April 2015 Orthodontic Therapy Periodontal Considerations Clinical Aspects

JournaCALIFORNIA DENTAL ASSOCIATION

Labial Veneers: A Multidisciplinary Approach Aaron Schwartzman, DDS You are not a market segment.

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DEPARTMENTS

169 The Editor/The Right Question

171 Letter to the Editor

173 Impressions

211 RM Matters/Precise Documentation Is an Advantage in Veneer Cases

217 Regulatory Compliance/Reasons to Read Employment Posters 222 Tech Trends 173

FEATURES

183 Labial Veneers: A Multidisciplinary Approach An introduction to the issue. Aaron Schwartzman, DDS

185 Orthodontic Management of Patients Undergoing Prosthetic Rehabilitation The practical application of orthodontic therapy in restorative dentistry as well as an approximate time frame for a proposed orthodontic intervention is described in this article. Varun Acharya, BDS, and Deepak Victor, MDS

193 Periodontal Considerations in Veneer Cases This article addresses basic concepts such as biologic width, altered eruption patterns, appropriate gingival contouring and smile design to give practitioners the tools to diagnose, evaluate and treat cases successfully and predictably. David Peto, DDS, MSD

199 Clinical Aspects of Porcelain Laminate Veneers: Considerations in Treatment Planning and Preparation Design This article is a review of the traditional clinical approach to porcelain laminate veneer case planning, intraoral preparation and provisionalization. Current research is also discussed, summarizing some of the published literature as well as newer products/technologies in each area. Andrea Jordan, DDS, FACP

203 Improved Communication With the Laboratory for the Fabrication of Labial Veneers This paper focuses on lithium disilicate and predominately glassy ceramics and improving the communication with the dental laboratory. Aaron Schwartzman, DDS, and Alan E. Zweig, DMD, FAGD

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Volume 43, Number 4 JournaCALIFORNIA DENTAL ASSOCIATION April 2015 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Manuscript California Kerry K. Carney, DDS, CDE May/Electronic Health Submissions EDITOR-IN-CHIEF Priceless results. Dental Association Records www.editorialmanager. 1201 K St., 14th Floor [email protected] June/Forensics com/jcaldentassoc Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE July/Geriatrics 800.232.7645 ASSOCIATE EDITOR Letters to the Editor cda.org Advertising www.editorialmanager. Brian K. Shue, DDS, CDE Doug Brown com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR ADVERTISING SALES Walter G. Weber, DDS [email protected] PRESIDENT Aaron Schwartzman, DDS 916.554.7312 Subscriptions GUEST EDITOR [email protected] Subscriptions are available Tiff any Carlson only to active members of ADVERTING SALES Kenneth G. Wallis, DDS Andrea LaMattina the Association. The PUBLICATIONS SPECIALIST PRESIDENT-ELECT Tiff [email protected] subscription rate is $18 and [email protected] 916.554.5304 is included in membership Blake Ellington dues. Nonmembers can TECH TRENDS EDITOR Permission and Clelan G. Ehrler, DDS view the publication online VICE PRESIDENT Reprints at cda.org/journal. [email protected] Courtney Grant Andrea LaMattina COMMUNICATIONS PUBLICATIONS SPECIALIST Manage your subscription SPECIALIST Natasha A. Lee, DDS [email protected] online: go to cda.org, log in SECRETARY 916.554.5950 and update any changes to [email protected] Jack F. Conley, DDS your mailing information. EDITOR EMERITUS Email questions or other Kevin M. Keating, DDS, MS changes to membership@ TREASURER Robert E. Horseman, DDS cda.org. HUMORIST EMERITUS [email protected] CDA classifiedsclassifieds wworkork harder to Stay Connected cda.org/journal bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, Production MBA SPEAKER OF THE HOUSE Val B. Mina or a piece ooff equipment? Now you SENIOR GRAPHIC DESIGNER [email protected] can include photos to help buyers Go Digital cda.org/apps James D. Stephens, DDS Randi Taylor SENIOR GRAPHIC DESIGNER Look for this symbol, noting additional video see the potential. IMMEDIATE PAST PRESIDENT content in the e-pub version of the Journal. [email protected] And if you’re hiring, candidates Journal of the California Dental Association (ISSN 1043-2256) is published monthly by the anywhere can apply right from Management California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Peter A. DuBois the site. Looking for a job? You can Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal EXECUTIVE DIRECTOR of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. post that, too. And the best part— Jennifer George The California Dental Association holds the copyright for all articles and artwork published it’s free to all CDA members. CHIEF MARKETING OFFICER herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Cathy Mudge any expression of opinion or statement of fact, all of which are published solely on the authority All of these features are designed to VICE PRESIDENT, of the author whose name is indicated. The association reserves the right to illustrate, reduce, COMMUNITY AFFAIRS help you get the results you need, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal. faster than ever. Check it out for Alicia Malaby COMMUNICATIONS Copyright 2015 by the California Dental Association. All rights reserved. yourself at cda.org/classifieds. DIRECTOR

