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INSIDE THIS ISSUE: A special CE course about negotiating lease renewals

March 2018 real dentistry for real dentists »

real dentistry for real dentists March 2018

Dr. John O. Burgess explains what it is,
how to use it, and which one goes where
p. 62


Get the scoop on 30+ A contemporary approach 11 things to consider
new/improved items by Drs. Andonis Terezides before you recommit
p. 89 and Sundeep Rawal p. 54 p. 102
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In This

12 | Howard Speaks 62 | ALL ABOUT 89 | SPRING PRODUCT
Education Update
22 Howard Farran, founder of
Dr. John O. Burgess explains
the differences between
Dentaltown introduces more
than 30 new and redesigned
Live CE Events: Dentaltown magazine, shares zirconia materials, and when products and services that
Travel and Learn the importance of discussing each should be used. recently have launched in the
fi nances with patients and dental market.

how dentists can get their
current customers to buy more.

Industry News

26 16 | Professional Courtesy
Dr. Thomas Giacobbi, Dentaltown editorial director, shares the importance of building goodwill in
the dental practice.

30 | Show Your Work


Dr. Matthew F. Bickel walks readers through a recent two-implant sinus lift.


Drs. Andonis Terezides and Sundeep Rawal share their concept for fi xed mandibu-
lar full-arch rehabilitation.


Dr. Bryan Laskin discusses intraoffice communication and capabilities that

doctors should consider if they’re looking to change up their practice management

BOTTOM LINE Need more Dentaltown? Don’t miss the opportunity to have the most
DENTALTOWN.COM clinical and business-savvy information at the touch of your fingertips.

4 MARCH 2018 //

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In This

Product Profile: 82 | INFORMATION, PLEASE

Voco Grandio Blocs Dentaltown’s special projects editor, John Lannon, exam-
ines the technologies and approaches being introduced

53 at at Columbia University College of Dental Medicine’s

Center for Precision Dental Medicine—wireless tracking
Product Profile: on instruments, the dental chair as data collection hub, and “deep data mining” for oral
Designs for Vision precision medicine. How—and how soon—will this show up in everyone’s practice?
High Definition
Imaging 102 | Continuing Education

88 eff randfield and Dale illerton of The Lease oach discuss the dos and don ts of
renewing a lease for your dental practice.
Ad Index

Dentally Incorrect



MONEY/TIME WHILE 42 An oral surgeon shares a
case that illustrates the
MAINTAINING OR importance of performing
INCREASING QUALITY thorough checks for head
This con ersation be an in and neck cancer.
and continues today Townies
sound off about the changes

they’ve been pleased to make.
A Townie looks for tips on a
molar extraction.

2018 Farran Media LLC. All rights reserved. Printed in the USA.

No article appearing in Dentaltown may be reproduced in any manner or format without the express written permission of Farran Media. message board content is owned solely by Farran Media and may not be reproduced in any manner or format without its express written consent.
Farran Media makes reasonable effort to report clinical information and manufacturer’s product news accurately, but does not assume and disclaims any responsibility
for typographical errors, accuracy, completeness or validity of product claims. Neither Farran Media nor the publishers assume responsibility for product names, claims, or
statements made by contributors, in message board posts, or by advertisers. Opinions or interpretations expressed by authors are their own and do not necessarily reflect
those of Farran Media, or the publishers.
The “Townie Poll” is a voluntary survey and is not scientifically projectable to any other population. Surveys are presented to give participants an opportunity to
share their opinions on particular topics of interest.
Letters: Whether you want to contradict, compliment, confirm or complain about what you have read in our pages, we want to hear from you. Email: or hop online at

Dentaltown (ISSN 1555-404X) is published monthly on a controlled/complimentary basis by Farran Media LLC, 9633 S. 48th St., Suite 200, Phoenix, AZ 85044. Tel. (480) 598-0001. Fax (480) 598-3450.
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6 MARCH 2018 //

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Editorial Director
Thomas Giacobbi, DDS, FAGD
Clinical Director
Timothy Burke, DMD
Editor and Creative Director
Sam Mittelsteadt •
Associate Editor Dr. Cari Callaway-Nelson Dr. Joshua Halderman Dr. Donald Roman
Kyle Patton • Las Vegas, Nevada Galloway, Ohio Hackensack, New Jersey
Assistant Editor
Arselia Gales •
Special Projects Editor
John Lannon •
Graphic Designers
Ed Younkin •
Anthony Grazetti •
Sales Director
Mary Lou Botto •
Dr. Doug Carlsen Dr. David Harnick Dr. Timothy Tishler
National Sales Manager
Denver, Colorado Albuquerque, New Mexico Green Bay, Wisconsin
Stephan Kessler •
National Account Manager
Tom Delaney •
Regional Sales Manager
Benjamin Lund •
Executive Sales Assistant
Leah Harris •
Traffic Coordinator
Tanya Anderson •
Circulation Director Dr. Seth Gibree Dr. Michael Kelliher Dr. David A. Wank
Marcie Donavon • Cumming, Georgia Longmeadow, Massachusetts New York, New York
Circulation Assistant
Macy Gross •
Live Events CE Director
Jason Luchtefeld, DMD, KOS
Events Director
Marie Leland •
Events and Tradeshow Coordinator
Kami Sifuentes • Dr. Barry Glassman Timothy Lott, CPA/CVA Dr. Fayette Williams
Marketing and Brand Manager Allentown, Pennsylvania Hunt Valley, Maryland Weatherford, Texas
Chris Bailey •
Marketing Coordinator
Juliann Yungkans •
Director of Continuing Education
and Message Board Manager
Howard M. Goldstein, DMD
I.T. Director
Ken Scott •
Internet Application Developers Dr. Cory Glenn Dr. Jeanette MacLean Jason P. Wood, atty.
Nick Avaneas • Winchester, Tennessee Glendale, Arizona Mission Viejo, California
Angie Fletchall •
Jake Reed •
Mobile Application Developer
Larry Bridges •
Member Services Specialist
Sally Gross •
Multimedia Developer
Devon Kraemer •
Digital Media Developer Dr. Tim Goodheart Dr. John Nosti
Brian Morales •
Dr. Josh Wren
Raytown, Missouri Mays Landing, New Jersey Brandon, Mississippi
Howard Farran, DDS, MBA
Lorie Xelowski •
Stacie Holub •
Receivables Specialist
Suzette Robles •
Seminar Coordinator Dr. Brian Gurinsky Dr. Jay Reznick Rick Zieska
Rebecca Parent • Denver, Colorado Tarzana, California Minneapolis, Minnesota

8 MARCH 2018 //

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What you can find on ...

So you read the magazine, but did you know we also have an active online community?
The magazine is just a part of what we do at Dentaltown. Visit for an ongoing conversation about
everything from tough cases to staff issues to who’s going to win the NBA Finals this season. Join the discussion!

Message Boards
New Giant Practice Down the Street! Panic Level?
Just two years into practice, this doc learns that a new practice is opening
up a half a mile down the street. How should this Townie prepare?

Giant Practice

I Sectioned a Maxillary Molar for the First Time

Download the App Moving out of his comfort zone, this doc goes after his first maxillary molar. Now
he has questions on the best methods for sectioning. Read what Townies suggest.
You can keep tabs on the most active
message boards without ever sitting down Maxillary Molar
at your computer. The Dentaltown app is free
to download and is available for both Apple
and Android devices.

Case Presentation
Losing Bone
Why Am I Losing Bone Here?
A doc second-guesses himself after an
implant shows signs of failure. Townies
weigh in on what could have gone wrong.

Online CE
Connect with Us
Composite Bridges the “dkdocterry” Way by Dr. Terry Shaw
Anterior missing teeth can be a conundrum. Do you do a Maryland Bridge,
a flipper partial, implant or conventional fixed bridge? For the past 25 years
Receive Dentaltown e-Newsletters Shaw has been doing composite bridges with excellent success. This course
reviews how composite bridges are a great solution for post-ortho patients
missing anterior teeth until they’re are old enough for implants, seniors on a
limited budget, and other patients.

10 MARCH 2018 //

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howard speaks

Getting More Out of Dentistry

A practice’s success relies on your ambitions

As I mentioned last month, there are only Get comfortable talking

three ways to increase your dental business: about finances
Acquire new patients, upsell a current customer, A lot of dentists, physicians and lawyers
or get your current customers to buy more are not hard-wired to talk about money. You
frequently. also weren’t hard-wired for calculus or physics
This month, we’ll focus on the third or geometry—and how did you ever find out
option—specifically, why it’s so important the ATP result of a Krebs cycle?—but
that you and your staff are able you learned it. You’ve got to be
to discuss money with cus- able to talk money—your
tomers—and the mindset treatment coordinator, yes,
required to make that but you as well.
happen. You must be able to
I’m a firm believer sit next to a patient and
that 2 out of 3 people say, “This tooth needs
will accept a treatment a root canal, buildup
plan if it’s reasonable. and crown, and that’s
I don’t believe in that about two grand, but
old concept of “save teeth you’ve got a lot going on
at any cost.” I’ve seen a lot here. I need to know what
of patients get burned out of your budget would be, because
dentistry by that adage: They come in I don’t want to spend $2,000 on one
with 14 cavities, one tooth’s in pain, they’re tooth when you have 10 others that also need
hurting financially, and the dentist wants help. That could have been the money that fixed
them to pay $2,000 for a root canal, buildup 10 cavities that next year could’ve all turned
and crown. Their dental budget for the year into root canals. What is your budget—and
is gone, to treat that single tooth, and when more importantly, if you can tell us what kind
they return the following year, the same thing of monthly payment you could make, we could
has happened to another tooth, and additional go to our outside finance people and see how
ones also are hopeless and need to be extracted. much money we have to work with. We might
The people who sell the most dentistry get be able to fi x all the teeth.”
a sense of what’s going on with a patient. If
their budget is only $2,000, I’m not going to A lack of ambition holds you back
spend it on a root canal, buildup and crown Ninety-five percent of dentists won’t do
on a molar, if that $2,000 could have fi xed 10 a full-mouth rehab this year. Meanwhile,
other cavities and prevented future damage. 5 percent of dentists in the U.S. do a full-mouth

Spread the news about Dentaltown!

Dentaltown owes its success to registered Townies who engage
on forums and message boards, contribute articles for publication,
and share articles and columns via social media. Log in today at to get started.

by Howard Farran, DDS, MBA, publisher, Dentaltown magazine

12 MARCH 2018 //

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howard speaks

rehab not just once a year, but once a month. full-mouth rehab costs about as much as a new
They have $2 million, $3 million, $4 million car—and in 2016 Americans bought more than
practices, located in the same medical/dental 17.5 million new cars, at an average cost of
building as those other dentists who’ll never more than $35,000. If you tell me there’s no
do a $35,000 case in their life. money in your community, I’ll walk out into
If you have a PPO-only practice and your parking lot and say, “So how did these
say, “Everybody’s only going to take what people buy all these cars?” America has money!
the insurance pays in the yearly max,” your When I see dentists who are on PPO
lack of success is a mind game. If you believe treadmills, working in dental factories, it
that, I can’t change your mind—but I can looks like they’re running up a mudslide.
call you on your own hooey. The average They’re not getting anywhere, doing fillings
all day long and barely breaking even, and
doing cleanings for a loss. The energy just
drains out of them.
See Howard Live! It’s time to crank it up a notch
Howard Farran, DDS, MBA, is an international speaker who
I want to talk about energy. The older I get
has written books and dozens of articles. To schedule Howard
and the more practices I observe, I’ve realized
to speak at your next national, state or local dental meeting,
email that people who work fewer hours are usually
more productive, because they’re going faster

2018 and getting more done. They crank it out.

Think about your pacing: If I ask you
to run 100 meters, you’ll run as fast as you
can and do it in 10–13 seconds. But if I ask
MARCH Brace Place Orthodontics you to run a mile, your speed will be totally
7 New Jersey different … and if I ask you to run a marathon
(26.2 miles)? That’s just, like, fancy walking.
If I set your work hours at 8 a.m. to 5 p.m.
Monday through Friday, and a half-day on
APRIL Townie Meeting Saturday, you’d pace yourself as if you’re
13 Orlando, Florida running a five- or six-hour marathon. If I
said you’d work 8 a.m. to 5 p.m. Monday
through Thursday, with lunch from noon to
1 p.m., you’d probably pace yourself more
APRIL Oklahoma Dental Association like running a 5K.
20 Oklahoma City When I hear dentists say, “We’re going
to crank out six hours of dentistry per day,”
everybody there is doing the 100-meter dash.
And if they’re working 5½ days a week, most
MAY Riverside/Corona Study Club of them could come in and do in two hours
15 Riverside, California what a typical dentist does all day Friday
and Saturday.
So, get focused! Get motivated! Start
selling! Are you still looking for a New Year’s
JUNE Wyoming Dental Assocation resolution? I want you to sell the dental equiv-
15 Jackson Hole, Wyoming alent of one of those 17 million new cars
in America. Somebody is doing it in your
ZIP code, your county, in your state, every
month—it’s your turn! ■

14 MARCH 2018 //

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professional courtesy

Goodwill Hunting
L.L. Bean is one of the greatest retail companies a crown that fell off after six months would not be
of all time. Even if its “woodsy Maine” style doesn’t fit unreasonable. Every procedure we complete has some
in your closet, you have to respect the company’s total expectation for success. How you handle a case that
commitment to customer satisfaction. The company did not meet your expectations or the patient’s will
had an unconditional satisfaction guarantee have a huge impact on the growth of goodwill.
in place for more than 100 years with a When you have to redo a procedure, it’s an
lifetime return policy. The founder, opportunity to learn a valuable lesson
Leon Leonwood Bean, launched the the same way L.L. did more than a
policy when the majority of his first century ago.
batch of hunting shoes fell apart. Growing goodwill in your
Bean not only fixed the boots but practice is not just about pro-
also refunded each customer. viding a warranty or standing
This move generated tremendous by the quality of your work; it
goodwill with customers and led can be as simple as staying on
to a better boot the second time schedule, calling patients after
around. treatment or sending a thank-you
Recently, L.L. Bean announced an note for a referral. A happy dental
end to this generous return policy, because team will keep your patients happy, and
of growing fraud. Over the past five years the happy patients will give some goodwill back to
company lost more than $250 million to items returned you with a positive review. Building this intangible
in such poor quality they could only be sent to a landfill. goodwill adds value to your practice and ensures that
How did they lose a quarter of a billion dollars in just you will have loyal patients. It is a well-known fact that
five years? Some people took advantage of the company retaining your existing patients is less expensive than
by returning items they purchased at a thrift store or replacing them with new patients. You can then grow
found in their attic decades after purchase. Others your practice with referrals from your happy patients.
would treat the policy as an annual opportunity to trade This added value is important when it’s time to sell
their purchase for the latest model. Now, shoppers will your practice.
have just one year from the time of purchase to make a I don’t want to overstate the financial value of your
return. It was only a matter of days before an individual goodwill when you retire, but I will say that having
claiming to be “a loyal customer” filed a lawsuit. Last goodwill in your practice can make it much easier to
time I checked, loyal customers wouldn’t want their get up and go to work in the morning. There will also
favorite store to go out of business because buffoons are be times when you need to spend some of that goodwill,
taking advantage of their generosity. I digress. such as when your schedule is running behind, a lab
Getting back to the business of case is delayed or a tooth is sensitive after it was filled.
dentistry, this story begs the question: Therefore, my best advice is to pay attention to the
How do you generate goodwill with many ways you can grow the goodwill balance in your
the patients in your practice? Whether practice. Spend it wisely and be sure you have some left
you realize it or not, goodwill is in the account when you sell your practice.
something you should be generating Please feel free to comment on this article online
every day. A lifetime warranty on a at You can follow me on Twitter
crown would be absurd, but replacing @ddsTom and email me at ■

by Thomas Giacobbi, DDS, FAGD, editorial director, Dentaltown magazine

16 MARCH 2018 //

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CE update

What’s New in Continuing Education?

March is here, and spring is a time of renewal for all of us. So, let’s renew our knowledge of
dentistry and check out the CE offerings recently released on Dentaltown.

The Townie Meeting 2017 Series your dental office. Pulp therapy and stainless
The Townie Meeting 2017 series contains steel crowns are often considered complex when
13 courses from the meeting’s excellent performed on pediatric patients; this course will
speakers, including Drs. Cory Glenn, David alleviate any fear of the unknown that leads
Hornbrook, Art Volker, Bruce Baird, Anne to this misconception. Indirect pulp therapy,
Koch, Tarun Agarwal, Mark Murphy, Steve pulpotomy and pulpectomy are discussed,
Rasner and Mac Lee. You can also enjoy with emphasis on diagnosis and technique.
courses from Vicki McManus, Fred Joyal, The procedural steps for stainless steel crowns
Paul Edwards and Joleen Jackson. Together, are explained and shown, as well as Wren’s
these courses provide 25 hours of excellent process for using nitrous oxide, appropriate
education in both clinical dentistry and topical anesthesia and local anesthesia.
practice management.
Everyone who attended Townie Meeting Improving Case Acceptance
2017 can access these courses for free. If you by Dr. Mark Murphy
missed the meeting, don’t worry: It’s only $295 Helping patients want what we know they
to receive these 25 hours of CE credits. (But need drives the economic and reward engines
be sure to sign up for Townie Meeting 2018!) of our practices. Help patients have better
health, do more of the dentistry that fulfills
Dental Implants: Tips and Tricks and stimulates you, and be more successful
by Dr. Cory Glenn in your practice. This course demonstrates
Dental implants are a reliable option to how to improve the educational value of the
replace missing teeth, but at times can seem examination experience and how to overcome
unnecessarily complex and cost-prohibitive. the “insurance entitlement” behavior that
By utilizing some simple techniques such as patients often exhibit.
model-based guides, and learning basic implant
lab work, clinicians can make many cases more Composite Full-Mouth
predictable and profitable. Rehabilitations
the “dkdocterry” Way
Pediatric Dentistry: by Dr. Terry Shaw
Anesthesia, Pulp Therapy For the past 25 years, Shaw
and Stainless Steel Crowns  has been doing composite bridges with excellent
by Dr. Josh Wren success. Bridges provide a great solution for
When the Affordable Care Act mandated post-ortho missing anterior teeth until the
dental coverage as an essential health care benefit patient is old enough for an implant, seniors on
for those 19 and younger, millions of pediatric a limited budget, or a fast solution for someone
patients were added to 150,000 dental practices. waiting for bone healing and remodeling before
Treating children likely became a necessity for more definitive treatment.

by Howard M. Goldstein, DMD, director of continuing education, Dentaltown magazine

18 MARCH 2018 //

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CE update

Full-Arch Implant Supported Zirconia help manage dental caries. This course will present indications
by Pinhas Adar and Dr. John Heimke for these materials, including using them as liners, bases, sealants
Implant-supported hybrid appliances have proven to be an and restorations for root caries and noncarious cervical lesions.
exceptional and highly specialized treatment option for patients Differences between traditional glass ionomers and resin-modified
with non-restorable teeth or existing edentulism. This presentation glass ionomers will be discussed.
will stress the importance of treatment planning, CAD/CAM
technology and the need for the laboratory technician’s human Next Level Endodontics:
touch. Surgical aspects, provisionals during healing, management The Expanding Role of Vital Pulp Therapy
of soft tissues and the protocol for final fabrication are discussed. by Dr. Martin Trope
New knowledge and materials may allow us more predictability
Silver Is the New Black: Improving Your Practice in vital pulp therapy in cariously exposed teeth. This course proposes
with Silver Diamine Fluoride  a protocol for the treatment of carious exposures that expands vital
by Dr. Jeanette MacLean pulp therapy in the endodontic treatment of vital teeth.
Silver diamine fluoride is a revolutionary approach to combating
caries in an effective and noninvasive manner. Discover the history Fundamentals of Fixed Prosthodontics
and science behind this powerful oral medicine that recently received by Dr. Lane Ochi
the prestigious FDA “breakthrough therapy” designation and learn Successfully treating patients with fixed prosthodontics requires
how to successfully incorporate this caries management treatment a mastery of materials and mechanical concepts, as well as a respect
into your clinical practice today, including restorative options. for tooth structure. We need to be aware of the interactions between
preparation design, margin configuration, core buildups or posts,
The Top 10 List for an Emergency Kit: and the luting agent. After viewing this course, you’ll be able to
Color Coding identify the causes of failures and prevent them from recurring.
by Dr. Daniel Pompa
This course describes the essential drugs needed Avoiding Burnout: Use SMARTER
for an emergency kit and how to use them according Systems to Work Less, Make More
to color coding the medical emergencies. It also addresses how and Enjoy Practice Again 
dentists can recognize the early signs and symptoms of potential by Dr. Chris Griffin          
crisis situations. We all struggle. Burnout is an increasing problem
in our industry, and it’s not going away. Learn to apply Griffin’s
Improving Your Confidence and Competence “SMARTER systems” framework to create a practice that makes
in Office Oral Surgery: Atraumatic Surgical your dream lifestyle possible and experience the freedom of having
Extractions, Flaps and Splitting Teeth options. The system’s only goal is to help you work less, make more
by Dr. Jay Reznick and enjoy practice—because you deserve it!
This presentation, recorded at Townie Meeting, will cover
important oral surgery topics for the general dentist, including The Essentials of Endodontic Emergencies:
management of the patient on anticoagulants, antibiotic prophylaxis, Diagnosis, Safe Access
design and use of surgical flaps, handpieces and hand instruments, and Infection Management 
surgical extractions, splitting teeth, retrieving root tips and atraumatic by Dr. Brett E. Gilbert
extraction techniques. This course teaches the essential skills needed to confidently
handle endodontic emergencies in a general practice setting. The
Dental Duct Tape material presented will help clinicians apply protocols and tips on
by Dr. John Maggio how to efficiently diagnose, access and locate canals safely. Infection
Glass ionomer materials have come a long way in the past management and postoperative instructions and communication
few decades; these bioactive materials are uniquely positioned to are discussed in detail. ■

