensure they don’t get 

stuck in an undercut. Now, after being my longtime chairside temporary material of choice, Luxatemp’s 

newest formulation has become my BioTemps reline material of choice as well. 

Dr. DiTolla’s Clinical Tips11


CLINICAL TIPS 

PRODUCT........ Picasso ® Lite 

SOURCE........... AMD LASERS ® LLC (Indianapolis, Ind.) 

866-999-2635, www.amdlasers.com 

I use my diode laser on nearly half of my patients, typically for small amounts of gingival recontouring or 

pre-impression troughing. There really isn’t any other instrument that can do what the diode does as quickly 

and as bloodlessly. When I ask most dentists why they don’t have a diode laser in their operatory, it’s always 

the same answer: “I’m waiting for the price to come down.” Good news: That day has come. The affordable 

laser is here. You can now have a full-featured Picasso Lite diode laser in your practice, without losing any 

sleep over what you paid for it. Whether you use it to clean up tissue prior to taking an impression or seating 

a crown, perform a gingivectomy next to Class V decay, or make the clinical crown length of tooth #8 match 

tooth #9, you’ll wonder how you ever lived without your Picasso Lite. 


Photo Essay 

Porcelain Veneers for Tetracycline 

Using 

Blockout 

Method 

– ARTICLE and CLINICAL PHOTOS by 

Michael B. Miller, DDS 

NOTE FROM THE EDITOR: I don’t know how 

many dental books you own, but I have a 

couple of cabinets full of them. Most of them 

start gathering dust after my initial read, some 

come out a couple times per year (especially my 

favorite local anesthesia book), but only one 

has its own permanent parking spot on my 

desk: REALITY Publishing’s “The Techniques: 

Volume 1.” This publication, based on everyday 

applications of research and clinical 

experience, is the greatest gift young dentists 

could receive to help them achieve success in 

esthetic dentistry. It is also a useful reference 

manual for us older dentists. Dr. Michael Miller 

put this volume together and has been generous 

enough to share excerpts of it in Chairside. In 

this installment, Dr. Miller shares an esthetic 

challenge we have all faced: placing porcelain 

veneers on tetracycline-stained teeth. Visit 

www.realityesthetics.com for more infor mation 

on REALITY’s various publications. 


1 

2 

3 

4 

5 

Figures 1–5: Patient, with recently completed orthodontics and 

maxillary all-ceramic crowns on incisors and porcelain veneers on 

canines and premolars, wants mandibular veneers to mask tetracycline 

stains, despite not showing his mandibular teeth in a full smile. This 

type of color change can be done with an extended regimen of home 

bleaching instead of the expense and invasive nature of veneers, but 

patient wants immediate improvement and is not concerned about the 

upkeep necessary or cost for veneers. 

Note that the tetracycline stains are in the incisal half of each tooth, 

except for the central incisors, where the stains extend almost to the 

gingival crest. Masking stains in the more incisal portions of the teeth is 

much easier than when the stains are at the gingival margins. Because 

the stains are more incisal, the gingival color is quite normal. 

Porcelain Veneers for Tetracycline Using Blockout Method15

6 

Figure 6: Cord is placed prior to the preparation to accelerate the 

procedure. 

7 

Figure 7: Finished preparations. Note that tetracycline teeth usually 

become darker when they are prepared. The bonded lingual retainer 

obviously eliminates interproximal extensions. 

8 

9 

Figures 8, 9: Areas of preparations not to be masked with opaquer are covered with resin blockout material. Only dark stained areas need to be masked. 

Resin blockout material keeps etchant and adhesive off stained areas. 

10 

Figure 10: Opaquer has been applied to dark stained areas after 

etching and adhesive application. Even though the preparations are 

relatively aggressive, mandibular teeth cannot be reduced to the extent 

possible for larger maxillary siblings. Therefore, the opaquer must be 

kept quite thin. 

11 

Figure 11: Resin blockout has been removed. Note that only darkstained 

areas are covered by the opaquer. 


12 

Figure 12: Veneers returned from the lab. Note that, despite their 

polychromatic buildup, the veneers have built-in masking ability. This 

built-in masking can eliminate the need to apply opaquer directly 

on the teeth in all but the darkest cases, assuming the veneers are at 

least 1 mm thick. 

13 

Figure 13: Mandibular anterior teeth at luting appointment two weeks 

after preparations. No provisionals were placed, but tissue is still 

inflamed. 

14 

15 

16 

17 

Figures 14–17: Postoperative views two months after seating veneers. Maxillary and mandibular restorations match perfectly. There is no evidence of 

dark stains and tissue health has improved. Patient has been using an electronic interproximal cleaning device, which may have caused minor recession 

of papillae. CM 

Dr. Michael Miller is the co-founder, president and editor-in-chief of REALITY. He maintains a dental practice in Houston, Texas. Contact him at mm@realityesthetics.com. 

Reprinted by permission of REALITY Publishing. REALITY: The Information Source for Esthetic Dentistry, The Techniques, Volume 1, 2003, REALITY Publishing Company, 

pp. 272–74. 

Porcelain Veneers for Tetracycline Using Blockout Method17

Repair, 

Don’t 

Replace 

Part 1 

Resurfacing an Existing Porcelain Fused to 

Metal Restoration with a Porcelain Veneer 


Robert A. Lowe 

DDS, FAGD, FICD, FADI, FACD, FIADFE 

Introduction: The Porcelain “Repair” 

Repairing a broken porcelain (or porcelain-fused-to-metal) 

restoration is a clinical reality in every dentist’s practice. 

The traditional technique is to use composite resin to repair 

chipped porcelain. This is an attempt to use unlike materials 

to accomplish a long-term repair, but it rarely works. 

Early “porcelain repair kits” used 37 percent phosphoric 

etch, silane primer, and adhesive and composite resin to 

repair chipped porcelain. This system did not work because 

37 percent phosphoric acid cannot appreciably etch a 

porcelain surface. Without adequate micromechanical retention 

to affix the composite resin to the porcelain surface, 

any repair will likely not withstand the forces of mastication. 

The use of hydrofluoric acid provides an adequate etched 

surface to create an improved micromechanical bond of 

composite to porcelain. However, the bond of composite 

to porcelain is not the only clinical problem. Another is the 

finishing and polishing of the porcelain-composite interface. 

Regardless of the finishing and polishing technique and 

materials used, the fine line of demarcation between the 

composite and porcelain is hard to eradicate. 

Repair, Don’t Replace – Part 119

Figure 1: A smile in need of a remake. The patient requested a porcelain 

makeover of the esthetic zone with occlusal corrections to prevent future 

porcelain fracture. The posterior bridgework is clinically acceptable; however, 

the anterior abutments in the esthetic zone will require resurfacing to 

match the anterior units. 

Figure 2: Preparations for porcelain veneers on tooth #27 and #28. The 

small metal exposures will not appreciably affect the bond of the veneers 

to the porcelain surface. 

Figure 3: A 2x magnified facial view of the veneer preparations 

Figure 4: A dentin desensitizer with antibacterial agent (AcquaSeal B, 

AcquaMed Technologies) is applied to cleanse the prepared tooth surface 

prior to the etching procedure. 

If the broken restoration is a single unit, a complete remake 

may be the most predicable solution. But what about 

multiple-unit fixed bridgework? It may not be feasible 

economically or clinically to sacrifice a long-span restoration 

for one unit with a porcelain fracture. In esthetic cases, a 

clinically acceptable posterior bridge may not be the same 

shade as the one chosen for the anterior reconstruction. So, 

for these clinical problems, is there a long-term solution 

short of replacing the entire restoration? 

Reveneering Existing Porcelain Restorations 

The patient in Figure 1 presented with the desire to remake 

his porcelain reconstruction. Some of the anterior units 

were fractured due to occlusal issues. The patient’s desire 

was to remake the restorations in the esthetic zone with a 

high value shade. The posterior bridgework was clinically 

acceptable, but the shade was much lower in value and hue 

than the desired anterior shade. Figure 2 shows a segment 

of this reconstruction, where an old single-unit crown was 

replaced and a veneer preparation was made into the existing 

anterior abutment of the posterior bridge immediately distal 

to it. The key to success with this procedure is the original 

thickness of porcelain on the existing bridge. The goal is 

to have little or no metal exposed. Tooth #27 and #28 are 

prepared for stacked porcelain veneer restorations (Fig. 3). 

The total thickness of the labial reduction of the natural 

tooth surface and porcelain surface is 0.5 mm facially and 

1 mm incisally. 


Figure 5: Hydrofluoric acid is used to etch the porcelain preparation. 

Figure 6: Phosphoric acid is used to etch the prepared tooth surface. 

Figure 7: Both solutions are rinsed off with copious amounts of water. 

Figure 8: Preparations prior to placement of adhesive resin 

Once preparations are complete, the natural tooth surface 

is treated with a dentin desensitizer that has an antibacterial 

component (AcquaSeal B [AcquaMed Technologies; West 

Chicago, Ill.]) (Fig. 4). The porcelain preparation is treated 

with hydrofluoric acid for 60 seconds (Fig. 5). This material 

can be caustic to the gingival tissues, so if tissue contact is 

anticipated, a light-cured “liquid dam” is applied for patient 

protection. Thirty-seven percent phosphoric acid is applied 

for a 15-second total etch to the prepared tooth surface 

(tooth #27) (Fig. 6). Thoroughly rinse both the tooth and 

porcelain surface with water for 60 seconds (Fig. 7). Figure 8 

shows the natural tooth surface and porcelain surface 

after rinsing and air-drying. AcquaSeal B is reapplied to 

tooth #27 and the excess is removed using a high-volume 

Without adequate micromechanical 

retention to affix 

the composite resin to the 

porcelain surface, any repair 

will likely not withstand the 

forces of mastication. 


Figure 9: Bonding resin is applied to both prepared surfaces. 

Figure 10: Bonding resin is light-cured for 30 seconds. 

Figure 11: Facial view of the prepared surfaces after curing of the adhesive 

resin. Note the shiny appearance of both the dentin and porcelain surfaces. 

This clinically shows the presence of the hybrid zone for bonding. 

Figure 12: The porcelain veneer for tooth #28 is filled with resin cement 

and placed on the preparation. 

suction. A moist, wet surface is left for the application of 

a hydrophilic bonding resin, and adhesive resin is applied 

in multiple applications to create a quality hybrid zone for 

bonding (Fig. 9). 

Following air thinning, the adhesive resin is light-cured 

(Fig. 10). Figure 11 shows the prepared surfaces after the 

adhesive resin has been placed and cured. The porcelain 

veneers are now ready for placement. A dual-cured resin 

cement is placed on the inside surface of the veneer 

restoration and the veneer is placed on the porcelain 

prepared surface (Fig. 12). A number 2 Keystone brush 

(Patterson Dental; El Segundo, Calif.) is used to remove 

excess resin cement prior to reaching a gel set (Fig. 13). The 

porcelain veneer restoration is then placed on tooth #27 

(Fig. 14). The porcelain veneer on tooth #27 is stabilized 

using veneer stabilizers (Nash/Taylor Esthetic Instrument 

Kit [Hu-Friedy; Chicago, Ill.]) while the gel set is completed 

(Fig. 15). After using a scaler to remove marginal cement 

excess post gel set (Fig. 16), a cotton pledget is used to 

complete resin cleanup prior to light curing (Fig. 17). 


Figure 13: The excess resin cement can be removed with a Keystone 

brush. 

Figure 14: The restoration is placed on tooth #27. 

Figure 15: The veneer is stabilized while the gel set is completed. 

Figure 16: The excess can then be removed easily with a sharp scaler 

or explorer. 

It may not be feasible 

economically or clinically 

to sacrifice a long-span 

restoration for one unit 

with a porcelain fracture. 

Figure 17: Before the final cure, any excess resin can be removed from the 

surface of the restoration with a cotton pledget. 


Figure 18: Cross section through a crown that had been veneered with 

porcelain. The distal abutment of this bridge had failed, necessitating 

removal. Note the uniform thickness of the remaining porcelain and the 

veneer restoration. The film thickness of the resin cement is also very 

uniform and micromechanically lutes the surfaces together. 

Figure 19: A full-smile, retracted view after delivery of restorations on 

tooth #4–12 and #21–28. The veneers on tooth #4 and #5 are veneered to 

a long-span PFM bridge as well. Note how well these restorations blend 

in with the new anterior restorations. 