168 APRIL 2015 Editor CDA JOURNAL, VOL 43, Nº4

The Right Question Kerry K. Carney, DDS, CDE

ne of the most important steps in good research is constructing the A lack of understanding of the question. It must be problem can lead to the formulation concise, answerable and Orelevant. The right question can focus the of any number of unhelpful questions. shape of the research project. Direction and methodology become clear and extraneous investigation can be cut away. Many things can get in the way around poor questions. Previous study The practicing dentist has little time of formulating the right question. questions revolved around whether for primary research. We rely on experts A lack of understanding of the problem there was an increase in the number of gathered by the ADA to do the heavy can lead to the formulation of any number bacteria in the patient’s bloodstream lifting when it comes to systematic of unhelpful questions. A poorly formed after dental appointments or whether reviews and treatment guidelines. We question can lead to extremely precise yet maintaining oral hygiene was important. adapt our everyday clinical protocols completely inaccurate or irrelevant results. Sometimes the question was confounded based on what these authorities advise. Competing interests can interfere with by the concern for potential costs of Granted, future research may cause the construction of the right question. If infected joint replacement.6 Sometimes a need to re-evaluate guidelines. They the problem under consideration involves the study question was so tentative should never be considered static. a clinical issue, it can be easy to confound that the ensuing advice was of little As professionals, we must exercise patient welfare with the payer’s competing help. We were told that practitioners judgment and be alert to changing fi nancial considerations of funding care should be cautious in deciding whether evidence but we should be able to and/or the provider’s liability risk in to follow the recommendation and expect our national organization to providing or not providing specifi c care. should exercise judgment, be alert keep us apprised of those changes. The right question can produce to emerging publications that report Should our clinical practices be called research results that have an important evidence and consider patient preference. into question, it carries more weight to impact at the local doctor-patient level Because we all try to do that all the be able to cite our national organization and at a more global level on issues time, the advice was of little help. and its guidelines as our authority. It affecting the health of the public. The However, this last study has does not matter if my local study group right question is a powerful tool. fi nally asked the right question: does an in-depth review of the published In January of this year, the Is there an association between evidence. Even a state commissioned ADA announced the release of an dental procedures and prosthetic joint paper on the subject could never be evidence-based clinical practice infection (PJI), and, therefore, should considered on the same level as an guideline for dental practitioners with systemic antibiotics be prescribed advisory guideline issued by the ADA. a new recommendation on antibiotic before patients with prosthetic joint At last, the right question produced prophylaxis for joint implant recipients implants undergo dental procedures? a guideline that truly guides. We about to undergo dental treatment. At last, we have a clear question can be confi dant incorporating this This is the most recent in a series of that led to a systematic review that evidenced-based guideline into the attempts to answer a question important produced clear guidance for our care we provide our patients. to both joint implant patients and the discussions with our patients. The ADA’s “Power of Three” program dentists responsible for overseeing their The recommendation is as follows: In should calibrate, coordinate and celebrate oral health. Over the past 18 years general, for patients with prosthetic joint the services of organized dentistry at the there have been at least fi ve advisories implants, prophylactic antibiotics are not local, state and national levels. The 2015 released on the subject.1-5 Too often those recommended prior to dental procedures prophylactic antibiotic guidelines are a previous advisories/guidelines waffl ed to prevent prosthetic joint infection. perfect example of what ADA, as our