Email us your ideas for continuing ed courses

If you’ve got an idea for a CE course you’d like to offer, email Dentaltown’s director 
of continuing education, Dr. Howard Goldstein, at

20 MARCH 2018 //

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live CE

Live CE Events: Travel and Learn

Each month, the Composite CE team selects the
most intriguing and appealing live courses scheduled Mastering Restorative Dentistry A to Z:
Adhesion to Zirconia
throughout the world that are designed to help dental
Want to experience some real Southern charm? Plan a
professionals hone their skills (and collect their required spring weekend in Birmingham and attend this University of
continuing education credits). These nine educational Alabama restorative dentistry course.
courses cover everything from restorative dentistry to Organizer: University of Alabama
practice management and take you from our Townie When: May 18
Meeting in Orlando to a cruise along the Douro River Where: Hyatt Regency Birmingham Wynfrey Hotel
Cost: $169
in Europe. Costs listed may vary based on applicable
discounts and don’t include accommodations or any
additional activities.
Dental Business Masters Series
Head to San Antonio to learn the skills and tools needed
to optimize the efficiency and profitability of your practice.
Allow a couple of extra days to stroll the Riverwalk, visit the
Alamo and maybe even check out a rodeo.
Organizer: Breakaway Practice
When: May 24–25
Where: Hotel Valencia, San Antonio
Cost: $2,600

Minimally Invasive Dentistry,

Maximum Practice Growth
Townie Meeting 2018 Want to take advantage of time off over Memorial Day
Pack up the whole family and head to sunny Orlando, weekend? Sign up for this DenMat course and enjoy some
Florida, to hear from some of the best in the industry. During R&R in Sin City.
your downtime hit up Disney World and Universal Studios or Organizer: DenMat
just lie by the pool and relax with fellow Townies. When: May 25–26
Organizer: Dentaltown Where: Bellagio, Las Vegas
When: April 11–14 Cost: $795
Where: Hilton Orlando Bonnet Creek, Orlando Information:
Cost: $275–$1,700
Academy of General Dentistry
2018 Scientific Session
North Carolina Dental Society Annual Meeting The AGD’s annual meeting takes place in early June
Take a long weekend and head to the NCDS annual before the 90-degree days hit. Take advantage of the
meeting in Myrtle Beach, South Carolina, to beat the summer lectures and hands-on sessions and allow some downtime for
crowds and enjoy some of the best weather of the year. fun in the French Quarter.
Organizer: NCDS Organizer: AGD
When: May 17–20 When: June 7–9
Where: Kingston Plantation Embassy Suites Resort Where: Hyatt Regency New Orleans
Cost: $299–$349 Cost: $199–$665
Information: Information:

22 MARCH 2018 //

Demystifying Occlusion Ontario AGD Jamaican Vacation
Check out this popular summer Spear course in San Planning a summer vacation for the whole family? The
Francisco. See all that summertime in the city has to offer all-inclusive Royalton Resort & Spa has something for every-
and pick up a CityPass, which will get you on cable cars, into one. This event lasts a whole week so there will be plenty of
the aquarium and even on a cruise around the bay. time for relaxation.
Organizer: Spear Education Organizer: Ontario Academy of General Dentistry
When: July 26–27 When: Aug. 5–12
Where: Hyatt Regency San Francisco Where: Royalton Resort & Spa, Negril, Jamaica
Cost: $1,695 Cost: $499–$899
Information: Information:

Douro River Cruise

Portugal is quickly moving up the list of tourist hot spots.
This CE cruise is a unique way to experience Portugal’s
scenery and culture from the waters of the Douro River on
the luxury Scenic Azure vessel.
Organizer: Arkansas AGD and OPCE Seminars
When: Sept. 25–Oct. 2
Where: Scenic Azure, Porto, Portugal
Cost: $495

Simple - easy - predictable composites

Before Setup After

Greater Curve Technique

• Cumbersome mylar strips and wedges
- no longer needed (class III & IV) Featured in
• Sequester deep preps (class II, III, IV, & V) the Dental
• Fashion rounded emergence profiles Town Blog
• Fabricate contacts with width and depth

FREE FACTS, circle 15 on card \\ MARCH 2018 23


NuSmile Launches
Pediatric Dentistry
Locator Website
Ultradent Products Celebrates 40th Anniversary NuSmile, a provider of pediatric
Ultradent Products, a family-owned, international dental supply and manufacturing aesthetic restorative dental prod-
company, is celebrating 40 years in the dental industry. ucts, recently launched its “I Love My
Forty years ago, Dr. Dan Fischer, a young dentist who had recently graduated from NuSmile” program. Through its website,
Loma Linda University, wanted to create a product that would act as a solution to a common this new program helps parents
problem dentists face—achieving predictable, rapid and profound hemostasis in the mouth. understand the best restorative dental
He began experimenting with different chemistries after-hours at his small dental practice options available for their child and pro-
in Salt Lake City, and by 1978, he had invented and patented Ultradent’s first product, the vides a locator feature to find providers
hemostatic Astringedent. That same year, he founded Ultradent Products. with nearby dental practices that offer
As business grew, Ultradent expanded from its first headquarters, a 40-by-60-foot metal NuSmile’s aesthetic pediatric crowns.
hay barn on Fischer’s property, to its South Jordan, Utah, headquarters, which encompasses Mike Loessberg, NuSmile director of
more than 460,000 square feet. The company has gone from one offering to more than 1,600 sales, North America, says the website
dental products worldwide, and has offices and subsidiaries in Asia, Australia, Europe and will help parents grasp the pros and
South America. Ultradent researches, designs, manufactures, packages and ships 95 percent cons of differing restorative options
of what it sells in its South Jordan facility. It also exports 70 percent of its products to more for their children, with photographs
than 100 countries. showing treatment outcomes of each.
Beyond the dental community, Ultradent supports and donates products to humanitarian He noted that this consumer-focused
efforts locally, nationally and internationally, including the Crown Council and Sealants approach has been successful in the
for Smiles. The company founded and sponsors its own 501(c)(3) nonprofit organization, orthodontic clear aligner market and
the Diversity Foundation, an outreach program committed to preventing hate crimes and should also work well with parents who
intolerance. The foundation is currently helping support more than 50 students in their are looking to find the best restorative
efforts to pursue higher education at the college and graduate level. treatment options for their child.
For more information, visit or call 800-552-5512. Diane Johnson Krueger, NuSmile
founder and CEO, thinks dentists will
appreciate the solution as much as
parents will, saying that the company
will make a significant investment in

Industry News
advertising that draws parents to the
For more information about the
new program, visit
Information in this section is culled from releases that were delivered to For more information about NuSmile, All material is subject to editing and space availability. visit

Young Innovations Acquires Mydent International

Young Innovations, a global manufacturer and distributor of dental supplies and equipment, has acquired Mydent International. Launched in 1985,
Mydent is a supplier of infection control products, disposables, preventives, impression material systems, rotary instruments and restoratives in more than
45 countries.
Andrew Jones, vice president of corporate development at Young Innovations, says the acquisition complements the company’s infection control,
preventive and restorative brand, and product portfolio, and aligns well with its commercial strategy.
Andy Parker, Mydent founder and CEO, says Young Innovations is the best partner to allow sustained growth of the Defend brand. Parker will serve in an
advisory role for a transitional period. There will be no immediate changes to ordering and service procedures for customers or vendors.

24 MARCH 2018 //

FREE FACTS, circle 2 on card

Dentaltown’s monthly poll helps you see how other practices operate—
what’s working, what isn’t—and how dentistry is evolving.
The information we gather helps us measure the trends of the profession.
This poll was conducted Jan. 8 to Feb. 8. on

Are the hygienists in your office compensated based on a percentage of the production?

8 3 % 1 7 %
No Yes

What sort of periodontal charting does your hygiene department use?

12% Hygienist records manually
An assistant helps the hygienist

Do the hygienists How much should Do the hygienists in

in your practice a hygienist the practice record
wear loupes? generally produce? patients’ blood pressure?

49% 12% 34%

Yes Two times
their wages Yes

51% 69% 19% 55% 11%

Three times Four times No
No No, the
their wages their wages doctors do

26 MARCH 2018 //


The Genius hybrid files can be used in both

reciprocation and rotation, and most procedures
can be completed using just two files. The Genius
endodontic motor switches between reciprocation
and rotation with the touch of a button, and the
open design gives you the freedom to provide the
best treatment for your patient.

800.552.5512 |
© 2018 Ultradent Products, Inc. All Rights Reserved.

FREE FACTS, circle 40 on card


On average, how long have the hygienists worked in your practice?

More than 5 years

57% 3–5 years
1–3 years
21% Less than a year

Generally, how are purchases made for the hygiene department?

I buy based on the hygienists’

53% I make all of the purchases
The hygiene department
has purchasing power

Are the hygienists in the

Does the hygiene department What is the doctor-to-hygienist practice expected to upsell
use a diode laser? ratio in the practice? services or treatments?

6% 34% 30%
9% More than >1:4
1:1 Yes
Yes 87%
11% 49% 70%
4% 1:3 1:2 No
It will within
a few years

28 MARCH 2018 //

FREE FACTS, circle 19 on card
show your work
case study

A Simple Approach
to Crestal Sinus Augmentation
by Dr. Matthew F. Bickel The world of the general dentist has guided bone regeneration (GBR) and sinus
changed a lot over the years. When I grad- augmentation. One of the things I enjoy
Matthew F. Bickel, DMD, uated from the University of Medicine and most about implant surgery is that I have
and his wife, Kathleen
J. Bickel, DMD, own and Dentistry of New Jersey–New Jersey Dental total control over the restorative position of
practice at Dayspring School (now Rutgers School of Dental my implants.
Dental in Sewell, New
Jersey. The Bickels focus Medicine) in 1992, implant surgery was not
on providing advanced common among GPs. We got zero exposure Case study
dental technology,
including laser dentistry
to implants as undergrads; I merely knew A 59-year-old patient presented with a
and CBCT. He focuses on that they existed, and thanks to a sales rep failing implant at #4—which happened to
restorative, endodontics and implants, while she
focuses on restorative, orthodontics, and infant
at a school presentation I knew you had be one of the first implants I had ever placed!
tongue and lip tie revisions. to use a special plastic scaler to clean one. The patient had disappeared from the practice
Email: But that was the extent of my dental school for a couple of years before I could restore it,
implant education. he had been a smoker, and his periodontal
During my Advanced Education in Gen- disease was now uncontrolled. In addition,
eral Dentistry residency, also with UMDNJ, I the implant was placed without a CBCT,
had the privilege of being taught by Dr. Stanley and it’s possible there was an osseous defect
Praiss, a pioneering implantologist/surgeon GP that I was not aware of.
who taught the residents much more about Fig. 1 shows the CBCT images of the
surgery than we learned in dental school. failing implant and the resulting osseous
Praiss tried very hard to get the residents defect. You can also see sinus thickening
to learn implant placement, but the school because of the infection penetrating the sinus
administration would not sanction it; it floor. The patient was now a nonsmoker, and
believed that GPs had no business placing was fully committed to treating his periodontal
their own implants. My, how times have disease and restoring his missing teeth.
changed! Most, if not all, GP residency Step 1 was to remove the failing implant,
programs now teach implant placement, completely debride the area and graft the
and many older docs, myself included, have defect. A flap was laid with a WaterLase iPlus
taken continuing education to learn implant dental laser, and the defect was thoroughly
placement. curetted as well as cleaned with the laser
My implant surgery journey began in until we were down to clean, healthy bone.
Show your work 2013, when I took a Hiossen surgical course. The area was grafted with Steiner Socket
in Dentaltown! Through the teaching
Fig. 1
of some great specialists
If you’ve got a case you
think might be a great study and GPs (including my
for Show Your Work, email implant mentor, Dr. Paul
editor Sam Mittelsteadt:
Goodman), I was able
Be sure to include a sentence to start placing implants
that sums up why the case is in my off ice. A s my
so special to you, to help us
review and select the best experience progressed, I
contenders for publication. began taking courses in

30 MARCH 2018 //

Putty Plus (a fully synthetic graft material zero chance of a membrane perforation.
containing b-TCP and osteogenic factors) and According to the kit’s instructions, after
covered with a Cytoplast titanium-reinforced the sinus floor is penetrated, the membrane
membrane. The membrane was removed is hydraulically lifted with sterile saline
three weeks later. Fig. 2 shows the sagittal
CBCT image from the healed defect. Fig. 2 Fig. 6
Fig. 3 shows the coronal CBCT image
three months postop. We were able to
regenerate only about 50 percent of the
bone height, but we got a nice, wide ridge
with resolution of the sinus thickening. The
patient was aware of the amount of bone
loss on #5, and knew it would most likely
be replaced by an implant at some point.
However, his home care had been exemplary;
all his probings were at 3 millimeters or
less, and he is staying on a three-month Fig. 3

recare schedule.
At this point, the patient was ready
to place implants on the UR. We would
be extracting #31 because the restorative
prognosis was poor, so we were looking to
replace #3 and #4 with implants. Fig. 4 shows
a sinus septum directly at the #3 position.
The decision was made to place implants
at #2 and #4, bypassing the septum (which
appeared fairly high, had a sloping ridge, and
was therefore more difficult to augment via
crestal approach), and to make a three-unit Fig. 4 Fig. 7
bridge from #2 to #4.
Fig. 5 shows the implant and sinus graft
treatment plan in the Anatomage software.
The plan was sent to the Anatomage lab
for fabrication of a surgical guide (Fig. 6).

Surgical treatment begins

On the day of surgery, the patient was
anesthetized with three carps of Septocaine
and rinsed with Peridex before the procedure.
The surgical guide was tried in to confirm
Fig. 5
fit. A flap was laid with the WaterLase iPlus
dental laser, and the surgical guide was
Fig. 8
used to make the initial pilot hole for the
osteotomy position. Using the pilot holes
as a guide and the CBCT measurements to
gauge depth, the osteotomy was prepared with
Hiossen’s Crestal Approach Sinus surgical
kit. The kit uses safe-ended drills (Fig. 7)
that cut a “manhole cover” of bone out of
the sinus floor, and allow penetration of the
osteotomy into the sinus floor with almost \\ MARCH 2018 31

show your work
case study

Figs. 10 and 11 photos courtesy of Dr. Greg Steiner and Steiner Biotechnology
Fig. 9 Fig. 10 Fig. 12

Fig. 11 using a special syringe (Fig. 8, p. 30). Bone

graft is then supposed to be added into the
space created after the membrane is lifted.
However, as simple as this process is,
there is a way to simplify it even more.
Fig. 9 shows the two syringes used for the
Steiner Sinus Graft material. Steiner Sinus
Graft is designed to hydraulically lift the
membrane as it is injected, so we were able to
skip the saline step outlined in the Hiossen
CAS kit protocol.
The osteotomy was made through the sinus floor; the material
was mixed, the tip placed on the syringe, and it was injected into
the sinus. The tip can be trimmed to better seal the hole. As you
put pressure on the plunger, the graft material hydraulically lifts
the membrane while the graft is deposited (Figs. 10 and 11).

Modifying the standard technique

Besides combining two steps in one, there are three main
advantages to the Steiner Sinus Graft over conventional allograft:
1. Steiner’s graft is completely resorbable, so there is no
concern over particles that may not completely turn over
into native bone.
2. Steiner’s graft—actually a bone cement—hardens within
about 20 minutes of placement. This keeps the shape of
the augmentation done at the surgery.
3. Steiner’s graft particle size is very small—small enough that
it will pass through the ostium without causing a blockage
if you do have a membrane perforation.

Osteotomies into sites #2 and #4 were completed into the sinus

floor. Each site was lifted using one entire 2cc Sinus Graft syringe.
Even though the CBCT graft-volume measurement showed that
only 1cc would be needed for each site, an ultra-low-res CBCT
taken after 1cc of material showed that the membrane was not
sufficiently and symmetrically lifted (Fig. 12).
Because the Steiner Sinus Graft hardens after 20 minutes, it is
necessary to prep the entire depth of the implant osteotomy after
the graft is completed. The surgical guide was used to complete the
FREE FACTS, circle 36 on card

32 MARCH 2018 //

Fig. 13

osteotomies, and Hiossen ET3 4.5-by-8.5mm implants were placed

in both sites. Implants were torqued to 35 newton centimeters.
Fig. 13 shows final ultra-low-res CBCT of both implants, which
were buried with cover screws.
The patient had been placed on preoperative antibiotics, which
were continued for seven days because of the grafting procedure.
He was given standard postop sinus graft instructions, including
not to blow his nose for four weeks, and reported only very minor
discomfort when he was contacted the evening of the surgery.

A complication, one-week postop

At the one-week postop suture removal visit, there was a slight
exposure of the cover screws because the sutures opened. The patient
was getting ready to go on a three-week vacation, and I wouldn’t
be able to follow up until he got back. He also wears a temporary
acrylic removable partial denture (RPD) that was relieved over the
implant sites. The decision was made to remove the cover screws,
place healing abutments, and drastically relieve the RPD over the
implant sites.
When the patient returned from vacation, and also at his last
visit (approximately three months postop) the gingival tissue around
the healing caps was completely healthy with no inflammation. He
will be ready for restoration of the implants in about one month
(four months postop).
I hope this modification of a popular sinus lift technique has
been of interest, and will drive you to investigate new materials
and techniques! ■

Products used
• WaterLase iPlus dental laser
• Steiner Socket Putty Plus
• Cytoplast titanium-reinforced membrane
• Anatomage software and surgical guides
• Hiossen Crestal Approach Sinus Surgical kit
• Steiner Sinus Graft
• Hiossen ET3 implants

FREE FACTS, circle 28 on card \\ MARCH 2018 33


Townies sound off about the products

that helped them save time and money

The conversation, taken

from one of Dentaltown’s
busiest message boards,
begins on the next page. \\ MARCH 2018 35

message board

Material Switches You’ve Made to

Save Money/Time While Maintaining
or Increasing Quality
This conversation began in 2016 and continues today! Townies sound off
about the changes they’ve been pleased to make

Member Since: 03/04/06 I’ve been trying out some new (or new to me) materials to save time or money while main-
Post: 1 of 154 taining or increasing quality. Was curious if anyone else had done a similar project in their office.
Just a few changes I’ve made so far:
• Went from Kerr Extrude to GC Exafast. Set time from 5 min. to 2.5 min. (sweet), costs
half as much and delivers better impressions. Win, win, win.
• Decided to use Estelite Sigma Quick more often (I’d previously only used it sparingly
for hard-to-match areas). It’s a great composite, and is like $73 for 20 capsules, vs. most
composites $100–$110 for similar size.
• Shofu One Gloss for polishing (on the removable mandrels). $1.15 per polishing point
rather than $6–$7 for others.
• Microcopy for burs.
• Edge Endo — these files are way cheaper than the ProTaper Gold, and are actually better
and faster for me. Another triple win.
Any good-value products you use that do just as good or better than the big players?
Especially curious about people using stuff from smaller vendors—Parkell, Practicon, Apex,
stuff not sold through vendors. ■

Tom Mitchell
Member Since: 02/16/04 • Surpass by Apex for bonding and desensitizing. No need for any Gluma product.
Post: 3 of 154 Procedure takes the same time as any other reputable bonding system. Bond strengths
created are higher than any other system.
• Anchor by Apex for buildups and for composite cement. No need for any other composite
bonding cement.
• RelyX luting powder liquid form for most cementing. Less expensive and stronger than all
the others. ■

Member Since: 12/26/12 • Greater Curve bands for anything and everything that cannot be completed with a
Post: 5 of 154 sectional. No more, “Let’s pick which band to use.”
• Dentalree for burs. Learned about them here on Dentaltown, and are a good product that
is very well priced. ■

Member Since: 02/28/14 I’m loving Bulk EZ from Danville for quads of fills. I switched to fast-set Genie Extra Light
Post: 8 of 154 and Regular Body, and love the cost and time savings. Also just started using Massad trays for
dentures—they are a big time-saver. ■

36 MARCH 2018 //

FREE FACTS, circle 41 on card
message board

Member Since: 03/17/11 System I and II alginate for dentures instead of polyvinyl. Best denture impression material
Posts: 15 and 21 of 154 in my hands.
For both the maxilla and mandible I use reusable silicone base formers. We block out the
tongue with wax or a paper towel on the mandible and I have taught my assistant to build the
models up absolutely huge in all respects. We can always trim them back, but it always gives my
lab every landmark and has made my life with dentures more tolerable. ■

Member Since: 10/29/02 The tip that will save a ton of money: Do not buy the disinfecting solutions that come in the
Post: 26 & 27 of 154 gallon jugs. Or on the wipes. Buy them in concentrate.
• Bi-Arrest from ICT (as far as I can tell, it’s the exact same thing as Birex). It sells for 60
bucks for a bottle of concentrate and it dilutes out to 16 gallons. That comes out to about 4
bucks a gallon instead of 30.
• Another one is HB Quat disinfection cleaner. This stuff costs about 70 bucks and I think
it dilutes to … can’t remember, but like 60 gallons. It’s even cheaper.
They are both hard-surface disinfection for areas that don’t have blood all over them. I put
barriers on places where blood might be found.
I changed from Impregum to PVS recently. It’s generally worked well, but with a few hiccups
depending on which assistant uses it. That saved some big money.
I order most filling materials from Safco Dental. Everything else I get from a company
called Goetze. I do this for convenience and for sales tax reasons; Safco doesn’t charge sales tax
on anything, Goetze charges the proper sales tax. In my state, I don’t have to pay sales tax on
products that stay in the mouth. This keeps me out of sales tax problems.
One last tip, and I can’t stress this one enough: Don’t let the staff completely take over the
ordering. Your money will fly away. You need to see the order and approve of it every week. The
staff gives me the order and I order it myself. There are online tools to order my supplies and the
process takes me 10 minutes a week.
I saved thousands of dollars a year, removing spend-happy assistants and spend-happy com-
pany reps from the ordering process. ■

Member Since: 09/04/14 Temporary matrix buttons for crown temp impressions—accurate and inexpensive. I think
Post: 32 of 154 Advantage Dental makes them. ■

Member Since: 01/03/14 Not a material, but I buy patient sunglasses, kid toys, alcohol, hand soap and sanitizer at the
Post: 46 of 154 dollar store. Amazing what you find there—bandages, denture cases, floss picks, etc.
Paper products/stuffers/office supplies at Costco. ■

Member Since: 03/16/03 I think that if you can find a product that you like as much which costs less, then that is a
Post: 47 of 154 win. But I will say it again: Use a buying group/GPO like Synergy.
You will pay less for the products that you already use so that you don’t have to find a cheaper
alternative. But if you have found a cheaper alternative that you like, that product will be less
through Synergy as well. I use Komet burs from them and they cost $3.75—that is about what
disposable diamonds cost.
I have said it many times. Synergy is run by dentists who work in mouths every day. They
get the deal. We individual docs can’t negotiate the same deals that they can because they have

38 MARCH 2018 //

FREE FACTS, circle 20 on card
message board

the buying power of 1,500 offices behind them.