Figure 18 shows a cross section through a porcelainfused-to-metal 

crown that was reveneered with porcelain 

to change the facial color to a brighter value, in order to 

match the adjacent restorations. Note the uniform thickness 

of resin cement and veneered porcelain. The bond of the 

porcelain veneer to the prepared porcelain surface is as 

strong as that bonded to dentin. Figure 19 shows the 

affected area in a full-arch, retracted view after placement 

of the esthetic anterior restorations. The previous bridge 

was retained, however the facial surface that was visible in 

the patient’s smile (tooth #28) was altered with a porcelain 

veneer to match the anterior restorations. 

Conclusion 

This technique demonstrates how to repair existing porcelain 

restorations by bonding a porcelain veneer to the affected 

porcelain surface. By taking advantage of the strength of a 

porcelain-to-porcelain bond using resin cement technology, 

we can now make predictable porcelain repairs and resurface 

existing porcelain (and porcelain-fused-to-metal) crown & 

bridge restorations in a very predictable manner. CM 

Dr. Robert Lowe is in private practice in Charlotte, N.C. He lectures internationally 

and publishes on esthetic and restorative dentistry. Contact him at 704-364-4711 

or boblowedds@aol.com. 


Repair, 

Don’t 

Replace 

The “Saddle Crown” 

Part 2 


Robert A. Lowe 

DDS, FAGD, FICD, FADI, FACD, FIADFE 

In the first part of this series on repairing an existing bridge (“Repair, Don’t 

Replace – Part 1,” page 19), a case was presented where a patient fractured the 

facial ceramic of a maxillary central incisor on a six-unit porcelain-fused-to-metal 

bridge. The facial fracture was stress related and did not involve the exposure of 

the underlying metal substructure. A successful repair was made by creating a 

veneer preparation into the ceramic and placing a new porcelain veneer on top 

of the affected surface. 

Now, what happens if the ceramic fracture is substantially larger and involves 

the exposure of the underlying metal framework? The following case will demonstrate 

how, in some circumstances, the remaining porcelain can be removed 

from the metal and a “saddle crown” can be fabricated and cemented over the 

existing bridge. 


Figure 1: A preoperative view of tooth #7, part of a multiple-unit fixed 

bridge that has sustained a porcelain fracture on the facial surface 

Figure 2: An incisal view of the fractured abutment showing a porcelain 

fracture down to metal on the disto-incisal angle 

Figure 3: The fractured unit has been prepared using rotary diamond 

instrumentation down to the metal understructure, then polished with a 

fine diamond and rubber polishing abrasives. Care was taken not to disturb 

the porcelain on the adjacent teeth and the metal covering the damaged 

unit, especially the interproximal metal bridge connectors. 

Figure 4: Lingual view showing the surface after preparation. The original 

bridge had metal lingual surfaces, so preparation was made into the metal 

to create space for the “saddle crown” on the functional surface. Some 

of the metal was removed to tooth structure, but care was taken not to 

remove so much as to compromise the integrity of the original bridge. 

A patient presented with a porcelain fracture on an anterior 

multiple-unit fixed bridge (Fig. 1). The fracture involved 

the entire facial surface of tooth #7 and exposed the metal 

framework at the disto-incisal angle. When viewed from 

the lingual aspect (Fig. 2), the fracture extends down to 

the porcelain-metal junction of the mostly metallic lingual 

surface. Because of the occlusal forces placed on this tooth 

in both protrusive and lateral excursions, it was decided to 

prepare the remaining porcelain down to the metal understructure 

and create a “saddle crown” to repair the defect. 

The saddle crown consists of a facial and lingual surface 

only. These surfaces are only joined proximally incisal to 

the solder joint of the existing bridge. The preparation 

is designed to create negative space for this “telescopic” 

structure without compromising the structural integrity of 

the bridgework below. 

A round-ended, tapered, coarse diamond is used to prepare 

the remaining porcelain and metal. Care must be 

taken not to score the adjacent proximal ceramic surfaces 

during the preparation phase (Figs. 3, 4). Also, be careful 

not to create undercuts when preparing the cervical areas 

of the preparation. In this case, it was a challenge to create 

sufficient space on the lingual surface without prepping 

away some of the existing metal framework. This should 

be kept to an absolute minimum to avoid compromising 

the strength of the existing bridge. 

Figure 5 shows the incisal clearance created for the saddle 

crown as the patient closes into centric occlusion. This 


Figure 5: This view shows the space created for incisal reduction as 

the patient closes to centric occlusion. 1.5 mm of space is needed in all 

functional movements. 

Figure 6: Retraction cords in place on the facial and lingual surfaces prior 

to the registration of the master impression 

Figure 7: Facial view of the gingival retraction cords in place 

Figure 8: The #00 cord is left in place after removal of the #1 cord, leaving 

an obvious sulcus prior to injection of the light-bodied impression material. 

clearance is checked in protrusive and lateral excursions 

as well, to make sure adequate space has been provided. 

The preparation is polished with a round-ended 30 micron 

finishing diamond, followed by rubber polishing abrasives 

to smooth the cut metal substructure and porcelain. 

Next, a retraction cord (UltraPak ® [Ultradent; South Jordan, 

Utah]) is placed on the facial and lingual marginal 

areas of the preparation (Figs. 6, 7). A two-cord technique 

is used, first placing a #00 cord, then a #1 on top of it. 

After a few minutes, the top cord is removed leaving 

the #00 in the sulcus (Fig. 8). The master impression is 

then made using a syringeable light-bodied and heavybodied 

vinyl polysiloxane impression material (Honigum 

[DMG America; Englewood, N.J.]) (Fig. 9). 

Figure 9: The impression is made using a polyvinyl siloxane impression 

material. Note the margin is captured, as well as approximately 0.5 mm 

of tooth or root surface apical to the prepared margin. This will ensure an 

accurate fit of the saddle crown. 


Figure 10: A provisional restoration is fabricated from a preoperative 

impression taken prior to preparation of the fractured unit. Flowable composite 

resin was used to fill in the fracture prior to taking the impression, so 

that the provisional restoration would have the correct contours. 

Figure 11: The fabricated saddle crown on the master laboratory model, 

shown from the facial aspect 

The saddle crown consists of a 

facial and lingual surface only. 

These surfaces are only joined 

proximally incisal to the solder 

joint of the existing bridge. 

Figure 12: Incisal view of the preparation as seen on the master laboratory 

model 

A provisional restoration is then fabricated using a bisacrylic 

provisional material (Luxatemp ® [DMG America]) 

and is cemented with polycarboxylate cement (Fig. 10). 

Digital photographs are provided to the ceramist to aid 

in characterization. 

Figure 11 is a facial view of the saddle crown on the laboratory 

cast model. An incisal view of the master cast shows 

the preparation design that basically strips the porcelain 

down to the metal substructure on the facial and lingual, 

and is “tied in” with a continuous mesial and distal proximal 

finish line on the metal connectors of the preexisting 

bridge (Fig. 12). A proximal view of the completed restoration 

highlights the “saddle” design (Fig. 13). Interproximal 

margins are in metal and are located incisal to the metal 

connectors of the understructure. The lingual surface of 

the restoration is made in metal to match the preexisting 

bridge and limit the amount of lingual reduction (Fig. 14). 

The completed saddle crown is tried in after removal of 

the provisional restoration (Fig. 15). After verification of fit 

and checking occlusion with articulating paper, the restoration 

is ready for cementation. In this case, resin-modified 

glass ionomer cement was used (Fig. 16). A 4-META-type 

cement is also good to cement metal to metal if retention 

is less than ideal. The cement is mixed according to the 

manufacturer’s instructions (Fig. 17) and pushed into place 

on the preparation (Fig. 18). It is recommended to hold the 


Figure 13: The saddle crown shown from the proximal view 

Figure 14: The saddle crown on the master laboratory model from the 

lingual aspect 

Figure 15: After removal of the provisional restoration, the saddle crown 

is tried in and the fit is evaluated. 

Figure 16: A resin ionomer cement (RelyX Luting Cement [3M ESPE; 

St. Paul, Minn.]) is dispensed prior to mixing. 

Figure 17: The mixed cement is placed into the saddle crown. 

Figure 18: The saddle crown is held in place while the cement is allowed 

to set. 


Figure 19: A lingual view of the cemented saddle crown 

Figure 20: A view of the completed saddle crown on tooth #7 from the 

facial aspect 

Figure 21: A view of tooth #7 prior to the fracture. Compare this to 

Figure 20, which is the same view of the repaired bridge using a saddle 

crown. A beautiful, esthetic and functional match was made without having 

to remake the entire bridge. 

restoration in place until the cement is completely set, as 

hydraulic pressure can in some cases push the restoration 

incisally as the cement sets. 

Figure 19 is a lingual view of the cemented restoration. 

The metal lingual surface of the saddle crown fits the adjacent 

metal margin of the bridge like an inlay. Figure 20 is 

a facial view of the completed saddle crown. Compare this 

to Figure 21, which is a facial view of the previous bridge 

prior to the fracture. 

The esthetics of a repair made using a saddle crown makes 

it an excellent alternative to replacing the entire multiunit 

restoration. This solution works well in anterior and 

posterior regions for pontics as well as abutments. CM 

Dr. Robert Lowe is in private practice in Charlotte, N.C. He lectures internationally 

and publishes on esthetic and restorative dentistry. Contact him at 704-364-4711 

or boblowedds@aol.com. 

The esthetics of a repair 

made using a saddle crown 

makes it an excellent 

alternative to replacing the 

entire multi-unit restoration. 


– ARTICLE and CLINICAL PHOTOS by Gregg Tousignant, CDT 

and Leendert Boksman, DDS, BSc, FADI, FICD 

In practice, many dentists today want to use the fastestsetting 

dental products, the fastest curing lights, the fastest 

single-step adhesives and the fastest-setting impression 

materials. These faster products are desired for a number 

of reasons. Some clinicians want to save time in order 

to pack more patients into the day. Some want to make 

procedures faster and more comfortable for their patients. 

Some manufacturers even promote the so-called fast curing 

lights in ways to make you think you will save so much 

time you can take extra vacation days at the end of the year. 

One light manufacturer even claims that all you need is a 

one-second cure for a 4 mm layer of composite resin! 

Freedman states that “faster setting impression materials 

are very advantageous in the efficient practice.” 1 He then 

rightly qualifies this statement with “the underlying assumption 

is that faster setting in no way compromises the 

Faster Is Not Always Better When It Comes to Impressioning35

quality of the impression.” However, in a recent study of 

the quality of dental impressions for fixed partial dentures, 

89 percent of the impressions had one or more detectable 

errors that would impact the final fit of the restorations; 

51 percent had voids or tears at the finish line (Fig. 1); 

40 percent had air bubbles at the finish line (Fig. 2); and 

24 percent had flow problems (Fig. 3). 2 Could there be 

any relationship to using fast-set impression materials? 

Figure 1: Impression of molar with multiple voids at the margins 

Figure 2: Air bubbles and voids incorporated into the light body 

When it comes to impression materials, the goal of a fast-set 

product is to limit the amount of time the impression is in the 

mouth, both for patient comfort and to limit the opportunity 

for the patient to move and distort the impression while it is 

setting. 3 Although the concept is admirable, many clinicians 

experience drags, pulls (Fig. 4), inaccuracies (Fig. 5) and 

distortion in their impressions simply because they don’t 

understand how much working time they really have. 

Terry, in his article on the impression process, gives us two 

definitions: “The setting time of impression materials is the 

total time from the start of the mix until the impression material 

has completely set and can be removed from the oral 

cavity without distortion, and the working time is measured 

from the start of the mix until the material can no longer 

be manipulated without introducing distortion or inaccuracy 

in the final impression.” 4 These two processes are, of 

course, intimately related by the chemistry of the impression 

material. Many clinicians think they know the working 

time of their light-body and heavy-body impression 

materials, but we can pretty much guarantee that most do 

not! One of the disadvantages of PVS impression materials 

is their relatively short working time. 5 If you think the 

working times of your light-body polyvinyl siloxanes are 

what is listed in the manufacturer’s instructions, then you, 

too, may not understand the true “intraoral” working times 

of your material. 

In a recent study of the quality of 

dental impressions for fixed partial 

dentures, 89 percent of the 

impressions had one or more 

detectable errors that would impact 

the final fit of the restorations. 

Figure 3: Flow problems demonstrated as multiple areas of lack of 

adaptation 


By specification, the working times of impression materials 

are calculated at 23 degrees Celsius and at 50 percent relative 

humidity. Unfortunately, the oral cavity is much warmer 

and significantly wetter. In the ADA Professional Report on 

Elastomeric Impression Materials, the ADA found that times 

measured at 23 degrees Celsius were 66 to 77 percent longer 

than those measured at 35 degrees Celsius (intraoral 

temperature range). 6 Some PVS impressioning materials 

such as Genie Ultra Hydrophilic (Sultan Healthcare Inc.; 

Hackensack, N.J.) and Correct Plus (Pentron Clinical Technologies 

LLC; Wallingford, Conn.), whose instructions claim 

working times of 135 and 90 seconds respectively, actually 

have less than 10 seconds working time intraorally. 6 This 

makes it difficult for some, and impossible for others, to 

impress a single unit, let alone multiple units, and be able 

to deliver the tray prior to the light body setting. 