APRIL 2015 169 APRIL 2015 EDITOR

CDA JOURNAL, VOL 43, Nº4

national organization, can best provide 4. American Academy of Orthopaedic Surgeons and American past two months or matters of general Dental Association. Prevention of orthorpaedic implant its members. It formulated and answered infection in patients undergoing dental procedures: evidence- interest to our readership. Letters the right question with the authority based guideline and evidence report. American Academy of must be no more than 500 words and of a national body. Thank you ADA. Orthopaedic Surgeons, Rosemont, IL; 2012 (available at) www. cite no more than fi ve references. No aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf. ■ It is time for a celebration. 5. January 2015 vol. 146, issue 1, pp. 11-16.e8 The use of illustrations will be accepted. Letters prophylactic antibiotics prior to dental procedures in patients should be submitted at editorialmanager. REFERENCES with prosthetic joints. DOI: http://dx.doi.org/10.1016/j. com/jcaldentassoc. By sending the letter, 1. Advisory statement. Antibiotic prophylaxis for dental patients adaj.2014.11.012. with total joint replacements. American Dental Association; 6. Mary Ann Porucznik AAOS releases new statement on the author certifi es that neither the American Academy of Orthopaedic Surgeons. J Am Dent Assoc, antibiotics after arthroplasty. www.aaos.org/news/aaosnow/ letter nor one with substantially similar vol. 128, no. 7, 1004-1008. 1997 American Dental Association. may09/cover2.asp. content under the writer’s authorship has 2. Advisory Statement: Antibiotic prophylaxis for dental patients with total joint replacement. J Am Dent Assoc 2003; been published or is being considered for 134(7):895-898. The Journal welcomes letters publication elsewhere, and the author 3. Information Statement 1033: Antibiotic Prophylaxis for We reserve the right to edit all acknowledges and agrees that the letter Bacteremia in Patients with Joint Replacements. February 2009 American Academy of Orthopaedic Surgeons. Revised communications. Letters should discuss and all rights with regard to the letter June 2010. an item published in the Journal within the become the property of CDA.

UCSF Dental Center Compliance Officer

The University of California, San Francisco Dental Center seeks applicants for a full time Compliance Officer.The University The UCSFof California, Dental CenterSan Franciscois comprised Dental of seventeenCenter seeks individual applicants clinics for a Compliancewith over 120,000Liaison visits position. reportedPlease see annually. our website http://ucsfhr.ucsf.edu/careers/ and job number #41534BR. The UCSF Dental Center is comprised of seventeen individual clinics with over 125,000 visits reported annually. The UCSF Dental TheCenter UCSF Compliance Dental Center Liaison Compliance is responsible Officer for a iscomprehensive responsible for approach a comprehensive that promotes approach ethical, that safe promotes and ethical,proper safe behavior and proper in the behavior School. This in the Compliance School. This Liaison Compliance implements Officer and enforces implements University and enforces and School Universitypolicy with and the School goal of policy minimizing with the risk goal associated of minimizing with laboratory risk associated and clinical with laboratory operations and in theclinical Dental operationsCenter. The in the Compliance Dental Center. Liaison The reports Compliance to the AssociateOfficer Deanreports for to Clinical the Associate Affairs Deanand forworks Clinical closely Affairswith andthe works Clinic with and the Program Associate Directors Dean, toClinic establish Directors standards and Clinicand procedures Manager to establishbe followed standards by Dental and Center proceduresemployees to and be trainees.followed Thisby Dental is a non-tenure-track Center employees position and trainees. in the SchoolThis is of a Dentistry.non-tenure-track position in the School of Dentistry. Candidates must possess good clinical skills, dental knowledge, and ability to effectively communicate Candidatesverbally and must in possesswriting. good Demonstrated clinical skills, ability dental to work knowledge, collaboratively and ability with to otherseffectively and provencommunicate ability to verballyinfluence and inothers writing. and affectDemonstrated change withoutability to direct work supervisory collaboratively authority. with others Must andhave provenexperience ability with to Quality influenceAssurance others or Continuous and affect Quality change Improvement without direct programs. supervisory Dental authority. experience Must (private have experience or academic with institution), Quality Assuranceexperience or teachingContinuous dental Quality students Assurance preferred. programs. Dental license Dental is experience required and (private if involved or academic in clinical institution),supervision experience must have teaching a valid CA dental license. students Interested preferred. applicants DDS, shouldMA, MS submit or RN a coverrequired. letter Interested and curriculum applicantsvitae to: [email protected] submit a cover letter (Attn: and Maria curriculum Guerra, vitaeManager) to: [email protected] as well as the website. (Attn: Maria Guerra, Manager)

