CJCD

The Official Publication of the Canadian Academy of Cosmetic Dentistry

Canadian Journal of Vol. 5 No. 2 I June 2009

Tooth Whitening: Concepts and Controversies

Development of a Functional Occlusion

CJCD_V5N2_JUN09:CJCD 6/25/2009 5:15 PM

Inthis Issue…

features

8 Tooth whitening: concepts and controversiesJohnny Fearon

24 Development of a Functional OcclusionDr. Ron Goodlin

Canadian Journal of Cosmetic Dentistry Vol. 5 No. 2 • June 2009

departments5 President’s Message — Dr. Steve Hill

6 From the Editor — Dr. Edward Lowe

40 Speaking the same Language — Hilary Ford

42 Career & Practice Transitions — Nadean Burkett

45 Announcements

46 Product Showcase

Canadian Journal of Cosmetic Dentistry I 3


4 I Canadian Journal of Cosmetic Dentistry

Executive Board and Staff

Canadian Journal of Cosmetic DentistryThe Official Publication of the

Canadian Academy of Cosmetic Dentistry

This Journal is the official journal of the Canadian Academy of Cosmetic

Dentistry. The CACD is a non-profit organization affiliated with the American

Academy of Cosmetic Dentistry. Bi-annual publication of this journal with the

co-operation of the Toronto Academy of Cosmetic Dentistry occurs twice a

year: April and September. There will be one annual Scientific meeting of the

CACD each year, and moving to different locations within Canada. The

Toronto Academy of Cosmetic Dentistry holds 4 meetings per year, 3 general

sessions where leading speakers in the field of Cosmetic Dentistry present

various topics of current importance. There is an additional Members Only

night open to TACD members and corporate sponsors only. Both the CACD

and the TACD membership is open to all Canadian Dentists with an interest in

Cosmetic Dentistry. For more information, please contact the TACD or CACD

via the Executive Director at 604-669-5550 or online at www.tacd-online.com

or www.cacd.net. We encourage the development of regional Academies of

Cosmetic Dentistry. For more information contact the CACD via Christine

(Executive coordinator) at 604-669-5550, by e-mail at [email protected] or visit

the website at www.cacd.net

CACD Board of DirectorsDr. Steven Hill, British Columbia – PresidentDr. Deborah Cooper�Lall, Alberta – Vice�President, President ElectDr. Robert Knudsen – DirectorMarek Bedynski, Ontario – DirectorsDr. Stephen Phelan, Ontario – DirectorDr. Alain Methot, Quebec – DirectorDr. Jeffery Norden, British Columbia – DirectorDr. Janet Roberts, British Columbia – DirectorDr. Roderick Toms, Ontario – DirectorChristine Wyatt, British Columbia – Executive DirectorTelephone: 604�669�5550Website: www.cacd.net

DisclaimerArticles published express the viewpoints of the author(s) and do not

necessarily reflect the views and opinions of the Editor and Advisory Board.

All rights reserved. The contents of this publication may not be reproduced

either in part or in full without written consent of the copyright owner.

Publisher:Palmeri Publishing Inc.

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Tel: 905-489-1970

Fax: 905-489-1971

Design and Layout: Lindsay Hermsen B.Des.Hon.

Printed in Canada Canadian Publications Mail

Product Sale Agreement 1033352

Editor in ChiefDr. Ed Lowe

Associate Editor Dr. Ron Goodlin

PresidentDr. Steven Hill

Vice-PresidentDr. Deborah Cooper-Lall

DirectorMarek Bedynski, RDT

DirectorDr. Robert Knudsen

DirectorDr. Alain Methot

DirectorDr. Jeffery Norden

DirectorDr. Stephen Phelan

DirectorDr. Janet Roberts

DirectorDr. Rodrick Toms

Executive DirectorChristine Wyatt

PublisherEttore Palmeri, MBA, AGDM, BEd., BA


President’sMessage

The global financial crisis seems to still be aroundus – the depth and extent of its impact to all of us seemthat it will be in the future. The World Bank lowered itsoriginal predictions of growth in most of the world’seconomies but just what does that means to us? Itdepends upon to whom you listen.

Who do you trust?

In this market, do our patients trust us to make theright treatment recommendations or do they fear wecould be financially motivated to promote the more costlyoptions? Trust is as elusive in philosophy as it can be inpractice. In The Republic, Plato tells of an argumentbetween Socrates and Glaucon, Plato’s older brother. Alengthy story is told about a shepherd who finds a ringthat makes him invisible. Glaucon argues that only thefear of detection and punishment prevents a human beingfrom acting for the sake of his own self-interest.

In his discourse, On Trust and Philosophy, Tom Baileyargues, ‘But the heart of trust lies elsewhere… my relianceon others can be ensured simply by their takingresponsibility for how their behaviour will influence mydecisions about how to act in a particular regard… If I trustthe doctor to prescribe me appropriate treatment, I rely on

her because I believe that she has taken responsibility forher role in my decisions about my health. Indeed, I mayeven allow her to effectively make these decisions for me.’

As dentists, we prescribe procedures for our patientsbased on a manufacturer’s recommendation? What is thescience behind it? Is it objective? Clinically, is this newprocedure similar to those we or our colleagues have somehistory and clinical experience with? These of course aresome of the questions we all have to ask ourselves daily.Fortunately, we have many ways to obtain reliableinformation about the changes and challenges in ourprofession in order to be responsible for our patients, butto whom will we turn for assuming responsibility for theeconomic global markets?

The challenge the financial markets has in dentistrythen is to become as responsible as possible for our clientsand patients. Then trust will follow.

ReferencesBailey, T. On Trust and Philosophy. BBCi. The Open University.Open2.net

Dr. Steve Hill,President

A Matter of Trust…




From theEditor Dr. Edward Lowe,Editor

I dropped in to a colleague’s office recently because thedoctor had requested some assistance on a challengingcase. His reception area had 2 people waiting, and thereceptionist was intent on her screen with pursed lips and ascowl on her face. She didn’t so much as glance up at me,and continued to ignore me for an additional 30 seconds.Had I been there to theoretically spend money, herwelcome behaviour alone would have changed my mindand I would have voted with my feet! This is the same galmy colleague counts on to ‘close’ his cases once patientsleave his chair. He says his numbers are way off, and simplyblames the economy. But, her poor attitude wascontagious – so do you think her behaviour may have apart in all this? How can we control our teams’ attitude?

Recently, my marketing company trained us in a DentalSales program. This was a 2 day seminar event combinedwith post seminar ‘homework’ to ensure that the trainingwas being used. Most professional offices, whethermedical, legal, or dental never entertain such aninvestment of time and resources. Very few people in‘professional’ positions understand they have a direct salesrole in the final acceptance of customer cases. Therationale is basic: every member of your team or staff is asalesperson, and some are simply better than others. If ateam member hates the concept of selling, she or he isundermining everything the rest of you are trying toaccomplish. They are ‘unselling’ you. This concept of‘selling’ may seem foreign, but the last time I checked wedental professionals also have payroll, rent, utilities,insurance, lease payments etc. That sounds like identicaloverheads that other business people enjoy – and theymust typically ‘sell’ their wares to someone to survive.Perhaps we better take a page from their book.

The consumer today is savvy and fickle. Thanks to theinternet, patients do arrive in our chair with anuncommon familiarity with dental options, pricing, andin some cases real misconceptions we must correct.Everyone on your team has a specific duty to provide allthe information your prospects require in order to maketheir best decision. Today’s buyer has a set number ofconditions that must be ‘right’ in order to facilitate thedecision to buy. There is a logical chronological order withpoints that must be satisfied in order for the ‘buying mind’to move forward. Most practices try and close the deal(be it cosmetic, implant, or restorative) before it is actuallyopen. This is not unlike asking the girl to marry youduring your first dance! Not only is it doubtful they willaccept, but you actually hamper the chances of ever

accomplishing your goal because you are trying to jumpfrom step 2 to step 5 with little regard for the otherpsychological conditions that must be satisfied.

In our workshop we learned the most appropriate ‘close’ Ihave ever experienced – one that doesn’t alienate the patientif they do not immediately accept. It is really abouteducation and communication. In dental school I neverstudied sales techniques, nor has any of my team in theirtraining. Every new technique requires repetition andscripting at least 20 times before it becomes a ‘habit’, so ourfacilitators rehearsed us in this workshop environment withrepeated role playing until it became second nature. Frankly,without the discipline and supervision in this role playingexercise, this program couldn’t work to its full extent.

A sidebar – if you happen to have an employee who is inreality ‘not’ a team member – an off-site 2-day workshopwill be troubling for them and this will be self evident.None of us can afford to have the wrong people in anyposition in our practices, so this type of intensive teamtraining may lead to a restructuring of positions withinyour office. It has been proven that making the wrongdecision in hiring a key member of your team will cost youa minimum of six figures annually. Most dentists hire toofast, and fire too slow. Keeping the wrong individual in theincorrect position prevents them from being more satisfiedelsewhere, and it is disastrous to your pocketbook. Thesesame team members accumulate ‘lost opportunities’ notonly in new patient numbers but also in acceptance ofrestorative work with existing charts because they justdon’t communicate efficiently - and the consumer leavesyour office to ‘think about it’.

Our practice was able to develop our own scripting withpost workshop assistance from Prosales Systems. Each teamposition has not only a responsibility to provide the patientwith the information they want and deserve – but they havean obligation to present a case properly, providing it is in thepatient’s best interests. We are not talking aboutmanipulation or a ‘canned’ process, but rather a structuredapproach to ensure every patient is making their bestdecision with every piece of information they deserve.

If our front end team doesn’t do their job properly, wedon’t get to perform any dentistry. If our clinical teamdoesn’t present cases properly, we don’t earn theopportunity to do advanced clinical work. If we don’t trainour team to professionally communicate in what isabsolutely a consumer sales environment – we cannot shapethe future of our practice. It is time to take a proactive role.You may wish to go to www.prosales.tv and learn more!

If They Don’t Accept Treatment – Who Do We Blame?



Concepts and Controversies

AbstractToday’s society dictates that it is the norm for people to havestraight, white teeth. The demand therefore for tooth whitening indental practice has increased exponentially over the last decade. Acommon approach to achieving this goal is by bleaching. Thisarticle discusses clinical aspects of dental bleaching by providing anevidence-based review of current literature. Topics covered includeaetiology of tooth discolouration, indications for bleaching, itsmode of action, and different types of bleaching regimes,indications and potential side effects.

The Introduction The cosmetic impairment of tooth discolouration,especially in the anterior region, can be treated by anumber of invasive therapies such as indirect crowns andveneers, microabrasion, or by the placement of directcomposite. In certain clinical situations, the procedure oftooth whitening or bleaching can be employed as a lessinvasive alternative to restoration with either ceramic orcomposite. Bleaching of teeth can be achieved either by anexternal – or vital – approach (nightguard vital bleaching)(Heywood 1991), where vital teeth are bleached by directcontact with an agent such as carbamine peroxide, or byan internal – or non-vital – approach, where non-vitalteeth are bleached with an agent such as sodium perboratein a walking bleach technique (Attin et al 2003). A thirdapproach, which is a modification of both techniques, canbe employed when bleaching vital and non-vital teeth inthe same arch. This is called inside/outside bleaching(Settembrini et al 1997). The aim of this review is to discussthe concepts involved in both the vital and non-vitalbleaching of teeth, and to provide advice, based on theevidence from current literature, to reduce the risks ofcomplications and to ensure successful bleaching therapy.

Causes of Tooth Discolouration Tooth discolouration may be described as intrinsic,extrinsic or a combination of both (Hattab et al 1999). Itvaries in appearance, aetiology, severity, localisation andadherence to tooth structure (Dahl and Pallesen 2003). Thecauses of intrinsic tooth discolouration can be attributedto changes to the structure of dentine or enamel (Fig. 1), orby incorporation of chromatogenic material into toothtissue, either during odontogenesis or post eruption. Themain cellular changes observed in intrinsically stainedteeth often provide a clue to the aetiology of thepathologic process involved. Discolouration can manifestas either a red, brown, grey or yellow appearance. Internalpulp bleeding caused by trauma or pulp extirpation cancause a temporary red colour change to the crown.