So why is this relevant? In order to ensure a fluid blend 

between your light-body and heavy-body PVS impression 

materials, both materials must be fluid and unpolymerized 

at the time the tray is inserted. If not, this could lead to 

gaps or ledges between the different viscosities of material 

(Figs. 6, 7), which will lead to inaccuracies and high 

occlusion of your final restoration. We as practitioners also 

assume that upon insertion of our heavy body material, 

it will drive the light body into better adaptation to our 

preparation. Of course, this is not possible when the light 

body is already set (Fig. 8). This means that unless the 

light body is meticulously placed in the first instance, we 

cannot improve the impression by the hydraulics of the 

heavy body impression material. 

Where are your impression materials stored? Are they 

stored in a wall cabinet with hot fluorescent lights underneath? 

Is your air conditioning on a timer? Do you turn the 

air conditioning down to save energy over the weekend? 

Figure 4: Drags or pulls resulting from premature set of the impression 

heavy body 

Figure 5: Inaccurate margins due to lack of flow, lack of hydraulics or 

inadequate retraction 

To ensure a fluid blend between 

your light-body and heavy-body 

PVS impression materials, 

both materials must be fluid and 

unpolymerized at the time 

the tray is inserted. 

Figure 6: Obvious gap between the light body and heavy body 


Figure 7: Gaps and ledges with lack of union between light and 

heavy body 

Figure 8: Lack of adaptation of light body around implants — light 

body was set and could not be moved by heavy-body hydraulics 

If your air conditioning is on a timer or the temperature of 

your operatory or office is higher than 23 degrees Celsius 

over the weekend or during the day, you need to keep in 

mind that it takes eight hours for impression materials to 

acclimatize. On those hot humid summer days or nights, 

your impression materials can get significantly warmer 

than room temperature (70 degrees Celsius) and will not 

cool back down until eight hours after the air conditioning 

comes back on. This is of significant importance when it 

comes to your working times. For every 10 degrees above 

room temperature, you lose up to 50 percent of your working 

time! For some materials, this may mean less than five 

seconds intraoral working time. It is impossible to impress 

one unit of crown & bridge in this time, let alone multiple 

units. Hence the need for a temperature-controlled storage 

unit for temperature-sensitive materials or strict control of 

the office temperature environment. 

In clinical crown & bridge cases where you must take 

an impression of multiple units, it can be difficult (if not 

impossible) with any standard impression material, due to the 

shortened intraoral working times, which for most materials 

on the market today is less than half or even a third of what 

is stated on the manufacturer’s instructions. However, there 

was a product introduced to the market a number of years 

ago which is designed specifically for these cases. Multi-Prep 

from the Affinity line of impression materials (CLINICIAN’S 

CHOICE Dental Products Inc.; New Milford, Conn.) has 

the longest intraoral working time on the market today. 

Although not the 2:40 minutes stated in the manufacturer’s 

instructions, it has an intraoral working time of 90 seconds 

followed by a relatively short and independent intraoral set 

time. Figure 9 shows a full-mouth reconstruction impression 

taken with Multi-Prep, which shows superb detail, 

adaptation and marginal capture. Two other materials come 

close to this working time for their light bodies as tested 

by the ADA: Examix NDS (GC America Inc.; Alsip, Ill.) at 

70 seconds and the polyether Impregum Penta Soft Quick 

Step (3M ESPE ; St. Paul, Minn.) at 70 seconds. 

For every 10 degrees above 

room temperature, you lose up to 

50 percent of your working time! 

For some materials, this may 

Figure 9: Full-arch rehabilitation Multi-Prep impression showing 

excellent detail, flow, adaptation and marginal capture due to 

proper working time 

mean less than five seconds 

intraoral working time. 


If you are trying to make a decision on choosing a new 

impression material for your practice, you must beware of 

clever marketing and advertisements. Many manufacturers 

will make you think singular qualities of their material 

should be important in your decision-making process. One 

example shows images of the contact angles of water droplets 

on the manufacturer’s material, which are lower than the 

contact angle of others. What does this prove? The idea is to 

make you think that if the contact angle is lower than their 

competitors that it must flow better in the presence of moisture 

or effectively displace moisture during impressioning. 

Some of these tests are done on set impression materials, 

which is a clinically irrelevant test, as we use the materials 

during the polymerization process. With some PVS materials, 

the movement of the surfactant to the surface to affect 

the wetting properties becomes limited as the material is 

polymerizing. 7 “Hydrophilic” PVS impression materials may 

continue to be hydrophobic in the unpolymerized state, and 

they will not properly capture detail on wet surfaces, but 

the surfactants have enhanced PVS wettability with gypsum 

products. 8 There is no relation between the contact angle 

and the ability to displace moisture contamination. 9 Similarly, 

another example is the “shark fin test,” which is designed 

to test how a material flows — the larger the fin, the more 

it must flow. Yet, how relevant is this if you have less than 

10 seconds to take the impression? There is no correlation 

between results of the shark fin test versus dimensional accuracy, 

and respectively, surface detail reproduction. 10 

References 

1. Freedman G. Buyers’ guide to impression materials. Dent Today. 2006 

Mar;25(3):144-5. 

2. Samet N, Shohat M, Livny A, Weiss EI. A clinical evaluation of fixed 

partial denture impressions. J Prosthet Dent. 2005 Aug;94(2):112-7. 

3. Pitel ML. Successful impression taking, first time, every time. 1st Ed. 

Armonk, NY: Heraeus Kulzer; 2005. 

4. Terry DA. The impression process: part 1 — material selection. Pract 

Proced Aesthet Dent. 2006 Oct;18(9):576-8. 

5. Chee WW, Donovan TE. Polyvinyl siloxanes impression materials: 

a review of properties and techniques. J Prosthet Dent. 1992 

Nov;68(5):728-32. 

6. ADA Professional Product Report. Elastomeric impression materials. 

2007;2(3):11. 

7. Grudke K, Michel S, Knipel G, Grudler A. Wettability of silicone and 

polyether impression materials: characterization by surface tension 

and contact angle measurements. Colloids and Surfaces A: Physicochemical 

and Engineering Aspects. March 2008;317(1-3):598-609. 

8. Trushkowsy R. Accurate impression material and technique for 

well-adapted restorations. Dent Today. 2007 Feb;26(2):120, 122-3. 

9. Norling BK, Ibarra J, Gonzales J, Cardenas HL. Wettability and 

moisture displacement of vinyl polysiloxane impression materials. 

University of Texas at San Antonio, IADR/AADR/CADR 82nd General 

Session, March 2004, #1927. 

10. Balkenhol M, Wöstmann B, Kanehira M, Finger WJ. Shark fin 

test and impression quality: a correlation analysis. J Dent. 2007 

May;35(5):409-15. Epub 2007 Jan 24. 

Reprinted by permission of Oral Health, November 2011. 

There are a number of choices for impression materials 

on the market today and, as with anything, each has its 

pros and cons. Should your decision be based on: water 

droplet contact angles, shark fin tests, price, color and 

taste, and powerful advertising? Or should it be based on 

clinically relevant qualities such as: intraoral working times, 

polymerization rate, dimensional stability, tear strength, 

accuracy, consistency, quality control, and most important 

of all, independent clinically relevant research? CM 

Gregg Tousignant, CDT, is a technical support manager for Clinical Research 

Dental, where he provides technical support and hands-on courses. E-mail him at 

gtousignant@clinicalresearchdental.com. 

Dr. Len Boksman retired from practice in London, Ontario, Canada, at the end of 

2011 and currently does freelance consulting and lecturing for the general practitioner. 

He can be reached at lenboksman@rogers.blackberry.net. 



Interview with Dr. Lee Ann Brady 

– INTERVIEW of Lee Ann Brady, DMD 

by Michael C. DiTolla, DDS, FAGD 

As someone who is involved in dental 

education, reading Dr. Lee Ann 

Brady’s résumé makes my head spin! 

Having spent several years teaching side 

by side with some of dentistry’s best, 

she recently re-entered private practice 

to reclaim her nights and weekends. 

Lee is smart and funny, and I have 

been lucky enough to spend time with 

her when lecturing. I hope you enjoy 

our conversation. 

Interview with Dr. Lee Ann Brady43

Dr. Michael DiTolla: The thing I love about you, Lee, is that 

you are dentistry’s version of Justin Timberlake, in the sense 

that you really do it all. You teach photography. You teach 

occlusion. You teach adhesion. You teach preparation. There’s 

almost nothing beyond your reach. I think that’s due to a 

combination of talent and your educational background. It’s 

been an amazing path that has taken you to where you are 

today. So as we get started, for our readers who are not familiar 

with your background, take us through what you’ve done since 

you graduated from dental school. 

Dr. Lee Ann Brady: Absolutely. As you were describing that 

broad range of topics, one of the things that came up for 

me is that it also mimics what I do in my practice every 

day because I’m a general practitioner, so I have to be well 

versed in all of those topics. My path did not happen with 

intention, so much as it just happened serendipitously. I am 

a general dentist, as I said. I graduated from the University 

of Florida in 1988 and was in and out of various practice 

models in the years between then and 2005, when I was 

asked to join the Pankey Institute down in Key Biscayne, 

Florida, as a full-time faculty member. So I moved down 

to Pankey and taught there full-time. I was their clinical 

director for four years. 

MD: That’s amazing to me that you got asked to be a part of 

Pankey because the only communication I’ve had with Pankey 

is they have asked me not to come to the courses. 

LB: (laughs) Oh, come on! 

I was sitting in one of their classes ... 

and Monday morning of that class, 

Irwin Becker, who was chairman of the 

department of education at the time, 

came up to me and said, “I’d really like 

for us to talk privately.” And, honestly, 

I thought for sure they were kicking 

me out. It was like being called into 

the principal’s office. 

MD: So I’m amazed that they asked you to come on board like 

that. How did that happen? 

LB: You know, I’ll tell you as best as I know the story. 

From a purely factual perspective, I was sitting in one 

of their classes — I was taking their second class, which 

at the time they called “C2,” their bite splint class — 

and Monday morning of that class, Irwin Becker, who 

was chairman of the department of education at the 

time, came up to me and said, “I’d really like for us to 

talk privately.” And, honestly, I thought for sure they 

were kicking me out. It was like being called into the 

principal’s office. 

MD: You thought he was going to hand you a check with a 

refund for your tuition and have you leave out the back door? 

LB: (laughs) Exactly. “Get out of here!” So I was nervous 

until we found a time to talk. We finally found the time 

and went to lunch together and he asked me, “Have you 

ever considered doing anything in dental education?” That’s 

literally how I got asked. Up until that point, I really hadn’t 

considered it. I taught briefly at the dental hygiene program 

at Santa Fe Community College, which is in Gainesville, 

Florida, my first year or two out of dental school, just 

because my practice wasn’t busy and I was looking to keep 


usy and make a little more money. So I went and taught 

in the dental hygiene clinic. But other than that, I had no 

experience in dental education. I went in cold turkey. 

MD: So that was in 2005. How long were you there? 

LB: I was there until the end of 2008, so just shy of four 

years. That accounts for my huge background in occlusion. 

I had already been doing that. Actually, as a student, I 

had decided at one point that I might focus my practice 

on TMD patients. I was taking some courses with Mark 

Piper. I went through the craniofacial pain mini-residency 

at the University of Florida with Henry Gremillion and 

was taking Pankey courses. When you’re there full-time at 

Pankey for four years, you are immersed in the conversation 

on occlusion. 

MD: How interesting that early on you thought you might focus 

your practice on TMD patients. For most of the dentists I know, 

that’s one of the first early referrals they decide to make — pedo 

patients and TMD patients. I used to run from those patients. 

What drew you to that? 

LB: I still do a fair number of those patients. But I decided 

that, as much as I enjoyed TMD, I also missed restorative 

dentistry. I loved that, too. So I’ve created a balance now in 

my practice. What I love about it is the unknown and the 

mystery. In the beginning, it’s daunting, and you wonder 

how you will ever figure it out. The more I got to learn 

about it, the more I realized it’s just a puzzle that can be 

solved if you are willing to stay curious and stay in the 

puzzle with the patient, and combine what they’re telling 

you with what you are finding in an exam. You really have 

to work through it. One of the things that I think is hard for 

folks to grasp when they start treating TMD patients is, you 

don’t actually know when you start what we call “therapy,” 

which for most of us is an appliance, that this is actually 

the therapy. The appliance is almost as much diagnostic as 

it is anything else, because you make it based on a design 

you think might work. But then, if it does or doesn’t work, 

that’s diagnostic information. It makes you go, “Oh, I need 

to go down this other path.” So I like that piece of it. I like 

the investigative piece of it; that it’s different and always a 

challenge. It’s not repetitive, like doing an MO composite. 

