Stephen Malone, DMD 

Our Knoxville, Tennessee, dental practice has grown to where we now have four dentists, as well as four hygienists, six dental assistants, two patient coordinators, a practice manager with two front-office patient care specialists, and one more primary partner in our dental practice—Bob Cutshaw. Bob is a master lab technician with over 40 years of experience and owner of Cutshaw Labs. He has been a partner in care with me for nearly 25 years and collaborates with our doctors on all dental restorations requiring lab work. 

Recently, I was thinking again about how grateful I am for my association with Bob and for the many benefits of having his lab located downstairs within our practice facility. Perhaps, having a lab in-house is something other dentists might aspire to eventually have in their own private practice. 

Bob is involved in care planning just as much as I and the other dentists. We can sit side by side to collaborate on treatment using a combination of digital 3D modeling and analog articulated models and wax-ups. 

For patients with complex needs, he routinely comes into the operatory or the consultation room to meet with patients. As he explains his involvement in their care and how the highest quality materials and latest techniques will be used, they become fascinated in the laboratory methods and technologies. Some request a tour of the lab and want to watch some of the process. 

We use digital designs for all prosthetics. Bob’s professional-grade 3D printers work all day long for predictable, efficient fabrication of custom restorations. Then he hand-paints and glazes the crowns and prosthetics for optimal natural aesthetics. Because he is involved in planning our most complex cases that involve implant supported hybrid denture, he is deeply invested in the details that allow the finished product to be delivered with ease. 

Having his lab in-house allows us to rapidly fix issues that arise, for example, alterations to a restoration when it doesn’t quite fit right or has a slightly incorrect shade. Instead of waiting for days or weeks to deliver back and forth a restoration to an outside lab, we make the changes here on the same day. 

For Patients undergoing clear aligner treatment, we manufacture our clear aligners in-house. If a patient loses or damages a tray, it is immediately replaced so the patient doesn’t lose precious time in treatment. The same goes for our occlusal splints, night guards, sports mouth guards, and Essix retainers. 

One of the branding traits of our practice that has earned us our high reputation is the in-house laboratory. Without a doubt, having this lab just downstairs is a major way in which we enhance the quality of care we provide to our patients. 

By Lee Ann Brady, DMD 

When a crown comes off and we are going to put it back in the mouth, we need to remove the old resin cement that is inside the crown. What is the best way to go about this? 

First, we need to know if the crown is made of zirconia or lithium disilicate. If you have a radiograph of that restoration, you can tell immediately which one of those two things it is. If you don’t, you can always attempt to X-ray it. (That’s what I do.) Alternatively, you can assume the crown is made of lithium disilicate, which is the more technique-sensitive material when it comes to removing cement. 

For crowns confirmed to be zirconia, employing 30-micron aluminum oxide air abrasion effectively clears out the old resin cement. Subsequently, re-etching the inside of the zirconia prepares it for reseating. For crowns presumed to be lithium disilicate, this approach should be avoided to prevent crack propagation. 

In the case of lithium disilicate crowns, two alternative methods can be employed: 

1. The crown can be placed in a porcelain oven to liquefy and evaporate the old resin. However, caution must be exercised to avoid rapid heating of the hydrated ceramic that has been in the oral environment. Rapid dehydration will introduce cracks and lead to crown fracturing. 

1. An alternative method involves using a brown silicone point in a high-speed handpiece, adjusted to lowest speed. A brown silicone point at slow speed effectively removes resin without damaging ceramic. 

How will you know when all the resin has been removed? When etching lithium disilicate, whether using red 5% hydrofluoric acid or Monobond Etch & Prime from Ivoclar Vivadent, any remaining resin will be evident because the dye sticks to it after the etching solution is rinsed off.  

By Lee Ann Brady, DMD 

For addressing the access hole of a screw-retained implant crown, my preferred method involves applying Teflon tape over the hole followed by temporary filling material, such as Telio Inlay from Ivoclar Vivadent. 

I emphasize to patients the importance of maintaining accessibility to the screw for potential adjustments without jeopardizing the integrity of the ceramic crown. Hence, immediately after seating the crown, I ensure no adjustments are needed before doing the filling. 

Patients are scheduled for a final post-op appointment with the surgeon after the restoration is in place. If there are no issues requiring crown removal, the Teflon tape and Telio Inlay may remain indefinitely, monitored during hygiene recall appointments. As long as the temporary filling remains intact, replacement is unnecessary. 

In cases where the Telio Inlay dislodges but the Teflon tape remains intact, I inform the patient of our plan to reapply the temporary filling. However, if repeated dislodgment occurs, leading to inconvenience, we consider transitioning to a permanent filling. In such instances, fresh Teflon tape is applied, and the access hole is filled with composite that precisely matches the crown’s color. 

Even if years pass and the Telio Inlay needs replacement, I opt for a temporary filling for ease of identification if removal is necessary. Only if frequent filling replacements prove bothersome do I consider switching to a permanent filling because I prioritize easy retrievability of the screw. 

Kelley Brummett, DMD 

Resin-based temporary cements are wonderful due to their translucency and their ease of cleanup after light curing. My favorite is TempoCem from DMG.  