Then, as blood degenerates and breaks down, productssuch as haemosiderin, haemin, haematin andhaematoidin release iron (Dahl and Pallesen 2003). Theiron can be converted into black ferric sulphide withhydrogen sulphide produced by bacteria, which causes agrey staining of the tooth. In addition to blooddegradation, degrading proteins of necrotic pulp tissuemay also cause discolouration. If pulp tissue is notcompletely extirpated and remains in the pulp horns,discolouration may result from the break up of theproteins of the necrotic pulp tissue (Guldener andLangeland 1993), causing a grey or brown hue to the crown(Fig. 2). Yellow discolouration is often due to thereactionary laying down of tertiary dentine sclerosing theroot canal and pulp chamber. Because enamel is relativelytranslucent, the additional volume of dentine obliteratingthe pulp chamber produces a yellow hue to the crown(Fig. 3) (Faunce 1983). Intrinsic discolouration is alsocaused by exposure to high levels of fluoride, tetracycline

Johnny Fearon talks about clinical aspects of dental bleaching by providingan evidence-based review of modern literature

Tooth Whitening:

Johnny Fearon

CJCD_V5N2_JUN09:CJCD 6/26/2009 9:32 AM

administration during childhood, inheriteddevelopmental disorders, jaundice in childhood,porphyria, caries, restorations and trauma to thedeveloping tooth germ. After eruption, ageing, pulpnecrosis and iatrogenesis are the main causes of intrinsicdiscolouration (Olgart and Bergenholtz 2003). Extrinsicstaining results mainly from dietary factors and smoking(Fig. 4). Foods containing tannins such as red wine, coffeeand tea can give rise to extrinsic stain. Carotenes inoranges and carrots, and tobacco use, whether it issmoking or chewing, also give rise to extrinsic stain (Wattsand Addy 2001). Wear of tooth structure, deposition ofsecondary dentine due to ageing or as a consequence ofpulp inflammation, and dentine sclerosis affect the light-transmitting properties of enamel and dentine, resulting ina gradual discolouration. For example, tetracyclinestaining is persistent, whereas discolouration of ageingresponds quickly in most instances (Heywood 1995).

HistoryThe first publications describing techniques andchemicals for bleaching non-vital teeth appeared in thelatter half of the 19th Century. The bleaching agent ofchoice was chloride of lime (Dwinelle 1850). Otheragents described for the bleaching of pulpless teethincluded aluminium chloride and hydrogen peroxide,

used either alone or in combination with heat. The activeingredient common to all the early medicaments was anoxidising agent, which acted either directly or indirectlywith the organic component of the tooth. Concern aboutthe side effects of some of these agents was justifiedhowever, because some chemicals used were ver ypoisonous, such as cyanide of potassium (Barker 1861).The walking bleach technique that was introduced in1961 involved placement of a mixture of sodiumperborate and water into the pulp chamber, which wassealed into place between dental visits (Spasser 1961).This method was later modified by replacing water with30-35% hydrogen peroxide to improve the whiteningeffect (Nutting 1963). Although most of the earlypublications described non-vital bleaching, a 3%solution of Pyrozone was used safely as a mouthwash asearly as 1890, which not only reduced caries, but alsowhitened teeth (Atkinson 1893). The observation thatcarbamine peroxide caused lightening of teeth was madein the late 1960s by an orthodontist (Klusmier), who hadprescribed an antiseptic containing 10% carbamineperoxide to be used in a tray for the treatment ofgingivitis. This technique, which is the method of homebleaching today, was not widely accepted by the dentalprofession until 20 years later when it was described in a1989 publication (Haywood and Heymann 1989).

Fig. 2: Brown/grey appearance of a nonvital central incisor

Fig. 4: Yellow discolouration of the maxillary anterior dentition due toextrinsic agents such as food colouring and tobacco use

Fig. 1: Intrinsic tooth colour change due to tetracycline staining

Fig. 3: Yellow intrinsic discolouration of the upper right central incisor dueto sclerosis of the pulp chamber




MechanismHydrogen peroxide is a colourless liquid with a bitter tasteand is highly soluble in water to give an acid solution. Ithas a wide number of industrial applications, for examplebleaching or deodorising textiles, wood pulp, fur and hair,and in the treatment of water and sewage. Hydrogenperoxide, a reactive oxygen species, acts as a strongoxidising agent through the formation of free radicals(Tredwin et al 2006), which attack the organic moleculesresponsible for tooth discolouration. When complex,pigmented organic molecules (chromaphores) are brokendown by the action of free radicals, simpler molecules areproduced, which reflect less light (Frysh 1995). Duringtooth bleaching, more highly pigmented carbon ringcompounds are converted to carbon chains, which arelighter in colour. The carbon double bond chains (yellowin colour) are converted into hydroxyl groups, which areessentially colourless. The radicals also reduce colouredmetallic oxides like Fe2O3 (Fe3+) to colourless FeO (Fe2+).The bleaching process continues until all of the originalpigment is rendered colourless (Albers 1991). Thechemistry of carbamine peroxide, used for nightguard vitalbleaching, is slightly different from hydrogen peroxide as italso contains urea, which permits the peroxide to remainin contact with the tooth for longer. Although the actionof carbamine peroxide also causes the breakdown ofpigmented carbon compounds as described above, thedegradation is slower than with hydrogen peroxide alone.

External (Vital) Bleaching The bleaching of vital teeth can occur inside the surgery(power bleaching) or outside the surgery (nightguard vitalbleaching). Power bleaching accomplishes completelightening during treatment in the surgery, whereasnightguard vital bleaching involves the application of aperoxide gel to the tooth surface via some means of carrier,usually a custom fitting bleaching tray.

Power Bleaching Power bleaching of vital teeth generally uses a highconcentration of peroxide solution (35-50% hydrogenperoxide) placed directly on the teeth, often supplementedby a heat or light source to activate or enhance peroxiderelease (Feinman et al 1987). Because the hydrogen peroxideconcentration is so high, soft tissues must be very wellprotected to prevent injury (Fig. 5). Definite indications for itsuse include treatment of generalised gross staining such astetracycline staining and perhaps dentine sclerosis, whichtake a long time using the nightguard vital bleachingtechnique, and for patients who may have difficulty incompliance with the nightguard vital bleaching technique.

Power Bleaching has Several Potential Disadvantages: 1. Neither the patient nor the dentist can exactly control

the amount of lightening (compared to the nightguardvital bleaching technique). The technique runs the riskof both over- and under-bleaching.

Fig. 7:Take-home

bleachingtray in situ

Fig. 6: Take-home bleachingtray, extended as far as the

gingival margin

Fig. 5: A whitesilicone barrier

material is usedto protect the

gingival tissuesduring power

bleaching



2. The fee is usually higher as a greater amount of chairtime is required.

3. There is a possibility of soft tissue damage due to thecaustic nature of the high concentrations of peroxide.

4. There is a greater risk of post-operative sensitivity(Goldstein 1988). A higher incidence of tooth sensitivity(67-78%) was reported after power bleaching (Heywoodand Berry 2001, Cohen and Chase 1979) compared withthe nightguard vital bleaching method, using 10%carbamine peroxide (15-65%) (Nathanson and Parra1987, Heywood 1996, Leonard 1998, Schulte et al 1994).

Nightguard Vital Bleaching Nightguard vital bleaching, or ‘take home’ bleaching, isthe more commonly used bleaching technique because itis easy to perform and is generally less expensive for thepatient. It involves the use of a 10-20% solution ofcarbamine peroxide in a gel form (approximately equal to3.4-7% hydrogen peroxide) delivered to the tooth surfaceby a custom-made, vacuum formed, plastic bleaching tray(Figs. 6 and 7). Manufacturers have offered carbamineperoxide in a variety of different concentrations, rangingfrom 10% to over 20%, but the best combination of safety,limited side effects and speed of action is obtained with a10% solution of carbamine peroxide approved by the ADA(American Dental Association). Products carrying the ADAaccepted label have passed a rigorous set of safety andefficacy standards (Tam 1999). A survey by Christensen(1989) indicated that 90% of dentists surveyed used a 10%concentration of carbamine peroxide for take homebleaching (Christensen 1991). Although the evidence basein the dental literature on the efficacy of nightguard vitalbleaching is mostly limited to case reports, it is generallyadvocated that most teeth are susceptible to bleaching(Tam 1999). The process requires longer contact timecompared to power bleaching, but it is safe and the resultsare generally excellent (Fig. 2). The first subjective changein tooth colour is generally observed after two to foursessions of bleaching. In a clinical study of nightguard vitalbleaching with 10% carbamine peroxide, 92% of subjectsexperienced some lightening of teeth after a six-weekperiod (Haywood et al 1994). Another clinical trial by Swift

et al (1999) examined the efficacy of 10% carbamineperoxide nightly for two weeks. They reported that thelightness of the crown of the tooth increased by, onaverage, eight shade units on the Vita¨ shade guide,calibrated according to a lightness value.

Internal (Non-vital) BleachingThe whitening of endodontically treated teeth can becarried out by an internal whitening treatment known asnon-vital bleaching or the ‘walking bleach technique’. Thistherapy involves placement of a bleaching agent into theempty pulp chamber of a non-vital, discoloured tooth, andis a more conservative option compared to restoration withveneers or crowns. The two most common bleachingagents used for this technique are hydrogen peroxide andsodium perborate, and various sources have been applied tospeed up the reaction and improve the bleaching effect. Thedecomposition of hydrogen peroxide into active oxygen isaccelerated by application of heat or light (Howell 1980).The thermocatalytic breakdown of hydrogen peroxide wasproposed for many years as the best technique for thewhitening of non-vital, discoloured teeth because of thehigh reactivity of hydrogen peroxide upon application ofheat (Hardman et al 1985). In this procedure, heat from aspecial lamp or hot instrument was applied to a well of 30-35% hydrogen peroxide in an empty pulp chamber.Temporary restorations impregnated with 30-35%hydrogen peroxide were often used between visits.Although there is little doubt regarding the clinical efficacyof non-vital bleaching using 30-35% hydrogen peroxide(Chen et al 1993) (either thermoactivated or not), seriousconcerns regarding the safety of this technique, inparticular the risk of producing external cervical rootresorption, which is discussed later, have rendered thistechnique unadvisable, and the application of sodiumperborate instead of hydrogen peroxide is nowrecommended. Sodium perborate is a hydrogen peroxidereleasing agent, and since 1907 it has been employed as anoxidiser and bleaching agent, especially in washingpowders and other detergents. It comes in powder form andcan be mixed into a paste or putty with either pure water orhydrogen peroxide. Several studies have reported bleaching

Fig. 8: The distance between the CEJ and the incisal edge is measured with aperiodontal probe on the facial

Fig. 9: Having recorded the measurement between the CEJ and the incisaledge, the periodontal probe now assists in accurate removal of GP



effectiveness by comparing mixtures of sodium perboratewith distilled water or hydrogen peroxide in differentconcentrations. Rotstein et al (1991, 1993) and Weiger et al(1994) did not report any significant difference ineffectiveness between sodium perborate mixed with 3-30%hydrogen peroxide, and distilled water, except for the timetaken to achieve a clinically acceptable result. However,mixing sodium perborate with hydrogen peroxide wasshown to accelerate the rate of colour change. In the case ofsevere discolouration, it is safe to mix sodium perboratewith a 3% solution of hydrogen peroxide; however it is notappropriate to use 30% hydrogen peroxide because of thepossible risk of inducing cervical root resorption (Friedmanet al 1988). This is discussed in more detail below.

Clinical Stages for Internal Bleaching 1. Radiographic Examination: A recent pre-operative

radiograph is necessary prior to treatment to assess thequality of the root canal treatment. The root canalshould be thoroughly condensed along its whole lengthto prevent the apico-coronal migration of micro-organisms or bleaching agents, which may have adetrimental effect on the surrounding tissues. Shouldthe quality of the root canal treatment be suboptimal,the tooth should undergo corrective endodontic therapyprior to the commencement of bleaching (Fig. 8).

2. Preparation of the Access Cavity: The pulp spaceshould be completely debrided of any necrotic material,pulp tissues, or restorative or root canal materials. Thesmear layer on the dentinal surface of the pulp chamberis removed by applying 37% phosphoric acid gel andirrigated with 2.5-5% sodium hypochlorite.

3. Cervical Seal: Gutta-percha (GP) is removed with a roundended, long shank bur to a level of 1-2mm below the CEJ(cementoenamel junction). It is helpful to measure thisdistance pre-operatively by recording the distance fromthe incisal tip to the CEJ on the facial aspect with agraduated probe (Figs. 9 and 10). The coronal access isthen sealed with a glass ionomer cement (GIC) oraccelerated zinc oxide (ZOE) plug to prevent the diffusionof bleaching agents from the pulp chamber throughoutthe root filling, as root fillings do not provide an effectivebarrier on their own (Fig. 11) (Attin et al 2003). Rotstein etal (1992) demonstrated that a 2mm layer of GIC orcomposite is essential. Alternatively, Bergenholtz et al(1982) showed histologically that ZOE cement alsoprovides a hermetic seal.