MD: That might be where the disconnect is for some dentists. 

We take a bitewing radiograph. We find some decay. We go in 

and we drill it out. We place a restoration. It’s done, problem 

solved, and we’re on to the next thing. But TMD is not like 

that. It’s ongoing and you have to be inquisitive. You have 

to interpret what the patient is telling you and what you’re 

seeing through the therapy you’re providing. 

LB: Exactly. If you’re one of those folks where you like to 

just do what you do and be done, and then in your mind 

it’s handled, TMD should not be the part of dentistry you 

go into. If you like the challenge of it being a continuous 

process and asking what’s next and how are we going to 

do this, then TMD is a great aspect of dentistry that has 

that, whereas a lot of other aspects of restorative dentistry 

don’t. For me, like I’ve said, I’ve balanced it. I like treating 

TMD patients in my practice, but I would miss restorative 

dentistry, so I don’t do that every day that I’m in my office. 

I have created a balance, and I think a lot of other folks can 

do that, too. 

MD: So you like to be able to mix it up and change gears a 

little bit, go in and solve a few problems, and then also see a 

few TMD patients. This is starting to sound like what might be 

called the “thinking man’s dentistry,” if you will. Less about 

handpieces and injections, and more about interpretation and 

trying to figure out what might make the situation better. 

LB: That’s the best way I’ve ever heard it explained! 

MD: Well, then we’re going to end the interview here. Thanks so 

much for being with us. (laughs) So you were at Pankey until 

the end of 2008? 

LB: Yep. Then I was asked to join Frank Spear. It was right 

when he was moving the Seattle Institute for Advanced 

Dental Education from Seattle and partnering with the 

Scottsdale Center for Dentistry, which of course now 

has become Spear Education and is based in Scottsdale 

(Arizona). So he asked me to be part of that transition, and 

be the person who moved to Scottsdale, because he and 

Greg Kinzer and Gary DeWood were still all in Seattle at 

that point. So I did that at the end of 2008, and I was there 

full-time until last year. 

MD: How did that invitation come about? Because now, for the 

second time in your illustrious career, you’re being tagged by 

one of the more powerful people in dentistry to come be part 

of their organization. Are you just relying on your good looks? 

How did this happen? 

LB: You know, that could be a part of it, and we won’t dismiss 

that piece. But, honestly, I knew Frank as a student because 

I had taken his classes in my own continuing education 

journey, and he also used to come down to Pankey once 

a year to do a program called “Masters Week,” so I got to 

know him even better at that point. Gary DeWood, who is 

a dear friend who I worked with at Pankey, was already 

in Seattle and had joined Frank at the Seattle Institute for 

Advanced Dental Education. I also had three kids at that 

point, and my daughters, who are now almost done with 

high school, were just on the crux of being teenagers. So I 

really was looking to not live in Miami anymore, to have my 

kids someplace where I felt more comfortable with them 

learning to drive and starting to date and do all of those 

things in a less cosmopolitan setting. Gary knew that, so I’m 

sure that was part of it. And, talk about having your heart 

stop, there’s nothing on the planet like having your phone 

ring (at that point I still had an actual house phone) and 


you go over and the caller ID says “Frank Spear,” and you’re 

like, “Really?” I can remember that evening at my house 

because I went over to the phone and was screaming to my 

husband, “It says Frank Spear.” My kids were like: “Answer 

it. What’s your problem?” 

MD: That’s great. And when you answered the phone, did you 

say, “Frank, I’d love to talk, but I’ve got Gordon Christensen on 

the other line”? 

LB: (laughs) No. Unfortunately, I was so tongue-tied that I 

don’t know what I said! 

MD: I don’t blame you! So what was your role at Spear? 

LB: I was the executive VP of clinical education. 

MD: And you were there for how many years? About the same 

amount of time you were at Pankey? 

LB: A little bit less. I was there for almost three years fulltime. 

MD: And you recently decided to get back into private practice 

and spend a little more free time with your family? 

LB: Absolutely. June of last year I left Spear Education as 

an employee and went back into private practice. I practice 

here in Glendale, Arizona. I am still teaching. My intent was 

always to continue to teach some. But I really wanted a lot 

more control over my schedule because, as I said, I’ve got 

three kids and two of them are in high school and the other 

is just about to be in high school. The other part of it for 

me was I felt like I really needed to be seeing patients in 

order to continue to grow as an educator. I had spent eight 

years in formal general continuing education with very little 

opportunity to interact with patients, so I wanted to go out 

and do the things I was talking to other folks about. 

MD: As I alluded to earlier, that really is an amazing 

background. With the experience you’ve had, I’m not sure 

what’s left for you to do, except maybe I’ll nominate you for 

ADA president because it sounds like you have a hard time 

saying “no.” But it really is an amazing background, and it 

has all added up to someone who is not only able to do all these 

things in your practice, but you’re able to teach it and teach it 

well. That’s a gift, too. 

To get back to occlusion, because I know you’re so well 

grounded in that, here at the laboratory, about 75 percent of 

the restorations we do are single-unit restorations, and then 

another 11 percent are 2 adjacent units. Basically, 86 percent 

of what we do here at the lab is either 1 or 2 units. So, from our 

perspective, for the typical dentist out there sending us work, 

it looks like dentistry is being done one crown at a time; not 

big, full-mouth rehabs. For the doctors who spend most of their 

time doing single-unit crowns, I think occlusion is having the 

patient bite on the paper, see the blue dot and getting rid of an 

interference, and that may be all they need to be concerned 

about. But for those kind of basic cases, what do you do? What 

do you look for? Are you doing full-mouth occlusal adjustments 

on those patients who come into your practice and maybe just 

need one crown? 

LB: That’s a great question, and my practice really mirrors 

what you guys are seeing in the lab. For the majority of my 

patients, we do dentistry in very small units. Honestly, even 

when I do patients where we’ve talked together about a 

comprehensive treatment plan and the patient is ready to 

do that, because of their time constraints or their economic 

constraints, we have to figure out how we do dentistry in 

little pieces over 10 years. So that’s mostly what I send to 

the laboratory. 

MD: Wouldn’t you agree that it’s much easier for most of us to 

do 28 units of crown & bridge one or two crowns at a time then 

it is to do it all at once? 

LB: It depends what you mean by easier, but I think there 

are pieces of it that are easier. It’s easier on the patient, 

definitely, from a patient experience. Unless you’ve been 

a patient and sat in the chair and had 14 units prepped 

on the same day, you have trouble comparing that. There 

are pieces of it that are easier from a treatment-planning 

perspective, from a case-presentation perspective. 

I guess for me, when you ask what people should know 

about occlusion, it does go back to that planning piece. I 

think we need to spend a little bit of energy understanding 

who are our high-risk patients from an occlusal perspective. 

Those are the ones where you do the single-unit or the 

2-unit, and now you find yourself in a situation you’re 

not sure how to get out of. So you lose your clearance on 

your prep, or you grind the crown in and the patient never 

feels that their bite is the same. You’re looking at the dots 

thinking it looks right to you and wondering what the heck 

they’re talking about. Or maybe, the worst one, where you 

come in and there’s a hole in the provisional. In the old days 

with porcelain fused to metal, at least you knew you could 

adjust through and the worst thing that would happen is 

you would tell the patient they had a little silver amalgam 

in their crown. With all-porcelain, now you don’t have that 

opportunity to back out any more. So I would say, figure 

out who those high-risk patients are and, at a minimum, 

know for yourself and have a conversation with the patient, 

so if some of those sequelae happen, now it’s something 

you knew might happen and it’s something you’ve already 

talked about and predicted. It’s not something where you’re 

wondering how you are going to make it right. 

MD: Give me an example of a typical case that might walk in 

off the street, something simple like a single-unit crown. The 

patient walks in with a broken cusp — it’s cutting their tongue 

or their cheek — and they’re basically begging you to prep it. 


Give me an example of a case that might be one of those highrisk 

cases. 

LB: Well, the first one I think of, which is super common 

in your scenario of a fractured cusp, is you’re going to do 

an upper or lower second molar. For most folks, if we look 

at, percentage-wise, which tooth in the arch is the one that 

trains our lateral pterygoid and has our brain know how to 

find intercuspal position, it’s going to be on a second molar. 

Now you look at that tooth and you don’t know, when you 

prep the rest of the occlusal table away, if they are going 

to lose that muscle memory, and therefore, the instant you 

do your prep, you go in to check and there’s no occlusal 

clearance. I don’t know if you’ve done this, but I’m geeky 

enough that I’ve actually looked at the research, and five 

minutes is nowhere on the bell curve for normal supereruption. 

Teeth don’t do that. If you lose your occlusal 

clearance literally while you’re prepping, it’s because the 

lateral pterygoid muscle is relaxing and releasing and the 

condyle is receding. 

So what do I look for in that situation? Sometimes it’s hard 

if the cusp is broken because they may have just eliminated 

their own first point of contact. But I look for wear because 

patients who have wear on their second molars — no place 

else on their arch but on their second molars — what runs 

through my head is they get their condyles back in centric 

relation. They either peri-function back there or this is a 

place they go to. I need to be thinking about this. I also 

always look for the difference between intercuspal position 

and that seated condylar position from a standpoint of the 

relationship of their front teeth. How much do their front 

teeth come apart vertically? Is there an A-P piece of that? 

What’s the distance? Because if their front teeth open 3 or 

4 millimeters when you get their condyle seated, and that 

gets deprogrammed, that is going to translate to 1 or 1.5 

millimeters off the top of your prep, and there goes your 

clearance. If the discrepancy is little, which fortunately for 

us it is in 85 percent of the population — it’s less than 

1 to 1.5 millimeters — we’re never even going to notice on 

that second molar. 

MD: OK, let’s say the patient comes in and it’s not a broken 

cusp. Somebody’s got a large amalgam in a lower second molar 

and it’s got a little recurrent decay and you’re getting ready to 

prepare it. How do you handle that and how do you go into that 

to minimize the risk of those kinds of sequelae happening when 

you prep that second molar? 

LB: For me, it’s super simple. I reach for a leaf gauge. I keep 

a leaf gauge on my exam tray. It takes me probably less 

than a minute with a leaf gauge to find out, number one, if 

they have a positive load test, which tells me their lateral 

pterygoid is kind of tight. If I can get it released, can I find 

first point of contact? Is it marking on the tooth I’m about 

to prep? If it’s marking on a different tooth, my risk is really 

For the majority of my patients, we do 

dentistry in very small units. Honestly, 

even when I do patients where we’ve 

talked about a comprehensive treatment 

plan and the patient is ready to 

do that, because of their time restraints 

or their economic restraints, we have 

to figure out how we do dentistry in 

little pieces over 10 years. 


low. If I’m about to prep away that contact, now the risk 

just went up. I can also see visually with the leaf gauge in, 

when they’re touching that first contact, how far apart their 

front teeth are. Again, if the number is 3 or 4 millimeters 

and something changes, I know I’m going to see it and it’s 

going to affect my prep. 

MD: So the take-home message for dentists is that the most 

common trap we’re going to fall into is on those second molars? 

LB: Exactly. Then, statistically, are there first molars? Sure, 

but it’s a smaller number. Are there people who have it on a 

pre-molar? Sure, but now it’s a really small number. Maybe 

you do nothing more than stopping before you prep the 

second molar and asking if this is the tooth that’s the first 

point of contact. I used to get really weird about that when 

I thought I had to do a bilateral manipulation, and I don’t 

think I’m unique to that. I think that’s a technique where 

people aren’t sure what the heck they’re doing. But do it 

with a leaf gauge, and it’s super simple. You can learn to do 

it with a leaf gauge very quickly, probably one time using it 

and having someone explain it to you, and now you have it 

on your tray so you can figure that out. 

MD: I’m sure that is of the things you teach in your course. In 

fact, you do some online courses as well. Is that one of them, the 

occlusal therapy course? 

LB: Absolutely. I just completed the online course called 

“Occlusal Diagnosis: Identifying Risk,” and it really is 

geared toward the general dentist, the restorative dentist. 

What we talk about is how you do an exam in a way that, 

if somebody is going to have risks from joints, muscles 

or their occlusion, you can identify those people; those 

red flags are obvious. With this group of people you can 

say to yourself, I’m going to slow down and get more 

information, versus the folks where you can just prep 

the teeth. 