They save me money every week. ■

Member Since: 12/14/13 Tristate Dental is a dental supplier located out of New Jersey. Excellent customer service to
Post: 48 of 154 boot. Check them out.
Mr. Coffee is a tabletop coffee warmer. I throw some compules of Tetric Evoceram Bulk
Fill in a ceramic bowl and place it on the coffee warmer right before I do some composite
restorations. The warmer helps warm up the composite nicely (and reduce its viscosity).
I tried to upload an image of the coffee warmer but couldn’t. Easily available at online and
all department stores (Target, Kohl’s, etc.). ■

Brad Blair
Member Since: 01/11/08 One thing that saved me tons of $$$: Staff always seems to fall for the “buy 10, get 1 free”
Post: 56 of 154 gambit, but maybe I don’t want 2 years’ worth of something that expires. Or that I might not
like in 2 months.
Disposable stuff like paper towels we get from Staples. Order one afternoon, here by next
morning. Cheaper than Costco. ■

Member Since: 03/13/02 Activa BioActive for bulk fill composite. Not cheap, but superfast—more than 50% speed
Post: 69 of 154 increase on composites. ■

Adam W
Member Since: 08/04/11 Kettenbach for all crown and bridge impression material. Impression quality went way up,
Post: 71 of 154 and it’s cheaper than Aquasil. ■

tooth college
Member Since: 05/06/07 Switches I have made that have made my life easier. Not necessarily cheaper or to save
Post: 92 of 154 money, but have saved my stomach lining:
• Surpass bonding agent
• SonicFill resin
• Greater Curve matrices.
• My wireless loupe/headlight
• Rubber dam
• Genie PVS
• Alveogyl for dry sockets
• My cheap intraoral eBay cams (biggest ROI to date)
• Not buying from Patterson Dental ■

Member Since: 10/29/09 Net32 for all disposables. ■
Post: 115 of 154

Tell fellow Townies what you’ve changed!

Search: “Material Switches”
Who doesn’t want to save time or energy? To read more of this
conversation online, and share your own stories about switching
materials, go to and search “material switches”—
this message board will be the top result.

40 MARCH 2018 //

FREE FACTS, circle 38 on card
message board

Christmas Cancer
An oral surgeon shares a case that illustrates the importance of
performing thorough checks for head and neck cancer

Member Since: 08/10/04 It seems like every December, I get a patient with head/neck cancer that I have to operate on,
Post: 1 of 52 so they spend Christmas in the hospital. This year I have three.
This poor guy had a lymph node in his neck start growing. A needle biopsy showed squa-
mous cell carcinoma, which prompted a search to look for the source (usually tonsil or base of
tongue). Couldn’t find the primary site, but this started to grow very quickly and soon began to
grow through his skin and was attached to his mandible. Strangely, he also had a huge lipoma in
his neck that went down under his sternocleidomastoid muscle (SCM) into the carotid sheath.

Fig. 1 Fig. 2 Fig. 3 Fig. 4

Fig. 5 Fig. 6 Fig. 7 Fig. 8

Fig. 1: On the OR table after intubated and prepped.

Fig. 2: This MRI shows the lipoma (the large black mass) and the cancer (the white mass
at the top). The larynx is the white mass in the center and the airway is the black hole in
the middle of the larynx. Luckily, the cancer wasn’t invading the larynx, so he got to keep
his voice box.
Fig. 3: After doing a trach and marking the planned margins of excision.
Fig. 4: The incision was made all the way around the mass. The lipoma was exposed
posteriorly, which is the yellow part. The lipoma had to be removed just to get access to
the deeper parts of the neck to remove the lymph nodes.
Fig. 5: The lipoma retracted anteriorly to expose the internal jugular vein (which is kind
of bluish with the glare on it). The cancer was attached to the lipoma, so it was all removed
together. The two retractors at the bottom are holding the SCM.
Fig. 6: A view from below after the mass was dissected off the strap muscles, carotid
sheath and SCM. It’s now just tethered to the mandible. The carotid artery still has some
fascia over it, but you can sort of see the superior thyroid artery coming off and coursing
inferiorly. We ended up using it later.
Fig. 7: An osteotomy in the inferior border of the mandible where the tumor was attached
to the bone.
Fig. 8: This is after mobilizing the bone segment and rotating it downward. The marrow
can be seen in the bone. Perforated into the floor of the mouth, so I closed it.

42 MARCH 2018 //

Fig. 9 Fig. 10 Fig. 11

Fig. 12 Fig. 13 Fig. 14

Fig. 9: Specimen on the table of lipoma, cancer and mandible.

Fig. 10: This shows the size of the defect. I decided to put a plate across this bone defect
because the remaining upper mandible was full of teeth and probably more prone to
fracture. You can also see the facial artery that was preserved and sticking out. The original
plan was to use this to hook up a flap to later, but we ended up using the superior thyroid
artery instead. The superior thyroid ended up having a better-sized match and geometry.
Fig. 11: Decided to do a free latissimus dorsi flap to cover the hole. This involves taking
skin over the lat dorsi muscle and raising it up with the thoracodorsal artery/vein pedicle

FREE FACTS, circle 4 on card \\ MARCH 2018 43

message board

going into the deep surface. This shows the incision around the skin paddle, which was
positioned over the muscle.
Fig. 12: Now the muscle/skin is elevated off the chest wall. This is the view from the deep
(muscle) side of the flap. You can kinda see the shadow of some ribs; also, the serratus
anterior muscle in the upper half of the photo.
Fig. 13: Another view of the lat dorsi flap flipped up and lying up on the shoulder. It’s still
being perfused by the thoracodorsal artery and vein, which is in the fat at the top of the
incision and not yet exposed. After this, we skeletonize the vessels through the fat. Then
ligate and divide the vessels so the flap of skin, subcutaneous fat and muscle is completely
freed from the body.
Fig. 14: The flap artery and vein were anastomosed to the superior thyroid artery and the
external jugular vein. This is done under a microscope using 9-0 nylon. Then the flap
is inset into the defect to cover the hole. He had this redness in the neck skin which I’m
not sure of. We took some biopsies at the beginning of the case for immediate frozens to
make sure it wasn’t cancer. I suspect it was an inflammatory reaction to the cancer eroding
through the skin. ■

Bifid Uvula
Member Since: 05/17/06 Great case!
Post: 6 of 52 Haven’t seen a latissimus dorsi fl ap in a while. This is a really neat fl ap for head
and neck reconstruction because it can be used both as a pedicle-d fl ap (meaning kept
attached to its blood supply and extended as far as the artery and vein will permit) or as a
free-microvascular fl ap (as shown here, where it can literally be transplanted almost any-
where else on the body).
That giant lipoma is also pretty weird to be occurring at the same time. In residency we had
a lady in her 80s with a pretty big one on the back of her neck and head who also had an oral
squamous cell carcinoma, so she had both removed/resected. ■

Member Since: 03/30/10 Terrifying and amazing. Thanks for sharing. ■
Post: 7 of 52

Bifid Uvula
Member Since: 05/17/06 Let’s talk about his teeth here. What does he have in the mandible? This case will almost
Post: 8 of 52 certainly be receiving postoperative radiation therapy, given the neck involvement.
So what does he have in the mandible, and what, if anything, did you leave behind? I can
only make out some maxillary teeth in your photo, and it looks like this was only a marginal
resection of the inferior border of the mandible.
I usually explain to my GPs and the patient that we don’t always have to remove all of the
teeth. A lot goes into the decision. Reliable, compliant patients with an otherwise healthy/intact
dentition (and a good history of regular/frequent hygiene and restorative dental care) with a
stable/healthy periodontum may lose their second premolars back to second or third molars in
the mandible when it comes to the typical base of tongue, posterior lateral tongue, and tonsillar
squamous cell carcinomas.
Cancers located in an area that would prompt a greater field of radiation to include the
anterior mandible region (anterior central tongue, anterior floor of mouth, anterior mandibular
gingiva/mucosa/bone) will often obligate me to consider removing all of the mandibular teeth.
For our fellow Townies to understand, we don’t always know if a patient will definitely be
receiving postoperative radiation therapy, but we have a pretty good hunch who probably will

44 MARCH 2018 //

require it. We base that on criteria that includes the size of the malignant tumor, microscopic
depth of invasion into adjacent tissues, presence of cancer cells found in the head/neck lymph
nodes, and presence of cancer cells found outside of the lymph nodes.
This is an area where I have a beef with many head and neck tumor board teams. Most of these
cancers in the U.S. are treated by ENTs, who do a fine job with the tumor surgery. They often
have some extraction training, but the vast majority are not comfortable removing teeth and unless
they are totally loose and practically falling out they won’t touch them. They do the surgery, the
definitive pathology results come back a week or two later and there is an indication for head and
neck radiation therapy to be initiated (usually to be started right about six weeks after surgery). So
they shuffle the patient to the radiation oncologist a week or two after that tumor board meeting to
prepare for radiation, and the patient is now only 2–3 weeks away from initiating therapy.
As you would expect, they don’t usually have a dentist, they don’t usually have one with
an opening to see them who can perform the extractions, and they probably don’t have the $
either for potentially full mouth extractions and four quads alveoloplasty, etc. There is a big
difference in the healing and complications of a patient who had teeth removed 6–8 weeks prior
vs. 2–3 weeks prior to initiating radiation therapy and those who had to have teeth removed
after radiation therapy was completed.
Academic centers with general dentistry residencies and OMFS residencies usually can meet
and coordinate to provide this service with better timing than at most outside institutions.
Then there is the rare breed (slowly increasing in numbers) of people like @toofache32 that
can do the entire head/neck surgery, the oral surgery, and the reconstruction themselves. … ■

The back is closed by under- toofache32

Member Since: 08/10/04
mining and advancing the tissue
Post: 20 and 21 of 52
deep to the subcutaneous fat.
We had to undermine pretty far so we could slide an entire
hand under the edges. It was still under lots of tension,
so we did a trick where we use towel clamps to hold the
skin together for a couple hours while we sew in the flap
to the neck. This allows it to stretch and relax a little, and
it’s called “intraoperative creep.” If we still cannot get it
closed, then we have to skin graft it.
Bifid, the patient has premolars forward. We removed
the teeth 2–3 weeks ago when we did a panendoscopy
with biopsies of the base of tongue and tonsils to look for
the primary tumor.
Just so everyone understands: When carcinoma of
squamous cell origin is found in lymph nodes, it doesn’t
originate in the lymph nodes; there are no squamous
cells in normal lymph nodes, because squamous cells
are epithelial. Therefore, it spread from somewhere else.
So the next step is to try to locate the primary tumor.
Nothing showed up on a CT scan or PET scan, so we
perform directed biopsies of the most common areas
such as base of tongue and tonsils. When we can’t find it,
this is a phenomenon known as “the unknown primary.”
They generally get radiation treatment to all the tonsil,

FREE FACTS, circle 25 on card \\ MARCH 2018 45

message board

base of tongue, and neck lymph nodes. We did surgery on him because there was suspicion of
mandible invasion on the imaging. Radiation will not kill cancer invading into bone, and this is
usually an indication for surgery. ■

Timmy G
Member Since: 04/14/02 What is the estimated five-year survival rate in a situation like this? ■
Post: 22 of 52

Member Since: 08/10/04 30–50 percent, depending on HPV status and other factors. ■
Post: 23 of 52

Member Since: 04/22/02 I’m in awe of your skill and level of training! It scares me to think that tumor may have been
Post: 27 of 52 caused by HPV. I have been with more than one girlfriend who had mild dysplasia on a Pap, so
I’m thinking that I have been exposed to one or more of the types that can cause neoplasms. ■

central incisor
Member Since: 01/19/05 So, no luck finding the source/primary neoplasm? Is this common? Is there a greater chance
Post: 32 of 52 of recurrence in this instance? ■

Member Since: 08/10/04 It happens, but not that common. Probably about 2–3 percent of all head and neck
Post: 34 of 52 cancers. ■

Member Since: 04/30/07 Jeebus — that’s impressive and scary.
Post: 35 of 52 So, is this the right thread to ask what currently is the best recommended way to screen for
oral/head/neck cancer? Can I just refer patients to an oral surgeon for screening, and how much
would something like that cost? ■

Member Since: 08/10/04 We should all be screening all of our patients. I had a video I created of the “60-second oral
Post: 36 of 52 cancer exam” where one of my residents let me do an exam on him, but I can’t find it.
Look at the oral soft tissues. Visualize everywhere. I don’t grab their tongues and york
it around like Bessie the Cow. I grab four cotton-tip applicators (really long Q-tips) and
put two in each hand. The dry cotton is like a miniature 2x2 gauze because it sticks to the
tongue and soft tissue to let me push, pull and manipulate the tongue and soft tissue. Then
I say, “Open big and say ahhhh but don’t stick your tongue out,” because everyone wants to
stick out their tongue for some reason, which only obstructs your view of the pharynx. This
is about 30 seconds.
For the next 30 seconds, get up and walk behind the patient. This is important to be able to
use both hands at the same time to feel for symmetry. There are lots of times I will feel a “mass”
but then realize that the same “mass” is also on the other side and symmetrical. This is usually
the submandibular glands. The other common mass, especially in older skinny patients, is the
carotid bulb. When I feel a mass, I like to hold still for 3–4 seconds to see if it pulsates. If it does,
then it’s just the carotid artery.
In the past, if the mouth had no abnormalities and looked good, I would say, “That
looks good.” If the neck felt good I would say, “That feels good.” These days, if the neck
feels normal then I say, “Well, that feels normal.” Someone pointed out to me that I probably

46 MARCH 2018 //

shouldn’t be feeling women’s necks and saying, “That feels good” so now I just say, “That
feels normal.” ■

JJ Westside
If you ever find that cancer screening video, I’d love to see it. ■ Member Since: 09/01/05
Post: 37 of 52

We were told in school to always to always do an oral cancer exam on each patient at six- Member Since: 05/16/11
month intervals. We were told if we caught one case during our careers, the effort would have Post: 38 of 52
been worth it.
So far, I have caught two cases in my career. Both on family members. ■

Absolutely amazing. So kind of you to dedicate some of your time to post photos and info. Member Since: 06/09/14
Just out of curiosity: If you skin graft, what happens with the donor site? Won’t that need Post: 42 of 52
skin graft as well, or would that be a site that you can close primarily? Would this latissimus flap
be able to heal by granulation (secondary healing)? ■

There are two types of skin grafts: split thickness and full thickness. They both have pros Member Since: 08/10/04
and cons. Post: 44 of 52
A split-thickness skin graft donor site does not need
to be closed; just put a bandage over it and it heals like
a bad case of road rash. A full-thickness graft must be
closed primarily; therefore, the size of the graft is limited.
So a skin graft (when used in this type of case)
would be a split thickness. It’s harvested usually from
the upper outer thigh using a dermatome that lets us
select the thickness of the graft, between 0.008 to 0.02
inch. That’s thousandths of an inch thick. Because the
dermis and follicular units remain in the wound, it will
re-epithelialize in a few weeks.
[Editor’s note: Go to to
watch a YouTube video this Townie linked to that demon-
strates using a dermatone and meshing the graft.] ■

Got a question
for this Townie?
Search: “Christmas Cancer”
If this case got you thinking,
head to and
search for “Christmas Cancer.”
This message board will be the
top result, and you can post your
question or opinion there.

FREE FACTS, circle 31 on card \\ MARCH 2018 47

message board

I’m Getting Myself Hyped Up About an Ext.