4. Application of Bleaching Agent: A small drop ofdistilled water is mixed with sodium perborate powder(Amosan ̈Oral-B) until a putty consistency is achieved(Fig. 12). The sodium perborate putty is applied to theempty pulp chamber with an amalgam plugger or

Fig. 10: Good quality root canal treatments,showing thorough obturation and accesscavities prepared for internal bleaching

Fig. 11: Sodium perborate (Amosan ®, Oral-B) mixed withdistilled water to a puttylike consistency

Fig. 12: The pre-operative appearance of the maxillary right lateral and central incisors

Fig. 13: The whitening effect of sodium perborate on the maxillary right lateral and centralincisors after two applications


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similar instrument, covered with cotton pellet andsealed with an adhesive provisional restoration. It isoften difficult to place the provisional restorationdirectly over the cotton pellet without displacing it. Toimmobilise the pellet, it is helpful to first wet the pelletwith a bonding agent and then light cure the bond oncethe pellet is in place. A provisional restoration mustthen be placed, as a sound seal is required around theaccess cavity to prevent leakage of the bleaching agentinto the oral cavity. A light cured GIC or an acceleratedZOE material can be employed for this purpose. Thisprocedure is repeated every three to four days untilsuccessful bleaching becomes apparent. This normallyoccurs after one to four visits (Fig. 13).

5. Permanent Restoration: Once the desired colourchange has been achieved, a sound restoration withsealed dentinal tubules is a prerequisite to a successfulbleaching therapy (Abou Raas 1998). The access cavityshould be restored with a composite, which isadhesively attached to both enamel and dentine. It isrecommended to choose a composite with a high value(light colour) to help compensate if the bleachingtherapy alone does not provide the full extent of desiredlightness. The timing of placement of the finalrestoration is also important, as it has been shown thatthe bond strengths of composite to bleached enameland dentine is temporarily reduced. It is recommendedto wait for at least seven days post bleaching prior tobonding composite as a definitive restoration(Nathanson and Parra 1987).

Inside/Outside BleachingAnother bleaching technique has been described for clinicalsituations where an endodontically treated tooth is presentwithin the arch and the arch as a whole is to be bleached.This technique, called ‘inside/outside bleaching’ allows theendodontically treated tooth to be bleached both fromwithin the sealed pulp chamber (inside) and from the facialenamel (outside) simultaneously. The technique for

inside/outside bleaching involves the fabrication of avacuum-processed plastic mouthguard, trimmed to thefacial and lingual margins as previously described fornightguard vital bleaching. Coronal access to theendodontically treated tooth (or teeth) is achieved and thecoronal GP is sealed with a light cured GIC or acceleratedZOE, as previously described for non-vital bleaching. Thepatient is instructed how to inject 10% carbamine peroxidegel into the coronal orifice and into the nightguard. Thebleach tray is worn for a minimum of two hours, up to amaximum of an overnight period, as described above. Thepatient is then instructed to insert a cotton wool plug intothe coronal access to prevent the ingress of food particles.Once the non-vital tooth has been bleached to anacceptable match with the adjacent teeth, coronal accesscan be definitively restored with a high-value shadecomposite resin, and further nightguard vital bleaching canbe continued if desired (Settembrini et al 1997).

ControversiesTooth Sensitivity Unfortunately the aetiology of bleaching-related toothsensitivity is neither well understood nor easily measured;however the hydrodynamic theory is a mechanismfrequently cited to explain it (Brannstrom 1986).According to this model, peroxide solutions introducedinto the oral environment contact available dentinalsurfaces and cause retraction of odontoblastic processes,resulting in rapid fluid movement inside the dentinaltubules. This ultimately manifests in stimulation ofmechanoreceptors at the pulp periphery, with theresultant feeling of pain when such teeth are exposed tocold or pressure, or even when they are at rest. Toothsensitivity, if present, normally persists for up to four daysafter the cessation of bleaching (Frysh et al 1993, Jacobsenand Bruce 2001, Blong et al 1985).

Patient selection must be carefully considered prior toprescribing bleaching, as some patients are moresusceptible to tooth sensitivity than others. In particular, it

Fig. 14: Generalised gingival recession. This patient presented with severe pain after fourdays of external bleaching with 10% carbamine peroxide



is wise not to recommend bleaching for patients withgeneralised gingival recession (Fig. 14). Age may also havean effect on tooth sensitivity as the dentinal tubules inyounger dentine are wider and enamel is more porous.Also the presence of old, leaking restorations provides amore rapid portal of entry into the pulp for irritatingchemicals. Several agent-related factors can also affecttooth sensitivity. Increasing the concentration of peroxideprovides a more rapid bleaching effect; however it alsoincreases the risk of tooth sensitivity. When prescribing ableaching regime, it is important to differentiate betweenthe concentrations of hydrogen peroxide and carbamineperoxide. A 10% solution of carbamine peroxide isapproximately 3% hydrogen peroxide and 7% urea.Concentrations higher than 10% carbamine peroxide maycause increased tooth sensitivity (Giniger et al 2005).Increasing the temperature can also enhance the effect ofbleaching while also having an adverse effect onsensitivity. A 10% increase in temperature doubles the rateof chemical reaction; however temperatures elevated to aclinically uncomfortable level may result in latent toothsensitivity or even irreversible pulpal inflammation. Inaddition to concentration and temperature, the degree ofbleaching is also related to the amount of time that thebleaching agent is in contact with the tooth surface. Thelonger the time, the greater the lightening effect and thegreater the likelihood of sensitivity (Baratieri et al 1995).

Tooth sensitivity can, however, be reduced by reducingthe amount of time spent bleaching per day, bleaching onalternative days or by the substitution of a desensitisingagent, such as KNO3 gel, into the bleach tray betweenperiods of bleaching. Another approach to reducingsensitivity during bleaching is by the addition ofdesensitising agents such as potassium nitrate (KNO3) orfluoride, in the form of SnF2, to carbamine peroxide toproduce ‘sensitive-formula’ gels. Fluoride acts as a tubuleblocker to limit the fluid flow to the pulp. KNO3 penetratesthe tooth to the pulp and has a numbing or calming effecton nerve transmission. Unfortunately, neither agent hasproven to be particularly effective. KNO3 has a limitedcapacity to achieve antihypersensitivity unless used for

long periods, and fluoride formulations are also slowacting and can cause significant tooth discolouration. In arecent double blind clinical trial by Giniger et al (2005) theeffect of addition of amorphous calcium phosphate (ACP)to a 16% carbamine peroxide gel on the degree ofhypersensitivity was studied. The results reportedsignificantly reduced hypersensitivity compared tocarbamine peroxide bleaching alone after 19 days, both interms of intensity and duration. There was no associatedreduction in the degree of tooth lightening with the ACPsolution. This is the first study to show that ACP added tocarbamine peroxide may reduce hypersensitivity and,although the results appear promising, further research isrequired before making a clinical recommendation for theuse of ACP-containing products.

External Cervical Root Resorption Cervical root resorption is a painless, inflammatory-mediated external resorption of the root, which can beseen after trauma and following internal bleaching. It isusually detected only through routine radiographs;however papillary swelling or tenderness to percussion cansometimes be observed. While the causes of resorption arenot fully known, a review of the literature indicates anumber of possible causes (Lado et al 1983). Patients tendto be younger than 25 years and most report a history oftrauma. From a clinical viewpoint, what does appear to bean important factor is the regime of internal bleachingemployed. It has been proven that formulations usingeither 30% hydrogen peroxide alone, or in combinationwith sodium perborate, are more toxic for periodontalligament cells than sodium perborate mixed with water(Harrington and Natkin 1979). Heating the peroxide with ahot instrument also appears to promote resorption.Application of heat leads to a widening of the dentinaltubules and facilitates diffusion of molecules in thedentine (Pasley et al 1983). Moreover, application of heatresults in generation of hydroxyl radicals from hydrogenperoxide, which are extremely reactive and have beenshown to degenerate components of connective tissue(Dahlstrom et al 1997). Unsurprisingly, therefore, several


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authors have demonstrated that a high concentration ofhydrogen peroxide, in combination with heating, seems topromote cervical root resorption (Baratieri et al 1995).

Table 1 provides an overview of clinical studies inwhich the occurrence of cervical root resorption wasobserved in association with the technique used. Wheninterpreting the data in Table 1 it is important to notethat a large number of cases had suffered known trauma.Perhaps the observation of greatest clinical significance isthat there have been no reported cases of cervical rootresorption following internal bleaching using acombination of sodium perborate and water, or sodiumperborate and a low concentration, i.e. 3% solution, ofhydrogen peroxide. The author was unable to findpublished data on the incidence of cer vical rootresorption using a 10% carbamine peroxide solution inthe inside/outside technique.

StabilityAdvice regarding the long-term stability of bleaching isperhaps the most uncertain aspect of the therapy, asmany factors must be considered when attempting topredict the outcome, including the aetiology and originaldegree of discolouration, dietary and smoking factors,patient age, etc. Data on the duration of both externaland internal bleaching are mostly related to case reports,and only a few clinical trials are available for review. Tamet al (1999) reviewed 23 patients 1.5 and three years postexternal bleaching, and reported that 62% reportedslight or no reversal in tooth colour. Another study byRitter et al (2002) reported that 43% of patients perceivedtheir tooth colour as stable 10 years after a six-weekcourse of external bleaching. Swift et al (1998) reportedthat two years after external bleaching, regression of twoshade tabs on the Vita® shade guide occurred; howeverthe regression occurred during the first six months afterbleaching. Amato et al (Amato et al 2006) evaluated the

chromatic stability of internal bleaching from apopulation of 50 patients after 16 years. They reportedcolour stability in 62.9% of cases.

Effects on Enamel Questions have been raised about the effect of bleachingon the structure of the tooth itself. Surface alterations inenamel topography have been reported in several studies.Shannon et al (1993) evaluated the surface topography ofenamel tabs exposed to 15% carbamine peroxide for 15hours a day, using scanning electron microscopy, anddetected significant alterations compared to a controlgroup. This is due to a detectable loss of calcium from thesurface enamel along with a loss in surface hardnessdepth of approximately 25μm. Bitter (1998)demonstrated that teeth bleached in vivo with 35%carbamine peroxide (35 min/day for 14 days) lost theiraprismatic layer and the damage was not repaired after 90days. However, the concentration of peroxide andamount of exposure may influence the amount ofalteration to the enamel. Using infrared spectroscopy,Oltu and Gürgan (2000) compared the mineralcomposition of enamel exposed to 35% carbamineperoxide, to 10% and 16% carbamine peroxide, anddetected change at 35% but no detectable change at 10%and 16%. A clinical implication of these findings may bethat teeth are more susceptible to extrinsic discolourationafter bleaching due to increased surface roughness.

Effects on Restorations Bleaching has little or no effect on most of the commonrestorative materials (Dishmann et al 1994). Bleachingmay increase the solubility of glass ionomer and othercements (McGukin et al 1991) and reduce the bondstrength between enamel and resin composites, at leastfor a short time. Because bleaching releases oxygeninto the tooth, the oxygen released inhibits the

Table 1: Overview of cervical root resorption observed in clinical studies

Overview of cervical root resorption observed in clinical studies

Abou-Raas (1998)4 112 Wbt: sodium perborate +30% H2O2 No - - 0

Anitua et al (1990)70 258 Wbt: sodium perborate +30% H2O2 No - - 0

Friedman et al (1988)30 58 a) Thermocatalytic - 30% H2O2 No No 1

b) Wbt: 30% H2O2 No No 1

c) Thermocatalytic + 30% H2O2 No No 2

Heithersay et al (1994) 71 204 Wbt: sodium perborate +30% H2O2Thermocatalytic Yes Yes Yes 4

Holmstrup et al (1988)72 69 Wbt: sodium perborate + H2O No Yes Yes 0

Reference SampleNumber

Treatment Heat CervicalSeal

Trauma Resorption


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polymerisation of the resin (Titley et al 1989). A delay ofa week or more following the bleaching process isadvised, prior to the placement of a new composite, toallow for this effect to be dissipated (Haywood 1992).Bleaching may cause a slight increase in surfaceroughness of some types of resin composite, and thehardness may be very slightly increased, but neither isclinically significant (Christensen 1989, Friend et al1991). Bleaching has no effect on porcelain and,although it does encourage the release of mercury fromsome types of amalgam, the clinical relevance of this isnot known (Hummert et al 1993).

ToxicityIt has been reported that the safety of bleaching usingcarbamine peroxide should not be an issue since bothhydrogen peroxide and urea are found in every humancell; however, it must be remembered that the dosemakes the poison. Controversy still does exist regardingthe safety issues of peroxide-containing products.Heymann (2005) has stated that: ‘Literally hundreds ofmillions of teeth in the US have been bleached over thepast 15-20 years without one credible account of anysignificant untoward effect appearing in the literature.Dozens upon dozens of clinical trials over this same timeperiod have also affirmed the safety of vital toothwhitening when used in a shor t-term treatmentduration according to manufacturers’ instructions.However, Heymann accepts concerns regarding thesafety of tooth-whitening products, if not used correctly,by stating that: ‘Valid concerns still exist regardingindividuals who may ignore manufacturer or dentistinstructions and overuse whiteners for months or years.Long-term adverse effects on soft or hard tissues cannotbe totally ruled out when these products are badlyabused or overused’. (Heymann 2005).