MD: If people want to find that online and sign up for that 

course or watch that course, where do they go? 

LB: They just go to my website: www.leeannbrady.com. 

MD: Perfect. That would be a great place for them to go. 

I was just reading the American Association of Cosmetic 

Dentistry’s State of the Cosmetic Dentistry Industry report they 

released for 2011, and it talks about how cosmetic dentistry 

has really been down. How veneers have been down almost 10 

percent since 2007. When you break down the veneer numbers 

here in our laboratory, the IPS Empress ® veneers (Ivoclar 

Vivadent) continue to shrink and shrink at an alarming rate. 

But the good news is, at least for the veneer department, that the 

IPS e.max ® (Ivoclar Vivadent) numbers for veneers continue 

to grow, and that mirrors what I do for any multi-veneer case 

now. IPS e.max is my go-to material, and I love something that 

looks essentially as esthetic as IPS Empress, though maybe not 

exactly the same in terms of esthetics, but certainly no patient 

can tell the difference. I love the fact that it’s three-times as 

strong as IPS Empress. Are you finding yourself using e.max 

more for veneers as well? 

LB: That is a great question. Of my posterior restorations in 

my practice now, I can’t tell you what percentage are e.max, 

but the vast majority of them are lithium disilicate. For me, 

it has really replaced porcelain fused to metal. I do lithium 

disilicate almost exclusively in the posterior now. For the 

anterior, it’s a place where I’m playing with it. I go to the 

research and I look up how important that extra strength 

is in the anterior. Really the science doesn’t support that 

it makes much difference around materials, and we went 

through that for years when we talked about the different 

kinds of ceramics in the anterior. Now if you want to talk 

about a patient who is a bruxer, who has edge-to-edge 

wear, I wouldn’t even think twice about it now. When 

people say, “I want to do beautiful anterior veneers and 

I’m concerned about strength,” e.max, or lithium disilicate, 

is definitely the material of choice. But in patients where 

that’s not a concern, I don’t have a strong preference. 

I’ll tell you how I do it: I actually talk with my technician. 

I send my technician all of the pre-op photographs for the 

case. I tell them what the pre-op shade is. I show them 

that this is what the patient wants. The patient wants this 

much of a shade change in the final restoration. They want 

Hollywood, where it’s monochromatic and it’s really high 

value, or they want totally natural. I give the technician all 

of those parameters, and then I say, “What do you think you 

can get me the best results with? What do you feel like you 

work with the best to get me those results?” At that point, 

it’s really an esthetics decision. I have preferences over what 

kind of composite I use for different esthetic situations, and 

I want them to know that I happen to like this color system 

or this staining system better, but because the ceramist is 

the person stacking the material and working with it, they 

get to choose. 

One of the technicians I work with all of the time is a 

huge fan of lithium disilicate, so I have had a chance to 

do a number of anterior cases, veneer cases, using lithium 

disilicate. What they have done with the esthetics is just 

dramatic in the last couple of years. With the esthetics of 

Ivoclar’s new Opal series, their ingots and their blocks, it’s 

going to get to a place here really, really quickly, where 

it’s going to be hard to differentiate, from an esthetic point 

of view, what material was used. In that case, sure, why 

wouldn’t we use the strongest thing we have out there? 

MD: If you look at the numbers of what we’re doing in the 

lab, probably the most shocking thing in the last two years 

has been how the PFM is literally disappearing. It’s gone from 

being about two-thirds of the crowns we made here five years 


ago to less than a quarter of the crowns we make here today. 

You would almost think that a bunch of research came out 

saying PFMs are causing cancer or something because of the 

way dentists are turning and running from them. But, really, 

it’s these high-strength, cementable all-ceramics like IPS e.max, 

and a product that is a little less researched and a little uglier 

than IPS e.max, the full-contour zirconia material BruxZir ® 

Solid Zirconia — the one that we’re doing here at Glidewell. 

It’s amazing. We totally underestimated how much more the 

average American dentist was concerned about strength than 

they were about esthetics. So with what I’ve seen here in the 

laboratory, it has evolved to the point where I’m doing mainly 

BruxZir restorations in the posterior and the less esthetic 

areas, and mainly IPS e.max in the anteriors. I don’t do that 

many single-unit PFMs anymore. For me, the PFM has just 

really become a bridge material. Is that what you find for 

PFMs as well? 

LB: Exactly. I cannot think of the last single-unit PFM that 

I did. Actually, I can. I had a patient who had some of the 

worst discolored teeth — combinations of secondary dentin 

and old metal post/cores — and we just decided to go with 

PFMs with metal cutbacks to try to maximize the esthetics. 

But that was a very unique situation. Single-unit PFMs in 

the posterior? I can’t remember the last time I did one. And, 

yes, Glidewell is right on the cutting edge of developing 

those materials. 

I guess it doesn’t surprise me how it’s been adopted, simply 

because I think a lot of dentists, like me, have the experience 

of recommending a crown for a person and having them get 

this weird look on their face. If you actually stop and ask 

them about their reaction, they ask if the crown is going to 

have this “black line”? And they point someplace in their 

mouth to an old PFM that was done with a metal margin. It’s 

amazing to me how patients find that so offensive, where 

they can see that metal margin, way more so than having to 

have the exact shade of a posterior tooth match. It’s really 

rare for me with a patient, especially when you are doing 

single teeth, to have the patient say, “Oh no, I don’t want 

you to cement that one because it’s slightly darker than my 

tooth or slightly brighter than my tooth.” I actually show 

them. I will actually hand them a mirror and say, “I want 

you to look at the color before it’s fully cemented in.” And 

they usually look at me and say, “Why are you asking me 

this?” But that metal margin, they just hate. So my guess is 

that other folks’ experiences are similar. And then you know 

you have a material that’s strong, which has always been 

the PFM’s claim to fame. Why wouldn’t you use something 

that’s all-porcelain? You also have patients who say to you 

that they don’t want any metal in their mouth. 

MD: I’ve had a couple of patients over the years get really 

demonstrative about that, and they did happen to be women 

— probably because they pay more attention to themselves 

than men do! Once most men get married, we just give up 

and stop caring about how we look. But I had a woman get 

really upset because she could see a lingual metal margin on 

an upper second molar. I told her no one was ever going to see 

it, and she said, “You can see it if I’m lying on my back with 

my mouth open.” I had to ask her what she did for a living. I 

mean, how often does someone find themself in this situation?” 

I saw a patient who had a gold stud in her nose, but shuddered 

when I mentioned placing gold in her mouth on a lower second 

molar where I didn’t think I would be able to get enough 

occlusal reduction. So there is something weird. Gold is highly 

acceptable around your neck, hanging from your ears, stuck 

through your nostril, for some people, but you put it next to a 

tooth and it’s a cardinal sin. 

LB: I agree. I think that’s been a huge boon to it. I also think 

the other part of it is it allows us to be more conservative, 

if we don’t have to put all of the margins subgingival. And 

dentists love saving a half-millimeter or a millimeter. I think 

that’s one of the things I love about our profession, how 

concerned we are about preserving tooth structure. 

MD: Well, OK, I’ll give you that. I know that you’re conservative 

and you want to do that, but many of us under-reduce 

and when called out on it, we say we were trying to be 

conservative. If a dentist prescribes a PFM, for which our lab 

and the manufacturers of the materials have always asked 

for 2 millimeters of occlusal reduction, and they give us threequarters 

of a millimeter, I’m not going to say, “Oh, doctor, 

you’re so conservative.” If you’re that conservative, prescribe 

a cast gold crown because you’re under-preparing. It’s either 

laziness or not having a system to reduce enough. But I hear 

what you’re saying because one of the things about BruxZir, 

or any solid zirconia for that matter, is it can be made thinner 

than, for example, an IPS e.max crown, especially if it’s not on 

a posterior tooth. You can’t go below a half-millimeter with a 

contoured zirconia restoration on a posterior tooth, but on an 

anterior tooth, you can get away with a half-millimeter, maybe 

a little less. 

I’m going to start experimenting with minimally invasive 

crowns, where we remove the least amount of material possible 

and see what it looks like to put one of these super-thin, highstrength 

crowns on top of it. We’re not going to start selling 

those anytime soon, but we are going to start experimenting 

with those. It would allow us to be more conservative, like we’ve 

seen for veneers. When I went through LVI, we were not only 

prepping veneers into dentin, but prepping into deep dentin. 

Have you noticed over the years the change in the way that you 

prepare veneers, in terms of the depth? 

LB: Oh, absolutely. I am much more conservative now. I 

make decisions about the amount of tooth reduction based 

on things like how much I am going to change the shade of 

the tooth. I don’t want to tie my technician’s hands behind 

his back and say, “I’ve given you 0.3 millimeter of reduction, 

but can you take this from an A5 to an OM3 please?” Part of 


that is we have to give the technician adequate reduction. I 

would tell you from the experience of teaching a lot of handson 

preparation courses — and I think every technician in 

every laboratory I’ve ever talked to agrees with this — that 

under-reducing is the classic problem in dentistry when we 

do indirect restorations. When I work with dentists on prep 

design, what I find is they mentally know how much tooth 

reduction they want to send the laboratory. Where it breaks 

down is they’re using their visual cues to try to assess how 

much they have, instead of actually using hard facts like 

depth-cutting diamonds to know how much they’re doing 

their depth cuts and reduction, and then going back and 

checking the amount of reduction. 

I do a thing in my prep course where 

I have everybody prep a tooth without 

measuring. I have them write down 

how much they want to prepare, 

then prep the tooth. Then I go back 

and show them how to measure, and 

everybody, across the board, underreduces. 

I do it! If I don’t measure, 

I always under-reduce. 

I do a thing in my prep course where I have everybody 

prep a tooth without measuring. I have them write down 

how much they want to prepare, then prep the tooth. Then 

I go back and show them how to measure, and everybody, 

across the board, under-reduces. I do it! If I don’t measure, I 

always under-reduce. Now, one of the things that’s happened 

after a couple of years of doing a prep design technique, 

where I have been very meticulous about measuring my 

reductions, is that now my eye is getting better because 

I’m sort of training it. But I still don’t trust it. So one of 

the classic things that I’ve gone back to, if I’m going to do 

occlusal reduction on a posterior tooth, is placing depth 

cuts. But you’ve got to know what you’re doing. Pull out 

an old 330 carbide bur. Everybody has one of those in the 

office somewhere. You don’t use them for anything because 

they’re too wimpy for most preparations anymore, but 

they’re exactly 1.5 millimeters from the tip of the bur to 

where the shank starts. Just drop a bunch of pinholes in an 

occlusal table. Go up on the cuspid. Go on the inclines. Go 

on the central groove. And then connect the dots. 

MD: Yeah, I had to do that when I started practicing in the 

lab and we started filming everything. I realized I had to start 

getting better in a hurry. I was a chronic under-prepper, too. 

I stumbled onto these depth-cutting burs, these self-limiting 

depth-cutting burs that come in different depths. There’s a 

1.5 and 2 millimeter. I was shocked when I put a 2 millimeter 

hole in the occlusal surface of a molar and then prepped until 

I thought I was done. I had half the hole left the very first time! 

And I thought, no wonder I was chronically under-preparing, 

because if you’re not used to seeing 2 millimeters, it looks like a 

really deep hole. It looks like an endo access. 

LB: It does! 

MD: But the weird thing is that dentists will never give us, 

as a laboratory, 2 millimeters of occlusal reduction because 

when you under-prep for so long, it feels like malpractice to 

do 2 millimeters of occlusal reduction. But, meanwhile, they’ll 

do 2 millimeters of occlusal reduction for a Class I amalgam 

or composite, or a Class II amalgam or composite all day 

long because every time you do a crown prep and make a 


2 millimeter hole in a molar, it goes all the way down to the 

base of the amalgam. So, for some reason, dentists don’t have a 

problem prepping 2 millimeters into the tooth if it’s for a direct 

restoration, but when it comes to an indirect restoration, all 

of sudden, 2 millimeters seems like it’s over the top. I’ve never 

quite figured out where that disconnect comes from. 

LB: I actually don’t know. I haven’t thought about that. 

But, you’re right, that’s my experience of it, as well. I don’t 

know, maybe it looks more aggressive when the cusps are 

gone, but with a Class I or Class II direct restoration, it 

looks like there’s tooth there. I’m old enough that, when I 

first learned how to do crown preps, we actually depended 

on retention form and resistance form to keep them in. 

So my brain is going, “How much wall height do I go?” 

Nowadays, we bond everything, so that’s really almost 

become a non-conversation. 