170 APRIL 2015 Letter CDA JOURNAL, VOL 43, Nº4

Marketing Claims and Genetic Tests

I read with interest the October 2014 have signifi cantly higher gingival levels October 2014 National Interprofessional editorial by Dr. Kerry Carney, titled “You of the IL-1 cytokine that has been Initiative on Oral Health Pediatric Dental Residency Training The Oral Physician Have to Shake Your Head,” discussing a centrally implicated in periodontitis over JournaCALIFORNIA DENTAL ASSOCIATION new risk-based insurance plan. Certainly, several decades with strong scientifi c change to health care delivery and evidence. The IL-1 genetic test has also fi nancing are important topics for debate been associated with severe periodontitis within all health care professions. As in four meta-analyses and in multiple CEO of Interleukin Genetics and a studies exceeding 1,000 subjects, which researcher in genetics of periodontitis in the context of evidence-based for 20 years, I was surprised that Dr. dentistry represent strong evidence Carney devoted much of the article for test validity. For example, smokers challenging the validity of our company’s who were also IL-1 genotype positive interleukin-1 (IL-1) genetic test. lost an average of fi ve more teeth

Part Three 3 INTERPROFESSIONAL Although bacterial plaque is than genotype-negative smokers. EDUCATION AND PRACTICE … THE DENTIST OF THE FUTURE essential for periodontitis initiation, With recent evidence that Lindsey A. Robinson, DDS we know disease severity is NOT a periodontitis will affect nearly half (47 simple function of plaque amount percent) of the adult population,4 I over time. In fact, genetics explains cannot share Dr. Carney’s sentiment approximately 50 percent of clinical that the interleukin-1 test could lead U, Kocher T. Dose-eff ect relation of smoking and the differences in periodontitis.1 We know toward “detection of abnormalities interleukin-1 gene polymorphism in periodontal disease. J that periodontitis severity is amplifi ed that are not destined to ever bother us.” Periodontol 2004;75:236-242. 4. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. by several risk factors that modify the Recently, the IL-1 test was associated Prevalence of periodontitis in adults in the United States: 2009 body’s response to bacteria, and the best with severe periodontitis in 1,700 and 2010. J Dent Res 2012;91:914-920. validated are smoking, uncontrolled subjects and added signifi cant value 5. Wu X, Off enbacher S, Lomicronpez NJ, et al. Association of interleukin-1 gene variations with moderate to severe chronic 5 diabetes and IL-1 genotype. Patients beyond smoking and diabetes. periodontitis in multiple ethnicities. J Periodontal Res 2014. with these factors are at greater risk Dentistry has always been a leader KENNETH KORNMAN of severe periodontitis, and it is in preventive health. The profession CEO, Interleukin Genetics rational to consider more preventive has always embraced and greatly Waltham, Mass. care for those at greater risk. benefi ted from new technology that A recent study of 5,117 patients does what it claims and adds value Dr. Carney’s Response with no prior diagnosis of periodontitis, to clinical care. We certainly should Dr. Kornman states that I have and with regular once- or twice-annual not dismiss new technology without a challenged the validity of Interleukin prophylaxes, analyzed tooth loss over thorough assessment and understanding Genetics IL-1 based genetic test. He 16 years.2 Patients with any of the of the scientifi c evidence relative is correct. I have, and I continue to above three risk factors, IL-1 genotype to the potential it may serve for our hold this position, as I have not seen being the most frequent, benefi ted patients, independent of any fi nancial evidence to support clinical use of IL-1 signifi cantly with lower tooth loss rates implications. Dentists, patients and genetic tests to manage dental patients. if they had two cleanings annually employers, who often pay for our Dr. Kornman states that genetics versus one. Patients with two or three care, will ultimately decide in time is estimated to explain 50 percent of risk factors appeared to need more whether the IL-1 genetic test adds the clinical variance in periodontitis.1 than two cleanings annually, and in value to the care of our patients. While this statement is supported, there patients with none of the risk factors, is no indication that the IL-1 gene(s) REFERENCES two cleanings annually versus one had 1. Michalowicz BS, Aeppli D, Virag JG, et al. Periodontal are primary drivers of this 50 percent no signifi cant effect on tooth loss. fi ndings in adult twins. J Periodontol 1991;62:293-299. genetic contribution to periodontitis. Gene variations measured in the 2. Giannobile WV, Braun TM, Caplis AK, Doucette-Stamm In fact, modern genetics suggests L, Duff GW, Kornman KS. Patient Stratifi cation for Preventive IL-1 test change the way infl ammation is Care in Dentistry. J Dent Res 2013. that many hundreds to thousands of controlled. Genotype-positive patients 3.Meisel P, Schwahn C, Gesch D, Bernhardt O, John genetic variants are likely to underlie