Concerns have been expressed over the potentialadverse effects of the use of hydrogen peroxide as ableaching agent. Effects such as localised tissueirritation and external cervical root resorption havealready been discussed. However, clinical studiesaddressing other adverse effects, in particularcarcinogenesis, are lacking (Haywood 2006). Reactiveoxygen radicals are a potential source of cell damage,causing DNA strand breaks, genotoxicity andcytotoxicity. Although these radicals tend neither to crossbiological membranes nor travel large distances within acell, numerous animal studies have demonstratedprecancerous cellular changes, and indeed carcinoma,when hydrogen peroxide has been in direct contact withtissues, indicating that hydrogen peroxide might possiblyact as a promoter (da Costa Filho et al 2002). It istherefore prudent to recommend that until clinicalresearch to address the question of possible mutagenicityis concluded, bleaching therapies utilising highconcentrations of hydrogen peroxide should not be usedwithout gingival protection, and that hydrogen peroxide-containing products should not be used in patients withdamaged oral mucosa (Kinomoto et al 2001).

Conclusion • Whitening of teeth can be achieved either by an external

– or vital – approach, where vital teeth are bleached bydirect contact with an agent such as carbamineperoxide, or by an internal – or non-vital – approach,where non-vital teeth are bleached with an agent suchas sodium perborate, in a walking bleach technique;

• most teeth are susceptible to bleaching; • during tooth bleaching, reactive oxygen produced by

the breakdown of peroxide causes more highlypigmented carbon ring compounds to be converted tocarbon chains, which are lighter in colour;

• increasing the concentration of peroxide provides amore rapid bleaching effect; however it also increasesthe risk of tooth sensitivity;

• tooth sensitivity, if present, normally persists for up tofour days after the cessation of bleaching and can bereduced by reducing the amount of time spentbleaching per day, bleaching on alternative days or bythe substitution of a desensitising agent, such as KNO3gel, into the bleach tray between periods of bleaching;

• there is a greater risk of post-operative sensitivityfollowing power bleaching than with take-homebleaching;

• there have been no reported cases of cervical rootresorption following internal bleaching using acombination of sodium perborate and water, or sodiumperborate and a low concentration of hydrogenperoxide;

• the stability of bleaching is multi-factorial and variable.Only a few clinical trials are available for review;

• enamel may become more susceptible to extrinsicdiscolouration after bleaching due to increased surfaceroughness;

• bleaching has little or no effect on most of the commonrestorative materials; and

• controversy still exists regarding the safety issues ofperoxide-containing products.

For a full list of references contact:[email protected]

About the AuthorJohnny qualified in 1993. He completed his Masters in RestorativeDentistry from The Leeds Dental Institute in 2000. He thencompleted a three-year, full time residency programme inProsthodontics from Trinity College Dublin in 2004. He gained hisMFDS from the Royal College of Surgeons of Edinburgh in 2000. Hecurrently runs his own referral Prosthodontic Practice near Dublinand is part-time faculty at the Dublin Dental School and Hospital.He both lectures and runs courses on Restorative and ImplantDentistry, nationally and internationally.



Developement of aFunctional Occlusion

BackgroundThe longevity of any dental work is dependent on thefunctionality of the occlusion. The goal of the occlusalscheme is to allow the patient masticatory efficiency withharmony in the musculoskeletal system while protectingthe cosmetic result which has been created.

There remains many controversies amongst theproponents of the different theories of occlusion, andthere are often many ways to solve an occlusal issue for apatient. Many patients have a high tolerance andadaptability which will often allow any of the varioustheories to work, while others with low tolerance andadaptability will provide the greatest challenge.

Goals of TreatmentThe goal is to provide a cosmetic solution for the patientwith a responsible, minimally invasive, predictabletreatment plan that will provide many years of comfort,function and aesthetics. This article will describe onemethod of accomplishing this goal.

Occlusal SchemeThe fact is that if we do not create a harmonious functionalocclusal relationtionship,the dentistry we provide will fail.All the different theories of occlusion basically agree onsome areas of common ground. Longevity is a function oftime over force. L=T/F 1

The greater the force and the longer the time, the lessthe longevity. So the rule is to spread out the load of theocclusal forces and reduce the time that the teeth and jointare being loaded.

1. All teeth should have a tripod of occlusal stops on theposterior teeth in CR (Dots in back, lines in front) (See Fig. 1)

2. The centric relation position should match the dentalposition of maximum intercuspation.

3. Anterior guidance shouldconsist of canine guidance inlateral excursions and centralguidance in protrusive, bothexhibiting posterior disclusionwithout interferences.

4. There must be freedom ofmovement within theenvelope of motion. Teethmust remain in the neutralzone 2 (See Fig. 2)

5. There should be an evenocclusal load and themusculoskeltal system of theTMJ should be free from stressand pain.

Dr. Ron Goodlin

Fig. 2: Envelope of motion(Courtesy Dr. P. Dawson)

Fig. 1: Occlusal stops,note the dots in back andlines in front indicatingthe tripod of occlusalstops on posterior teethand the anterior guidancesignified by the lines onthe front teeth. (CourtesyDr. P. Dawson)

for Longevity in the Aesthetic Restorative Case



There are seven tests for a successful occlusal scheme:1. Negative load test: No TMJ pain on loading in the

CR position2. Negative Clenching test: patient should nave no pain

in teeth or joint when they clench and squeeze hard.3. Negative grinding test: Patient should have no posterior

interferences in excursive movements, protrusiveand lateral.

4. Negative Fremitus test: when patient taps up anddown, place your finger on the labial aspect of eachanterior tooth and you should not feel any toothmovement.

5. Stability test: Teeth are not mobile, no excess wearover time.

6. Comfort test: patient is comfortable. TMJ, lip positionand speech.,

7. Does it look good test: Patient is happy with theappearance of the case.

PredictabilityThe process must be predictable. How can we develop thefunctional occlusion and the aesthetics at the same time?A system is used to create the appropriate cosmetic result aswell as building in the occlusal scheme which will conformto all of the above principles.

Diagnosis and Treatment PlanningUsing Photographic Assisted Diagnosis3 and the principlesof Smile design4 it is easy to look at a case and determinethe areas of deficiency and what will be desired to correctthe cosmetic situation.

By analyzing the various photographs, such as the lipsat rest, smile view, full face and profile views and theretracted views, a list can be created according to theprinciples of smile design. There are several methods toachieve this, overlaying a sheet of tracing paper or acetateand using a marker to draw the new position of the teeth5

Fig. 3: Standard series of extra oral photographs full face, R profile, lips atrest, L-M-R smile views

Figs. 4a-4o: Standardseries of intra oral

photographs: L–M–R1:2 retracted (one set

each for partially openand fully closed)

L–M–R 1:1 Mx andMdb Occlusal views.

Fig. 4a

Fig. 4b Fig. 4f

Fig. 4e

Fig. 4d

Fig. 4c


or using computer imaging techniques to make the desiredchanges and overlaying the after onto the before using areduced opacity on the layers. (see Fig. 3)6 Once this wishlist has been determined, it is a simple matter ofdetermining the best approach, and oftentimes, multipleapproaches, to achieve these changes.

There are eight steps that have been recommended bySpear5 when analyzing and treatment planning anycosmetic restorative case.1. Determine the maxillary incisal edge position.2. Determine the maxillary incisal inclination and incisal

plane.3. Determine the appropriate gingival height of contour

maxillary.4. Determine the appropriate arrangement of the

maxillary anterior teeth and posterior teeth along thecorrect occlusal plane.

5. Determine the mandibular incisal edge position6. Determine the mandibular inclination and anterior

guidance.7. Determine the mandibular gingival heights of contour.8. Determine the mandibular tooth arrangement.

Fig. 4k

Fig. 4m

Fig. 4n

Fig. 4o

Fig. 4j

Fig. 4i

Fig. 4g

Fig. 4h

Fig. 4l



Fig. 6: Profile view

Fig. 5: Full Face

Fig. 7: Lips at rest: Tooth show is an important variable to understand if theteeth need to be lengthened or shortened.

Fig. 8: Smile view: Determination of gingival “show” and if the maxillaryincisal plane follows the lower lip line, as well as midline deviation and canting.




It is important to remember the interdisciplinaryapproach7 during the diagnosis and treatment planningstage, which is often a simple matter of emailingphotographs of the case to the lab technician, periodontist,orthodontist and oral surgeon for their input. Having ateam in place is a critical factor for success in this age ofincreased patient demand, knowledge and expectations.

The standard series of photographs8,9 is the standard ofcare which will allow the practitioner to provide superiorservices and results to the patient. (See Fig. 4)

Analysis of these photographs using anthropometricand smile design and principles of Photographic AssistedDiagnosis will lead to a working concept of whatcorrections need to be made to restore the case.(See Figs. 5-10)

Once the wish list has been determined, thepractitioner will be able to create a comprehensivetreatment plan complete with alternative methods toaccomplish the outlined goals. Often this plan willinvolve several pre-restorative phases such asorthodontics, periodontics and sometimes surgery.Cosmetic treatment such as bleaching and multiplediagnostic wax-ups along the way,will follow before a buris allowed to touch a tooth.

One of our primary objectives, of being minimallyinvasive, will often dictate that orthodontics be used tomove teeth into a more favourable position before therestorative phase. It is important to understand that thefinal result should be planned for before any work begins.

Vertical Dimension of OcclusionIn some situations the patient will exhibit overclosure,short incisors due to wear, or loss of teeth which willrequire the opening of the vertical dimension of occlusion(VDO) in order to restore the correct incisal edge positon,and the dentition to a functional occlusion. (See Fig. 11)

The vertical dimension of occlusion can be determinedby using cephalometric and anthropometric facialanalysis. If the VDO needs to be opened; this will result inthe ability to lengthen the IEP, giving the practitionerlonger incisors with which to build the anterior guidanceand subsequent occlusal scheme.

It has been recommended that provisionals be left on theteeth for six months before proceeding to the finalrestoration stage as research indicates that there will be a ½ -1mm intrusion of the teeth over the first 6 months whenthe VDO is opened.5

Fig. 9: Anterior Retracted view: Allows the practitioner to determine if theteeth are in alignment and which teeth should be repositioned. GHOC isalso determined as well as papilla height and periodontal condition.

Fig. 10: Occlusal views: Helps determine arch form problems

Fig. 11: Overclosure and VDO must be determined before treatment isbegun. In order to gain tooth height, an increase in a VDO is often required.

Fig. 12: PAD profile view to determine UFH :LFH and VDO requirements.

Fig. 13: Tooth show at rest



The use of cephalometric principles of skeletal upperface height to lower face height can be extrapolated toanthropometric guidelines and the use of photographicassisted diagnosis (PAD) to assess the UFH:LFH.

The UFH is measured from nasion to anterior nasal spinein the lateral ceph, and can be interpolated to thephotograph using glabella to subnasion. The LFH ismeasured on the radiograph from ANS to Me. Thephotographic version is from SN to Me. The ratio of UFH:LFHshould be about the same, with the LFH being slightly longerin some instances. When there is a difference of more than95+/- 10% then the practitioner should examine thediscrepancy more closely for determination of skeletaldysplasia which would alter the treatment plan. (See Fig. 12)

Maxillary Incisal Edge PositionThe key to the entire process is the correct placement ofthe maxillary anterior teeth. Just as in the denture set up,the first teeth we place in the wax rim are the two centralincisors, making sure the midline was centered andstraight. We also concentrate on getting the idealmaxillary central incisor position as our first step in therestorative process.

There are several so called rules to use in determiningthe IEP, but the final result must be controlled by thepractitioner and the patient together. The following arereally guidelines to use to locate the approximate incisaledge position. It is recommended that these guideliness befollowed in order.

IEP-1 Tooth Show at RestThe lips at rest photograph is one of the mostunderutilized, yet one with the utmost diagnosticimportance. Have the camera lens set to 1:2 magnificationratio and straight on to the patient on both the horizontaland vertical planes. Ask the patient to lick their lips,swallow, then part their lips and stay there...by parting thelips the tooth show at rest will be revealed. (See Fig. 13)

Analysis of this photograph will allow the practitionerto utilize PAD techniques to actually measure tooth show.The following table indicates the age appropriate toothshow at rest. As the patient ages the entire facial musculo-facial complex will sag and droop, this causes the upper lipto cover the maxillary teeth and the lower lip will becomemore flaccid causing greater exposure of the lower incisorsas a result (See Fig. 14)

Fig. 14: Age appropriate Tooth Show whenlips are at rest.