I know that when I really started paying attention to this, 

one of my least favorite words ever in dental school was 

“armamentarium.” If someone says that to me again, I’m 

going to lose it. Every day in the clinic you’d go to get ready 

and they would say, “Tell me about your armamentarium.” 

Oh man! Now I teach that to dentists and I use that word 

because, especially when it comes to preps and indirect 

preps, you’ve got to know what you’re putting in that 

handpiece. Tell me the diameter of that bur. Tell me the 

length of that bur. Tell me what the tip looks like. Are you 

trying to cut a chamfer or a shoulder? Well you need to put 

the right bur in the handpiece to do that, or you’re going 

to frustrate yourself and your lab is going to wonder what 

they’re supposed to do with it. 

MD: Exactly, and so my prep technique — I just had to come 

up with it for myself because I couldn’t prep well without it — 

is really intellectually insulting, in a sense. I’m a professional, 

and my whole prep technique is a 2 millimeter hole on the 

top and a 1.5 millimeter one on the axial and a 1 millimeter 

round bur cut on the gingival. At times I think, “I should be 

better than this.” I graduated the same year you did. I should be 

able to prep this tooth and get it right without any depth cuts. 

But, you know what, it’s not a big deal. Pilots have a checklist 

before they take off in a plane for the 2,000th time. To me, it’s 

just an easier way to do it than to prep it and then go in with 

bite registration after the fact, or wax and calipers, and try to 

measure how much you took off. Just put some holes there and 

prep until you can’t see the holes. 

LB: That’s exactly how I do it. The other thing I would 

say on that is, I think it’s actually more efficient. When I 

watch dentists prep, it seems less efficient when they’re 

taking the same burs in and out of the handpiece multiple 

times, versus using this one first until they’re done, this 

one second until they’re done. I find that by having those 

marks on the tooth, I can cut a tooth way faster and more 

efficiently than I ever did before, and it’s more effective! So I 

don’t get those phone calls from the laboratory. We love you 

guys and all, but I have to tell you that when my assistant 

tells me the lab is on the phone during the day in the office, 

I’m thinking: “Oh really? What did I screw up?” (laughs) 

MD: Exactly. Once you have the depth cuts in, it’s just a race 

to see how quickly you can get the rest of the tooth structure 

off because you know exactly where you’re going. And, by the 

way, I hate the word “armamentarium,” too. I want to back 

you up on that. It’s my second least favorite word. My least 

favorite word in dentistry is “dentifrice.” Why are we calling it 

dentifrice? I hate when we try to sound like we know more than 

the patient does. “I’m going to suggest a dentifrice for you that 

I think is going to help with your abrasion problem.” 

One of the things I teach at my courses, which I’ve learned from 

being here in the laboratory, is there doesn’t seem to be any 

easier or quicker thing you can do to get better results from 

your laboratory when it comes to esthetic dentistry than digital 

photography. I just notice here when I watch the technicians 

work that they try harder when there is a digital photograph in 

front of them because now they see what they’re aiming at. We 

are here in California, but we have dentists that prep crowns on 

tooth #8 and #9 in New Jersey, and they’ll send us the impression 

to make crowns on #8 and #9 using IPS e.max, shade A2, and 

there’s no photograph that goes with it. We can match the shape 

of the laterals next to it on the model, but there’s nothing about 

what the teeth look like, what the lateral incisors look like. It 

seems like a tall order for the technicians, and they have to 

think: “You’ve got to be kidding me. You want me to make 

crowns and match these teeth based on a yellow stone model?” 

I see what happens when we give them digital photographs. 

Then they know it’s a dentist who cares, who has a little bit 

higher standards. Even if they weren’t great photographs, I 

think digital photography is a great way to ensure that you 

get the highest-quality esthetic dentistry your lab is capable of. 

I know you teach courses on digital photography, and I just 

want to get your take on that. 

LB: I couldn’t agree more. I couldn’t practice without 

photography. Let’s go back one step even before laboratory 

work. I would tell you that taking photographs in my 

practice is the thing that transformed my case acceptance, 

even if it’s just four simple photographs. You just want to 

take an upper and lower occlusal, a smile and a retracted 

with the front teeth in it. Now you and the patient can sit 

and look at the same thing. We don’t think about the fact 

that our patients don’t know what their teeth look like. 

They don’t know what their mouth looks like. 

MD: Did you use an intraoral camera at any point, or have 

you always done it with digital photography? 

LB: Yes, I used to use an intraoral camera myself. I actually 

still have an intraoral camera and both of my hygiene 

operators have them. To show a patient a single tooth, such 

as a recall patient where everything is healthy, but there 


is one little spot where there’s a little recurrent decay or a 

little recession, I think an intraoral camera is great for that. 

I always use my digital camera, mostly for new patients. I 

want them to see their whole mouth. I want to be able to 

talk to them about that ugly, old black filling on their lower 

first molar, and have them be able to see, without me saying 

it, that there are four more on their lower teeth, because 

they are all in the photograph. 

MD: I take it you’re not just showing them this on the little LCD 

screen on the back of a camera after you shoot these four shots. 

LB: No. Our protocol is I take the four photographs: upper 

and lower occlusal, full smile, and then with retractors 

in and the patient’s upper and lower teeth apart so both 

occlusal planes are visible. Then we take the card out of the 

camera, throw it into a card reader that’s connected to a PC 

in my office, Microsoft Photo Viewer comes up, which is 

preprogrammed on every Windows PC in the world, and it 

lets us print those four pictures on a single sheet of paper. 

I actually do it on plain paper; I don’t buy photo paper. I’ll 

print them and take them to the patient. My conversation 

with patients will be, “We’ve got these in your chart as a 

part of your permanent record, but I thought you might 

want a copy of these,” and I’ll hand them to the patient. 

Most patients will then look at them. As soon as they do, my 

next comment is: “Do you see anything in the photographs 

of your teeth that you’re curious about or that you have a 

question about? Let’s really make sure we talk about that,” 

and I’ll hand them a pen. 

MD: Wow. See, I hand it to them and say things like, “I bet you 

didn’t know your smile was so ugly!” That’s too strong maybe. 

LB: (laughs) That might be less effective. So I can’t imagine 

practicing without photography. For me, when I’m sending 

stuff to the laboratory, I actually need to go overboard and 

send too many photographs. This has made such a big 

difference for me as far as what I get back in shade matching. 

People say to me all the time, people who are techie, “But 

it’s not all color corrected,” and I say that’s almost not the 

point. The point is that the technician can actually see, 

relative to the other teeth, what that looks like. They can 

see nuances from the standpoint of chromo-gradient and if 

there are little decalcification spots. My experience is that 

every technician I’ve ever met sees 100 times more in a 

photograph of teeth than I do as a dentist because they 

have that eye. 

MD: Exactly. Technicians love to have, not only the picture of 

the teeth, but let’s say an A2 in there next to the adjacent tooth. 

It doesn’t need to be a perfect match. They just need to see how 

it looks relative to the A2 shade tab because they’ve got that 

same shade tab in the lab and they can use that as a reference. 

Are you taking all of those pictures, or is your staff able to take 

those four pictures if you’re off doing something else? 

LB: My assistants are all trained to use the camera and take 

digital photography. I’d say that a few of them are better 

photographers than I am. So we can switch in and out to do 

that. If I’m doing a single central and it’s really challenging 

because it’s a high-esthetic-demand patient, I’ll probably go 

in and do the photographs, because then I can get analretentive 

and do stuff like exposure bracketing, give the 

ceramist one that’s a little dark and one that’s a little light. 

But that’s not my routine. My routine is usually two to four 

photographs with the shade tab in there, without the shade 

tab in there, and the ladies in my office all do that very well. 

MD: I bring that up mainly because I want dentists to 

understand that this isn’t something they have to do themselves. 

In fact, my assistant is as good as I am at this point, and she 

complains less. If I have to take those four photographs, and 

she’s not in there to help me, I’m pissed! But somehow she does 

all four without me anywhere near her, so in that respect I 

guess she does it better than I do. But I don’t want the doctors 

to feel like this is something else that’s thrown on their plate. 

This isn’t. You could just walk into the operatory and have the 

patient already be holding the sheet with the four pictures on it, 

and you could just sit next to them, say hi, ask them what they 

think, and let them tell you. 

LB: Exactly. I’m a huge fan of photography, and it’s so 

much easier than it used to be. Most of the cameras we 

use in dentistry now are basically the same camera bodies 

that you can buy anywhere, so you can learn to use them. 

Dental photography companies have training sessions, 

there’s online stuff, there’s stuff on YouTube. There are so 

many resources now to get over the initial learning curve, 

and most of the new cameras can be set on automatic. 

MD: Exactly. I understand why dentists were turned off from 

it in the past. I remember you would shoot Kodachrome 

or Ektachrome, and you would have to send it out for E-6 

processing and you’d get it back a week later. Before you could 

even prep the case, you had to make sure the “before” pictures 

turned out. That was crazy. But it’s instantaneous feedback 

now and, literally, any dental assistant can be taught to do it 

now. There are plenty of good classes like yours, and there are 

tutorials on YouTube. For all we know, we’re two years away 

from taking these pictures with our iPhone and then sending 

them to the laboratory. 

LB: Exactly. 

MD: As you do a lot of stuff with adhesive dentistry, I want 

to talk to you about self-etching adhesives. One of the things I 

noticed after I came out of LVI and started doing a lot of deep 

veneer preps using the total-etch technique was that I had more 

postoperative sensitivity than I cared to see. It always bothered 

me when a patient came in, completely asymptomatic, and we 

did 10 veneers on them, and now he had two teeth that were 

pretty hot for a few months and maybe one of them needed 

endo. That was always one of the things that disappointed 


me. I can’t blame the technique or the materials or myself. It 

was some combination of all three — I’m willing the take the 

blame. But when self-etching materials came out, it seemed like, 

by lowering the postoperative sensitivity potential, that it was 

going to be a step in the right direction, even if we didn’t have 

the same high bond strengths. I interviewed Dr. Jose-Luis Ruiz a 

few months ago, and he has gone fully self-etch for everything. 

He does not use total-etch anymore. So that’s one far end of 

the spectrum. I think over at the other far end of the spectrum 

are the dentists who just love total-etch and still use it all the 

time. Maybe they will use self-etch under a direct composite, 

or something like that. What has your experience been with 

self-etch adhesives, and where do you find yourself using 

them most? 

LB: I’m probably one of the folks in the middle. I was, for 

years, a total-etch fourth generation. I used to teach it as 

the gold standard. Technically, if you just want to look at 

brass tacks research numbers for bond strength, it’s still the 

gold standard. The challenge, for most people, is that it’s 

so technique sensitive that whether you talk about post-op 

sensitivity from the etching technique or marginal integrity 

because of the film thickness those generations of dentists 

use, the average general practitioner runs into trouble. 

So now we have three other generations of self-etching 

products and new total-etch products. 

What I use right now is what we call a “selective etching 

technique.” I actually use phosphoric acid and I etch only 

the enamel, and then I let it go for 25 seconds and I rinse it 

off and dry it. What do I avoid with that technique? I’m not 

worried about over-etching, which is having the phosphoric 

acid against the dentin for more than 15 seconds, or overdrying 

the dentin; these are the two big reasons why 

dentists have post-op sensitivity with phosphoric acid. Then 

I switch to a self-etching dentin adhesive. I apply it over 

all of the dentin surfaces — if I get it on the enamel, it’s 

not going to hurt anybody, and I use a self-etcher to do the 

dentin. Actually, I was recently reading up on some new 

research, and what folks are finding in the newer research 

with the newer generation of self-etchers, is that it actually 

gets higher bond strength than the old, fourth generation 

total-etch technique. 

I can’t imagine practicing without 

photography. For me, when I’m sending 

stuff to the laboratory, I actually need 

to go overboard and send too many 

photographs. This has made such a 

big difference for me as far as what 

I get back in shade matching. 

MD: Wow. Isn’t it ironic? When we graduated in 1988, I 

remember Ultradent, in addition to the etch they made, also 

made something to put on the dentin to identify it so we didn’t 

accidentally etch it. So now you’re talking about a technique 

that’s a great middle ground, with the ability to etch the enamel 

like that with selective etching, and then go in and do a selfetch 

on the dentin. It’s kind of the best of both worlds and really 

represents a step forward in terms of common sense for what 

we’ve been doing in adhesive dentistry. 

LB: I think so, too. It takes the stress off of worrying about 

the phosphoric acid, but it also takes the stress off of 


worrying that self-etchers don’t have the same bond strength 

to enamel. So you are getting the best of both worlds. It’s 

a technique I’ve been using now for almost a year, and it’s 

working really, really well. The other thing I like about it is 

I can do it for both direct and indirect. I can use the same 

technique, and that makes it easy as well. I’m fond of my 

new technique. 