A Townie looks for tips on a molar extraction

Member Since: 10/11/11 I’ve been tiptoeing into the world of surgical extractions. I’ve had a lot of great, successful
Post: 1 of 30 cases so far. But I have a patient coming in on Friday for the extraction of #19 and I’m getting
nervous for it. It’s heavily decayed, thin/curved mesial root—see pic.
I have some thoughts on how I’m going to approach this, but I would appreciate a convo and
advice from all of you. How would you guys go about this? I prefer to go the flapless route. ■


Member Since: 02/11/16 See if you can get some movement by luxating, then cowhorn in furcation. The roots are
Post: 2 of 30 fairly straight and along the same axis, so I bet you could get it out in one piece. ■

Rance Davis
Member Since: 01/22/01 I would luxate 360 degrees, then in the furcation. Go directly to sectioning the tooth (B/L)
Post: 5 of 30 and remove the distal root. This can be accomplished in less than five minutes. Use the remain-
ing time to remove the mesial root which may be a little bit of trouble. The key is to not hesitate
on the sectioning. To help conceptually, measure your surgical against the X-ray. If you begin on
the buccal and show caution as you approach the lingual, you’ll be fine. ■

Member Since: 03/05/13 I’ve found that if I can get at least some movement with luxators and elevators before section-
Post: 6 of 30 ing, the roots will move easier once separated. Also make sure to do a deep section so the pieces
have room to move. If I section shallow and the tooth isn’t moving, that is when I’ve gotten in
trouble with the roots just breaking off trying to elevate. ■

Member Since: 01/11/02 Here’s my two cents. Go in a stepwise fashion.
Post: 9 of 30 Step 1: Luxate all around the tooth and into the furcation with either a luxator or spade
proximator. Try to get some mobility.
Step 2: Do the same thing with a 301 elevator. (I don’t have Tommy Murph’s hands and I
can’t go straight to a 301.) Try and get some mobility.
Step 3: Cowhorn forceps, squeeze and pump, and figure 8 motions. Try and get some
mobility. (Mobility will make it easier to remove the roots when you go to the next step.)
Step 4: If it still hasn’t come out, then section buccal lingually and elevate out each individ-
ual root. Hopefully each root is loose by this point and they come out easily.
Step 5: You didn’t get enough mobility (or the tooth didn’t allow it) and now you are trough-
ing in between the roots to make a space for your elevator to hopefully get some mobility. At

48 MARCH 2018 //

FREE FACTS, circle 10 on card
message board

this point I’m usually using a thin-tipped instrument like a spade proximator or a luxator to
get into the PDL space around the root wherever it lets me.
Step 6: Still a no-go? Remember how it presented on the X-ray and remind yourself to refer
to an oral surgeon when it looks like that. Now start troughing on the buccal and using a thin-
tipped instrument to get some mobility wherever you can. ■

Member Since: 02/25/17 I am not a fan of the 301 elevator though it does work. I prefer the Hu-Friedy 11A Stout
Post: 12 of 30 for elevation. The tip broadens as you move away from the tip so as you work the instrument in
between the teeth it gradually elevates more and more. Frequently I find that the 301 elevates
nicely to a point and then it just isn’t wide enough to elevate any more. The 11A is my go-to
elevator. Come to think of it, most teeth I remove I only use the 11A and, if necessary, forceps.
I use the 11A to dig out all but the smallest root tips. I use it to remove anteriors and posteriors.
I may begin using it to eat lunch—I like it that much. ■

Member Since: 10/11/11 I really appreciate your feedback. Along with the other posters who gave their opinion and
Post: 16 of 30 how they would go about it.
So, I ended up getting to Step 5. Got out most of the tooth, then the D root split vertically
and the lower apical-mesial portion of the distal root remained stuck. No PDL to even squeeze
my spade proximator into. I elected to leave that sliver of root. Probably not what some others
would have done. But I’m okay with my decision to do so.
Just thought I would share for others who are in my shoes. We all have to start somewhere.
Learning can be difficult, but fun! ■

Member Since: 01/03/13 This was a disservice to the patient. OP knew several days ago he did not feel comfortable
Post: 19 of 30 with this extraction. He came on, posted his concern, received several “ideas” on how to do it
and talked himself into making a poor clinical decision and outcome … ■

Member Since: 08/15/16 Everyone learns somehow. If remaining piece of tooth that wasn’t necrotic to begin with is
Post: 20 of 30 less than 3mm it’s okay to leave. ■

Member Since: 10/11/11 Definitely less than 3mm. Necrotic. Extracted six teeth this week. This one was the trou-
Post: 23 of 30 blemaker. Moving on! ■

Member Since: 01/11/02 Inform the patient that it’s there and tell them that “if” it ever gives them a problem, you’ll
Post: 25 of 30 take care of it for no charge. ■

Bifid Uvula
Member Since: 05/17/06 Got a radiograph of the retained root portion to share with us? Did you inform the patient you
Post: 26 of 30 left part of the tooth behind? How long did you work on the patient before you threw in the towel? ■

Member Since: 01/03/13 Do not kid yourself into thinking it is appropriate to leave roots behind simply because you
Post: 28 of 30 could not finish the case. We are all held to a standard of care. Leaving roots behind in this

50 MARCH 2018 //

particular case is absolutely below the standard of care.
You may get away with it in this case, but you may not.
People need to understand that leaving roots behind
is justified in very few instances. Just because you cannot
remove them is never an excuse to just throw in the towel
and tell the patient they will be “OK.”
My partner acts as an expert to our state board and
reviews cases like this 3–4 times per year. The patient
ends up pissed because they want an implant and need
another surgery prior or develop an infection or lasting
pain, etc. The treating dentist loses every time.
In this particular case leaving roots behind is not up
to the standard of care. Period. ■

If you ever “give up,” which jsk070

Member Since: 10/03/13
you will (it will happen), don’t
Post: 29 of 30
freak out and give up. Refer to
an oral surgeon you have a good relationship with and
take care of the fees associated with it.
I’ve given up on three extractions in three years.
1. Root tip was too close to sinus
2. Sinus pneumatization (Man … I learned my lesson
on that one.)
3. Lower anterior that was just ankylosed, and I was
afraid of damaging adjacent teeth so refer out.
All three referred out and the OS took care of it and
patient was fine. I would never leave a root tip behind. ■

What’s your
extraction protocol?
Search: “Hyped Up”
This Townie had some hesitation
before extracting in this case and
left a portion of the root behind.
What would you have done?
To share your thoughts and
observations, go to
and search the message boards
for “hyped up”—this conversation
will be one of the top results.

FREE FACTS, circle 30 on card \\ MARCH 2018 51

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A contemporary approach
by Dr. Andonis Terezides
Introduction to six months before proceeding on to a
Dr. Andonis
Despite monumental advances in definitive fi xed prosthesis.
graduated modern dentistry and implantology, the At the same time, Brånemark and
from the
number of fully edentulous patients and his colleagues introduced the Novum
University of
Maryland School of Dentistry and those with failing or nonrestorable terminal concept, using only three implants in
completed his residency training dentitions has not significantly decreased. the mandible that were placed by a stan-
in oral and maxillofacial surgery
at Jackson Memorial Hospital/ This is in part because the dental field dardized surgical template to support a
University of Miami. has been unable to keep up with the sheer prefabricated two-piece framework for a
Terezides, a diplomate of the American Board of Oral & volume of patients requiring full-mouth definitive screw-retained fixed prosthesis
Maxillofacial Surgery, enjoys practicing the broad scope of
the specialty, with special emphasis in facial trauma and
rehabilitation. Estimates from the World that could be delivered within 24 hours.
reconstructive surgery, tissue engineering, digital implant Health Organization and other research Both techniques had high success rates
workflows, minimally invasive techniques, and full-arch
and immediate-load implant rehabilitation. He is also a
organizations indicate that there are more and patient satisfaction. These concepts
contributor to the Digital Dentistry Institute. than 60 million fully edentulous people paved the way for further improvement
in the Western world and upward of in implant design, surface treatment,
more than 250 million fully edentulous prosthetic components, and eventual
by Dr. Sundeep Rawal people in Asia. adaptation of the immediate implant/
Dr. Sundeep In the 1990s, Professor Per Ingvar immediate provisionalization and loading
Rawal Brånemark and a team of forward-think- of at least four implants in the maxilla.
from the ing clinicians embarked on a scientific Today, the All-on-4 treatment concept
University of Florida College of journey and mission to simplify treatment is considered a predictable and efficient
Dentistry in 2006. He completed
his training in prosthodontics techniques to provide edentulous patients treatment used daily to rehabilitate eden-
in 2009 at the University of with a fi xed full-arch implant rehabili- tulous patients and those with a terminal
California San Francisco, where he
was exposed to the most current
tation. The initial studies involved the dentition (Fig. 1).
technologies shaping dentistry. Rawal worked extensively mandible. Paulo Malo and others began There are, however, some anatomic
to utilize CAD/CAM technologies within the scope of clinical
work on what was eventually known as challenges in the severely resorbed/atrophic
dentistry and enhance his patients’ restorative treatments.
the All-on-4 concept. As few as four maxilla that make the All-on-4 concept
Rawal has lectured extensively across the U.S. and
internationally, and has published papers in numerous implants could be used to support an impossible without additional posterior
dental journals. He is a co-founder of, and frequent immediate/interim fi xed acrylic bridge implant anchorage. These have been
contributor for, the Digital Dentistry Institute. He is in
private practice in Orlando, Florida, and east to the Beaches. implant prosthesis converted from a successfully overcome in keeping with a
denture, which could be used for four graftless and immediate load approach

54 MARCH 2018 //

through the use of zygomatic implants.
Additionally, an alternative and lower-cost
treatment option in the mandible has been Fig. 1: Maxillary and mandibular rehabilitation with the All-on-4 treatment concept.
redeveloped to offer a fi xed mandibular
implant rehabilitation to a wider patient
In this article we will review the
anatomic challenges and highlight our
approach to these challenging situations
through the use of zygomatic implants
as a primary treatment method for the
severely resorbed and atrophic maxilla
and introduce a cost-effective therapy Fig. 2: Resorption patterns of dental alveolar bone down to basal bone.
using Nobel Trefoil for a fixed mandibular (Left: coronal view. Right: sagittal view.)

Anatomic changes and

challenges associated
with edentulism
The loss of teeth in the maxilla leads
to a progressive resorption of the residual
alveolar ridge. This pattern of bone loss
proceeds in a superior/posterior and
medial/palatal direction (Figs. 2 and
Fig. 3: Brånemark classification of anterior maxillary sinus wall extension.
3). This leads to changes in the facial
morphology, giving a sunken-in, collapsed This resorption pattern in both jaws
and aged appearance to the face without results in an unfavorable Class III skeletal
appropriate lip support. The resorption relationship as well as a crossbite relation-
pattern may lead to a shallow or flattened ship that creates significant surgical and
palatal vault and lack of adequate vestibular restorative challenges in the patient’s oral
depth. Additionally, over time patients rehabilitation. In the most severe cases,
often develop significant hyperpneu- the resorption proceeds all the way to
matization of the maxillary sinuses that the basal bone.
extends anteriorly to the premaxilla. When evaluating a patient with a
In the mandible, the edentulous terminal maxillary dentition or one who is
residual alveolar ridge resorption pattern already edentulous, radiographic screening
proceeds inferiorly and laterally. Severe begins with a panoramic image. Potential
resorption cases can lead to exposure of available bone sites are identified using
the inferior alveolar nerve and mental the Bedrossian zones (Fig. 4, p. 56).
neurovascular bundle to the top of the Careful clinical evaluation of the patient is
alveolar crest. With only thin mucosa performed to determine if there is a missing
overlying the exposed neurovascular tooth-only defect or a composite defect.
bundle, the already difficult task of wearing This evaluation includes determining the
and using a removable denture becomes appropriate incisal edge position, need for
painful and nearly impossible. lip support and the appropriate vertical \\ MARCH 2018 55

of maxillofacial oncologic patients who
had undergone maxillectomy procedures.
Later, zygomatic implants found use
as alternative or last-resort options in
Zone 1: Zone 2: Zone 3: Zone 4:
Premaxilla Premolars Molars Zygomatic bone full-arch maxillary rehabilitations—first
in delayed or staged manner, and later as
Fig. 4: Bedrossian zone classification an immediate function/load approach to
salvage cases while avoiding extensive
Bone Availability Surgical Approach bone-grafting procedures. Today, zygo-
Zones 1, 2, 3 matic implants are no longer considered
4–8 axial/traditional implants
(Lack of composite defect) alternative or last-resort options, but
Zones 1, 2 rather a routine, reliable and predictable
All-on-4 concept (4–6 implants)
(Composite defect) primary treatment by many surgeons and
Zones 1, 4 Anterior maxilla: 2–4 implants prosthodontists.
(Composite defect) Posterior maxilla: 2 zygomatic implants The original Brånemark protocol
Zone 4 dictated that the zygomatic implant
Quad zygomatic implants
(Composite defect) would have quad-cortical stabilization
Fig. 5: Maxillary treatment algorithm for graftless or immediate load approach based on a trajectory that proceeded from
based on available bone, using the Bedrossian zone classification. the palatal side of the residual alveolar
process through the maxillary sinus,
with subsequent entry into the zygomatic
bone, ultimately exiting through the
superior/lateral cortex of the zygoma. The
main drawback from this approach was
often a significant palatal emergence of
the implant restorative platform, which
then resulted in bulky prostheses, made
Fig. 6: Ad modum Brånemark technique, which sometimes
hygiene more difficult and sometimes
necessitated a palatal emergence of the restorative platform created difficulty with speech (Fig. 6).
Modifications of the ad modum
dimension of occlusion. The need for Brånemark technique were developed by
bone-reduction or alveolectomy is also several clinicians such as Drs. John Stella,
predetermined to provide for the necessary Carlos Aparicio and Paulo Malo in an
prosthetic component space, hiding the effort to overcome some of the challenges,
transition-zone and creation of a hygienic limitations and complications faced by
and cleansable prosthesis (Fig. 5). using the original protocols.
Aparicio devised a classification sys-
Zygomatic implant therapy tem called the zygoma anatomy-guided
Brånemark developed zygomatic approach, or ZAGA concept, which
implants in the mid-1980s for treatment focused on an individual’s anatomy rather

56 MARCH 2018 //

Fig. 7: The zygoma anatomy-guided approach classification system depicts zygomatic
implant trajectory based on the desired implant platform location and the lateral maxillary
wall and sinus anatomy.

Fig. 8: Ideal prosthetic emergence of the zygomatic implant fixtures, achieved by treatment planning
and placing the implants in accordance with the ZAGA classification.
Meet these
at Townie
Meeting 2018!
Drs. Andonis Terezides and
Fig. 9: NobelZygoma 45-degree implant. Sundeep Rawal are two of
the featured speakers at
Townie Meeting 2018, which
than a standardized implant trajectory the threads have been removed from the runs April 11–14 in Orlando,
Florida. To discover more
to determine the most ideal prosthetic implant head and body to decrease mucosal about the event, or to reserve
position of the implant platform emer- irritation and risks of mucosal dehiscence. a hotel room at the Townie
Meeting discount rate, visit
gence. Using the ZAGA concept, Aparicio The implant apex has been modeled to
demonstrated that zygomatic implant resemble the NobelSpeedy implant, which
surgery has the potential to be less invasive was designed for bicortical anchorage and
and faster, with less risk of sinus-related high initial primary stability.
complications. It also provides improved The new design permits for improved
prosthetic design/biomechanics, easier bone-implant contact and improved
hygiene, and improved comfort, speech soft-tissue attachment to the implant.
and aesthetics (Figs. 7 and 8). The implant body has also been widened
to provide for increased mechanical
Improvement in implant design resistance and implant strength. The
and prosthetic options restorative interface of the implants is
After more than 20 years of expe- now also available in the traditional
rience and success using the original 45-degree platform and a flat zero-degree
Brånemark machined and Ti-Unite platform (Fig. 9).
surface-coated zygomatic implants, a
redesign with improvement to the implants All-on-4 treatment concept
addressed some of the issues and complica- with zygomatic implants
tions such as mucosal dehiscence, sinusitis, A 77-year-old female presented with
prosthetic compromises and implant a failing maxillary PFM bridge and desir-
fracture. Most notably, the implants are ing a timely, less-invasive fi xed-implant
fully treated with a Ti-Unite surface and solution (Figs. 10–12, p. 58). \\ MARCH 2018 57

Figs. 10a–c: Maxillary terminal dentition. (a) Failing PFM bridge with nonrestorable A new mandibular solution
recurrent decay; (b) bone present in Bedrossian zones 1 and 4; (c) treatment planning using The Nobel Trefoil system (Fig. 13)
NobelClinician software. is an innovation in mandibular full-
arch rehabilitation. This concept has its
scientific underpinnings in the original
Brånemark Novum system popularized
in the late 1990s and early 2000s. By
using prefabricated surgical templates,
three implants were placed in the anterior
mandible and loaded with the definitive
fixed prosthesis on the same day. Patients
were pleased with the results and signifi-
Figs. 11a–d: Extractions, zygomatic implants and Nobel Active implants cantly decreased treatment time.
with immediate postop imaging. (a) Removal of failed bridge to reveal
The implants showed excellent mar-
decayed retained roots; (b) right zygomatic implant 47.5mm (ZAGA 1);
(c) anterior maxillary implants and left zygomatic implant 50mm
ginal bone stability and high survival
(ZAGA 0); (d) immediate postop imaging demonstrating four Nobel Active rate, but there were some problems with
implants in the anterior maxilla and two bilateral zygomatic implants. the prosthetics because the prefabricated
framework was so rigid and unable to
compensate for some discrepancies in
implant placement that a passive fit of the
framework could not always be achieved,
leading to prosthetic complications.
Ultimately, the Brånemark Novum was
abandoned in 2007 in favor of the All-on-4
treatment concept.
Dr. Kenji Higuchi believed that if
Figs. 12a–e: Immediate-load fixed provisional restoration removed for final impressions at techniques and materials could be devel-
six months. (a) Note excellent A-P spread and healthy mucosal tissues; (b) implant provisional oped to overcome the poor fit problems
showing screw access holes; (c) retracted frontal view with multiunit abutments; (d) provisional
that led to prosthetic complications in
prosthesis in place; (e) happy patient.
the Novum system, a more affordable
and less time-consuming approach to
full-arch implant treatment could be
realized for the mandible.
Higuchi believed that solution could
allow patients to have a more affordable
fixed mandibular implant prosthesis rather
than having to opt for an implant-retained
removable overdenture (Figs. 14 and 15,
p. 60). Thus, after several years of research
Fig. 13: Brånemark Novum, with its rigid double-bar framework, compared with the Nobel and re-engineering, the Nobel Trefoil sys-
Trefoil, which has five self-adjusting joints designed to correct the bar position to ensure a tem was developed to fit this patient niche.
passive fit of the prosthesis. In 2015, the system began a prospective

58 MARCH 2018 //

FREE FACTS, circle 6 on card
Fig. 14: Nobel Trefoil is intended to serve as a lower-cost alternative for a fixed mandibular prosthesis.

Fig. 15: Nobel Trefoil bar demonstrating the adaptive compensation mechanism to ensure passive fit
of the framework by compensating for angular, horizontal and vertical discrepancy in placement at
each of the three implant fixtures.

Fig. 16: Preoperative planning Nobel Trefoil using NobelClinician software.

multicenter, five-year study in the United no required provisional prosthesis, sig-

States, Spain, Italy, Chile and Australia. nificantly reduced chair time with sim-
The preliminary results have shown a plified restorative procedures, simplified
97.6 percent success rate regarding implant laboratory protocols, and delivery of the
survival and a 98.2 percent success rate definitive prosthesis the same day or
regarding prosthesis survival. within 24 hours.
Aside from the novel compensation It should be noted that Trefoil was not
mechanisms to ensure a passive fit of designed or intended to replace any cur-
the standardized prefabricated titanium rently accepted implant treatment method
framework, Trefoil offers several other for the mandible. Rather, it is meant to
unique features and advantages. The serve as another solution in the surgical
system offers guided surgery to place and prosthodontic armamentarium to
three implants in the anterior mandible, provide patients an efficient, cost-effective,

60 MARCH 2018 //

Figs. 17a–g: Nobel Trefoil procedure. (a) Bone leveling/reduction; (b) guide pin demonstrating
22mm of prosthetic space; (c) guided surgery; (d) implant sites with V-template in place;
(e) three Nobel Trefoil implants, 11.5mm length with 4.5mm collar; (f) verification index with
transfer abutments; (g) healing abutments in place and tissues sutured.

Figs 18a-d: Fabrication and delivery of the definitive Nobel Trefoil

prosthesis within 24 hours of surgery. (a) Occlusal view; (b) frontal
view; (c) intaglio surface; (d) definitive prosthesis delivered on first
postoperative day after overnight lab processing.

aesthetic, durable and predictable fi xed-implant reha-

bilitation of the mandible.

Nobel Trefoil case example

A 55-year-old male with a failing mandibular dentition
desired a fi xed-implant solution (Figs. 16–18).

Brånemark had a vision of simplifying treatment for
patients: “A decisive factor in patient care is simplification
of dental treatment, which should be based on identifying
and utilizing the enormous capacity of existing original
anchoring tissues. When possible, one should avoid
unnecessary, advanced and complicated major grafting
Supported by a vast array of long-term scientific
literature, our treatment philosophy follows Brånemark’s
vision by successfully caring for the edentulous and
terminal dentition patient population through the use of
digital diagnostics and treatment-planning technology,
minimally invasive, graftless surgical procedures,
immediate-load/provisionalized fixed-implant prosthetic
solutions and personalized patient care. ■

FREE FACTS, circle 7 on card \\ MARCH 2018 61

A primer on what it is, how to use it
and which one goes where
To begin reading, turn to p. 64 >
by Dr. John O. Burgess
Dr. John O. Burgess received his dental degree from Burgess is a member of the Restorative Academy,
Emory University School of Dentistry, completing the Operative Academy, the Academy of Esthetic
a one-year GPD and a two-year general dentistry Dentistry and the American and International
program. An adjunct professor at the University Associations for Dental Research, and has
of Alabama at Birmingham School of Dentistry, served on the Council of Scientific Affairs for the
he has authored or co-authored more than 400 ADA. He is active in clinical trials examining the
manuscripts and given more than 1,000 all-day CE effectiveness of ceramic materials, adhesives,
programs nationally and internationally. bulk-cured composite and bioactive materials.
Burgess would like to thank Ivoclar Vivadent and
Dr. Tom Hill for their assistance with this article.