Age Tooth Show

Young 16-30 3.0

Middle 32-50 2.5

Mature 50-65 1.5

Senior 65+ 0.5



The practitioner will now measure the tooth show atrest and determine if the maxillary centrals should belengthened and if so by how much. It is not uncommon towant to increase the length of the centrals by at least 1mmto provide anti aging.

IEP-2 Trubyte Tooth Form IndicatorMany years ago the trubyte tooth form indicator(Dentsply) was invented for use in denture setup todetermine the appropriate size of the central incisors tomatch the patient’s facial features . By placing the templateover the nose and lining up the eyes and mouth, thepractitioner then uses the red slides to touch the side of thecheek laterally and the inferior limit of the chin. The ratioof the face height and width to the tooth size is read off thetemplate. This most often will end up relating to theheight to width ratio of 78%. If the facial measurementfrom the TTFI does not match the 8X10 or 8.5X11 rangeone should suspect a problem with UFH:LFH discrepancy.(See Fig. 15)

IEP-3 Height to Width RatioSeventy eight percent height to width ratio is the generallyaccepted rule of thumb for the height and width of thecentral incisor. The table below gives the most commonheight to width ratios of central incisors. The averageheight of an adult’s central incisor is 10.5mm, giving theappropriate width of 8.25mm. As there is artistic license inthe height to width ratio, remember to use these numbersas a guide as opposed to an absolute.

IEP-4 22 mm ruleMeasure from the labial fold under the lip to the incisaledge and this is often found to be 22mm. (See Figs. 16a-b)By measuring the difference between the existing IEP andthe 22mm mark on the ruler, the practitioner can easilyuse this as a guide as to how much tooth must be added tothe existing IEP to achieve the desired IEP.

IEP-5 Golden ProportionThe use of a golden proportion ruler; placed from thesubnasion to the gnathion, will provide the centre part ofthe ruler on the location of the desired IEP. (See Figs. 17a-b)

Establishing IEP and GHOCBy putting the first 5 rules together we now know howmuch we want to lengthen the existing IEP. We combinethat with the appropriate H:W ratio of the teeth for thatpatient from the Trubyte Tooth Form indicator and theH:W ratio smile design principle.

Measure the patient’s existing tooth height and thensubtract the number of the existing tooth length from theideal tooth length and determine the amount of tooth weneed to add.

For example, if the existing tooth is 8mm in height and8mm width, we need to lengthen the tooth 2mm to get itto the ideal IEP. The ideal H:W ratio for this patient hasbeen determined to be 10.5mm. By adding 2mm to the8mm to lengthen the IEP we reach 10.0mm which means

Figs. 16a-b:Photo showing

correctplacement ofruler in labial

fold andmeasurement of

the IEP at 22mm.

Fig. 16a

Fig. 16b

Fig. 17a

Fig. 17b

Fig. 15: TrubyteTooth Form

Indicator(Dentsply Corp.)

Figs. 17a-b:Golden

proportion ruler(Safident) and

the positioningto determine IEP.



that to achieve the ideal H:W ratio we will want to extendthe tooth 0.5mm apically by ortho intrusion, or crownlengthening. (See Fig. 18)

We can now determine how much we will use to bringthe IEP to the proper length and the rest will be achievedby adding to the gingival level. This can be achieved withorthodontic intrusion, crown lengthening, or surgicalrepositioning. Analysis of the upper lip and lip mobilitywill be discussed later in this article, however, it has beenargued that if the upper lip line covers the maxillary teethin full smile, it is not necessary to add the additionallength to the apical portion by gingival alteration. Becareful here as many patients have learned to achieve aguarded smile through muscle memory and once the caseis completed they lose self consciousness and the lipmiraculously uncovers the upper CEJ to the dismay of bothpatient and practitioner.

Direct Composite BuildupUsing a mock-up by building composite along the incisaledge of the existing teeth will help to show the patient andpractitioner the approximate length that has beendetermined to be appropriate using the methods asdescribed above. At this stage, the patient and practitionercan analyze if it appears to be appropriate using asubjective approach. Remember that generally thesepatients have been living with short teeth for so long thatthis change may appear overwhelming at first.

Phonetic AnalysisTesting the phonetics will help determine if the IEP is toolong and if the incisal edge position is proclined, reclinedor appropriate. The thickness of the Central Incsior at theincisal 1/3 of the tooth will also be analyzed at this stage.(See Figs. 19 and 20)

Overbite and OverjetAnalysis of Overjet and overbite will allow the practitionerto make some minor alterations at this point. In mostsituations the addition of 1mm to the IEP of the centralincisors will vastly improve the aesthetics and function ofthe case and will not inhibit the overbite and anteriorexcursions of the patient.

In some situations however, lengthening the IEP to

what appears to be correct could result in a very deepoverbite that would limit the freedom of movement duringexcursions, then the practitioner must make a choice hereas to whether the lower anteriors will need to be shortenedto accommodate the new longer incisal length, or will theideal maxillary IEP need to be compromised somewhat toaccount for the overbite.

The practitioner must analyze this carefully asoftentimes shortening the lower anterior teeth could resultin the need for endodontic and crown lengtheningprocedures and even possibly full coverage restorations toaccount for the longer IEP.

Problems with overbite and overjet can often lead topain in the lateral pterygoid mm, chipping and fractures ofanterior restorations and wear.

Fig. 19: Table showing the phonetic sound and the appropriate tooth position.

Sound Sample Sentence Comments

F and V 16-30 very very fine IEP on vermillionborder of lower lip - if dimpled IEP too long

S-Sh she sells seashells If lisping the incisal 1/3 of the centrals are too thick or lowers too long

CH church cheese Tongue hits palate behind centrals in normal sound

TH the thing thinks things Tongue in cingulum may need to deepen cingulum

Phonetic Analysis and the Dentition

Fig. 20: The correct IEP during the “F” and “V” sounds, being at thejunction of the vermillion border of the lower lip. This is easily analyzedusing PAD with a lateral smile view during a prolonged “VVVVVV” or“FFFFFFF” sound by the patient.

Fig. 18: Establishment of the IEP, H:W ratio and GHOC



Shimbashi The shimbashi measurement states thatthere should be 18-21mm measurement from cemento-enamel junction of the maxillary central to the CEJ of themandibular central when the teeth are in occlusion. Thisused to be a standard of measurement of the VDO but hasbeen disputed. This measurement can be applied as a looseguideline to determine the IEP by establishing the IEP toIEP contacts in the diagnostic wax up phase.

Principles of Smile DesignThe application of the theories of smile design will ensurethe development of a highly aesthetic result. It is strongly

recommended that every practitioner make themselvesexperts in these principles whether or not they areaccredited with the AACD or planning to do so. Thesefundamental principles are the cornerstones of cosmeticdentistry and must be fully understood before they can beapplied with confidence and predictability.

MidlineThe midline can be off by as much as 1/3 of the width ofthe tooth without anyone noticing, however, if themidline is canted by even the smallest amount, it will benoticed immediately.10

In cases of crowding, it is important then to make sure themidline is straight up and down, but if the crowding dictatesthat too much tooth must be removed to create a centralizedmidline, it is often quite acceptable to create a midline that ismarginally deviated as long as it remains vertical.

Incisal PlaneThe incisal plane is determined by the length of theanterior incisor teeth stretching back and around the archform to the first molars. These teeth will show during asmile creating the incisal plane which should follow thecontours of the lower lip during a moderate smile.

Buccal CorridorThe buccal corridor is the concept of teeth showing duringa broad smile. If the front six teeth are restored but theback bicuspids are not, the smile will look awkward. Theresulting negative buccal corridor from a distance willappear as if the patient has front teeth but no back teeth!

Gingival Height of ContourThe gingival height of contour (GHOC) should follow themaxillary lip. A line drawn from the gingival crest ofcentral to the cuspid should pass distally along the crestalheights of the posterior teeth. The lateral incisor shouldrest on or just below this line.

Diagnostic Wax-upFollowing some adjustment to make the phonetics correctand allow for the subjective input of the patient andpractitioner, an index is made of the direct compositemock-up to give the lab technician guidance for thedevelopment of the diagnostic wax-up.

Face-bow mounting with CR and MIP bite registrationrecords should now be taken with either alginate of full trayPVS impressions. These are then transferred to the lab benchwhere the models are mounted on a semi or fully adjustablearticulator for developemnt of the diagnostic wax-up anddevelopment of the anterior guidance, vertical dimension ofocclusion and posterior occlusal scheme. (See Fig. 21)

Golden ProportionFor many years dentists and lab technicians have beenusing the golden proportion (1.67:1.67) as the way todevelop the width and height of the lateral and cuspid inthe arch-form. This like many of our tools is used as aguide only and artistic license was then applied to make it

Fig. 21: Diagnostic wax-up

Fig. 22: Modified Golden Proportion Software program (www.mydentalgps.com)

Fig. 23: Template for the wax up using the modified golden proportion



“look right”. Methot in his work has developed a computerprogram that,10 like the “trubyte tooth form indicator” inits simplicity, will allow the practitioner to take aphotograph and drop it into the computer program. Theprogram will ask for only the interpupillary distance, andwill then develop the correct golden proportion for thatpatient along with a wax-up template for the lab to use tocreate the position and size of the centrals, laterals andcanines for that patient. (See Fig. 22)

Printing out the template on the computer, or even simplyjust email the case to the lab technician and that will providethe template for the diagnostic wax-up. (See Fig. 23)

Anterior GuidanceOn the articulator the index is used to create the new IEPof the maxillary centrals. The existing tooth width is takeninto account and rarely adjusted except in cases ofcrowding where the teeth will be made narrower in thewax-up to straighten the smile (assuming the patient hasalready declined an orthodontic option) or the teeth maybe widened to close diastemata in order to provide anacceptable aesthetic result.

The goal of the anterior guidance is to providemaximum load sharing during protrusive between centralsand lower centrals and laterals. In cases where a youngerlook is the objective, we often will keep the IEP of lateralincisors slightly shorter than the IEP of the centrals to givea younger look. In a more mature appearance, the IEP ofcentrals and laterals can be even, and incisal embrasuresare used to accentuate a youthful - mature look.

The lateral excursions will be determined according toseveral parameters. When possible a cuspid guided lateralexcursion that is mutually protected is the preferredsituation. This allows for protection of the posteriorocclusion from balancing contacts during lateralexcursions and minimizes joint problems later, as long asthis can be accommodated by remaining within theneutral zone of the occlusal scheme as per the work ofPosselt in the Posselt diagram of the envelope of motion. 2

Mandibular AnteriorsSpecial attention must be paid to the position of themandibular incisal edge position during thedevelopment of the anterior guidance so that there is nocrossover contact on the lateral incisors during lateralexcursions as this is often the cause of fractured lateralincisor restorations.

The mandibular incisal edge position must haveproper labio-lingual inclination and contact position onthe lingual of the maxillary incisors. This positioning isdetermined by the TMJ anatomy and is created in the labdiagnostic wax-up utilizing the parameters as dictated bythe bite registration and face-bow mounting records.

Posterior OcclusionOnce the anterior guidance (protrusive and lateralexcursion and CR occlusal stops) have been developed, theposterior occlusal scheme can now be determined. It isgenerally accepted by all the theories of occlusion thattripod occlusal stops should be achieved on each tooth andthat during lateral excursion in a cuspid guided occlusalscheme, there should be no balancing contacts or slides onany of the incline planes of the posterior teeth.

In the occasional situation where a patient requires agroup function lateral guidance such as in a large implantrestoration case or a full denture case, then the posteriorteeth will need to have a flatter anatomical form to achievethis relationship and not create balancing interferences.

Treatment PhaseIn the previous section the rationale behind thedevelopment of the occlusion was determined and thetreatment phase now begins.

In a minimally invasive treatment modality the goal is tomaximize tooth structural integrity and preservation ofenamel by minimizing the amount of cutting into teeth. Theability to “test drive” the final occlusal scheme is ofparamount importance whenever undertaking a full mouthreconstruction or even the most minor of cosmetic alteration.



In many cases it will be possible to directly apply thediagnostic wax-up to the patient’s dentition with aminimal or no prep technique. This method will allow thepractitioner to supply the mock-up of the finished productfor the patient to try for a few weeks or months and to“work out the kinks” by simply adjusting the provisionalmaterial until the patient is happy with the aesthetics andcomfortable with the bite.