MD: So tell me what you’re going to do on a deep, Class I 

posterior composite, something simple like that. 

LB: How deep? Am I worried about the pulp? Am I thinking 

pulp cap? 

MD: No. You’ve got 1.5 millimeters of remaining dentin. I just 

mean something that’s primarily bonding to dentin with an 

enamel rim around it. Are you doing your selective etching on 

those direct composites as well? 

Whether it’s a Class I, Class II or 

Class III composite, even a metal 

Class V composite, I do selective 

etching. I put phosphoric acid just on 

the enamel. One of the things about 

that is you have to play with your 

etchings because you want one that 

is very viscous. It can’t be runny, or it 

runs everywhere. 

LB: I am. I’m doing my selective etching on those. I have 

been doing adhesive dentistry for a lot of years, and I really 

don’t have a lot of reason in my practice to not trust dentin 

bonding. Even with that, I like preparations that have enamel 

margins, and I want to make sure I have a great bond to 

that enamel. So even with something like that, whether it’s a 

Class I, Class II or Class III composite, even a metal Class V 

composite, I do selective etching. I put phosphoric acid just 

on the enamel. One of the things about that is you have 

to play with your etchings because you want one that is 

very viscous. It can’t be runny, or it runs everywhere. I’m 

actually using the new Select HV Etch from Bisco, and I 

use it for that reason, because it’s very thick. But the other 

reason I love it is the tip on there is teeny-tiny, so you can 

get literally a band of phosphoric acid that’s no more than 

a millimeter wide. 

MD: Are you placing any kind of flowable in there as the base 

of that restoration? 

LB: You know, I’m not. The only place I use flowable in my 

direct composites is on Class II and Class III, and I just run 

a little bead of it at the marginal interface on the box. I only 

do that because we still know that there are issues with 

adequate condensation right down into the corners of those 

proximal boxes. I’m not using it as a liner. 

MD: Are you finding much use for self-etching resin cements? 

Walk me through what you might use for a PFM bridge; for an 

IPS e.max crown; and for a bonded, single-tooth restoration, 

an all-ceramic in the anterior. I’m curious to see if you’re 

finding much use for the self-etching resin cements. 

LB: I do use the self-etching, self-priming resin cement 

family. I use them when I want to cement; when I have a 

prep that has retention form and resistance form, so I’m 

not worried about the bonding being my retention, and I 

want something translucent. If I’m doing a PFM and I’ve got 


subgingival margins, I don’t need something translucent. 

I’ll probably go with a resin-modified glass ionomer. If I’m 

doing that PFM and I’ve got supragingival margins because 

I did a 360 porcelain butt joint, I’ll use a self-etching, selfpriming 

resin cement because I don’t want the white at the 

margins; I want the translucency of those resin cements. 

If I’m doing full-coverage or I’m doing BruxZir or I’m 

doing lithium disilicate, but my prep is such that I’ve got 

great retention form and great resistance form, I’ll use a 

self-etching, self-priming resin cement. Or, I might actually 

even bond and go to a true dual-cure resin cement, and that 

would more depend on isolation than it would the material. 

So if I’m going to have problems isolating and I need to get 

in and out quick and I want a true cement, I’m using a selfetching, 

self-priming. If I have great isolation and I really 

want to bond this, I’m going to go to something dual-cure 

in the posterior. In the anterior, I just use regular light-cure 

veneer cement. 

MD: Our dentists love brand names. Give me some examples of 

your favorite resin-modified glass ionomers. 

LB: Right now, my favorite resin-modified glass ionomer 

is RelyX Luting Plus (3M ESPE ), and I’ve actually been 

using that for years. I used that when it was Vitremer 

Luting Cement. They’ve just changed the name a few times 

over the years. So I am still using that. As far as my dualcure 

resin cement, right now I’m using NX3 Nexus ® Third 

Generation from Kerr, and I use that because one of the 

things you run into with dual-cure resin cements is you 

need to think about your dentin adhesive and make sure 

it’s compatible. Kerr’s new self-etching OptiBond XTR 

actually is cured by their NX3, so it turns it into a dual-cure 

dentin adhesive. I am a little old-fashioned because I still 

don’t cure dentin adhesives prior to indirect placement. 

MD: Oh, look at you. You’re bucking the trend! You are going 

old school. It makes sense, as long as you’re confident in your 

ability to cure that. I think that’s a good idea. 

LB: Exactly. So I’ll use the OptiBond XTR with the NX3. 

I also use Multilink ® Automix from Ivoclar. I use them 

interchangeably. When do I choose one versus the other? 

Part of it, for me, probably has to do with working time. 

If I’ve got a patient that’s really great, and I’m not worried 

about getting in and out, I’ll probably using NX3. Multilink, 

for me, sets so much faster. If I do need to get in and out 

and get it cured because I’m worried about patient isolation 

or something like that, I’ll go to Multilink. 

MD: I think that makes sense. 

LB: For anteriors, Variolink ® Veneer (Ivoclar Vivadent) is 

my preferred veneer cement. I also do keep RelyX Veneer 

Cement (3M ESPE ) in the office. The reason I keep the 

RelyX is because it’s more viscous. So if I think I need 

something to fill a bigger gap underneath, then I’ll use the 

RelyX. Especially with a 0.3 or 0.5 millimeter veneer, I like 

that the Variolink isn’t viscous; it doesn’t feel like you’re 

going to crack something when you seat it. 

MD: Exactly. I know doctors who actually use Herculite ® 

(Kerr) to seat veneers. And you know they’re prepping at least 

a millimeter to be able to push a veneer down and not have 

it crack with an actual composite resin underneath it, versus 

cement. So as I have gotten more conservative and our veneers 

have gotten thinner and thinner, I have gone to something 

that’s a little less viscous, where you feel like you can get it 

completely seated, move it around and really get it settled 

without feeling like you’re going to crack the veneer down the 

middle. That would obviously be a mess. 

Well, Lee Ann, I want to thank you so much for your time today. 

It’s been a fascinating look at how you got to where you are, 

and what you’re currently doing in your practice. I like that it 

all has a common sense ring to it. Even though you spent all 

the time that you have at these institutions of higher learning, 

it sounds like you still have that connection to what most of us 

are going through on a daily basis as we treat these patients. It 

doesn’t sound like you’re telling us to go in and do full-mouth 

equilibration on every patient who walks in the door, even if 

they are just there for a Class I composite. 

LB: No, I don’t do that. (laughs) 

MD: I like that. That’s what I like about you, that your approach 

is more common sense. That’s what really resonates with 

dentists. They need something that’s going to work for them in 

their practices and in the outside world, where they can still 

make a good living. But, like you said, they need to be able to be 

focused on not stepping into those huge potholes, where you’re 

prepping those lower second molars and things like that. That’s 

why I think your courses are so good, because they’re going to 

help dentists avoid those nightmare cases, the ones you never 

forget and make it hard to sleep at night. 

I’m going to recommend that our readers go to your website 

and see where you’re going to be next. If they can’t get out to 

one of your lectures, I hope they will look you up and find one 

of your webinars, so they can connect with you that way. 

Chairside readers: Please read Lee’s blog. It’s a fantastic blog; I 

read it all the time. She’s very dedicated to making sure she puts 

something up on a regular basis. In fact, I’m kind of jealous 

and wish I had the drive to be able to update something as often 

as she does. 

I appreciate what you do for our profession, Lee, and I 

appreciate you spending an hour with us. Thanks so much. 

LB: My pleasure. It’s always fun to talk with you. CM 

Dr. Lee Ann Brady is a privately practicing general dentist in Glendale, Ariz., and a 

nationally recognized educator and writer. Contact her at www.leeannbrady.com or 

lee@leeannbrady.com. 


– ARTICLE and CLINICAL PHOTOS by Carlos A. Boudet, DDS, DICOI 

After many years of sharing information with colleagues, I have noticed that 

the majority of dentists do not take the time to document their work — even 

the interesting cases — with photographic records. In today’s economic and 

business environment, it has become increasingly necessary to adequately 

promote your practice, and I consider taking photographs to be a very important 

part of that. 

With this article, I would like to introduce a simple, but effective way of 

documenting your cases with dental photography. Following these guidelines 

will help your practice in many ways. 

An Introduction to Dental Photography57

Photo Documentation 

Dental photography has two parts: intraoral and extraoral 

photography. Here are some basic tools you will need: 

1. A camera that allows you to take both full-face and profile 

pictures, as well as intraoral close-up shots. 

2. Two sets of intraoral photographic mirrors and two sets 

of retractors. There should be one occlusal mirror and 

one lateral mirror in each set. 

I have adopted a simple series of standard dental photographs 

to document my cases. I take one set of preoperative 

pictures, and I take another postoperative set to document 

the final results. Simple before-and-after pictures of your 

work can help patients visualize and accept the work they 

need done (Figs. 1, 2). If I think I might make a presentation 

of the case, I take additional photos of the procedural steps. 

1 

Figure 1: Documenting treatments with high-quality “before” images 

is important. 

Standard Photos 

The required views for clinical case submission to the 

American Academy of Cosmetic Dentistry are 12 preoperative 

views and 12 postoperative views. My standard set of 

photographs consists of the following: 

1. Three extraoral photos: Two frontal views of the face 

(one in repose and one smiling) and one profile shot 

2. Five intraoral photos: Five retracted views, including 

an anterior view, a right view and a left view, and two 

mirror occlusal shots (one of the mandible and one of 

the maxilla) 

3. For cosmetic cases, an anterior retracted view with the 

teeth apart is very helpful. This makes for six intraoral 

photos instead of five. 

2 

Figure 2: This “after” photograph shows just how well the case was 

completed. 

Camera Choices 

Now let’s talk about cameras. Undoubtedly, the best camera 

system is an SLR digital camera like a Canon T3i or a Nikon 

D90, with a dedicated 100 mm macro lens and a ring flash. 

In this basic tutorial, however, we use a point-and-shoot 

camera. It’s simpler to use because there are no settings to 

change and focusing is automatic. This simple system was 

chosen because of the different levels of expertise exhibited 

by the dentists attending our courses, as well as the need 

for a camera that could take the use and abuse. 

We chose the Pentax Optio W90 for its simple-to-use 

instructions, as well as for its shockproof and waterproof 

characteristics. This 12-megapixel camera allows you to 

take great face shots and intraoral views without changing 

settings on the camera. 

3 

Figure 3: With the chair completely horizontal, you can take the 

maxillary and mandibular occlusal mirror views. 


Patient Positioning 

You can take the necessary pictures with the chair in two 

positions: completely horizontal and at 45 degrees from 

horizontal (Figs. 3, 4). With the chair at an inclination of 

about 45 degrees, you can take the anterior, right and left 

retracted views, as well as the three headshots. For nicer 

looking pictures, you can take the three headshots with the 

patient standing in front of a contrasting background. 

Tips for Better Photos 

• Standardize the photographs by taking them at the same 

distance from the subject every time. That way, it will be 

easier to compare “before” and “after” shots. 

• Do not change the “P” or program mode in the Pentax 

Optio W90. This will standardize your exposure settings 

because the camera’s default setting will adjust the focus 

and the exposure for you automatically, and the lighting 

should not change in the operatory. 

4 

Figure 4: With the chair inclined at about 45 degrees, you can 

take the anterior, right and left retracted views, as well as the three 

headshots. 

• Proper positioning of the camera avoids the errors associated 

with canting and taking the shots at angles that are 

“too high” or “too low.” 

• Reposition the patient’s head slightly instead of leaning 

over the patient. 

• For better headshot photographs, use a background. Do 

not place the patient too close to the background as this 

can create shadows. 

• Try to take the occlusal views looking down the incisal 

edges of the anteriors. 

5a 5b 5c 

Figures 5a–5c: The three headshots (full-face resting, profile and 

full-face smiling) 

• Use the interpupillary line and the vertical midline to 

orient the camera. 

• Finally, try to remove anything that would make the 

picture look bad, such as excess saliva, blood and food. 

The full-face shots should be at about a 1:10 magnification, 

while all the other frontal, lateral and occlusal retracted 

views should be at a 1:2 magnification. When you are taking 

headshots with the Optio W90 camera, be sure to place 

the camera about five feet from the patient’s face and zoom 

in or out to frame the patient’s head on the screen. For 

the intraoral shots, the retracted frontal and lateral views 

should be taken about one foot away from the patient’s 

face at maximum optical zoom, and about two feet away for 

the occlusals. 