62 MARCH 2018 //

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Introduction because these factors affect the success or
A 2015 survey reported that the most- failure of the final restoration.
prescribed ceramic material for posterior
crowns was monolithic zirconia, with lithium What is dental zirconia?
disilicate most often prescribed for ante- Zirconium is a soft silver-colored metal
rior crowns.1 This increase in prescribing found as a mineral called zircon (ZrSiO4).
full-contour zirconia as the favored posterior It is mined primarily from large deposits
ceramic material is due to several factors: in Australia and Africa and shipped to
• An increased demand for processing plants such as Tosoh (Japan), the
aesthetic restorations. largest producer of refined zirconia powder.
• The increased cost of metal Zircon is purified and during the production
(gold $1,340/ounce). process metal oxides are added: yttrium
• Zirconia being a strong to stabilize the polycrystals; aluminum to
aesthetic material. prevent water corrosion; hafnium oxide to
• The development of reduce pore development; and other coloring
CAD/CAM systems. components to produce a powder that is
Zirconia was introduced as a framework pressed into a disk or block and partially
for dental restorations, which was veneered sintered.
with feldspathic porcelain. At the time of its The partially sintered zirconia is milled
introduction, few computer-aided design and into a framework or restoration, then further
computer-aided manufacturing (CAD/CAM) sintered, which produces approximately
systems were available to fabricate milled 20 percent shrinkage in the finished resto-
zirconia restorations. ration. The density of zirconia is recorded
With the development of newer, more on each block or puck, because density
accurate CAD/CAM systems, milling determines the shrinkage during sintering.
zirconia restorations became commonplace. The mill enlarges the final restoration
The introduction of zirconia was a perfect to compensate for the shrinkage during
fit with the improved CAD/CAM systems, sintering.
producing relatively inexpensive aesthetic Zirconia is a polymorphic material
restorations with improved mechanical that may exist in three crystallographic
properties. forms, depending on temperature and
Zirconia has evolved through several pressure: monoclinic (stable at room tem-
significant modifications, and clinicians perature up to 1,170° C), tetragonal (stable
must be aware of the properties and at 1,170–2,370° C), and cubic (stable from
differences between zirconia materials over 2,370° C to its melting point, 2,716° C).
At room temperature, pure zirconia is present
in the most stable phase, monoclinic. As the
temperature rises to about 1,170° C, the
monoclinic phase transforms into
the tetragonal phase, accompa-
nied by a shrinkage in volume of
approximately 4–5 percent. The
tetragonal phase converts into the
cubic phase at about 2,370° C,
with only minimal changes in

64 MARCH 2018 //

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Fig. 1: Maxillary second bicuspid zirconia crown cemented in vivo.

Dental zirconium dioxide is formed into toughness describes the ability of a material
a polycrystalline ceramic called yttrium- to resist crack propagation or how a crack
stabilized tetragonal zirconia polycrystals, spreads from a notched specimen. Cracks
or simply “zirconia.” Materials containing originate from flaws in materials—created
only tetragonal phase are strongest, while by finishing, machining or porosity—and
cubic-containing zirconia is significantly act as an initiation point for crack growth.
weaker but more translucent (cubic zirco- For example, a car windshield hit with a
nia). The yttrium oxide, or yttria, content rock chips the windshield, and the crack
largely defines the mechanical and physical spreads from the chipped area across the
properties: windshield.
• Zirconia containing 3 mole-percent The energy required to grow the crack
yttria is strongest (100 percent is measured by fracture toughness. Low
tetragonal phase) but most opaque. toughness can lead to chipping and bulk
• Zirconia containing 5 mole-percent fracture in materials. Fracture toughness
yttria produces a more translucent measurements for feldspathic porcelain range
material, with approximately from 1 to 1.3, translucent zirconia, 2–4, and
50 percent cubic phase. opaque zirconia ranges from 7–9 MPa•m1/2.
Yttrium increases the zirconia grain Chipping occurs more frequently in the
size and lowers the coefficient of thermal less-tough veneering materials compared
expansion. with the zirconia frame. 5Y-TZP containing
more than 50 percent cubic phase has little
Ceramic flexural strength or no low temperature degradation and lower
vs. fracture toughness fracture toughness, and because the material
Flexural strength specimens are polished has little residual stress, water corrosion is
or milled samples (2 by 4 by 22 millimeters) limited. High-cubic-containing zirconia
and the strength is affected by the sur- is weaker but its strength does not degrade
face roughness of the specimen.4 Fracture further from low-temperature degradation.

3Y-TZP: Opaque Zirconia 4Y-TZP: Some Translucency 5Y-TZP: Most Translucent

High mechanical properties High mechanical properties Lower mechanical properties
White opaque Some translucency High translucency
Low temp degradation Decreased low temperature degradation Little or no low temperature degradation
Mainly tetragonal phase Tetragonal and cubic phases >Cubic less tetragonal phases
Table 1: Defining zirconia used in dentistry by the yttrium content and its effect on physical and mechanical properties.

66 MARCH 2018 //

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Fig. 2: Crown removed and monoclinic Fig. 3: Opaque zirconia crown on mandibular
transformation being measured using first molar. (Issaquah Dental Laboratory)
X-ray diffraction.

Zirconia evolves eliminated; as long as the tetragonal form was

Unt i l 2014, z irc on ia c ont a i ned present, the positive effect—transformation
3 mole-percent yttria, or approximately toughening—created a transformation zone
5 weight-percent. The original frame or around forming cracks that slowed crack
opaque zirconia materials (Lava, BruxZir, growth, producing few chips and fractures
Cercon, IPS E.max ZirCad, DC-Zirkon) were in the frame material.
composed of yttria partially stabilized tetrag- An accelerated aging test for measuring
onal polycrystals larger than 1 micron (1u) transformation from tetragonal to monoclinic
with a small cubic component. Partially phase is conducted by autoclaving the
stabilized tetragonal crystals spontaneously specimens under steam pressure.7 This
revert to the monoclinic crystal with a in vitro test demonstrates that grain size
3–5 percent expansion by low-temperature affects transformation and, within limits,
transformation. Low-temperature trans- small grains transform more slowly. An hour
formation to the monoclinic phase begins of autoclaving represents approximately
at the restoration surface and produces a 3–5 years of intraoral function. X-ray
rougher occluding surface.3 The fear was, diffraction of aged tetragonal containing
because zirconia was three times harder zirconia, translucent-containing zirconia
than the occluding enamel, that opposing and cubic-containing zirconia demonstrates
enamel wear would increase, and continue reduced low-temperature transformation
to increase as the restoration aged and to monoclinic phase in cubic-containing
the zirconia continued to transform. To zirconia.
reduce this potential wear and reduce the Recently8 the tetragonal-to-monoclinic
opacity of the restoration, the zirconia transformation was tested by measuring the
frame was covered with veneering porcelain. change of partially stabilized (tetragonal-
Unfortunately the veneering material was containing) zirconia crowns (Lava Plus
porcelain with low flexural strength and from 3M) cemented in vivo and worn for
fracture toughness, creating chipping of 12–14 months (Fig. 1). After that period
the veneered restoration.5 the crowns were removed and transforma-
After 2014, the zirconia crystal size tion was measured using X-ray diffraction
decreased to approximately 0.2–0.5u and (Fig. 2). The monoclinic transformation
increased yttria was added to stabilize was 10.6 percent—a small change.8
zirconia by forming the cubic phase, which Opaque (3 mole-percent yttria) den-
decreased low-temperature degradation. With tal zirconia has high fracture toughness
these changes the veneering material was (5–9 MPa•m1/2), with a flexural strength

68 MARCH 2018 //

Fig. 4: Image of two zirconia crowns, first and second molar, Katana ML
puck. Before milling the second molar, the puck was lowered in the mill
and more of the translucent zirconia appeared in the occlusal of the
crown. (This technique was used in the second molar, not the first molar.)

of 1,000–1,400 MPa. The original frame 5 mole-percent yttrium has a flexural strength
zirconia contained 3 mole-percent yttria to of 600–900 MPa and a fracture toughness
partially stabilize the tetragonal phase. Alu- of 2.2–4 MPa•m1/2, compared with opaque
mina (0.025 percent) was added to stabilize 3 mole-percent yttrium-containing zirconia’s
grain boundaries, to act as a sintering aid flexural strength of 1,000–1,400 MPa and
to decrease pore formation during sintering fracture toughness of 5–9 MPa•m1/2. Lower
of the green state zirconia, and to prevent fracture toughness of translucent zirconia
water corrosion. But the alumina produced materials could mean more chipping and
additional opacity in the final restorations cracks in the translucent zirconia material.
(Fig. 3, p. 68). Water corrosion affects all Translucent zirconia has similar but
ceramic materials and leads to decreased higher f lexural strength and fracture
strength with water or saliva storage. toughness compared with IPS E.max lith-
The second major change in zirconia pro- ium disilicate, and this material could be
duced a more aesthetic translucent zirconia by considered a stronger but less translucent
reducing alumina from 0.25 weight-percent lithium disilicate. Translucent zirconia
to 0.05 weight-percent while maintaining the contains approximately 50 percent cubic
same yttria component as the original opaque crystals, which are weaker and do not
frame material. Although the reduction in transform. Zirconia with 8 mole-percent
alumina content produced a more aesthetic yttria will completely stabilize the cubic
restorative material, zirconia was still too phase,7 whereas the third generation of
opaque for anterior restorations. The most zirconia with 5 mole-percent yttria is partially
recent version of zirconia (translucent) stabilized zirconia with approximately
alumina remained at 0.05 weight-percent 50 percent cubic zirconia.7–9
while yttria increased from 3 mole-percent Stabilized cubic zirconia does not trans-
to 5–8 mole-percent, depending upon form at room temperature, and therefore
the brand. At 5–8 mole percent yttria, cubic zirconia will not undergo transfor-
the zirconia contains more cubic phase, mation toughening or low-temperature
preventing low-temperature degradation and degradation. Translucent zirconia has lower
improving zirconia translucency (Fig. 4). mechanical properties but does not transform
Cubic-containing zirconia is more over time.9-11
translucent but has lower mechanical prop- Current zirconia can be classified into
erties.19 Translucent zirconia containing 4 or two basic groups:

70 MARCH 2018 //

Fig. 5: UAB eight-station wear testing machine.

• Strong 3 mole-percent Y-TZP Wear of zirconia and the

(fully tetragonal): IPS E.max opposing enamel
ZirCad LT and MO, Lava Plus, Multiple in vitro and in vivo studies have
BruxZir, Katana HT. reported the low wear of zirconia-opposing
• Cubic phase-containing, more enamel.12–17 Despite the lower strength and
translucent 4–5 mole-percent fracture toughness of translucent zirconia,
Y-TZP (with reduced mechanical no surface fracturing or roughening was
properties): IPS E.max ZirCad MT observed during our wear testing, which
Multi and MT, BruxZir Ant, Lava used a unground enamel cusp and a 2mm
Esthetic, Katana UTML. slide across the ceramic being tested (Fig. 5).

FREE FACTS, circle 43 on card \\ MARCH 2018 71

Light Transmission—Why is Zirconia Opaque?
Result of Birefringence:
Scattering in Grain Boundaries

• Light scattering
Incident light caused by different index
Absorbed light
of refraction of light
Reflected light
due to different grain

Transmitted light • Light scattering

caused by grain
Scattered boundaries, pores
*French RH, et al. Experimental and theoretical determination of the electronic-structure and optical-properties of 3 phases of ZrO2. Phys Rev 8. 1994; 49:5133-5141.

Fig. 6: SEM of zirconia surface with irregular borders showing how light is affected as it
attempts to pass through zirconia. Light is reflected, absorbed, transmitted or scattered
depending upon the crystal border, differences in the index of refraction of light in different
components in the zirconia, and porosity.

Zirconia specimens after wear testing Why is dental zirconia

remained smooth throughout the wear opaque? How is it different
process, and limited opposing enamel wear from cubic zirconia?
was seen. In our laboratory, wear has been Why does a curing light not penetrate
reported in multiple studies comparing wear zirconia? When the properties of a material
of the opposing enamel vs. zirconia, and the are the same in all directions, the material
following can be summarized from the results: is isotropic. For polycrystalline materials
• Polished zirconia wears the opposing like zirconia, the grain orientations are
enamel 10 times less than feldspathic random and have different refraction indexes
porcelain (the ceramic covering (Fig. 6). The tetragonal phase of zirconia is
porcelain fused to metal restorations). nonuniform in a three-dimensional space;
• Polished zirconia wears the opposing therefore, light has preferred directions when
enamel slightly less than Type IV passing through a tetragonal grain of zirconia.
gold-opposing enamel. If light passes through one tetragonal grain
• Wear does not increase with time and then hits another tetragonal grain with
nor autoclaving (an accelerated a different preferred direction at its grain
aging test to induce low-temperature boundary, the light will scatter.
transformation). Cubic zirconia, on the other hand,
• Wear of glazed zirconia was signifi- is isotropic. When light hits the grain
cantly greater to the opposing enamel boundary of two grains of cubic zirconia,
compared with polished, nonglazed it is more likely that they will share pre-
zirconia. ferred directions and allow the light to
• The articulating surface opposing pass through. Birefringence is the optical
enamel should be polished zirconia property of a material having a refractive
in all anterior and especially posterior index that depends on the polarization and
areas. propagation of light. Optically anisotropic
Lack of opposing enamel wear and materials are birefringent. See the path
higher fracture toughness of zirconia has led light takes in attempting to pass through
to an effective posterior restorative material zirconia (Fig. 6).
recommended for patients with bruxism and Light transmission has important
longer-span fi xed partial dentures. implications when light-curing zirconia

72 MARCH 2018 //

restorations. A zirconia thickness of 0.5mm reduction on the occlusal of the prepared
shows a 50 percent decrease in light trans- tooth). Because thin occlusal restorations
mission and a 75 percent reduction at may fracture, bonding the restoration is
1mm thickness. With moderate staining strongly recommended.20 We measured the
and 0.5mm thickness, light transmission fracture strength of sandblasting the intagilo
is reduced by 85 percent; at 1mm there is a surface of zirconia crowns and bonding
95 percent reduction.18,19 them with RelyX Unicem 2 or cementing
Some translucent zirconia has colorants with a resin-modified glass ionomer (RelyX
added internally to improve the chroma of from 3M). The fracture strength of the
the zirconia and to reduce laboratory pro- cubic-containing crowns was maintained
cessing time. The optimal balance between when bonded but not cemented. Bonding
translucency and strength continues to be strengthens thin zirconia crowns.
modified to develop an optimal balance for There are three types of dual-cured
an aesthetic strong restoration. resin cements:
Opaque zirconia may be beneficial in • Total-etch (most retentive):
some cases, especially when masking a single Variolink Esthetic from Ivoclar,
discolored tooth. Translucent zirconia is Calibra from Dentsply.
less translucent than lithium disilicate or • Self-etching (intermediate
enamel; if a highly translucent anterior retention): Panavia V5, Kuraray.
restoration is needed, E.max or layering the • Self-adhesive (less retentive):
facial surface of the zirconia restoration is a Unicem2, SpeedCem Plus.
possible solution. The improved translucent Nonamine dual-cured resin cements
zirconia makes it a more viable option for less have been developed with excellent color
demanding monolithic anterior restorations stability; Variolink Esthetic and Panavia V5
than previous versions of zirconia. are good color-stable resin cements. Both have
Zirconia is supplied in disks, multi- new initiators and no longer use an amine
layered disks and machinable blocks. First system. Total-etch cements require etching
introduced by Kuraray, the multilayered the prepared tooth with phosphoric acid,
disk is now supplied in blocks that can be applying a bonding agent to the tooth and
sintered in ovens with a 30-minute sintering ceramic, and applying a dual-cured resin
cycle, making chairside zirconia milling cement. While total-etch cements produce the
a clinical reality. Ivoclar has introduced greatest retention, light-curing the adhesive
IPS E.max ZirCad MT Multi when high creates a film and may interfere with seating
mechanical strength, low wall thicknesses the restoration. Bonding is indicated with
and high aesthetics are needed. Suitable for short, tapered preparations, with long-span
monolithic and veneered crowns and bridges FPDs and with thin restorations. Bonding
for the anterior and posterior regions, its is not always required.
flexural strength ranges between 850 and It is difficult to bond to the restoration at
1,200 MPa. times because of poor isolation and possible
contamination of the bonding agents. In
Bonding or cementing these cases, cementing with resin-modified
a zirconia restoration glass ionomer requires less time (reducing
Bonding a monolithic zirconia restoration contamination) and provides a successful
is necessary when the preparation is short cementation. RMGIs have easier cement
or overtapered, or when the restoration removal after set and have a successful
lacks the desired thickness (generally 1mm clinical record. \\ MARCH 2018 73

The clean-prime-cement use in this situation are Panavia V5
(CPC) bonding technique (Kuraray) or RelyX Ultimate (3M),
Bonding to zirconia provides predictable because no light-curing of the primer
long-term bonds22–29 if the sequence below or adhesive is necessary with either.
is followed every time. Using a contact cement, the bond
After a restoration is tried in, phosphate forms when the resin cement contacts
groups from phospholipids in saliva occupy the adhesive or primer, preventing
the bonding sites on the zirconia restoration an adhesive film buildup that could
and block the 10MDP monomer. Trying to prevent restoration seating. Our
bond to this surface is like trying to park testing showed that you can bond to
two cars in the same parking space; both zirconia and the zirconia bond is the
cars (adhesives) can’t occupy the bonding same as bonding to lithium disilicate
space. To deal with contamination, these at 24 hours and after 5-month water
procedures are recommended: storage and 10,000 thermocycles.
1. Clean the prepared tooth with fine All groups (lithium disilicate and zirconia)
pumice and water to remove any showed a reduction in bond after water storage.
remaining provisional cement. Clinical implications of this bond durability
2. Clean the intaglio surface of con- are important for conservative partial coverage
taminated zirconia restoration by zirconia restorations, resin-bonded fixed partial
sandblasting with alumina using Etch dentures, onlays and veneers. ■
Master (Groman) or a Microetcher
(Danville Engineering) and 30–50u References:
1. Makhija SK, Lawson NC, Gilbert GH, Litaker MS,
alumina, 30psi for 10 seconds.
McClelland JA, Louis DR, et al. Dentist material selection
Saliva-produced phosphate groups for single-unit crowns: Findings from the National Dental
Practice-Based Research Network. J Dent 2016;55:40-47.
can’t be removed with phosphoric acid 2. Chen, Y-W, Moussi J, Drury JL, Wataha JC. Zirconia
or alcohol, but Ivoclean (Ivoclar), a sat- un biomedical applications. Expert Rev Med Devices
urated solution of zirconia, effectively 3. Kelly JR, Denry I. Stabilized zirconia as a structural
ceramic— an overview. Dent Mater 2008;24;289-298.
decontaminates the zirconia. Sodium 4. International Organization for Standardization. ISO
hypochlorite has been recommended21 6872:2015, Dental ceramic. Geneva: ISO; 2015.
but our testing shows that applying 5. Abdulmajeed AA, Donovan TE, Cooper LF, Walter R,
Sulaiman TA. Fracture of layered zirconia restorations at
sodium hypochlorite to zirconia
5 years: A dental laboratory survey. J Prosthet Dent. 2017
reduces the zirconia-to-tooth bond if Sep;118(3):353-356. doi: 10.1016/j.prosdent.2016.11.009.
Epub 2017 Feb 17.
the hypochlorite contaminates dentin. 6. R. Shahmiri, O C. Standard, J. N. Hart C.C. Sorrell. Optical
3. Prime the clean intaglio surface by properties of zirconia ceramic for esthetic dental restorations”: a
systemic review. J Prosthet Dent 2017
applying Monobond Plus (Ivoclar), a 7. T. J. Lucas, N. C. Lawson, G. M. Janowski, J. O. Burgess.
Effect of grain size on the monoclinic transformation, hardness,
10MDP-containing primer; Z Prime roughness, and modulus of aged partially stabilized zirconia.
(Bisco) or a 10MDP-containing Dent Mater 2015.
8. C.C. Fu and N. Lawson In vivo phase transformation of
adhesive (Scotchbond Universal, dental zirconia J Dent Res 2018.
9. Zhang F, Inokoshi M, Batuk M, Hadermann J, Naert I,
3M).21–28 Monobond Plus or the
Van Meerbeek B, et al. Strength, toughness and aging stability
Kuraray Ceramic Primer have silane of highly-translucent Y-TZP ceramics for dental restorations.
Dent Mater 2016;32:e327-337.
and a phosphate monomer to bond to 10. Zhang Y. Making yttria-stabilized tetragonal zirconia translu-
zirconia. Silane-containing phosphate cent. Dent Mater 2014;30:1195-203.
11. Harada K, Raigrodski AJ, Chung KH, Flinn BD, Dogan S,
bonding systems can be used for Mancl LA. A comparative evaluation of the translucency of zir-
conias and lithium disilicate for monolithic restorations.
lithium disilicate or zirconia, so one J Prosthet Dent 2016;116:257-63
material can simplify your procedures. 12. Lawson N et al. Wear of enamel opposing zirconia and lithium
disilicate after adjustment, polishing and glazing.
4. Bond. The two cements easiest to

74 MARCH 2018 //

Journal of dentistry 42 (2014)1586–1591. on shear bond strength of high translucent zirconia.
13. Amer R, Kürklü D, Kateeb E, Seghi RR. Three-body wear J Dent Res, 2017
potential of dental yttrium-stabilized zirconia ceramic after 22. Tzanakakis EG1, Tzoutzas IG2, Koidis PT3. Is there a poten-
grinding, polishing, and glazing treatments. tial for durable adhesion to zirconia restorations? A systematic
J Prosthet Dent. 2014 Nov;112(5):1151-5. review. J Prosthet Dent. 2016 Jan;115(1):9-19. doi: 10.1016/j.
14. Park JH, Park S, Lee K, Yun KD, Lim HP. Antagonist wear prosdent.2015.09.008. Epub 2015 Nov 6.
of three CAD/CAM anatomic contour zirconia ceramics. 23. M. Özcan, M. Bernasconi. Adhesion to zirconia used for
J Prosthet Dent. 2014 Jan;111(1):20-9. dental restorations: a systematic review and meta-analysis
15. Janyavula S1, Lawson N, Cakir D, Beck P, Ramp LC, Burgess J. Adhes. Dent., 17 (2015), pp. 7-26
JO.The wear of polished and glazed zirconia against enamel. J 24. F. Lehmann, M. Kern Durability of resin bonding to zirconia
Prosthet Dent. 2013 Jan;109(1):22-9. ceramic using different primers J. Adhes. Dent.,
16. Lawson NC, Janyavula S, Syklawer S, McLaren EA, 11 (2009), pp. 479-483
Burgess JO. Wear of enamel opposing zirconia and lithium 25. L. Chen, B.I. Suh, D. Brown, X. Chen Bonding of primed
disilicate after adjustment, polishing and glazing. zirconia ceramics: evidence of chemical bonding and improved
J Dent. 2014 Dec;42(12):1586-91. bond strengths Am. J. Dent., 25 (2012), pp. 103-108
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Enamel wear opposing polished and aged zirconia. zirconia primers with yttria-stabilized zirconia surfaces. Dent.
Oper Dent. 2014 Mar-Apr;39(2):189-94. Mater., 32 (2016), pp. 353-362
18. Kim MJ, Kim KH, Kim YK, Kwon TY. Degree of conversion of 27. H. Xie, F.R. Tay, F. Zhang, Y. Lu, S. Shen, C. Chen.
two dual-cured resin cements light-irradiated through zirconia Coupling of 10-methacryloyloxydecyldihydrogenphosphate to
ceramic disks. J Adv Prosthodont. 2013 Nov;5(4):464-70. tetragonal zirconia: effect of pH reaction conditions on coordi-
19. Kwon SJ, Lawson NC, McLaren EE, Nejat AH, Burgess JO. nate bonding Dent. Mater., 31 (2015), pp. e218-e22
Comparison of the mechanical properties of translucent zirco- 28. M. Inokoshi, A. Kameyama, J. De Munck, S. Minakuchi,
nia and lithium disilicate. 10.1016/j.prosdent.2017.08.004. B. Van Meerbeek Durable bonding to mechanically and/or
[Epub ahead of print] chemically pre-treated dental zirconia J. Dent., 41 (2013)
20. J. Burgess, N. Lawson, G. Morris. Fracture Strength of Zirco- 29. Inokoshi M, De Munck J, Minakuchi S, Van Meerbeek B.
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J Dent Res 2017 (Abstract #2020). J Dent Res 2014;93:329-34
21. Rosentritt M, Behr M, Hahnel S, Preis V. Surface treatment

FREE FACTS, circle 12 on card \\ MARCH 2018 75

by Dr. Bryan Laskin
Dr. Bryan Laskin is a practicing
dentist and self-proclaimed
technology geek in Wayzata,
Minnesota. A 1999 graduate
of the University of Minnesota
Dental School, Laskin is a certified
Cerec trainer, the founder of
Operability, and the developer of
OperaDDS, a total communication
dashboard for
the dental profession, which includes
intraoffice messaging, HIPAA-
compliant secure emails, laboratory
prescriptions and
specialty referrals.