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this genetic variance.A The idea that genotype itself has a major effect: clinical settings to manage patients. IL-1 genetic testing provides the whether it is associated with either This is an important distinction. basis of this genetic susceptibility is periodontitis, tooth extraction over 16 I agree that dentistry has been a simply not consistent with current years or the effect of one versus two leader in preventive health. However, thought regarding the genetic basis preventive visits. The paper does not before the profession embraces new of common complex diseases such evaluate the independent effect of technology, including SNP-based as periodontitis and tooth loss. IL-1 genotype on any of the clinical testing for common, complex diseases Dr. Kornman further states the outcomes. As such, the study does not such as periodontitis or tooth loss, we Giannobile paper2 supports clinical in fact support its claims for clinical must be vigilant to ensure unsupported use of IL-1 genetic testing to stratify use of any of the Il-1 genetic tests marketing claims are not used to patients for the number of annual the company offers. Citing research prematurely launch genetic tests. preventive visits they should receive. evidence for a role of IL-1 in the broad REFERENCES The paper cited did not perform scope of periodontitis is not the same A. Kinane DF, Shiba H, Hart TC. The genetic basis of standard statistical analytical as demonstrating evidence for use periodontitis. Periodontal 2000 2005; 39:91-117. approaches to evaluate whether IL-1 of common IL-1 genetic variants in

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172 APRIL 2015 Impressions CDA JOURNAL, VOL 43, Nº4

How Much Is a Gored Ox Worth? David W. Chambers, EdM, MBA, PhD

There are two ways to handle damages. One is based on who is right; the other is based on fairness. We tend to use both methods, depending on which better serves our interests. The patient approved the provisional. It says so right there in your notes. Now there is a complaint about color match and the bite is not exactly right. As the tussle goes on and other parties are brought into the discussion, the patient seems to have recalled that the dentist was “abrupt and condescending, perhaps so much so that informed consent was compromised.” Which is better: standing by one’s principles or looking for some common ground? Lawyers and economists tend to divide on this issue, with lawyers urging that their clients purchase all the right they can afford. Economists are generally inclined toward rational division of the pie. Philosophers, including ethicists, come down unambiguously in both camps. Warning: choose your advisors carefully! Ronald Coase (rhymes with rose) won the Nobel Prize in Economic Sciences in 1991, based on what may be the single The nub: most widely read and cited paper in economics: “The Problem 1. It is unethical to force third of Social Cost,” Journal of Law and Economics, 1960, 3, 1-44. The case he dissects goes something like this: A doctor expands parties to guarantee our rights his practice to include sensitive diagnostic testing. The factory when we can secure them located next door installs equipment that causes vibrations that ourselves. interfere with the doctor’s testing. The doctor estimates that the vibrations are costing him $20,000 per year in lost business. He 2. If we sometimes choose rights has the option of moving to a new location at a cost of $10,000. On the other hand, the factory could either move (costing about and sometimes choose justice, $75,000) or install vibration mitigation barriers for $5,000. neither is a primary good. One approach is to go to court in hopes of getting a judgment. If the decision goes against the factory, the doctor 3. Our image of who we are, would be awarded $10,000 and the factory would pay court costs what we are entitled to and and lawyers’ fees. If the decision goes the other way, the doctor the recognition of others are loses $20,000 and additional costs are piled on accordingly. Either way, somebody loses a lot and the lawyers prosper. precious, but not without cost. There is another approach based on justice rather than rights. The doctor could give the factory $5,000 to install mitigating measures. This would be a savings of $10,000 David W. Chambers, EdM, MBA, PhD, is professor for the factory and $5,000 for the doctor (the $5,000 paid of dental education at the University of the Pacifi c, Arthur out subtracted from the $10,000 needed to move). A. Dugoni School of Dentistry, San Francisco, and editor Coase’s Rule is that governmental regulations and court of the Journal of the American College of Dentists. decisions should mimic as closely as possible the solutions reasonable people would have negotiated. That is a good rule for people as well, even if it would put some lawyers and philosophers out of work. ■