To prevent resin-based temporary cement from bonding to the newly placed composite, some dentists apply Vaseline on the prep before placing the provisional. 

Instead of Vaseline, I use glycerin. We keep glycerin in a little syringe in the room, and we put just a smidge in a little dapping dish so I can coat the top of the prep with it. Since beginning to use glycerin, I have not had difficulty retrieving bonded provisionals. 

If your provisionals come off, just get a new and stronger temporary cement. No! I am just kidding! If the provisional comes loose, it is often because you do not have enough space, so excursive interferences are high. When this happens, I engage with the patient in checking their occlusion, and continue to work out the determinants of their occlusion.  

Figuring these things out while the patient is in a provisional that is retrievable due to the ease of the temporary cement used, helps me continue to make progress on their occlusion before moving forward with the final restoration.  

It is not a failure of cement; it is a growth opportunity for discovery and patient engagement! 

Laura Harkin, DMD, MAGD 

Let’s delve deeper into the preclinical interview! 

It’s helpful to understand a patient’s perception of their overall health and oral health, as well as what type of restorative dentistry they’re hoping to have and why they feel the way they currently do.  

Sometimes, an integral family member has influenced the timing of care. For instance, you may hear, “My grandchildren are making fun of my teeth” or “My wife asked me to get my teeth fixed.” From this response, I know that I will need to be sure my patient personally desires treatment before rendering it. I’m also anxious to understand what type of restorative dentistry a patient is considering. For example, are they open to removable prosthetics, fixed crown and bridgework, or implantology? 

Recently a new patient came to my office with an emergency. Tooth #5 presented with the buccal wall broken to the gumline and a moderate-sized, retained, amalgam filling. He immediately said, “I do not want bridgework.” I listened quietly until he elaborated by saying, “When I had this front tooth replaced by my other dentist, I had to take it in and out, and I just found that so irritating.”  

I finally understood that he was referring to a flipper but calling it bridgework. So, it’s important to listen and ask questions when someone seems close-minded about having a certain modality of treatment. Delve deeper into the conversation because it may simply be confusion surrounding dental terminology. 

For the grandparents who ask for a better smile, I’d like to understand their thoughts on the scope of treatment and their expectations. Are they looking for a white, straight, Hollywood smile or a more natural appearance with a little bit of play in the lateral incisors? Are they mainly concerned about stains, gaps, or a missing tooth? Are there other problems they’re aware of such as tooth sensitivity, inflamed gums, or the need for a crown? This input is very important as we continue conversation with co-discovery throughout the clinical exam, diagnostic records, and treatment planning phase. 

Learn to count on your chairside for pertinent information. 

I’m fortunate to always have my assistant, Cindy, beside me for preclinical conversations, comprehensive examinations, and restorative procedures. Sometimes, Cindy interprets a patient’s statement or component of conversation differently than me. She may hear a message that I missed or read body language of which I wasn’t aware. Sometimes, auxiliary conversations between patient and assistant take place after I’ve left the room to complete a hygiene check.  

At the end of the day or in the morning huddle, we always take time to discuss interactions with our patients. Together as a team, we’re more efficient at acquiring accurate information so that we may approach the road to health most effectively for each individual. 

Determine if trust is present. 

As I’m getting to know a patient and before I choose to begin restorative treatment, I seek to understand if trust is present in our doctor/patient relationship. New patients often share past dental experiences, and, unfortunately, some have lost trust in dentistry itself. This may be warranted due to improper care, but it may also be due to a lack of understanding or unclarified expectations regarding a given procedure or material choice.  

It’s not unusual, particularly when a patient is considering a large scope of treatment, to serve as a second or third opinion. Building trust and waiting to be asked for our skills are key necessities before moving forward in irreversible therapy.  

The comprehensive examination, periodontal therapy, splint therapy, and gathering of records are all appointments during which opportunities exist to get to know our patients. True trust often takes time to establish, but the reward reaped is frequently one of empathy, friendship, and the ability to do our best work. 

The more complex the dental treatment plan gets, the more challenging the process becomes. Adding in interdisciplinary care with multiple specialists adds another layer of complexity. We need to clearly plan our sections, and clearly communicate the outcomes we hope for from the other providers.

The Challenges

One of the challenges has been communicating to my orthodontist my visual for the results. The other challenge has been how to visualize tooth movement to optimize my restorative. What has helped me tremendously is doing an ortho setup as well as a restorative wax-up.

My Process

This is a process I use when planning complex cases involving orthodontic and restorative that has helped create clear expectations for everyone.