Clear Up
These subtle changes in intraoffice exchanges
matter as much to patients as clinical mastery

Article begins on p. 78

76 MARCH 2018 //

FREE FACTS, circle 23 on card
D Dentistry is moving at an insanely rapid
pace, with new techniques and technologies
being developed almost weekly that transform
the way we deliver care.
In addition to all of the dental innovation,
the rest of our lives is also experiencing the same
explosive change. The mobile environments
we’re surrounded by, coupled with the ubiquity
Communication conundrum
Here are two statistics that illustrate the
horrible state of communication in health care:
First, 50 percent of the time a patient is
in the chair in a medical office, the doctor is
looking at a computer screen. Keep in mind,
in dentistry we don’t get much of a chance
to talk to people, because we’re often “in
of social media, alter the marketplace that we their mouth.”
work in, and quickly shift how our patients Secondly, one-third of all medical errors
select their dental care providers. are caused by miscommunication. Have you
We can place guided implants in five seen the elaborate systems that most health
minutes within 500 microns of where they’re care practices use? I think we in dentistry are
best suited to place the final restorations. Endo probably even worse.
will soon be similarly guided. In my office, When you go to the physician, how many
amazingly aesthetic CAD/CAM restorations times do you have to repeat your chief com-
are placed within 40 minutes of the patient’s plaint? My guess is it is at least three times:
butt hitting the chair. the receptionist, the nurse and the doctor all
In my opinion, though, none of this really ask you the same questions. It makes them
matters to patients. look less like a well-oiled machine and more
Patients aren’t great at evaluating the like they don’t have their systems together.
quality of their care, so it makes sense that the We in dentistry do the same thing—and
amazing improvements in quality that today’s we have fewer variables. There is no reason in
dentistry provides would fly over their heads. I, 2018 that we should not have all the extremely
like many of you, wish that I lived in a world valuable information the hygienist had discussed
where patients would truly value the quality with a patient before we enter the room. In
of care we provide, but instead I’m in the same my office we use a simple checklist through
reality, where that’s just not the case. Quality our practice management software that’s sent
dentistry is incredibly difficult to provide to our to me as soon as possible and includes, in this
patients, who often seem to be doing their best order every time:
to make our job near impossible, grumbling • Patient’s name
as they flop around in the chair. • Changes in medical history
So, from the patient’s side of the chair, • Chief complaint
it’s truly the quality of care that is the most • Perio status
undervalued service in dentistry. But I believe • Restorative needs
that there is a subject just as significant as the anticipated
quality of our care that is as undervalued from • Radiographs taken
the dentist’s side of the chair: communicating • General notes (got
with your team. divorced, just went to
The irony is that many dentists go out of Aruba,
their way to impress patients with things they etc.)
can see, like the latest and greatest technologies In t his
or gadgets. Yet one of the most impressive way, my team
tools—and most inexpensive, too—is some- is all on the same
thing patients never see: good intraoffice page without having
communication. to chase each other down,

78 MARCH 2018 //

or yell down the hall. There are enough bells patient. Plus, how can your team convey
and whistles built into all the software we use that Sally is frustrated today if you mention
daily and, because of that, we often overlook anything related to politics, and might give
just how valuable the most basic features—like you an earful when you enter? The “old way”
intraoffice messaging and alerts—really are. is not acceptable in our office.
The time it takes to craft a single, informative
HIPAA training—
note about an incoming patient and make Operatory oratory get it all done at
that note available to all team members will If you have to describe all the gory details Townie Meeting!
Dr. Bryan Laskin is one of the
not only save patients from having to repeat of the patient’s lack of hygiene while I’m in
speakers at “Get It Done Day,”
themselves, but also give them the immediate the room, you are shaming the patient. This a dental practice training
impression that they were listened to and that is because there are three people involved: the event that condenses the
tasks, trainings and licensure
everyone is working together toward a solution. patient, the hygienist and the doctor. It takes requirements for CPR, OSHA and
It’s not enough to say that you are “ready only three people to have a public forum, and HIPAA compliance renewals. It’s
for an exam” today. I, like most dentists, am I believe that all people over age 18 who aren’t included as part of the tuition at
Townie Meeting 2018, which runs
a linear thinker so I want all the information under the care of someone else should obtain April 11–14 in Orlando, Florida.
sent like a pilot’s flight checklist, where it is any negative feedback one-on-one, because To discover more about the event,
easiest for me to read it. If you poke your head being lectured is one of the top reasons people or to reserve a hotel room at the
Townie Meeting discount rate,
in the room and shout out this information, hate going to the dentist. visit
the patient who’s currently in my chair now So, we send information about the disas-
thinks that my focus is on getting to the next trous state of the patient’s gingiva via intraoffice

FREE FACTS, circle 24 on card \\ MARCH 2018 79

messaging before the doctor enters the room, “How are you doing today?” Now Bob has
then use a verbal cue to remind the dentist to to repeat his story about breaking #3 on a
support the hygiene instructions—something soft piece of bread. Then, after hygiene, when
like, “We discussed how to keep things the doc comes to check on Bob, he tells the
clean in the upper right.” I then can back same story for the third time. Bob gets a
the skilled hygienist’s previous conversation treatment plan for a crown at the end of his
with the patient by stating, “I see what visit but goes home with a broken tooth. The
your fantastic hygienist is talking about. patient’s chief complaint is ignored three
Your gums are angry up there, so be sure to times and often, Bob doesn’t ever come
heed her advice and use the tools she’s given back. This is not acceptable.
you to improve the area. I’m sure she will With good team communication, Bob’s
be excited to see your progress next time!” initial discussion with Mary would be
This keeps the language at a level the immediately passed along to the whole team.
patient can comprehend, validates the hygiene The hygienist, assistant, doctor and treatment
instructions and supports the previous coordinator would all be communicating
conversation with the hygienist, who happens throughout the hygiene visit to validate Bob’s
to be the fuel to your fire regarding case condition, make fi nancial arrangements
acceptance. and get the operatory ready to fi x that #3
Even more powerful is the transformation immediately—if Bob so chooses.
you will have in case acceptance by leveraging When Dr. Jones walks in the room,
complete intraoffice communication with all she needs to say is, “Jane told me you
your team regarding restorative care. Allow broke that tooth we’ve talked about since
me to illustrate this with an example: the day after the last mammoth died. Don’t
Bob enters your office for a routine worry—we’ll get you taken care of shortly
hygiene prophylaxis and exam. Meanwhile, after my evaluation.”
that tooth #3 (an amalgam with 12 pins) Behind the scenes in this example, the
that you’ve mentioned would benefit for a front desk and hygienist have the opportunity
crown finally broke but hasn’t caused him to share valuable information gathered from
pain, so he thought, “I’ll get it taken care the patient and pass it to doctor, treatment
of next time I get my teeth cleaned.” coordinator, etc., through means every dental
He walks into your practice, hangs practice already possesses.
his coat and tells Mary at the front, “Yup, This may seem like a subtle change, but
that tooth Dr. Jones told me about finally in the patient’s mind this is high-quality care.
chipped. She was right!” This is about as
common a scenario as any that we see in Foreseen finish
dentistry. That makes this example powerful, As stated at the beginning, patients
because it could transform many experiences cannot easily or often evaluate the quality
in your practice. of our care. They probably won’t notice the
How is Bob’s situation treated in most latest and greatest technology that you broke
offices today? Mary says something like, the bank to bring into the practice, or be
“Well, Dr. Jones is a genius, so you should aware of the clinical mastery you showed on
have listened to her when she told you a their case. Instead, patients primarily judge
decade ago and had the crown done,” or us on one simple concept: how we make them
maybe, “We can get you taken care of soon.” feel. Other than perhaps alleviating their
Fast-forward a few minutes when Jane, pain, nothing feels better for patients than
the hygienist, brings Bob back and asks, when they feel listened to and understood.

80 MARCH 2018 //

Think of all the greatest customer service yelling details down the hall—try the process
experiences you’ve ever received, and I’d of passing valuable information along the
guess the vast majority of them come down grapevine and just watch the positive impact
to superior communication. The opposite of patients who feel listened to, and a dental Bryan Laskin
is probably also true. Bad experiences come team working off the same page. covers more about
from bad communication. This is backed As a whole, we in dentistry have ignored patient information
up by the fact that many bad reviews and the reality of inefficient and redundant in a free e-book
lawsuits against dental practices are caused communication for too long. Elevate the Discover more about securing patient
information and your reputation in
by poor communications at the front desk care in your practice easily by treating a free five-page e-book. To download
(not poor dentistry). With a better patient team communication as the valuable asset the publication, visit
experience comes increased case acceptance that it is. Your team and your patients will

and production. This kind of change can immediately thank you. ■

take place in any practice without having
to pay a penny to implement it.
Keep everyone in the conversation, and
the opportunities from communicating
effectively increase exponentially. Whether
you use the checklist I provided earlier or
develop your own system—one better than

FREE FACTS, circle 13 on card \\ MARCH 2018 81

Information, Please

The Columbia University College of Dental Medicine is harnessing

the power of data to help transform the field of dentistry

I by Dentaltown special projects editor John Lannon

Imagine, if you will, a dental student preparing for a Class 2 restoration with a new
patient who represents the absolute definition of “skittish.” The student’s instruments,
equipped with radiofrequency identity (RIFD) chips, are laid out on a tray and “smart”
safety glasses sit snugly on the bridge of her nose. The dental chair has sensors in the seat
and drill, and is also equipped with a RIFD reader, biometric sensor and video monitoring.
The chair recognizes the patient and has begun monitoring the procedure, providing the
student with real-time data on his stress levels and her progress in finishing the restoration.

82 MARCH 2018 //

A few minutes into the procedure, the system monitoring all data streams identifies
increased stress in the patient and a nonstandard pattern of activity. It forecasts a high
likelihood of a poor outcome if the current workflow is continued, and sends the student
an alert via her glasses that a potential problem with the current procedure is likely. It
also notifies a senior faculty member that the student may need some assistance with the
restoration, and together they choose a different path of activity with a better outcome
and lower stress for the patient.
Far-fetched? Not really, considering what is happening at Columbia University College
of Dental Medicine and its new Center for Precision Dental Medicine. Data collection
technologies developed with the assistance of Planmeca, a Finnish technology company,
and the application of precision medicine will help the center accomplish two goals: to
offer personalized dental care and to make evidence-based connections between oral and
overall health a reality.

Medical treatment tailored to the individual,

not the average individual
“Precision medicine is probably the biggest thing for the future of the American health
care system, if not the world,” said Christian S. Stohler, DMD, DrMedDent, the dean
of the college. “It will put American health into the center of what shapes the future of
world health. I think there’s nothing bigger than this. It will be more complex, and it will
consider not just the genomic information but also many other data sets, including what
we use in dentistry.”
What is “precision medicine”? According to the Precision Medicine Initiative, a long-
term research endeavor being conducted by the National Institutes of Health and several
other research institutions, it’s an emerging approach for disease treatment and prevention
that takes into account each individual’s variable genes, environment and lifestyle. This
approach should allow caregivers and researchers to predict more accurately which health
care treatment and disease prevention strategies will work in which groups of people.
Contrast this with a “one size fits all” approach, whereby disease treatment and prevention
strategies are developed for the average person, with less consideration for the differences
between individuals.

“Precision medicine is probably the biggest thing for the

future of the American health care system, if not the world.”
— Christian S. Stohler, DMD, DrMedDent,
dean, Columbia University College of Dental Medicine
“Precision medicine will lead to a new kind of medicine that will serve people in their
individuality, as opposed to their average,” Stohler said. “We have learned over the years that
average medicine is not good enough—that average medicine makes too many mistakes.”

Data collection that’s comprehensive and wireless

At the heart of the center’s armamentarium will be data. Through passive data-collection
tools, the center will help tailor care to each patient and offer quantifiable feedback to each
dental student. Electronic dental records will be tied to medical records, better enabling \\ MARCH 2018 83

dentists as well as other providers to treat patients based on comprehensive health information,
rather than just oral disease. The center will also facilitate research that could help future
dentists treat patients based on thousands of parameters—genomic, environmental and
more—rather than just the handful used today.
Among the data-collecting technologies the center will be using are the aforementioned
wireless tracking instruments and a dental chair serving as a data-collection hub. RFID
tags attached to dental instruments, supplies, and student and faculty ID badges, as well
as sensors in the dental chair, will collect never-before-measured data such as in what angle
the patient was seated, for how long and during what procedure an instrument was used.
The feedback instructors provide to students will now be measurable, allowing them to
become more efficient and precise with their care.

“When something bad is happening, don’t wait until the

procedure’s over; shoot up a flag and say, ‘Hey, send over a
faculty member. The student may need help with this patient.’ ”
— Steven Erde, MD, PhD, chief information officer, Columbia
University College of Dental Medicine
The dental chair, assuming a larger role in the instructor/student and patient/provider
interaction, will feature two video cameras, allowing an instructor to view a procedure as it
occurs from the student’s point of view and provide specific feedback on the procedure, as
opposed to the procedure’s result. The chair also will collect data that determines a patient’s
stress levels, providing students with real-time information about the patient’s comfort.
“If you look at a typical surgical procedure in a hospital or in a procedure room, nobody
collects this kind of data,” said Steven Erde, MD, PhD, Columbia University College of
Dental Medicine’s chief information officer. “They might collect biometric data, heart data
and respiration data, but data about the instrumentation itself and how it’s been used? I
don’t think anybody has that kind of data except maybe with surgical robots like da Vinci
or something like that where they might have a log of data.”
Describing the data-collecting process, Erde said, “In a typical environment, patients
are going to come into [the center’s] waiting area. They’ll get registered into the electronic
health record and get a bracelet that will be like every other hospital bracelet, but rather than
having a bar code it will have a RFID chip in it. The difference between a RFID chip and
a bar code is that the chip can be read at a distance, whereas with a bar code, you’ve got to
read that with a scanner—not a lot of difference from the standpoint of privacy and security.
“Patient IDs and chart numbers will be listed just as they are with every other bar code
wristband in every hospital. What we’ll have, though, is the ability to follow the patients
in the facility to track their movements; for example, how long they’re waiting, when they
get to the dental chair, and when the provider shows up,” Erde continued.
“The patient’s RFID tag will be detected by the chair, so the data collected will be
tagged to the patient. Additionally, providers will have RFID chips in their IDs that will
also be detected by the chair. The stream of data that is then generated by the procedure
will have both provider and patient data stored in it.”

84 MARCH 2018 //

FREE FACTS, circle 26 on card
University research with real-world applications
Erde notes that the initial phase of the center’s data collection will be for its own
operational reporting—essentially a Columbia-only system. The second phase will
be to take the raw data and turn it into something more meaningful.
“We want to convert the data about how fast a drill is running when providers
picked it up, when they used water, when they used air, when the chair moved, and
turn it into a digital fingerprint of sorts so we can say a typical procedure for doing
a restoration is all these steps,” he said.
“We expect that this kind of technology will give us the ability to advise students
with a much more significant granularity than the way we have approached it in
the past,” Stohler adds. “Many of the things we do in dentistry are irreversible. For
that reason, we expect that the online feedback with the possibility to use predictive
analytics will give instructors and students feedback relative to ensuring that we are
fulfilling the needs of the patient in the best possible way.”
Erde said the center is currently exploring how to understand the data’s value.
“In this stage, we’re going to start looking at data retrospectively. And if we see bad
outcomes, we want to feed this back into a system that will use (artificial intelligence)
or another stream of analytics to say this: When something bad is happening, don’t
wait until the procedure’s over; shoot up a flag and say, ‘Hey, send over a faculty
member. The student may need help with this patient.’” Essentially, instead of finding
out about a problem after the fact, the center would try to intervene before it happens.

Applications beyond the dental chair

“Precision medicine is not just in the dental school,” Erde said. “It’s also a major
initiative for the medical school. We want to see more collaboration between different
parts of the medical school, so we don’t have just the dental school trying to do this
on its own. This is really a team sport.”
“Given the increasing comorbidity in our population, there’s a tremendous need
to bring together medicine and dentistry,” Stohler agreed. “A system of support for
dentistry needs to be based on the reality in a patient’s medical record.
“We have seen a tremendous increase in diabetes, in a number of inflammatory
conditions, and we are about to experience a transformation in the way we approach
various cancer conditions that are going to be much more chronic than they have
been in the past. The number of chronic conditions in the patient population that
seeks dental care is about to increase significantly, calling for a very different position
of dentistry in the mix of the health care system.”

86 MARCH 2018 //

New technology demands new medical training
Where is this data-driven, personalized technology taking us? In 10 years, when
a patient sits in a dental chair, would the personalized “fingerprint” in her mouth be
so unique that it will allow the dentist to tailor a procedure specifically to the patient?
“I think that’s a fair statement,” Stohler said. “But we also see a problem with
the statement. There will be so much information available that no human will be
able to integrate it in a meaningful way without the assistance of physician support
systems. That forces any kind of provider, whether a dentist or a physician, to
become a very different person in the future health care system.
“At this point in time, we are making diagnostic decisions based on one, two,
three, maybe four indicators of disease. In the future—when you’re looking at the
genome, you’re looking at epigenetics, you’re looking at all the omics—you realize
that the amount of data that needs to be considered to make a personalized decision
can be done only by computers,” he said.

“Precision medicine will lead to a new kind of medicine that will serve
people in their individuality, as opposed to their average.”
— Stohler

“That’s why the integration of dentistry in medicine is so crucial. We need to

train our students to assume a role whereby they are functioning in a very different
way in the 21st century. The support system should give them the information to
carry to the patient and translate it in ways so that the patient can make an informed
decision. That has not been in the past; a diagnosis was something that the patient
walked away with and never challenged.
“Today, we have patients—and we certainly will in the next 10 years—that
have access to the same information about themselves that a physician has. They
will be able to use support systems to make decisions, changing the role of what
we do and what we should contribute to their health and wellness in an enormous
way. And for this, I am grateful that our medical schools will include dentistry in
that process of reshaping the future of the health profession.”