Arch Form ReductionThe creation of an arch form reduction stent will allow thepractitioner to remove only the part of the tooth that isrequired so that the diagnostic wax-up can be directlytransferred to the patient’s dentition for analysis andassessment.12

In cases of crowding or where the teeth do not liewithin the arch form of the diagnostic wax-up, (the labtechnician has had to prep the models to bring the teethinto the archform) then a polyvinylsiloxane biteregistration material such as Sil Tek putty (Ivoclar) can beplaced in onto the diagnostic wax-up to create twoocclusal bite pads and an attached labial band lying onthe buccal aspects of the incisors. (See Fig. 24)

A slice is made into the material and transferred alongthe middle of the incisor across to the opposite sidewhere the cut stops before coming back up over theocclusal so as to create a hinge of sorts. This putty matrixcan now be gently pulled back away from the diagnostic

model to expose the incisal half of the labial aspect of theteeth from cuspid to cupsid. (See Fig. 25)

The putty matrix is now removed from the diagnosticmodel and is applied to the patient’s teeth. This allowsthe pracititoner to gently place the labial hinged matrixagainst the actual teeth. When the natural tooth is out ofthe arch form that is required by the diagnostic wax-up,this interference is gently removed with a bur until theentire putty matrix will fit passively onto the arch form.(See Fig. 26)

This minimally invasive method allows thepractitioner to develop the required arch form for thediagnostic wax- up to be utilized. (See Fig. 27)

Provisional After the arch form is reduced, the diagnostic wax-up istransferred to the patient’s teeth using a polyvinylsiloxaneimpression (Clear bite -Discus) . The impression is taken ofthe diagnostic wax-up. (See Fig. 28)

Once hardened, try in the clear bite to make sure it seatscompletely onto the patient’s teeth. (If the archform hasnot been correctly modified, this impression will not seatcorrectly and the entire provisional guide will beinaccurate requiring a lot of adjustment or completeremoval and starting over). If the provisional stent does notseat, go back and make sure the arch form reduction hasbeen completed such that the provisional stent will seatcompletely and passively.

Fig. 25: Arch form

reduction stentwith hinge to

expose anteriorsegment

Fig. 24:Arch formreduction

stent

Fig. 27: Arch form after reduction using stent

Fig. 26:Occlusal viewbefore arch formreduction



Then the patient’s teeth are spot etched, washed anddried, bonding agent placed and cured and the provisionalmaterial is placed inside the clearbite and transferred to thedentition. Minor adjustments are now made. (See Fig. 29)

As this material will often need to last many monthsmake sure you are careful to make sure air bubbles aresealed, IEP is correct and that the occlusion is milled in toprovide stability and longevity.

Test DriveThe patient will now be dismissed from the office and willtake the provisionals which are a direct copy of thediagnostic wax-up, out for a “test drive” (See Fig. 30)

The patient is invited back in a couple of days to checkon the occlusion, the fit and the margins.

One week later the patient is invited back for a fitting. Thisis a free appointment where the patient will ask for someteeth to be made longer, some shorter, some turned orstraightened. Once this has been accomplished the patient isasked to sign a release that they are satisfied with theprovisionals. At this time an index is made of the provisionals(Sil Tek Putty - Ivoclar) and the patient is dismissed.

If the patient is not yet satisfied with the appearance of

the provisionals they are invited back to the office in oneweek for a 30 minute adjustment session which has a feeapplied (this is made clear before the case is begun duringthe initial consultation and fee discussion stage). Incosmetics we can sometimes run into a patient who isindecisive and finds it difficult to get to the next step.These patients would often attend the office for multipleappointments having a tooth lengthened one week andshortened the next, never being able to finally say yeslet’s compete the case. In these cases, unless thepractitioner is fairly compensated for all the extra time,bad feelings could be generated from the experience. Theadditional fees will often times help the patient be able tocome to a decision much earlier in the process.

If there has been a substantial amount of adjustmentmade to the provisionals, a new provisional clear bite canbe taken at this time.

PreparationOnce the patient has signed off on the provisionals, themaxillary anterior teeth (cuspid to cuspid) are prepared.The preps are done ideally into the provisionals as these arewhere the final restorations will be developed to. There willbe some areas where the natural tooth will be not eventouched by the bur as the thickness of the overlyingprovisional material is thicker than the requiredpreparation depth, while other areas will have themaximum area of preparation into the tooth material ifthis is sticking through or just covered by the provisionalguide. (See Fig. 31)

Figs. 29 a-b:Applicationof provisionalmaterialusing clearbite

Fig. 28: Clear bite impression of diagnostic wax-up Fig. 30: Anterior view of provisional material

Fig. 29a

Fig. 29b

Fig. 31: Preparation of anterior restorations using provisional material as aprep guide.



The provisional clear bite impression is now used toreapply the provisional material. At this stage it is oftenadvised not to spot etch the teeth but to use a “shrink fit”technique. The margins are adjusted using a Zakrya(See Fig. 32) instrument to reflect the gingival tissue toallow direct access to the margins, and a needle nosedfine diamond bur or a multifluted carbide bur. Airbubbles are sealed with flowable composite and theprovisionals polished.

Try-in and CementationWhen the restorations are returned from the lab they areinspected and cross referenced against the shade mappingand lab prescription. The patient is then invited to theoffice for the try-in and cementation stage. The provisionalsare “flicked” off the teeth and the maxillary anterior teethtried-in. If shade alterations need to be made and cannot beaccomplished by the use of value altering try-in cements(variolink veneer Ivoclar) then the restorations are returnedto the lab for custom shading. If the appropriate shade canbe achieved with the use of the value shades then themaxillary restorations can now be cemented to place.

The case can now be completed in phased treatmentas follows:

1. Prep max anteriors2. Cement max anteriors’3. Prep mdb ants4. Cem mdb ants5. Post UR6. Post LR7. Post UL8. Post LL

Post-op CheckThe patient is invited to return one week postcementation of each phase, and every 6 weeks thereafter,as sometimes finances or time will dictate that the case becompleted over a prolonged period of time.

In such cases it may be advisable to use a lab fabricatedor an in office oven fired material that may last longer.This author has used Ivoclar System for many of thesecases with only minor alterations or adjustmentsrequired over prolonged periods of time.

Fig. 32a

Fig. 32b

Fig. 32c

Fig. 32d

Fig. 32e

Fig. 32f

Fig. 32a: Facial view (Before)

Fig. 32b: Smile (Before)

Fig. 32c: Before retracted Fig. 32f: Immediate post insertion

Fig. 32e: Smile (After)

Fig. 32d: Facial view (After)



Once the case is completed, the patient is seen oneweek post-op, then 3 weeks post-op for final photos andtissue health analysis. Any alterations can be finalized atthis point. The patient is then again invited to return 3months later for a final assessment. At this stage thepatient is released to the referring dentist or back into therecall pool. (See Fig. 32)

ConclusionThe determination of the incisal edge position of themaxillary incisors is the first and most important factorin any reconstructive case. The principles of smile designare used to determine, midline, tooth size, shape colourand arrangement follows.

The incisal plane is then determined by thearrangement of the anterior teeth using the principles ofgolden proportion, and modified golden proportion.Application of principles such as “age-gender-personality” factors and the contour of the lower lip lineare used to complete the positioning of the maxillaryanterior teeth. The maxillary lip line is used to guide thegingival heights of contour.

Development of the anterior guidance, the posteriorocclusion and occlusal planes (curves of spee and wilson)follows in order, using diagnostic wax-ups beforetransferring the information to the mouth, andminimally invasive arch form reduction and provisionalguide techniques.

This method of developing the occlusal scheme isrecommended for every case whether it be a full mouth

reconstruction or a simple cosmetic change to theanterior teeth, in order to achieve a predictable,minimally invasive and long lasting restorative solutionfor the patient.

References1. Goodlin R.M. Functional Stability, the 10 best secrets of Cosmetic

Dentistry Cdn J of Cos Dents Vol 4 No.1 April 2008 pg 32

2. Dawson. P, Functional Occlusion from TMJ to Smile Design Mosby 2007

3. Goodlin, R.M.Photographic Assisted Diagnosis Cdn J Cos Dent Vol 1 Issue1 Feb 2005

4. Blitz, N. Steel, C. Willhite, C. Diagnosis and Treatment EvaluationinCosmetic Dentistry AACD Accreditation criteria guide edn 1.

5. Spear, F. MASTERING THE ART OF ESTHETIC DENTISTRY TorontoAcademy of Cosmetic Dentistry September 19 - 20, 2008

6. Goodlin, R.M. Computer imaging for Cosmetic Dentistry DVD learningseminar www.smiledental.ca

7. Spear, F, Kokich V. Mathews, D. Interdixciplinary Management of AnteriorDental Aesthetics J Am Dent Assc. Vol 137 No. 2 160-169

8 Goodlin R.M. The Complete Guide to Dental Photography MichaelPublishing ISBN 0-96901957-1-0 1987

9. Goodlin R.M. Digital Dental Photography Cdn J Cos Dent Vol 4 No 1 April2008 pp 26-27

10 VO Kokich, H ASUMAN KIYAK, PA SHAPIRO Comparing the perceptionof dentists and lay people to altered dental esthetics - Journal of Estheticand Restorative Dentistry, 1999

11. Methot, A. Goodlin.R.M. The Modified Golden Proportion Cdn J CosDent April 2006, vol 1 no. 1

12 Goodlin R.M. Minimally invasive cosmetic dentistry Cdn J Cos DentVol 3 No 2



Have you ever wondered if the messages you try toget across to your patients are falling on deaf ears?Are you perhaps puzzled at why you don’t get more

people actually taking up a treatment that they have askedabout? Or maybe you’ve moved from one region toanother, and are regularly bemused by the locals’ turns ofphrase? We may all live on one island, but the Englishlanguage is complex and constantly evolving, and if youwant your practice to be as successful as possible you needto make sure you are using the same language as yourpatients. You need to ensure that what you are saying isbeing understood, that you use words which haverelevance to your patients, and that you are notunwittingly putting them off having treatment.

Cosmetic vs. AestheticTake for example the common debate over the wordscosmetic and aesthetic when used to describe dentaltreatments. This is something we struggles with for someyears – we just couldn’t find a definitive answer as to whichphrase was the best. It is only in more recent times that wehave discovered that that is because there is no definitiveanswer – it depends on where your practice is located, andwhat type of patients you are treating.

In some areas, the phrase aesthetic dentistry reallydoesn’t mean a lot to patients. They don’t fully understandwhat the word aesthetic means, and how it applies todentistry. They certainly don’t make the link between theword and how such treatment could benefit them.

Conversely, there are also some areas where patients do notview the word cosmetic as meaning a quick fix, in muchthe same way that make-up – also, of course, referred to ascosmetics – is a temporary solution. In fact, some of ourclients have had patients tell them that they do not wantcosmetic dentistry, they want something that lasts!

Speaking the JargonWe’re not always aware when we speak that we are usingjargon – ‘in’ words used by those we work or socialize with.It becomes so natural to us that we no longer notice it,unless someone who is not au fait with your phraseologystarts looking bewildered or simply asks straight out whaton earth you are talking about!

As a dentist, you are used to using clinical language, dayin, day out. You are happy to use phrases like buccal andmesial, to talk about pocket depths or shades of B3 or A2.But most of your patients won’t have a clue what you aretalking about. We’re not suggesting that you change thelanguage you use when, for example, charting a newpatient. But you need to make sure that you avoid anyclinical expressions when you are talking with patients,especially when explaining treatments. You are far morelikely to have a patient agree to treatment if theyunderstand exactly what it involves, and, moreimportantly, how it will benefit them.

Accentuate the PositivesWhich brings us nicely onto the marketing technique of

Hilary Ford of Blue Horizons emphasizes the importance of communicatingcorrectly with your patients

Speaking the same

Language

Hilary Ford



stating benefits, not features. In terms of treatments,patients are generally more interested in how a treatmentwill benefit them. Will they look better, will eating beeasier, will it stop those chronic headaches? Sometimesthey can be so taken with the benefits they will scarcelycare what the treatment will involve. On the other hand, ifyou explain in great depths every stage of treatment, andbarely mention the benefits, you are far more likely to endup with another non-conversion.

Eliminate the NegativesAccording to communications experts, the brain does notregister negatives. So if you say to your patients that atreatment is ‘not very expensive’, the word they will focuson will be ‘expensive’. Similarly, a patient who is told theywill ‘not fell much pain’, will only register the word ‘pain’.

Find positive ways of expressing things. Treatments are‘affordable’ or ‘great value for money’ rather than ‘not veryexpensive’. Your dentistry is ‘gentle’ and patients will feel‘comfortable and relaxed’, rather than being ‘virtuallypain-free’.

You should take a similar approach when encouragingpatients to go ahead with booking further appointmentsor committing to new treatment plans.