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Chronic Periodontitis and Severity of Heart Attacks In a recent study, researchers at the University of Granada surveyed 112 patients who had suff ered from an acute case of myocardial infarction and found that the extent and severity of chronic periodontitis is directly related to Study: Bacteria Can the severity of myocardial infarction. “The relationship between periodontitis and acute myocardial infarction is Provide Anti-Immune well documented,” the authors wrote, noting that the cross-sectional study was Defense Mechanism designed to “investigate the association of chronic periodontitis extent and A study published in the journal severity with acute myocardial infarct size as indicated by serum cardiac troponin Immunity has found that the oral I and myoglobin levels.” pathogen Fusobacterium nucleatum According to the authors, cardiovascular disease has been associated with protects a variety of tumor cells from 40 percent of deaths in high-income countries and 28 percent in lower-income being killed by immune cells, and countries. For their study, published in the Journal of Dental Research, researchers these fi ndings could open new avenues from the University of Granada surveyed 112 patients who had suff ered from for the treatment of cancer in human an acute case of myocardial infarction. These patients underwent a series of patients, according to a news release. cardiological, biochemical and periodontal health checks and tests. Fusobacterium nucleatum is an Results of the study demonstrated that the extent and severity of chronic oral pathogen that has been linked periodontitis were “signifi cantly associated” with troponin I levels after controlling for to periodontal diseases and is also sociodemographic and clinical confounders. However, the authors wrote, only the present in human colorectal tumors. extent index accounted for levels of myoglobin, total leukocytes and neutrophils. “Certain bacteria have previously been shown to fi ght cancer, so the surprising Researchers point out that it will be necessary to conduct follow-up checks fi nding of this paper is that bacteria such as with periodontal patients who have suff ered myocardial infarction in order to Fusobacterium nucleatum can grant tumors determine the severity (or lack thereof) of their clinical evolution (new coronary an anti-immune defense mechanism,” said events, cardiac failure or even death). co-senior study author Ofer Mandelboim, For more information, see the study published in the Journal of Dental Research, PhD, of The Hebrew University Hadassah October 2014, vol. 93, no. 10, pp. 993-998. Medical School, in the news release. “Blocking the interaction between these bacteria and immune cells might improve anti-tumor immunity both in general and with regard to colon cancer in particular.” In the new study, researchers discovered that this Fusobacterium bacteria from the tumors or inhibit TIGIT interactions in more detail and develop nucleatum protects a range of human with antibodies, we might enable immune ways to block these interactions. tumor cells from destruction by “human cells to kill the colon tumors more “Because Fusobacterium nucleatum natural killer cells,” which defend the effi ciently,” said fi rst author Chamutal Gur. specifi cally targets tumors, it may be body against a number of health threats, According to the news release, possible in the future to use a Fap2- including viruses and parasites. This the researchers now intend to test deleted Fusobacterium nucleatum immune evasion depends on the binding whether this bacterium is found in to guide therapeutic agents to kill of a bacterial protein called Fap2 to an other types of tumors and whether the tumors,” Mandelboim said. immune cell receptor called TIGIT. additional bacteria that colonize tumors For more, see the study “The implications are that if we either affect the activity of immune cells. published online in the journal remove the Fusobacterium nucleatum They also plan to study Fap2-TIGIT Immunity, Feb. 18, 2015.

174 APRIL 2015 CDA JOURNAL, VOL 43, Nº4

Periodontal Disease More Prevalent Among Ethnic Minorities A new study from the Centers for percent) and non-Hispanic blacks (59.1 Disease Control and Prevention (CDC) percent), followed by non-Hispanic Asian confi rms that nearly 50 percent of U.S. Americans (50 percent) and lowest in adults age 30 and older — 64.7 million non-Hispanic whites (40.8 percent). Americans — has periodontitis according The fi ndings provide valuable to a news release from the American information for population-based action Academy of Periodontology (AAP). to prevent or manage periodontitis The study also found periodontitis in U.S. adults, the authors wrote. prevalence was “positively associated While previous prevalence estimates with increasing age and was higher relied on data from the CDC’s National among males.” According to the authors, Health and Nutrition Examination prevalence was highest in Hispanics (63.5 Survey (NHANES) from 2009