1. I start my aesthetic treatment planning by drawing white shapes and lines on photographs of the teeth to determine the desired tooth proportions and gingival aesthetics. I’ve blogged about this before in these two articles: Tooth Proportion Aesthetic Ratio and Where the Pink Should Be. I also draw lines on photographs to determine the Anterior Segment Aesthetic Ratio.
2. When a complex restorative case involves orthodontics, I want a clear sense from my white lines of where I want the teeth moved so I can optimize my restorative. I will send a set of preoperative models to the laboratory and ask them to do an ortho setup. Multiple copies of the ortho setup allow us to move the teeth and do a restorative wax-up on the moved teeth. Once I examine the wax-up I decide if the teeth look the way I visualized they would. Do they have the right length to width ratios? Do they have all gingival margins in the right positions? If I were to just do a carved restorative wax-up, I wouldn’t understand if the tooth movement is helpful. If you are not familiar with ortho setups, I recommend reading this article from 2012.
3. Once I have the teeth positioned in an ortho model the way I think will be best for my restorative, I send my orthodontist the model to communicate exactly where I want the teeth moved. The orthodontist provides feedback on what will be involved to get those movements. Based on that, I can balance the risks and benefits of alternative treatment plans and discuss with the orthodontist whether restorative treatment should occur at the very end of orthodontics or be done in phases during orthodontic treatment.

Both dentin and enamel can be worn down at a more than normal pace when exposed to very abrasive toothpastes.

We have learned that this damage is not being caused by the toothbrush, but the material being put on the toothbrush. As the desire to have whiter and whiter teeth has become popular, manufacturers have increased the abrasiveness of toothpaste to more effectively remove the external stains. In addition, tarter control and other newer versions of toothpaste designed to grab market share of consumers can also tend to be more abrasive. 

Ideally, we would like to be brushing with a material that has an RDA (relative dentin abrasiveness) of less than 80, but the FDA allows toothpaste to be sold with an RDA up to 200. The original Colgate toothpaste has an RDA in the 70’s. Most Sensodyne have RDA’s below 85, but several of the 2 & 1 tarter control and whitening have an RDA close to the maximum of 200. The abrasiveness can damage restorations, increase wear of exposed dentin and exacerbate sensitivity. At my Scottsdale, AZ practice, we keep a list of the most common toothpastes with their RDA, so we can discuss this with our patients. 

Prophy paste, even the fine, is generally more abrasive then over the counter toothpastes.

In addition, it is applied using a prophy cup going at 20,000 rpm’s with much more pressure. Even though the incidence is much less frequent, being 2 to 4 times per year instead of every day, this can still be a significant issue. 

A cool little experiment is to take some microscope slides and using your fingers rub prophy paste around on them and then rinse. Look at the slides with light behind them. You’ll be surprised to see a slide is scratched after just one application. This is the same thing that will happen to ceramic restorations. The glaze will be easily scratched. The surface of the crown or veneer will begin to deteriorate. 

Similarly, abrasive prophy paste will increase a patient’s sensitivity if used on exposed roots, accelerate the wear on exposed dentin or cementum, and can damage other restorative materials. The RDA of prophy paste can range from 150 for fine to up over 300 for coarse. Alternatives are to use products like Clinpro 5000 or MI Paste as a prophy product, both of which are low in abrasiveness. In my office, we use a product called Proxyt, from Ivoclar. It is a non-abrasive prophy product and is available in 3 grits and with and without fluoride. All three of the varieties have RDA’s between 7-83 and are safe to use on dentin, cementum, and ceramic. 

Indirect restorations are the mainstay of most general practices.

Deciding whether to take triple tray or full arch impressions is a process that represents the classic dilemma we all face. It feels like we are deciding between “quality” and “economics”. In truth I think there are “quality” and “economic” pros and cons to both types of impressions.

From an economic perspective triple tray impressions are a straightforward decision.

A triple tray and the VPS to take it represent about $10 in materials compared to two full arch trays, VPS material, facebow and bite registration at a cost of about $25 in materials. Additionally a very important economic factor is productive chair time. A triple tray impression should take about 5 minutes of chair time, whereas full arch impressions and all the accompanying records take approximately 15 to 20 minutes.

The balance to the chair time on the front end is the chair time required to seat and adjust the case. In order to do an accurate comparison of the seat appointment we need to discuss the technical risks and benefits of the two approaches. We are going to assume on the front end that both techniques are done with proper retraction and accurately represent the prep and margins. A triple tray impression captures the occlusal information at maximum intercuspal position extremely accurately, but it is the only functional position they can replicate.

Full arch impressions taken without a facebow transfer, either hand articulated, or with a bite registration only over the prepared teeth only give the same information about maximum intercuspal position to the laboratory as a triple tray.

The advantage to taking full arch impressions is that they can be mounted with a facebow transfer and allow the laboratory to see the interaction of the teeth in excursive and end to end positions. A facebow records the relationship of the maxillary arch to hinge axis in all planes of space, and then transfers this information to an articulator. It can also be used to communicate esthetic information about the relationship of the incisal and occlusal plane to the horizon if the bow is leveled when the record is taken.

So the ultimate difference between a triple tray and full arch impressions is the addition of functional information about excursive movements and end-to-end positions. This requires taking a facebow record, and can be increased in accuracy by setting the condylar elements on a semi-adjustable articulator either with a protrusive bite record or an end to end retracted photograph. Using either technique the most accurate bite record is always captured with the unprepared teeth in full occlusal contact. So the decision between the two approaches really depends on the functional and esthetic risk factors of the case. The more esthetic and functional information we send to the laboratory the higher our chances of managing the esthetic and functional issues of the case precisely.