For example, if you would like an enquirer to book aninitial consultation, don’t ask: ‘Would you like to book anappointment?’ This hands them an easy opportunity tosay no, or not yet thank you. Instead, you should saysomething like: ‘What day would suit you best for anappointment?’. This makes it far more difficult for theenquirer to turn down the offer – instead they are morelikely to give you a day of the week, and you can take itfrom there.

Ask the Right QuestionsTake the time to really get to know your patients and theirneeds by making sure that you ask open ended questionsas often as possible. The answers should give you far moreinformation than a simple yes or no, and could wellhighlight an issue that had not previously arisen, and thatcould lead to additional treatment.

The Written WordRemember to follow through with your writtencommunications as well. Make sure your practice literatureis well written, with a strong focus on the benefits of beingwith your practice and of the treatments you arepromoting. Use reader-friendly language, and keep all yourmessages positive. Written words, unlike most spokenwords, are a permanent record of what you say, so it is wellworth investing in a professional copy writer to ensure thatwhat you say is perceived to be what you actually mean!

Finally, remember that a picture paints a thousandwords – use lots of great, aspirational photos (no goryclinical ones!) and get your literature professionallydesigned to portray the right image.

Oral Surgery for the GP A Practical Approach

Dr. Lawrence I. Gaum DDS, FADSA, FICD

A Three Day Hands-on Seminar:

October 2 - 4, 2009Renaissance Toronto Airport Hotel & Conference Centre Hotel

801 Dixon Rd. Toronto, ON, M9W 1J5 Canada

Everything You Wanted to Know about Oral Surgery & Were Brave Enough to Ask

2009 TIASC Members Receive a Special Discount!

TIASC Member Rate: $1895Non Member Rate: $2295

Includes a $299 Lab Fee

Ontario AGD members qualify for the TIASC members discount!

21 credits for seminar attendance

The Toronto Implant and Aesthetic Study Club34 -145 Royal Crest Court, Markham, ON L3R 9Z4

T. 905.258.0363 • F. 905.489.1971 • E. [email protected]

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Approved by:Co-sponsored by the Ontario AGD

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Course fee includes Dr. Gaum’s Book & DVD at no additional cost!

A must for your professional reference library!

Register now and receive Oral Surgery for the General Dentist &

Oral Surgical Videos for the General Dentistin advance!



Attraction and Retention

Nadean Burkett

Career & Practice Transitions

Building a loyal patient base is what most dentistsstrive to achieve. This is a two-way street. In order todiscuss this topic, however, we must first

acknowledge that not all patients are retainable in everypractice. Some statistical data may help to clarify this point– according to the ADA and CDA, only 50% of thepopulation in North America sees a dentist on a regularbasis (at least once per year for recall). This percentage hasnot changed since 1955, and is not influenced by dentalbenefits. Therefore, statistically only 50% of thepopulation of any community is retainable.

That is not to suggest or imply that every practice has a50/50 patient component. Every practice, no matter itslocation, visibility or age will have a certain percentage ofretained and transient patients. Let’s define a “transient”patient. This is a patient who has sought treatment in yourpractice, but is not on at least an annual recare schedule inyour practice. Typically, these are emergency patients or“walk-ins”.

You may be asking – what’s the difference, so long as Ihave a “busy” practice? The answer is that it DOES matter,and should matter to you because the difference in thesetwo basic categories of patients, both short and long term,is significant.

The comparative value of a retained patient issignificantly more that of a transient patient. The revenuesgenerated by transient patients are not only lower, but thenet cash flow is also much lower than that producedthrough services to retained patients. The difference invalue to your practice comes from several sources:

1. Referrals through word of mouth to family, friends,co-workers and neighbours come from retainedpatients. This is without question, the best form ofadvertising any business can get! The investment is inyour relationships with your patients and employeesand has minimal financial cost.

2. Reliability of future revenue through regular recare visits;this ensures that you will have a patient in your hygieneschedule at least every 12 months which enriches yourrelationship through prevention and education.

3. Case acceptance is much higher by retained patients.4. Collection of fees for services rendered is simpler and

faster when dealing with retained patient. Bad debt(uncollectible accounts) is more common when dealingwith a transient patients.

5. In transition, retained patients are more transferable to anew owner, with the endorsement of you and yourdental team.

There are many ways to “attract” prospective patients toyour practice. The focus in today’s dental marketplacetends to focus on the external options – display ads incommunity newspapers; visibility through physicalplacement of the clinic or signage, and conveniencefactors. Ads which offer specials or bonuses to new patientsexclusively are known as “an invitation to treat”.

It has become fashionable and popular to employadvertising in community newspapers, magazines and onthe Internet in order to “attract” patients. This method of“promotion” is very expensive and generally ineffective. Ifyou have a general announcement to the community –such as a relocation of your clinic – which is short term

Patients know what they hear, see andexperience. The value of your practiceto them is based on their experiencewith you and your team.



(+/- six months) placing a display or print ad can serve yourpurpose. Websites can be useful in patient education andcommunication especially for the internet-savvy patient,but I caution my clients not to expect it to be more than aninternal communication tool.

We have all seen examples of “invitation to treat” ads inour local papers. They offer “free” whitening kits, ordiscounts on cleaning with a “new patient exam”. In myopinion the “invitation to treat” ads are the mostdamaging to the dental practice because they are a net lossto the practice – you are working on that patient fornothing. Worst of all they can contribute to loss of patientretention in a practice because they demonstrate utterdisregard for a patient’s loyalty. If you are going to make aspecial offer, make the offer to those patients who have“earned” it – give a whitening kit to a patient as a “thankyou” for referring a friend or co-worker to your practice, oran electric toothbrush to a patient who has just completeda major restorative procedure, for example. If the patienthas been loyal for several years and is celebrating amilestone in their life, why not recognize that withsomething special from you? They will appreciate yourrecognition and your simple gesture tangibly expresses thevalue you place on your relationship.

Visibility and convenience by physical positioning ofthe clinic or through signage to a broad spectrum of people

(traffic) presumes that “if you build it, they will come”.Again, seemingly a reasonable premise if all you want ispractice traffic, not patient activity/retention. Physicalpositioning for maximum visibility generally requires astreet, mall or other store-front location which is subject toretail tenancy rates which increases your cost of doingbusiness and reduces your cash flow. This also makes youmore vulnerable to changes in community demographics.Patients know what they hear, see and experience. Thevalue of your practice to them is based on their experiencewith you and your team. That starts the first time they hearyour name in conversation with a friend and continueswith their first call to your office. When they see you andyour team for the first appointment, their first impressionswill either be affirmed or discounted to some degree.

About the Author With more than 30 years of practice and business managementexperience, Nadean Burkett is a career and practice transition coachto the dental and other professionals in private practice.Headquartered in Greater Vancouver, British Columbia, NadeanBurkett & Associates Inc provides consultation, counselling andassistance to dentists throughout North America since 2003. Nadeanoffers online resources through her web sites www.dentalbusiness.caand www.edu-dent.com. All published articles are the intellectualproperty of Nadean Burkett & Associates Inc.


Ronald M. Goodlin, DDS Elected to the AACDBoard of Directors

Ronald M. Goodlin, DDS of Aurora,Ontario, has been elected to the AmericanAcademy of Cosmetic Dentistry (AACD)Board of Directors. Ronald was elected to theAACD Board of Directors during the 25thAnniversary AACD Scientific Session, heldin Honolulu, Hawaii, April 27 - May 1, 2009.

“I am honored to serve on the Board ofDirectors of the AACD. This is the premier organization foradvancing excellence in cosmetic dentistry, and I amexcited to help lead the profession into the future,”commented Ronald.

The AACD Board of Directors is comprised of 16 electedofficials from varying cosmetic dental backgrounds. Itschief responsibilities include: supervising the direction ofthe AACD, determining its policies, and maintaining theAACD standard of excellence throughout all aspects fo theorganization.

The AACD is the world’s largest non-profit membershiporganization dedicated to advancing excellence incomprehensive oral care combining art and science tooptimally improve dental health, function, and esthetics.Comprised of more than 7,000 cosmetic dentalprofessionals in 70 countries around the globe, the AACDfulfills its mission by offering superior educationalopportunities, promoting and supporting a respectedAccreditation credential, serving as a user-friendly andinviting forum for the creative exchange of knowledge andideas, and providing accurate and useful information tothe public and the profession.

For more information, please visit www.aacd.com,send an email to [email protected], or call 800.543.9220.

Ronald M. Goodlin, DDS practices cosmetic dentistry at15213 Yonge Street, Ste. 6, Aurora, Ontario, Canada. Hemay be contaced by telephone at 905.727.6453 or via emailat [email protected]. His practice can be located onlineat www.smiledental.ca.

Fourteen AACD Members Achieve AccreditedDesignation

Fourteen American Academy of Cosmetic Dentistry(AACD) members achieved the AACD Accrediteddesignation and were recognized at the organization’s25th Anniversary AACD Scientific Session, held inHonolulu, Hawaii, April 27 - May 1, 2009. These AACDmembers join 320 dental professionals in the history ofthe AACD who have earned this prestigious designation.The highly sought Accreditation credential representsthe standard of excellence in cosmetic dentistry. TheseAACD members were awarded this status through thedemonstration of advanced skills and knowledge.

Newly Accredited AACD Members Include: KennethL. Banks; Sandra M. Cook, CDT; Keri L. Do, DDS; RichardP. Durkee, CDT; Marilyn S. Gaylor, DDS; Steven A.Gorman, DDS; Jack D. Griffin, Jr., DMD; Edgar Jimenez;Suzanna N. Lee, DDS; Trinh N. Lee, DDS; Stevan J. Orser,DDS; William K. Parks, CDT; Wayne B. Payne; andBonnie J. Rothwell, DMD. For more informationregarding the AACD, visit www.aacd.com, send an emailto [email protected], or call 800.543.9220 or 608.222.8583.

Accredited Status in the AACD

Sandra Cook, CDT, Richard Durkee, CDT, Edgar Jimenez,Wayne Payne, and William Parks, CDT, have achievedAccredited status in the American Academy of CosmeticDentistry (AACD) – joining 27 AACD Accredited memberlaboratory technicians in AACD history who haveearned this prestigious designation.

The highly sought Accreditation credential representsthe standard of excellence in cosmetic dentistry. Thesedental laboratory technicians were recognized duringthe organization’s 25th Anniversary AACD ScientificSession, held in Honolulu, Hawaii, April 27 – May 1,2009 and represent the largest group of dentallaboratory technicians to receive Accreditation at onetime since the inception of the AACD’s Accreditationprocess. For more information regarding the AACD, visitwww.aacd.com, send an email to [email protected], or call608.222.8583

Announcements



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3M ESPE - Expanded Lava Precision SolutionsPortfolio

3M ESPE unveiled an expandedLava™ CAD/CAM System withthe release of several new

products including hardware, software and materials. Labswill be able to achieve a higher level of automation with thenew Lava™ CNC 500 Milling Machine. In keeping with itsgoal of making it easy and efficient for dental labs to use,3M ESPE announced an upgrade to Lava Design Software5.0. A major software upgrade, version 5.0 will offer moredental technician-friendly features to enhanceproductivity. Supported by the new software and millingmachine, the new Lava™ Digital Veneering System is both amaterial set and a restoration procedure that facilitatesbetter productivity for dental labs. The system allows dentaltechnicians to produce more units per day than withpressed ceramics or traditional hand-layered porcelaintechniques. 3M ESPE is also introducing its own wax blockand new Lava™ Zirconia blocks. For more information visitwww.3MESPE.ca/lava or call 1-888-363-3685.

Functional Mandibular Advancer (FMA)

The Functional MandibularAdvancer (FMA) is a new-typefixed appliance, developed forthe correction of Class IIdiscrepancies, which is non-dependent on patient

compliance. The essential elements of this Herbst-alternative comprise protrusive bars and inclined planesfixed to cast splints or prefabricated brands on thevestibular surfaces of the posterior teeth in thegingivobuccal fold. Item No. 330-0100. For moreinformation, please call SNF Forestadent at 800.387.5031,416.510.2220 or visit www.forestadentcanada.com.

Prescribevita.com

Vident has launchedprescribevita.com, an interactivewebsite that provides a place fordoctors and technicians to sharebefore and after case photos,explore the entire line of VITArestorative materials and gain

access to specials and discounts. The site includesdownloadable prescription notes that can bepersonalized with a logo and practice information, aVITA lab finder using Google maps, and will feature anannual award for the best “before and after” case usingVITA materials as judged by a panel of experts. Visitwww.prescribevita.com or call 800-828-3839 foradditional information.