“We have taken the boundaries down, and we would like to be part of shaping
the future,” Stohler said. “I think we have a clear vision of what the future is looking
like, and I think we know what we’ve got to do to ultimately get to the point where
we can demonstrate the utility of the concept of precision medicine.
“The director of the genome project once said the project was similar to
the federal government building a highway system: By doing so, it didn’t tell people
where to drive; it only gave them the tools to go where they wanted to go. I think
that’s what precision medicine at this point in time is: a project with a tremendous
understanding that will lead to a new kind of medicine that will serve people in
their individuality, as opposed to their average.” ■ \\ MARCH 2018 87

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special feature

by Dentaltown staff

Learn more about the newest products
introduced at this season’s dental shows

Acclean One Step 5%

Sodium-Fluoride Varnish
Henry Schein
Acclean One Step 5% Sodium-Fluoride Varnish is an easy-to-use
translucent varnish that sets on contact with saliva and dries to a
natural tooth color. It delivers the highest fluoride concentration
available, with a smooth and even application, and helps treat
patients who have tooth hypersensitivies. The varnish is available
in 0.4-milliliter unit-dose packages in five flavors: caramel, bubble
ASAP Indirect+ Diamond gum, cherry, mint and raspberry.
Polishing System Information:
Clinician’s Choice
The new ASAP Indirect+ Diamond Polishing System helps dentists
refine and create an outstanding shine on all indirect ceramic resto-
rations. Ideal for any tooth surface—occlusal, lingual, interproximal
or facial—the system includes three diamond-impregnated adjusters
(disc, point and cylinder) that allow dentists to make minor adjustments
or remove scratches caused by diamond bur adjustments, and two
spiral wheel diamond-impregnated pre- and final polishers that deliver
a fast, high-gloss polish ASAP.

FREE FACTS, circle 44 on card FREE FACTS, circle 45 on card \\ MARCH 2018 89

special feature

Bulk EZ Dual-Cure Composite

Danville Materials
Bulk EZ is an easy-to-place dual-cure composite that combines
flowable cavity adaptation with high strength and wear resistance—all
in one step. Its self-cure, patent-pending IntelliTek technology is
designed to control and direct shrinkage and eliminate leakage in
all posterior restorations.
Bulk EZ has addressed the limitations in bulk fills that plague
BrioShine Feather Lite Composite current products, such as gap formation and stress from rapid curing.
and Ceramic Single-Use Polishers Among the composite’s many features:
Brasseler USA • Unlimited depth of cure
A convenient and economical alternative to traditional polishing • Complete curing in 90 seconds
and finishing systems, BrioShine Feather Lite Composite & Ceramic in the deepest of cavities
Single-Use Polishers are designed for the universal polishing and • Shrinkage that’s directed
finishing of ceramic and composite materials. Designed to automatically toward the bottom of
adapt to most tooth surfaces, the polishers minimize procedure time the restoration, virtually
by reducing the steps required for optimal results. Additionally, the eliminating voids
polishers lessen overhead costs by reducing dispensing labor and • Long-term color stability
eliminating time-consuming reprocessing. • Universal compatibility with
The Feather Lite polishers are color-coded and feature unique modern, more acidic bonding
markings to provide users with easy identification for application. agents
They’re recommended for use at slow speeds (4,000–6,000 rpm), Information:
with little or no water spray needed to provide excellent results.

FREE FACTS, circle 46 on card FREE FACTS, circle 47 on card

C Notes
Centric Notes
C Notes simplifies the writing of clinical notes by streamlining the time it takes to compose them;
comprehensive treatment notes are created simply by pressing buttons and following prompts. Using
the touchpad benefits of an iPad and “decision making routes,” dentists can write specific notes about
what occurred with each of their patients. The software covers 11 dental departments, so complete
notes can be written for many treatments.
Wish you had a template for every situation? C Notes, described as “templates on steroids,” solves the
problem of producing notes quickly without the need for manual editing of templates. For active practices
where both staff and doctor write notes, C Notes levels the playing field so all notes are written with the
same detail; all users have the peace of mind that comes from knowing that their notes are well written.
Soon the application will integrate with Dentrix practice management software systems, for even more
streamlined office communication.

“C Notes saves me time writing treatment notes. I am able to capture the details
of my procedures without having to use a great deal of mental input. I simply follow
the prompts of the treatments I performed and a very good note is written.”
— Dr. Israel Finger, Metairie, Louisiana

FREE FACTS, circle 48 on card

90 MARCH 2018 //

Cem EZ Adhesive Resin Cement
Danville Materials
Confidence, efficiency, aesthetics and value are attributes
clinicians will experience with new Cem EZ Adhesive Resin Cement.
Using innovative, patent-pending IntelliTek technology, chemists
worked with clinicians to develop a cement that provides exceptional
bond strength, long-term color stability, and universal compatibility
with modern, more acidic adhesive systems.
Cem EZ is formulated to provide excellent adhesion to enamel and
dentin tooth structure and a wide variety of restorative materials; to
protect against microleakage; to be efficient (for some procedures,
such as zirconia, only Prelude One adhesive and the cement shade of
choice is required); to clean up easily; and to provide the same level
of aesthetics found in many of the leading resin cements, without
having to pay premium prices. Three shades are offered: Translucent,
Warm and White Opaque.

FREE FACTS, circle 49 on card

Chlorhexidine Gluconate
0.12% Oral Rinse
Darby Dental
Offered in 4- and 16-ounce bottles, Darby Chlorhexidine Gluconate
0.12% Oral Rinse was created for professional use and in conjunction with
home care for gingivitis, periodontitis, oral irrigation and postoperative
healing. A mint-flavored oral rinse, it reduces bacteria in the mouth
while successfully treating bleeding, swelling and redness of gums.

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special feature

EdgeTaper Platinum Shaping and Finishing Files

EdgeTaper Platinum Shaping and Finishing Files set a new standard in safety and
canal centering by significantly improving the resistance to cyclic fatigue and flexibility.
Proprietary FireWire heat treatment improves the nickel titanium metallurgy, delivering
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EdgeEndo was founded by a practicing endodontist on the idea of creating superior
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Information: 855-985-3636 or

“The EdgeEndo promise is simple: Save money on your files, save time on your
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better procedures while using superior NiTi rotary files and saving users thousands
of dollars is why I created EdgeEndo. At half the cost and twice the cyclic fatigue,
EdgeEndo is all about elevating both your practice and your life.”
— Dr. Charles J. Goodis, Albuquerque

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Composi-Tight 3D Fusion Sectional Matrix System

Garrison Dental Solutions
The Composi-Tight 3D Fusion Sectional Matrix System has been completely
re-engineered to provide a reliable solution to even the most difficult of Class II
challenges. Whether dentists are restoring an entire quadrant, the distal of the canine
or a completely broken-down MOL, Composi-Tight 3D Fusion provides the materials
to achieve predictable results.
Among Composi-Tight 3D Fusion’s components is the world’s first Wide Preparation
Separator Ring, which makes the sectional matrix system versatile and user-friendly.
The ring simplifies what has been one of the most challenging posterior composite
restorations; dentists can now restore these big preps with confidence, knowing that
they can achieve excellent contact and contour without having to take extra steps.
Information: 888-437-0032 or

“The 3D Fusion Sectional Matrix System makes an already great matrix system
even better. Ease of use and perfect contacts every time makes the decision easy. In
addition, the new Wide Prep ring can make that one tricky tooth we all struggle
with more predictable.”
— Dr. Randy J. Kovicak, Muskegon, Michigan

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92 MARCH 2018 //

Estelite Bulk Fill Flow
Tokuyama America
Thanks to its higher aesthetics and strength, Tokuyama America’s new flowable
bulk-fill composite requires no capping layer of another composite for restorations
up to 4 millimeters, offering faster and simpler restorations. Estelite Bulk Fill
Flow’s spherical filler technology provides exceptional aesthetic restorations via
higher shade-matching ability, opacity and glossiness, and its 52 percent higher
compressive strength than other leading flowable bulk-fills allows patients to bite
with confidence.
Lower shrinkage stress and exceptional cavity adaptation ensure that doctors
can rely on Estelite Bulk Fill Flow to provide worry-free restorations that last.
To request a free mini kit, visit and enter promo code “TownPS.”

“With Estelite Bulk Fill Flow, I am able to achieve both speed and aesthetics.
When I first used the product, I couldn’t believe how quickly the restoration could
be completed, and when I polished, it looked as good as the traditional packable
composites I was used to using. I strongly recommend you add this product to your
daily routine as a clinician. It will not disappoint.”
— Dr. Mitri Ghareeb, Ghareeb Dental Group, Cross Lanes, West Virginia

FREE FACTS, circle 53 on card In-Office Solution

T he
In-Office Solution is a
chairside ecosystem
designed to simplif y
the restorative process.
With it, clinicians gain
access to Glidewell Lab-
oratories’ digital support
Futar Cut & Trim Bite Registration resources, with the abil-
Kettenbach LP ity to create restorations
Futar Cut and Trim bite registration, which replaces Futar Scan, is in the office or send cases to the lab—all from a single interface.
“scannable” and has a working time of 15 seconds, plus an intraoral After capturing a digital impression, practitioners can design and
setting time of 45 seconds, for a total setting time of one minute. mill the restoration in the practice. Or, using that same impression,
Nonslumping, it will not flow off the occlusal surface, and its new blue they can send the case to the laboratory with one click.
shade offers clinicians improved readability. Its D-35 final hardness The technologies behind represent an extension of
means it sets rigid to eliminate any risk of vertical distortion when tools and processes proven through years of use. In-office training
articulated, and it trims cleanly with a sharp blade. and setup performed by Glidewell experts is included with purchase,
With six choices—Futar Fast, Futar D, Futar D Fast, Futar D Slow and ensuring users get the most out of the system.
Futar Cut and Trim—Futar bite registration materials allow clinicians Information: 844-949-7184 or
to choose the appropriate material to fit their particular needs.
Information: 877-532-2123 or Glidewell Laboratories’ chief technology officer explains more about in our Townie News Wire video. Click here to watch..

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special feature

Greater Curve Matrix Bands

Greater Curve
The versatility of Greater Curve matrix bands is remarkable; it’s a wonder
G.V. Black didn’t think of it first. Each band has a fast setup with complete
isolation for Class II, III, IV and V composites. No wedging or separating springs
are needed; dentists can bridge wide-open embrasures with ease and restore
anterior and posterior teeth with smooth, tight ana tomical contacts. The
bands work particularly well for subgingival Class Vs.
Information: 866-493-3437 or

“The Greater Curve Band is one of the simplest yet most innovative products in
dentistry. The solutions we create and problems we solve using these bands are unlim-
ited. In our hands on technique courses, Greater Curve Bands always create a buzz
as participants discover a rare gem that they can immediately take back to use in their
practices. A day in my office without a supply of Greater Curve Bands is a bad day.”
— Dr. Bruce J. LeBlanc, Morgan City, Louisiana

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Jiffy Natural Universal Finishing System

Ultradent Products
Ultradent’s Jiffy Natural Universal Finishing System complements the company’s
Jiffy Universal Finishing System. Its pliable, fingerlike polishers are designed to
efficiently and easily reach all tooth surface areas to produce a natural finish on
all ceramic materials, including zirconia. The polishers can also be used to temper
superhigh-gloss finishes to create the look of natural enamel.
The system is designed to be used in conjunction with the Jiffy Universal
Finishing System to give clinicians the options and versatility needed to achieve
the right aesthetic look for their patients. This two-step process allows clinicians to
get the most natural finish they desire on any ceramic material, including zirconia,
lithium disilicate and porcelain.
Information: 800-552-5512 or

“In the search for a system that would adequately polish porcelain and zirconia
after adjusting, I found that the Jiffy Universal System did the job beautifully. It’s
the best polishing system I’ve used yet.”
— Dr. Richard Creaghe, San Rafael, California

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94 MARCH 2018 //

Katana Zirconia Block Listerine Sensitivity
Kuraray Noritake Dental Listerine
The new, multilayered Katana Zirconia Block achieves a balanced A new addition to the Listerine portfolio, Listerine Sensitivity
combination of high translucency and high flexural strength (763 offers first-of-its-kind protection to prevent tooth sensitivity at the
MPa). The blocks, an alternative to lithium disilicate-based glass source by blocking dentin tubules. An alcohol-free occlusive mouth
ceramics for all single-unit anterior and posterior restorations, were rinse powered by Crystal Block technology, it’s specifically indicated
introduced at the Chicago Midwinter Meeting, and are indicated for to block dentin hypersensitivity. Stop wincing; start rinsing.
use with Cerec systems and SpeedFire ovens. Customers will be able Information:
to place initial orders through Henry Schein and Patterson Dental
Supply for shipment at the end of March.

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LUM Subenamel Illumination

Digital Doc
The LUM’s subenamel illumination diagnostic methods extend the detection capabilities of Digital
Doc’s IRIS intraoral camera. Compact and easy to use, the LUM provides instant documentation as well
as detection of all findings.
Its specialized LED technology applies a high-intensity light source to the tooth, positioned so the
light travels perpendicular to the plane of the tooth. In a tooth without impurities, the light will travel
uninterrupted from the buccal surface to the lingual, which can be observed on the occlusal table of the
tooth by its uniform illumination. When a tooth has impurities such as fractures or leaking amalgam,
the light is dispersed, showing up clearly in images that are near X-rays in quality.

“Adding the LUM to our intraoral cameras was as good of an addition as the
intraoral camera itself. I’ve never seen cracks and the shadow of decay so clearly or
vividly. So many areas of ‘ innocent stain’ are confirmed to be decay with the LUM
technology, helping me avoid that ‘watch it’ conversation time after time. With the
LUM, I can now be confident when I say it is decay … or it simply isn’t.”
— Dr. Jordon Caine Smith, Broken Arrow, Oklahoma

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special feature

Locator F-Tx Fixed Attachment System Locator R-Tx Removable Attachment System
Zest Anchors Zest Anchors
The Locator F-Tx Fixed Attach- The Locator R-Tx Removable Attachment
ment System is revolutionizing the System, building on 15 years of clinical experience
way clinicians think about fixed full- with the award-winning Locator, is a better, simpler,
arch restorations by not requiring stronger system that relies on the same restorative
screws or cement to affix the techniques as its predecessor. With the Locator
prosthesis. The system’s design R-Tx, clinicians will realize such benefits as:
allows it to be the only immediate • A novel, new-to-dentistry DuraTec titanium
solution on the market today to carbon nitride coating that’s aesthetic,
rescue a fixed-hybrid prosthesis harder and more wear-resistant.
when an implant fails. • An industry-standard .050-inch/1.25-mm
Included in the system is a hex drive mechanism that requires no
novel “snap-in” attachment that special drivers (excluding connections that utilize a 0.048-in hex
is picked up chairside, ensuring a drive mechanism).
passive fi t while working in har- • Dual retentive features on the abutment and nylon retention
mony with existing screw-retained insert that work in harmony with the redesigned denture
abutments, saving both clinicians attachment housing, allowing for a 50 percent increase in
and patients substantial time, money and frustration. pivoting capability (60 degrees between implants) and providing
Information: easier alignment and overdenture seating during insertion/
removal for the patient.
The redesigned denture attachment housing also incorporates flats
and grooves that resist movement, and is anodized pink for aesthetics.
Information: 800-262-2310 or

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MI Paste One Meridian PM Oral Appliance

GC America The Center for Craniofacial & Dental
MI Paste One, the newest member of GC America’s MI Paste Sleep Medicine
family, is a two-in-one application—toothpaste and MI Paste Plus Recently cleared by the
containing Recaldent (CPP–ACP) and fluoride. As a replacement FDA to treat obstructive sleep
for current toothpaste, it gives users the benefits of cleaning and apnea (OSA) and snoring, the
treatment in a single step. Use it for Meridian PM oral appliance
hypersensitivity, remineralization, represents the next generation
tooth erosion and wear, sensitivity in oral appliance therapy. By
from whitening, and preventing caries holding the lower jaw in a
and white spot lesions. more comfortable position,
Information: it eliminates the potential jaw
pain and changes in a patient’s bite that’s often experienced with
traditional oral appliance therapy.
The Meridian PM appliance treats snoring, OSA and associated
breathing symptoms by stabilizing the lower jaw and training the
tongue to stay forward, maintaining a clear upper airway during
sleep. The natural result is a decrease in the frequency and duration
of apneic and hypopnea events, including snoring. The appliance also
supports oxygen exchange during sleep.
Information: 281-565-4100, or

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96 MARCH 2018 //

Micro 4.5EF Scopes NLZ Electric Micromotor Systems
Designs for Vision NSK
The newest offering in Designs for Vision’s award-winning Micro NLZ Electric Micro-
series, the new Micro 4.5EF Scopes utilize a revolutionary optical motor Systems feature
design that reduces the size and the weight of the telescope by 45 new technology, faster
percent while providing an expanded field view at an accurate 4.5x performance, compact
magnification. design and a new pro-
Information: prietary contra-angle
check function. The NLZ
has the highest torque
in its class (4.2 Ncm), with the smallest dimension. The NLZ-E, the
endodontic version, has both a reciprocating and rotary function,
making it compatible with Dentsply Sirona’s WaveOne files.
With its new technology, the NLZ is more powerful yet lighter and
with less heat generation than NSK’s existing models. The conventional
magnet rotor has been replaced with an improved magnet rotor to
offer more powerful rotation, and the water and air lines are now
integrated with the motor to make maximum use of space.
The Contra-Check Function helps detect abnormalities caused by
deterioration of the electric attachment and insufficient maintenance.
To use it, connect the electric attachment to the motor, press the
Check key and view the results on the Control Unit. If “Oil” or “NG” is
displayed, the motor will automatically slow down and stop.

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NoCord VPS Online Marketing

Centrix Dental Officite
Dr. Ron Perry noted that Even if dentists have the best practice website on Earth, it’s useless
half of the time and cost of if patients can’t find it. Making a practice visible is the first step to
taking an impression is due online success, and that’s what Officite is here to do. Now, as a Google
to retraction/hemostasis. Partner, Officite can help dental practices climb toward the top of the
Addressing this concern, search results, leading to more page views and more appointments.
NoCord VPS, offered in 50- Our experts target each dentist’s area and specialties to help the
and 380-milliliter cartridges, practice rank higher.
is the first and only one-step Information:
self-retracting impressioning 855-878-1563 or
system that removes the time, frustration and costs of traditional
cord retraction.
NoCord Wash incorporates a hemostatic agent to control bleeding
and fluid flows. NoCord MegaBody Tray Material drives the wash
to gently retract gingiva from the tooth. Together, they work as a
complete system to provide an optimal impression result without
separate retraction and hemostasis procedures. Because they are
VPS materials, they deliver the accuracy and dimensional stability
dentists expect from vinyl polysiloxane impression materials.
Information: 800-235-5862 or

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special feature

One Visit Crowns

Cost shouldn’t be a barrier to patients saying yes to the crown treatments they desperately
need. Dentists can add another tool to their box with the One Visit Crown, a procedure that enables
them to create anatomically correct, full-coverage restorations in one appointment without the need
for dental labs or CAD/CAM systems. The efficient procedure means that dentists can offer their
patients excellent prices, increasing patient satisfaction and improving case acceptance rates. The
One Visit Crown is made of 73 percent zirconia-filled hybrid ceramic, with a hard occlusal layer and a
soft underlayer. The system also includes anatomically correct contoured matrix bands, individually
shaped for each tooth shape and size, plus an innovative Stretch Wedge for optimal separation and
consistently tight contacts.
Information: or email

“The OVC gives dentists the potential to grow their practices by offering a service patients
will seek out. A clever and simple system, it can provide an affordable, conservative and aes-
thetic restoration in a single visit. What patient would not be interested in learning more?”
— Dr. Michael Miyasaki, Miyasaki Dental, Sacramento

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PainFree Gel Dentin Desensitizer Phasor Composite Warming System

Parkell Vista Dental Products
With just one 30-second treatment with PainFree Gel Dentin The patent-pending, first-of-its-kind Phasor Composite Warming
Desensitizer, even the most sensitive patients get immediate relief System uses NIR technology to rapidly warm highly filled composite
from painful cold stimuli. With a thick gel consistency that won’t run off compules. With the touch of a button, the system is able to heat
the tooth, it provides more precise, pinpoint placement of medication, composite material to 150 degrees F in seconds and maintain that
providing desensitizing results exactly where dentists need them. temperature throughout the procedure while remaining cool to the
PainFree Gel doesn’t require acid-etching the dentin or anesthetizing touch. This technique provides the benefits of bulk fill, highly filled
patients, which can lower their pain threshold and make the pain and flowable composite in one.
worse. It seals the tooth’s open dentinal tubules with its tripolymer Unlike other devices, the Phasor system is not limited to a single
formulation, penetrating deep down the side walls and grafting the brand of composite. This makes it versatile not only in quick posterior
molecules tightly to the calcium in the hydroxyapatite. This network bulk fills but also with traditional incremental layering techniques in
of polymer chains creates a durable barrier to the movement of fluid, aesthetic regions.
a known cause of tooth hypersensitivity. Warming composite
Information: 800-243-7446 or significantly lowers the
viscosity of the mate-
rial, resulting in better
adaptation, reduced voids
and microleakage, and
improved depth of cure.
Materials remain highly
sculptable, nonsticky and easily shaped during manipulation.
Information: 877-418-4782 or

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98 MARCH 2018 //

PremierAir Hygiene and Diagnostic PrograMill One 5-Axis Milling Machine
Instruments Ivoclar Vivadent
Premier Dental Products The PrograMill One 5-Axis Milling Machine has been designed to mill
Built to high standards by master beautiful, aesthetic IPS E.max restorations. The self-contained milling
craftsmen, PremierAir hygiene and system allows for high precision and convenience, and distinguishes
diagnostic instruments pair it from other mills that require separate filtration or suction units.
comfortable, balanced, ergo- An innovative rotary grinding process, 5XT produces shorter
nomic handles with nonslip duration of the milling process and minimal tool wear, while a camera
grips that require less pressure integrated within the mill automatically records all data on material
to maintain control, which translates and tool use. Now, material management is more expedient than ever.
into less hand fatigue. The PrograMill One is wireless,
The hygiene instruments are exceptionally allowing it to be positioned anywhere
light, weighing just 15 grams, and their precision within a practice or dental laboratory.
tips incorporate 440A steel with SmartSharp technology, It also can be controlled on a tablet or
which ensures well-defined edges and precise angles. smartphone by using its corresponding
The probes and explorers are also exceptionally light, weighing app. This integration between app and
just under 12g. The probes have recessed dark marking, machinery—combined with autoconnec-
making them easy to read and resistant to wear, while the explorers tion capabilities with intraoral scanning
have excellent tactile sensitivity and sharp points for quick detection partners such as 3Shape Trios—makes
of caries, calculus and irregularities. it an asset for dental professionals
Information: or email seeking simpler milling methods and
increased efficiency.
Information: John Isherwood, or 716-691-2233

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special feature

ProMax 3D LE Imaging System

Raising the bar on 3-D technology while lowering the costs for 3-D entry, the new Planmeca ProMax
3D LE provides 2-D and 3-D imaging combined with Planmeca Romexis software, offering great value
without sacrificing quality.
The Planmeca ProMax 3D LE offers:
• 11-by-8-centimeter volume: Capture all teeth, including third molars or airway and third
molars, in a single scan.
• One sensor for 2-D and 3-D images: There’s no need to switch or flip the sensor.
• The ability to take true 2-D panoramic, TMJ and sinus images.
• A 5-year warranty on the unit and a 3-year warranty on sensor.
• Planmeca Romexis implant-planning software, which includes an implant library of more than
66 manufacturers’ content. With the software, dentists can plan and verify implant placement
by using its realistic implant, abutment and crown models.