Figures 5a–9b illustrate the series of standard photographs 

previously described: 

6a 

6b 

Figures 6a, 6b: The two occlusal shots of the maxilla and the 

mandible 

An Introduction to Dental Photography59

Photo Editing 

A photo editing program is a very useful tool when working 

with digital pictures. There are a lot of good ones on the 

market, from free applications such as GIMP, Picasa and 

Photoscape, to those geared toward the professional such 

as Adobe Photoshop. Other programs include Adobe 

Photoshop Lightroom, Adobe Photoshop Elements, Corel 

PaintShop Pro and ArcSoft PhotoStudio. 

7a 

These programs will let you tweak your photos by cropping, 

rotating and adjusting exposure so they look great, 

even if you are not the greatest photographer. As a final 

note, make sure that your patients sign a simple photography 

release form that gives you permission to show their 

pictures. 

This brief tutorial was written in the hope that it will 

encourage more dentists to document their cases with 

photography. This will increase your cosmetic and implant 

case acceptance, and lead to patients inquiring about having 

you do their dental work. It will also benefit your marketing 

efforts, while making you a more humble and better dentist 

in the process. CM 

7b 

Figures 7a, 7b: The right and left lateral retracted views 

Dr. Carlos Boudet is in private practice in West Palm Beach, Fla. Contact him at 

www.boudetdds.com or 561-968-6022. 

General References 

• Goldstein MB. Digital photography update: 2011. Dent Today. 2011 May; 

138-142. 

• American Academy of Cosmetic Dentistry. Photographic documentation and 

evaluation in cosmetic dentistry: a guide to accreditation photography. 

• Maher R. Practical dental photography & high tech case presentation. 2005. 

8 

Figure 8: The anterior view 

• Soileau T. Dental digital photography columns. Dent Econ. 

• Terry DA, Snow SR, McLaren EA. Contemporary dental photography: selection 

and application. Compend Contin Educ Dent. 2008 Oct;29(8). 

• Bengel W. Mastering digital dental photography. 1st ed. Quintessence. Berlin, 

Germany. 2006. 

9a 

9b 

Figures 9a, 9b: The 1:1 views are reserved for case documentation, 

such as when you want to show one to three teeth in the picture, as 

in a step-by-step documentation of a case. 


BIOLOGIC SHAPING 

An Alternative to Extracting a 

Tooth with a Severe Fracture 


Daniel J. Melker, DDS 

When a cusp of a tooth is fractured subgingivally 

approximating the bone, extraction is a commonly 

considered treatment, due to concern about the significant 

bone removal required by other procedures to create 

space for the biologic width. That being said, addressing 

this primary concern of removing bone to create space for 

the biologic width presents the alternative procedure of 

biologic shaping. 

The premise for traditional crown lengthening to preserve 

a fractured tooth is that the surgeon must remove enough 

bone, starting from the most apical portion of the fracture, 

to create space for the biologic width. This method can 

result in a significant loss of bone, tooth mobility and, if 

the fracture is located near the furcation, a compromised 

furcation area. 

Biologic shaping offers an alternative to conventional crown 

lengthening through removal of the fractured portion of the 

tooth, allowing for a new biologic width to reform without 

significant removal of bone. The case presented here 

illustrates this technique. 


CASE EXAMPLE 

Figure 1: Provisional crown placed after the buccal cusps of tooth 

#30 fractured approximating the bone 

Figure 2: Removal of provisional crown to access the fractured tooth 

surface 

Figure 3: Reflected tissue verifying location of fracture into the 

furcation and approximating the bone 

Figure 4: Removal of fractured tooth surface using a coarse 

diamond bur 

Biologic Shaping: An Alternative to Extracting a Tooth with a Severe Fracture63

Figure 5: Smoothing the tooth’s surface using a superfine diamond 

bur (40 microns) to completely remove the old fractured portion of 

the tooth surface 

Figure 6: Smoothing the root surface creates a parabolic architecture 

to mimic the soft tissue contours, allowing for a new biologic width to 

reestablish without having to significantly alter the bone. 

CONCLUSION 

When performing traditional crown lengthening for a 

fractured tooth, the potential need to remove excessive bone 

to create space for the biologic width is cause for concern. 

Conventional thinking is to locate the apical location of 

the fracture and start removing bone from that point. With 

biologic shaping, however, the fractured portion of the 

tooth is removed first to preserve as much bone as possible. 

This conservative procedure can avoid excessive removal 

of bone and help preserve bone in the furcation area, 

leading to long-term stability and a successful restorative 

outcome. CM 

Figure 7: After 12 weeks of healing and the establishment of the 

biologic width, a new crown was placed just coronal to the gingival 

collar. Notice that the location of the new margin is in perfect harmony 

with the adjacent teeth. 

Dr. Daniel Melker is in private practice in Clearwater, Fla., and lectures nationwide 

on periodontics. Contact him at 727-725-0100. 


Figures in Dentistry Spotlight: 

• Doc Holliday • 

– ARTICLE by Michael C. DiTolla, DDS, FAGD 

and Megan Strong 

onsidering the incredible 

fear surrounding 

extractions, root canals 

and dental work in general, 

being known as “history’s most 

fearsome dentist” wouldn’t exactly 

bode well for one’s private practice. You 

get the feeling that his reviews on Yelp 

would have been less than stellar, and that 

word-of-mouth referrals would be few and far 

between. As a dentist in a time when any dental 

procedure seemed like something out of a nightmare, 

Dr. John Henry “Doc” Holliday was a man unafraid of 

blood, guts and violence. Doc spent his short but historically 

eventful life roaming the dusty trail in search of 

danger, fortune and caries. 

Born in Georgia to a wealthy family, Doc came into this 

world on Aug. 14, 1851. After losing both his mother and 

adopted brother to tuberculosis, 

Doc went on to attend the 

Pennsylvania College of Dental 

Surgery, which his cousin, Robert 

Holliday, founded. He graduated in 1872 

with a thesis titled “Diseases of the Teeth.” 

The next time you feel like complaining about 

how difficult state boards were, consider yourself 

lucky that you didn’t have to write a thesis. Or even 

read a thesis, for that matter. 

Shortly after graduating with a dental degree, Doc began 

work as a dentist in the office of Dr. Arthur C. Ford in 

Atlanta, Ga. It wasn’t long after starting his practice that 

he came down with tuberculosis, the same disease that 

claimed his mother and brother. Thinking the drier climate 

of the Wild, Wild West would be better for his health, he 

headed to the other side of the country. 

Figures in Dentistry Spotlight65

Doc moved to Dallas, Texas, and quickly picked up his 

instruments again as he started work with Dr. John A. 

Seeger. However, his dental career came to a screeching 

halt as the coughing spells from his disease began to scare 

patients away. Even though universal precautions wouldn’t 

be adopted for another 100 years or so, these patients had 

the good sense not to let someone with active tuberculosis 

cough into their open mouth. Doc Holliday was forced to 

find another way to earn a living. 

Naturally, he did what any dentist would do and turned 

to a career in gambling. An intelligent man, Doc was a 

successful gambler. Doc was made miserable, however, by 

the knowledge of his impending death. Moody, a heavy 

drinker and with no fear of death, he perhaps was more 

prone to the life he came to lead. 

Knowing he had to protect himself, given his dangerous 

occupation and his disease-weakened body, he began to 

train with a six-shooter. He quickly gained a reputation as 

word of this nearly 6-foot-tall, gun-slingin’ dentist spread 

like wildfire. After his first accounted gunfight on Jan. 2, 

1875, when Doc and a local saloonkeeper had a disagreement 

that quickly turned violent, Doc became increasingly 

fearless and dangerous. While several shots were fired, neither 

Doc nor the saloonkeeper was struck and both men 

were arrested, reported the Dallas Weekly Herald. Initially, 

the locals thought the gunfight was amusing, until just a 

few days later when Doc got into another disagreement, 

this time killing a prominent citizen with two aimed bullets. 

Only Wyatt Earp strolled out of it unharmed. Despite the 

name, the gunfight actually went down six doors west of 

the rear entrance to the O.K. Corral, as well as in the middle 

of the street. Shots were fired, and bullets flew for about 

30 seconds. Ike Clanton filed murder charges against the 

Earp brothers and Doc, but they were all acquitted. 

Doc was a nomadic creature, moving from one town to the 

next, staying only long enough to win some money at the 

table and put someone in their place. Dodging any serious 

jail time, Doc continued his wild rampage engaging in 

infamous showdowns and run-ins with the law, only to be 

eventually taken down not by a gun, but by his tuberculosis. 

When his health began to rapidly deteriorate in 1887, he 

headed to Glenwood Springs, Colo., in hopes that the 

natural hot springs there would improve his condition. 

Unfortunately, he did not recover, and a few months later, 

died at the age of 36. As the story goes, Doc always figured 

he would be killed with his boots on, so when he found 

himself barefoot on his deathbed, he asked for a glass of 

whiskey and drank it down. Then, looking at his feet, said, 

“This is funny,” and died. CM 

Fleeing Dallas, Doc moved to Jacksboro, Texas, where he 

found a job dealing Faro, a notoriously crooked French 

card game. He had become an expert shot, and quickly got 

caught up in some more wild shenanigans. Even though he 

left one man dead in the dust in a series of gunfights, no 

legal action was taken against him. However, his luck turned 

in the summer of 1876, when Doc killed a soldier, bringing 

the U.S. government into the matter. A reward went out for 

his capture, and the Army, Texas Rangers, U.S. Marshalls, 

local lawmen and ordinary residents all pursued him. 

To escape his inevitable demise if captured, Doc fled to 

the Kansas Territory (present-day Colorado), making stops 

along the way, where he left three more dead bodies in his 

wake. From there, Doc engaged in numerous shoot-outs 

and brawls, making friends and enemies along the way. 

Most notably, he gained the friendship of Wyatt Earp and 

his brothers, who were by his side fighting in the famous 

gunfight at the O.K. Corral in Tombstone, Ariz. 

On Oct. 26, 1881, outlaw cowboys Billy Clanton, Tom 

McLaury and his brother Frank McLaury battled it out 

against the Earp brothers (Wyatt, Virgil and Morgan) and 

Doc Holliday. Cowboys Ike Clanton and Billy Clairborne ran 

from the fight, but Billy Clanton and both McLaurys were 

killed. Doc and Morgan and Virgil Earp were wounded. 


Congratulations, Chairside ® PHOT 

A 

Hunt Winners! 

This must have been the most 

challenging Chairside Photo 

Hunt yet because not one set 

of your trained eyes found all 

27 differences. Based on your 

submissions, the toughest to 

find were the three differences 

circled in green. I guess we 

outdid ourselves this time! 

To reward your efforts, we 

decided to grade this contest 

on a curve and award the 

usual first-, second- and thirdplace 

prizes to those of you 

with the strongest results. 

• First-place winners: 

21 dentists will receive 

$500 in lab credit each. 

• Second-place winners: 



B 

• Third-place winners: 



If you need a suggestion for 

using your lab credit, you 

might consider prescribing 

BruxZir ® Solid Zirconia for 

your next crown or bridge 

case. As durable as ever, this 

monolithic zirconia restoration 

is now more esthetic for use 

in the anterior. What’s more, 

we consistently hear from 

dentists that the margins on 

their BruxZir crowns & bridges 

feel better to their explorer 

than those on the PFMs they 

used to prescribe. 

Chairside Photo Hunt Contest entries 

were individually scored after being 

sent to the lab via e-mail and standard 

mail. Prizewinners were notified by 

standard mail and/or phone. In total, 

113 prizes were awarded. 

Contest Results67

The Chairside® PHOT Hunt 

This photo was taken during one of 

the continuing education courses 

I give on digital intraoral scanning 

at the Glidewell International Technology 

Center. My assistant and I 

are demonstrating how to use various 

digital impression systems on 

a live patient. 

How many differences between the 

two pictures can you find? Circle 

the differences on version B below. 

Then, write down how many differences 

you found, tear out this page 

and send it to: 


Attn: Chairside magazine 

4141 MacArthur Blvd. 

Newport Beach, CA 92660 

Or scan your entry and e-mail it to 

chairside@glidewelldental.com. 

A 

Due to legibility issues, faxed entries 

will not be accepted. One 

entry per office. Participation grants 

Chairside magazine permission to 

print your name in a future issue or 

on its website. 

The winner of the Vol. 7, Issue 2, 

Chairside Photo Hunt Contest will 

receive $500 in Glidewell credit 

or a $500 credit toward his or her 

account. The second- and thirdplace 

winners will each receive 

$100 in Glidewell credit or a $100 

credit toward their account. 

B 

Entries must be received by 

July 6, 2012. The results will be 

announced in the summer issue of 

Chairside magazine. 

______________________________ 

Name 

____________________________ 

City, State of Practice 

____________________________ 

Phone 

Total Found:________

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