Zest Anchors - Locator for All-on-4 ImplantProcedure

A special Locator Abutment witha titanium collar has beendesigned for direct placementonto the Nobel Biocare Multi-Unit Abutment for the All-on-4Implant procedure. The use offree-standing Locator Abutmentseliminates the high cost of a cast

bar, while reducing the vertical height of the restoration.Patient oral hygiene is easier to maintain with individualLocator Abutments rather than the complex structure of acast bar. The Locator Attachment directs the patient intothe proper seating of their overdenture and provides longlasting performance. For more information, call ZestAnchors, Inc. at 800-262-2310.

Ivoclar Vivadent - IPS Empress® Direct

Ivoclar Vivadent introducesIPS Empress Direct, a highly-esthetic direct compositesystem offering the esthetics

of a ceramic combined with the convenience of a


ProductShowcase


composite. A wide range of shades, various levels oftranslucency and a simple application protocol providedentists with impressive options to easily mimic thenatural esthetics of teeth in all indications, similarto ceramic.

To further facilitate the restorative procedure, the IPSEmpress Direct material demonstrates convenienthandling characteristics in combination with superiorpolishing properties and long-term shade stability. Itsphysical properties are designed to satisfy the highestclinical demands. In addition, IPS Empress Direct offersextended working time providing freedom to design life-like restorations. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.

Multilink® Automix “Easy” Now Available fromIvoclar Vivadent

In response to marketdemands, Ivoclar Vivadentis pleased to introduceMultilink® Automix

“Easy”. This new “Easy Clean-Up” version of the clinicallyproven self-etching adhesive resin cement offers extendedclean-up time for those dentists choosing to pre-polymerizeexcess material with a dental curing light. Additionally,dentists will still recognize all of the Multilink Automixadvantages including: high immediate bond strengths;effective sealing of the dentin; fast and easy application;and the ability to bond restorations made from metal,metal-ceramic, all-ceramic, and composite materials.

Due to its patented, hydrolytically stable phosphoricacids (acidic monomers), Multilink Automix “Easy” iscapable of meeting the expectations of dentists and theirpatients regarding high bond strength and efficient,durable adhesion. Within only 10 minutes, MultilinkAutomix “Easy” establishes a reliable and long-lastingbond to a large variety of restorative materials.

For more information, call 1-800-533-6825 in theU.S., 1-800-263-8182 in Canada.

Ivoclar Vivadent Introduces OptraStick ®

Ivoclar Vivadent introducesOptraStick®, an easy-to-use,flexible plastic instrument thatenables clinicians and dentaltechnicians to easily andquickly pick up, hold, and

place/handle indirect restorations. Even if only slightpressure is applied, the OptraStick adhesive tip preciselyadheres to a wide range of small objects, such as inlays,onlays, crowns or veneers.

OptraStick features a ball-shaped, flexible adhesive tipthat can be easily bent and flexed in all directions toaccommodate a variety of clinical or laborator ysituations. The OptraStick adhesive tip is removed orseparated from restorations with a simple rotar ymovement (twist), or a hand instrument can be used tohold the restoration in place. OptraStick is available inrefill packages containing 50 instruments.

For more information, call 1-800-533-6825 in theU.S., 1-800-263-8182 in Canada.

Dentsply TruRx™ - Digital Denture Solutions

A new, integrated approachto tooth mould selection anddenture prescription, TruRxDigital Denture Prescriptionsoftware shows great promisein improving process ease-of-use and clinical outcomes.

TruRx is a chairside, digital prescription tool thatfacilitates the denture consultation while addressing keytherapeutic considerations, helping to make the dentureprocess easy, consistent, and profitable for denturists anddental professionals. Tr uRx guides the dentalprofessional/denturist and the patient through the keydenture considerations with interactive screens. Theunique strengths of the Tr uRx Digital DenturePrescription software lie in built-in intelligence to selectsuitable dental restoration options interactively with apatient and view the results live with them. The win forpatients, dentists, and laboratories is improvedinformation, selection accuracy, efficiencies, estheticoutcomes, and overall satisfaction.

For more information, please contact 1-800-263-1437 oremail [email protected].

Successful Launch of NobelActive™ Implant

NobelActive – a new implant design withinnovative features – was Nobel Biocare’s mostsuccessful product launch ever. More than130,000 implants have been sold to date.NobelActive is the first product launchedaccording to Nobel Biocare’s new scientificand clinical standards.

NobelActive is a hybrid implant: slightlytapered in design, although parallel walled drillingprotocols are followed in insertion site preparation.NobelActive is an implant for advanced users, especiallydesigned for extraction sockets and soft bone indications.

For additional information please visitwww.nobelbiocare.com.


ProductShowcase


Drug Information Handbook for DentistryThis handbook for Dentistry, 14th Edition, is specificallycompiled and designed for all dental professionals whorequire quick access to concisely-stated drug informationpertaining to commonly prescribed medications.Authors: Richard Wynn, BSPharm, PhD, Timothy Meiller, DDS,PhD, Harold Crossley, DDS, PhDPRICE: $45.95CAD/US, plus shipping & handling

Oral Surgery for the General DentistLiterally leads the practitioner through numerous surgicalprocedures in a well organized fashion. Utilizing a step-by-step approach for a variety of surgical techniquesaccompanied by detailed color photographs.Author: Lawrence I. Gaum, DDS, FADSA, FICDPRICE: $53.95CAD/US, plus shipping & handling

Oral Soft Tissue Diseases3rd Edition, is a visually-cued manual designed as a quickreference to assist in the management of oral soft tissue diseases.Authors: J. Robert Newland, DDS, MS, Timothy Meiller, DDS,PhD, Richard Wynn, BSPharm, PhD, Harold Crossley, DDS, PhDPRICE: $53.95CAD/US, plus shipping & handling

Oral Hard Tissue Diseases2nd Edition is designed as a quick reference for the visual recognition and diagnosis of common bone lesions. Author: J. Robert Newland, DDS, MSPRICE: $50.95CAD/US, plus shipping & handling

Dental Office Medical Emergencies2nd Edition, covers the most common dental emergenciesand is designed for use by the entire office staff during timesof crisis. Authors: Timothy F. Meiller, DDS, PhD, Richard L. Wynn,BSPharm, PhD, Ann Marie McMullin, MD, Cynthia Biron, RDH,EMT, MA, Harold L. Crossley, DDS, PhDPRICE: $48.95CAD/US, plus shipping & handling

Illustrated Handbook of Clinical DentistryThis handbook is a valuable reference manual for dentists anddental students that concisely summarizes the majordisciplines of clinical dentistry. It is written as an aid fortransition into clinical practice, or as a refresher for aseasoned dental professional.Author: Richard A. Lehman,DMD, MPHPRICE: $64.95CAD/US, plus shipping & handling

Clinician’s Endodontic Handbook2nd Edition, was developed as a quick reference to addresscurrent issues in clinical endodontics. Authors: Thom C. Dumsha, MS, DDS, MS James L. Gutmann.DDS, FACD, FICDPRICE: $43.95CAD/US, plus shipping & handling

Manual of Clinical PeriodonticsThis manual provides a quick reference for generaldentists, dental hygienists, dental students and dentalhygiene students. Both basic and clinical science topicsare arranged in a tabular form to allow for easy access toeach chapter.Authors: Francis G. Serio, DMD, MS, MBA, Charles E.Hawley, DDS, PhDPRICE: $53.95CAD/US, plus shipping & handling

Manual of Dental ImplantsThis manual is designed to initiate dental professionals andtheir staff into the world of implant restorative dentistryand maintenance. It is usable at multiple levels ofknowledge and training so the reader can continue tobenefit from it as he or she gains implant experience.Authors: David P. Sarment, DDS, MS, Beth Peshman, RDHPRICE: $53.95CAD/US, plus shipping & handling

Your Roadmap to Financial Integrity in the Dental Practiceprovides a structured format to assist in placing properinternal fiscal controls in the dental office. This referenceexplains how establishing good internal controls helpsminimize potential problems such as theft, fraud, andunintentional errors in recording accounting data.Author: Donald P. Lewis, Jr., DDSPRICE: $43.95CAD/ US, plus shipping & handling

Advanced Protocols for Medical Emergenciesis a must for all offices that administer nitrous oxide,conscious sedation, and general anesthesia. Authors: Donald P. Lewis, Jr, DDS, Ann Marie McMullin,MD, Timothy Meiller, DDS, PhD, Cynthia Biron, RDH, EMT,MA, Harold L. Crossley, DDS, PhDPRICE: $64.95CAD/US, plus shipping & handling

Lexi-Comp ON-DESKTOP for Dentistryis a complete Medication Management System. Elevate thestandard of patient care and help protect your practicefrom liability with this innovative electronic platform. Ourcomplete library of databases is downloaded to yourdesktop computer, or hosted on your network server,eliminating the need for a constant Internet connection. PRICE plus shipping & handling:

No.s of Computer Initial Purchase Annual Renewal1 $349.00 $175.002-5 $399.00 $199.006-10 $549.00 $299.0011+ Call for pricing Call for pricing

Mail orders to:Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON Canada L3R 9Z4Phone Orders: 905. 489.1970 Fax Orders: 905. 489.1971

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AdLink Our advertisers invite you to find out more about their products, materials,techniques and services. For more information, visit their website or call thenumbers listed below.

Acmedent Corporation www.acmedent.com 1.888.688.6555 28 • 29 Applied Arts Ceramic Laboratories 1.905.882.8955 39Astra Tech Dental www.astratechdental.com 1.800.531.3481 17Baluke Dental Studios www.baluke.com 1.800.263.3099 27Burlington Dental Studio Inc. www.burlingtondentalstudio.com 1.800.342.1508 21DeLuca Dental Laboratories www.DeLucaLab.com 1.800.268.6657 31Dentsply www.dentsply.ca 1.800.263.1437 51Incisal Edge 1.877.INCISAL 18Ivoclar Vivadent www.ivoclarvivadent.ca 1.800.263.8182 52Krest Dental Ceramics www.krestlab.com 1.800.997.9717 11Nadean Burkett & Associates Inc. www.dentalbusiness.ca 1.604.939.5009 43Nobel Biocare www.nobelbiocare.com 1.800.939.9394 2Picasso Dental Studio Inc. www.picassodentalstudios.com 1.905.883.9447 5Pro�Art Dental Laboratory Ltd. www.pro�artdentallab.com 1.800.268.6771 13Pro Sales System www.prosales.tv 1.800.492.0530 7Shaw Group of Dental Laboratories www.shawlabgroup.com 1.877.444.SHAW 35SmileTECH Dental Laboratory www.smiletechdentallabs.com 1.888.358.8190 15Swiss NF Metals, Inc. www.swissnf.com 1.800.387.5031 44Wieland www.wieland�dental�systems.com 1.866.876.0885 19


Tru Innovation

© 2009 DENTSPLY Canada. All rights reserved

www.dentsply.ca1.800.263.1437

Laboratory: • Drives premium denture business• Provides patient’s post-therapy

image, face shape, mould forms, arrangement & denture base

• Produces a complete and easy-to-read TruRx detailed prescription that can be received via e-mail, fax or print-out

Dental Professional: • Provides an interactive, custom

denture consultation• Standardizes and simplifies the

denture process• Enables the denture consultation

to be delegated to an auxiliary • Shows patients their post-therapy

image during their FIRST visit

Patient: • Educates patients for improved

understanding and acceptance of the treatment plan

• Shows patients a cosmetic approximation of what they will look like with their new denture

• Helps to ease fears and promotes more positive appointments

Whether it’s for the Laboratory, the Dental Professional or the Patient, TruRx is the Intelligent

Denture System that gives everyone a reason to smile.

Other DENTSPLY products:

For more information on TruRx - The Intelligent Denture System, please contact your authorized

DENTSPLY Distributor at 1.800.263.1437.


IPS ®e.max

all ceramic all you need

IPS e.max delivers the ultimate inmetal free esthetics and strength

• Outstanding esthetics and strength• Conventional or adhesive cementation• Choice of zirconia or lithiuimdisilicate ceramic• Press and CAD/CAM fabricationtechniques optimizing bothstrength and fitIPS

®

e.m

ax veneers

thin veneers

inlays/onlays

crowns

br idges

a strength forevery indication

all ceramicall you need

IPSe.max®

United States175 Pineview DriveAmherst, NY 14228716.691.0010800.533.6825Fax: [email protected]

Canada2785 Skymark Avenue, Unit 1Mississauga, Ontario L4W 4Y3905.238.5700800.263.8182Fax: [email protected]

©2009 Ivoclar Vivadent, Inc. All products mentioned in thiscatalog are registered trademarks of Ivoclar VivadentNA2810008 2/2009

100%CUSTOMER SATISFACTIONG U A R A N T E E D !

www.ivoclarvivadent.com

emax lab ad for 2009 Lab Product Catalog:emax ad for 2009 Lab Product Catalog 2/10/09 4:50 PM Page 1

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