“There are so many 3-D machines in the marketplace, but I purchased the Planmeca
ProMax 3D because of its Ultra-Low Dose protocol. It delivers the finest images at the
lowest radiation possible in the marketplace. Patient safety is important to me; when we
take radiographic images, we’re always concerned with the dosage that we deliver to our
patients. We’re looking to deliver the lowest dose possible to receive the highest benefit from
the images that we attain, and this machine allows me to do that. I believe the Ultra-Low
Dose protocol on the ProMax 3D gives the finest images available in the marketplace.”
— Dr. Gene Antenucci, Bay Dental Health, Bay Shore, New York

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Rear Delivery System

Engle Dental Systems
A fine complement to the Engle Traverse Chair, the Engle Rear Delivery System,
engineered with feedback from dentists for efficient and ergonomic two- or
four-handed dentistry, is available in doctor-and-assistant or assistant-only
delivery. With an adjustable 22-inch circular tabletop and a height-adjustable
control head, it’s as convenient as it is functional, and is compatible with new
or existing cabinetry.
A smart pairing for the Traverse Chair’s zero-clearance design, the traverse
function saves 10 inches of space behind the patient—suited for rear delivery
and 12 o’clock positioning.
Information: or email

“Operatory equipment like chairs and delivery units should be once-in-a-lifetime

purchases, lasting 30 to 40 years. My Engle equipment has been bulletproof; it’s built to last
(and has for my office), and I get quick support for any issues. It’s really nice to be able to
customize the equipment to fit my need, and I’ve been impressed with the overall engineering
of all my equipment. It’s a great product, and I’m glad I discovered Engle for myself.”
— Dr. David J. Spangler, Beaverton, Oregon

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100 MARCH 2018 //

Varnish Pen
Young Dental
Packaged in a convenient, all-in-one system, the Varnish Pen replaces sticky foil packets, varnish
pools and brush sticks. And say goodbye to double-dipping, thanks to a mess-free applicator
that sends varnish from brush to teeth with a quick twist and easy press. Among the pen’s
additional benefits:
• Great flavors—mint, bubble gum and grape
• Smooth flow—no stringing or clumping
• Clear color—transparent on teeth
• No mixing—it remains homogeneous
Information: Email

“This is such an awesome product. The application is so simple—there is no

mixing and there is no double-dipping. It’s just swiping and swiping on each arch.
It’s also very easy to use; you simply turn to engage the brush, squeeze and apply it. It
is a great product!”
— Sherri Foran, RDH, BSDH, MPA

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Dear Dentist,
If your lease is coming up for renewal in the next 18 months
(or you’re opening a new practice) call or email us to book
a no-obligation telephone consultation and receive a
SheerWhite! In-Office 20% Hydrogen complimentary autographed copy of our new book. It’s the
best investment you can make in your practice.
Peroxide Strips
CAO Group The Lease Coach Services
Using next-generation SheerFilm technology, flexible SheerWhite! L
 ease Negotiations (new & renewal)
Midterm Rent Reductions
In-Office 20% Hydrogen Peroxide Strips easily conform to the teeth Site Selection (& site evaluation)
while holding their potent formula to the enamel without leakage. Building & Property
It takes only one minute for a dental professional to apply them; Document Reviews
patients may then leave the office for the rest of the 30-minute (39 point inspection)
wear time—no isolation or lengthy chair time required. The strips Coaching and Consulting
(One on One)
provide an excellent option for an end-of-appointment in-office Lease Assignments
whitening experience and yield up to three shades whiter teeth in a Operating Cost Analysis /
Auditing Services
single application. Space Measurement
SheerWhite! strips are & Rent Recapture
available in a two-patient intro
Available at
kit and a six-patient value kit, Barnes & Noble, Amazon
both of which include strips or online at
for both the upper and lower
arches. Send patients home Dale (U.S.) (Canada)
with the SheerWhite! Take- 1 (800) 738-9202
Home kit for up to eight shades
whiter teeth when combined
with SheerWhite! In-Office.
Information: 877-877-9778 or

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a Lease Renewal
for Your
Dental Practice
by Jeff Grandfield and Dale Willerton Course description Learning objectives
Dale Willerton, top, Th is course details different avenues After reading this article, the participant
and Jeff Grandfield are dentists can take when approaching their should be able to:
commercial lease consultants.
They are professional speakers commercial lease renewal. If you agree • Understand why it can be so import-
and co-authors of Negotiating to the same terms and conditions as you ant to shop around for alternative
Commercial Leases & Renewals
for Dummies. Contact:
initially did with your landlord, you may sites to move a practice. miss out on numerous benefits. • Realize the amount of advance
time required when approaching
Abstract a commercial lease renewal.
Th ere are numerous challenges you • Understand why one should not
must overcome to ensure a better—and automatically exercise a renewal option.
fairer—commercial lease renewal. To • Recognize why it can be so important
be successful, you must plan in advance, to talk to neighboring tenants in the
consider all other options to move, and be same property.
vocal about what you want or need from • Choose and negotiate for a more
the commercial landlord. appropriate lease length.

Farran Media is designated as an Approved PACE Program

Provider by the Academy of General Dentistry. The formal AGD This print or PDF course is a
written self-instructional article
continuing education programs of this program provider Code: with adjunct images and is Farran Media is an ADA CERP Recognized Provider.
are accepted by the AGD for Fellowship/Mastership and designated for 1.5 hours of CE ADA CERP is a service of the American Dental
membership maintenance credit. Approval does not imply 550 credit by Farran Media. Participants Association to assist dental professionals in
acceptance by a state or provincial board of dentistry or will receive verification shortly identifying quality providers of continuing dental
AGD endorsement. The current term of approval extends after Farran Media receives education. ADA CERP does not approve or endorse
from 1/1/2016 to 12/31/2018. the completed post-test. See individual courses or instructors nor does it imply
Provider ID# 304396 instructions on page XXX. acceptance of credit hours by boards of dentistry.

102 MARCH 2018 //

1. Create competition for your tenancy.
Negotiate on multiple locations simultaneously—especially
with lease renewals. Even if you don’t want to move or cannot
justify a relocation, you don’t have to let your landlord know
that and hand over your renewal on a silver platter. Create
options and play one landlord against another. Let each
landlord know you are receiving other proposals. In addition
Negotiating a to making your landlord re-earn your tenancy, these efforts
lease renewal will help you understand the current market conditions.
Whether you are leasing a Additionally, this often creates a bidding war between
commercial space in a strip mall, landlords, with you winning in the end!
office building or a stand-alone
building for a practice, you will
eventually have to face a lease 2. Start the planning and site selection
process well in advance.
renewal negotiation with a landlord.
Existing dental tenants should begin planning
Starting with the end goal in mind
12–15 months in advance. This allows ample time for
and planning far enough in advance negotiating, completing paperwork, searching for alternate
will make this process much easier. sites (if necessary) and accounting for Murphy’s law.
Most landlords push for a rent
increase during a dental tenant’s
lease renewal. Th is is normal and
something you should anticipate. 3. Avoid automatically exercising options.
The landlord can also increase the Even if you have a renewal option, you may not want
rent by any amount he/she chooses. to exercise it—especially if the renewal term’s rental rate
Much can transpire between when automatically increases or can’t decrease. If you’re certain
you moved in and when you need that your landlord wants you to stay and market rates (the
going rate in the neighborhood) have softened, you may want
to negotiate a lease renewal in a
to negotiate the renewal from scratch. In addition, if you exer-
10-year lease term. Negotiating a
cise a renewal option, this will prevent you from negotiating
lease renewal is not an overnight
on other terms of the lease other than the rental rate, such as
process! This can take some time tenant allowances, free rent, removal of personal guaranties and
and involves a number of items further renewal rights. Starting the negotiations at least three
to consider. months before your deadline to exercise your option will allow
you to use your option as a safety net in the event that you believe
that your landlord may not want to retain your tenancy.

The authors declare that they are paid as consultants or lecturers to health care
professionals or commercial entities, representing approximately 75 clients per year. \\ MARCH 2018 103


6. Negotiate for lease

renewal incentives.
For some reason, dental tenants
neglect—or are simply fearful of—
negotiating for lease renewal incentives.
If your lease is expiring, you should ask
yourself what inducements, like free
rent or tenant allowances, the landlord
would give to a new tenant just coming
4. Keep success quiet. into the property.
Landlords often try to raise the rent because
of a dental tenant’s success. If you’re doing
well in a particular location, you likely won’t
want to move, even with a substantial rental
increase. Some agents and landlords may try 7. Avoid being too optimistic.
to take advantage of tenants, knowing how If your practice isn’t faring well but
expensive it can be to move and set up a new you want to renew the lease anyway,
dental practice. this is false optimism. Unless you
change locations or something about
the way you practice, you should not
realistically expect the next five years to
5. Talk to other tenants. be better than the past five or 10 years.
For lease renewals, talk with other tenants in Moving can be difficult, frightening,
the building who have recently renewed leases. time-intensive and expensive; however,
Ask how these renegotiations went and what sometimes this is absolutely necessary.
the landlord was willing to agree to in terms of
rental rates and further tenant incentives. You
may find out that they have plans to expand,
downsize or leave the property, which may
affect your future decisions.

104 MARCH 2018 //

8. Determine 11. Remember your
your appropriate operating costs.
lease length. Having the lease or operating costs
For new practices, an initial lease analyzed is an effective way to keep the
term is typically 10 years. However, landlord and property manager account-
when renewing a lease, you shouldn’t auto- able. Dental tenants often pay inflated
matically sign for the same or a similar time common area maintenance because
frame without considering your own future. You of padded or miscalculated
may sell your practice or retire. You may require a operating costs. Often, it can
longer term or further renewal options to facilitate a be advantageous for groups
sale of your practice. On the other hand, you may want of tenants sharing the
a shorter term to allow for retirement without a sale of your same property to unify
practice, or to allow for a sale of your goodwill and patients for an operating cost
that does not include the physical location. Consider what is analysis.
right for you.

9. Avoid settling for 10. Negotiate

the same rental payment. to get your
Achieving a rent reduction on a lease deposit back.
renewal is a very real possibility. If the If you’ve paid the
landlord is leasing space to new tenants landlord a deposit, you
at less than what you’re currently paying, should ask for this back
a rent reduction should be achievable. If upon the lease renewal date.
your current rental rate is artificially high As a tenant who has paid
because of your last tenant allowance, a rent rent for 10-plus years, you will
reduction on the renewal term could also be have proven your tenancy. Why
in order. Again, you should talk with other should the landlord keep
tenants who have recently renewed or moved your money?
in to see how much they are paying.

Although it can be, negotiating your
lease renewal does not have to be a difficult
process. Even with multiple avenues of
approach, by keeping these tips in mind
you can renew your lease with ease. \\ MARCH 2018 105


Claim Your CE Credits

Answer the test on the Continuing Education Answer Sheet and submit by mail or fax with a processing fee of $36. Or answer the post-test questions
online at To view all online CE courses, go to and click the “View All Courses” button. (If you’re not
already registered on, you’ll be prompted to do so. Registration is fast, easy and, of course, free.)

1. How should you approach your landlord regarding your renewal? 6. True or false: A dental tenant should renew a commercial lease
A. Search for alternative site options if things aren’t going well.
before contacting your landlord. A. True.
B. Contact your landlord to tell him that you B. False.
want to stay and have no intention of moving.
C. Ask your landlord if he wants to renew you and 7. What is the appropriate lease renewal length?
for a proposal for you to review. A. Two years.
D. Both A and C. B. Five years.
C. 10 years.
2. How far in advance should dental tenants begin planning D. It depends on your personal and practice’s
and selecting sites for their lease renewals? current situation or future.
A. Three months.
B. Six months. 8. When is the ideal and reasonable time for a landlord
C. Nine months. to return your damage deposit?
D. 12–15 months. A. Never—the landlord always keeps the deposit.
B. Within 10 days of your lease expiration.
3. Besides the rental rate, what else can a dental tenant C. Upon the expiration of your current term
negotiate for with a lease renewal? and signing of a renewal option.
A. Tenant allowances.
B. Free rent. 9. Which could be reasons that you may be in line for
C. Further renewal rights. a rent reduction on your renewal?
D. All of the above. A. Market rates have decreased.
B. You negotiated a large tenant allowance
4. True or false: You should share news of your into your initial lease term.
practice’s success with the landlord. C. You have a new landlord.
A. True. D. Both A and B.
B. False.
10. What is the average rental increase that landlords typically
5. Why is talking with neighboring tenants before charge dental tenants renewing their leases?
your commercial lease renewal a good strategy? A. 10 percent of the current rental rate.
A. It will give you a nice break from your workday. B. 15 percent of the current rental rate.
B. You may learn what they are paying for commercial rent. C. 25 percent of the current rental rate.
C. They can tell you if they plan to expand, downsize or leave the D. Whatever amount the landlord chooses.
property, which may impact your decisions.
D. Both B and C.

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error-free or that the content or materials are comprehensive. Any opinions expressed in the materials are those of the author of the materials and not the CE provider. Completing one
or more continuing education courses does not provide sufficient information to qualify participant as an expert in the field related to the course topic or in any specific technique or
procedure. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, expertise, skill and judgment of a trained health-care professional.

Licensure: Continuing education credits issued for completion of online CE courses may not apply toward license renewal in all licensing jurisdictions. It is the responsibility of each
registrant to verify the CE requirements of his/her licensing or regulatory agency.

106 MARCH 2018 //

Instructions: To receive credit, complete the answer sheet and mail it, along with a check or credit card
CONTINUING payment of $36, to:, 9633 S. 48th St., Suite 200, Phoenix, AZ 85044. You may also fax this

EDUCATION form to 480-598-3450 or answer the post-test questions online at This written
self-instructional program is designated for 1.5 hours of CE credit by Farran Media. You will need a minimum
ANSWER score of 70 percent to receive your credits. Participants pay only if they wish to receive CE credits; thus
SHEET no refunds are available. Please print clearly. This course is available to be taken for credit Feb. 1, 2018,
through its expiration on Feb. 1, 2021. Your certificate will be emailed to you within 3–4 weeks.

Negotiating a Lease Renewal for Your Dental Practice

by Dale Willerton and Jeff Grandfield
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For questions, contact Director of Continuing Education Howard Goldstein at \\ MARCH 2018 107

What did March say to all the madness? “What’s all that bracket?!” If you’ve stayed

with us after that awful joke, we applaud your resolve. And if you have real resolve, you’ll
make it through all 68 teams in this year’s bracket until one comes out on top. But do you
know who really comes out on top during the swell of basketball fever? Dentists. Don’t
believe us? Basketball has a rate of 11 dental injuries per 100 athletes, which is the highest

among all sports. Quite a lot for a “no-contact” sport, eh? Here’s a handful of other sports
Saint you ina business.
Patrick, fifth-century missionary You will need: Tequila, shot glasses, a
and bishop, probably didn't know that his handful of crowns, and no shame.

death on March 17, 461, would become a Instructions: Place one crown in a shot
Football Hockey Mixed martial arts
reason for the world to spend $5.38 billion
To make football playersdrink it without
and This onelooking. Guess the
is a no-brainer.
Historically, this one used to
on getting drunk
take the cake back before and buying green stuff. tooth
look like a bunch of wusses, by feeling with your tongue.
After Ronda Rousey’s famous Guess

Ireland's patron
mouthguards were common- saint achieved his sainthood
hockey players wrong?
weren’t re- Take another
defeat, shot.
she Repeat
admitted her until
place. By some estimates,
by converting thousands of the mostly pagan quired to wear helmets until teeth
you've guessed correctly. were so unstable that it
more than half the players the
Irish population to Christians. Presently, we start of the 1979 season. could be three to six months
Mouthguards still aren’t
in the 1950s suffered dental
dump 45 pounds of dye into the Chicago Flossy cup before she could eat an

injuries. Helmets have come mandatory. The stereotypical apple. More recently, fighter
aRiver to make
long way, it flow
which helps. green for fiimage
Keep ve hours,
of a hockey playerYou will need: Solomonrinse cups,
Rogers gotbeer,
mind 13
it wasn’tpints
until of Guinness,withand go
a gap-toothed and
smilea lack
is a of newhardpatients.
in the head that viewers
1962 that pinching
around facemasks were people—which stereotype
in 2018for a reason, and
Instructions: of the
Makefighta could
toast actually
with a rinse

seemsby every
reason player. even today
Thesefor a lawsuit,
enough so bemost pros
cup see
fulllos- see hisall
of beer, drink tooth fly then
of it, out ofposition
days the most common dental ing a tooth or two as a rite of gaping, unconscious mouth.
careful. In the spirit of the fourth-most it so that it hangs over the edge of a table.
injuries occur when fantasy passage. Player Duncan Keith If you haven’t thought of
popular drinking holiday in thehad U.S., weteeth missing
seven With flafter
oss wrapped around
buying yourbanner
a ringside fingers, aduse
football fans grind their teeth

present you with
for 16 weeks. That’s what you these dental drinking
taking a puck to the
the minty
mouth in strand to try
before, to
this fl ip
could the
be acup over
get ... which
for thinking thatyou should
kicker was totallya never do. which
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it lands
be face down on the
opportunity table.
to kick ’em Play
while in
going to be your X factor. some sort of record.teams or alone, they’re
sad. ■ down, so to speak.

humor with bite

FREE FACTS, circle 32 card

108 MARCH 2018 //

FREE FACTS, circle 3 on card



• Up to 2-minutes of adjustable working time gives control

over the pace of the procedure, while the abbreviated 2-minute
thermo-activated set time, saves time and improves patient comfort V-Posil
Time Optimized
• The rapid snap set reduces the time in the critical zone by up
to 50% minimizing potential distortion due to human error
VPS Impression System
resulting in less re-takes
• Heavy Soft Fast material offers an optimal viscosity to load the tray
but remains soft enough after it sets for easy removal from the mouth
• Due to its low polyether-like contact angle of less than 10° V-Posil’s
superior hydrophilicity displaces fluids (saliva, blood, etc.) creating an
enhanced contact to the dental anatomy – yielding more precise impressions
• Exceptional tear strength and elastic recovery ensures dimensional
accuracy of the impression during and after removal

Call 1-888-658-2584
VOCO · 1245 Rosemont Drive · Suite 140 · Indian Land, SC 29707 · ·
FREE FACTS, circle 42 on card