through 2010, the new CDC study is based on full-mouth periodontal Review Suggests Implant Overdentures Improve examination data collected as part of the NHANES from 2009 through 2012. Satisfaction, Chewing and Bite Force “The updated fi ndings verify a high According to a recent review, researchers found oral function with removable burden of periodontitis in the U.S. adult dentures is improved when dental implants are used for support. The review, published population. Public health programs that in the Journal of Oral Rehabilitation, assessed the impact of implant overdentures aim to prevent and control periodontitis are needed to improve the overall health (IODs) on masticatory performance, bite force, patient satisfaction and the nutritional of our adult population,” said CDC state of patients with removable dentures and described the outcome of these. epidemiologist and lead study author Paul A variety of methods was used to measure oral function and most of the studies Eke, PhD, MPH, in the news release. included mandibular overdentures while three included maxillary overdentures. “Periodontal disease remains a To be included in the review, the authors wrote that the studies “should be any signifi cant public health issue for people assessment of function/satisfaction before and at least one year after treatment.” of all backgrounds,” said Joan Otomo- According to the review, the studies suggested that the use of implant Corgel, DDS, MPH, president of the AAP. overdentures (IODs) improves patient satisfaction. “Implant-supported dentures “However, with the proper treatment were accompanied by high patient satisfaction with regard to denture comfort, but and care from a periodontist, periodontal this high satisfaction was not always accompanied by improvement in general disease is often reversible. A full-mouth quality of life (QoL) and/or health-related QoL,” the authors wrote. periodontal evaluation is the most The authors reported that bite force improved, masseter thickness increased, accurate way to assess for disease. These fi ndings support the need for all adults muscle activity in rest decreased and patients could chew better and eat more age 30 and older to receive an annual tough foods. They concluded that “treating complete denture wearers with comprehensive periodontal evaluation implants to support their denture improves their chewing effi ciency, increases from their dental professional to identify maximum bite force and clearly improves satisfaction.” and treat periodontal disease as needed.” For more, see the study published in the Journal of For more information, read the Oral Rehabilitation, March 2015, vol. 42, issue 3, pp. study titled “Update on Prevalence 220–233. of Periodontitis in Adults in the United States: NHANES 2009- 2012,” published online in the Journal of Periodontology, Feb. 17, 2015.

APRIL 2015 175 Practice Support

Endorsed Programs

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APRIL 2015 IMPRESSIONS

CDA JOURNAL, VOL 43, Nº4

Wisdom Teeth Stem Cells to Treat Corneal Scarring Stem cells from the dental pulp of wisdom teeth can be coaxed to turn into cells of the eye’s cornea and could one day be used to repair corneal scarring Survey: 75 Percent of due to infection or injury, according to a news release from the University of Parents Aren’t Bringing Pittsburgh School of Medicine. According to researchers from the university, results of their study indicate that those stem cells could also become a new source of Children to Dentist by Age 1 corneal transplant tissue made from the patient’s own cells. Through a new survey from Western Corneal blindness, which aff ects millions of people worldwide, is typically University of Health Sciences’ College treated with transplants of donor corneas, said senior investigator James of Dental Medicine, researchers have Funderburgh, PhD, in the news release. found that 75 percent of parents are “Shortages of donor corneas and rejection of donor tissue do occur, which can not complying with the American result in permanent vision loss,” Funderburgh said. “Our work is promising because Academy of Pediatric Dentistry (AAPD) using the patient’s own cells for treatment could help us avoid these problems.” recommendation to take children Experiments conducted by the research team showed that stem cells of the to the dentist by age 1. Instead, the dental pulp, obtained from routine human third molar extractions could be turned survey found that parents in the general into keratocytes, cells of the corneal stoma, which have the same embryonic origin. population bring their children to the The team injected the engineered keratocytes into the corneas of healthy dentist for the fi rst time at the average mice, where they integrated without signs of rejection. They also used the cells to age of 2.5 years old while parents who fall under the U.S. poverty threshold develop constructs of corneal stroma akin to natural tissue. bring their children to the dentist for “Other research has shown that dental pulp stem cells can be used to make the fi rst time at approximately 3.5 years neural, bone and other cells,” noted lead author Fatima Syed-Picard, PhD. “They old, according to a news release. have great potential for use in regenerative therapies.” Among survey respondents with These fi ndings demonstrate a potential for the clinical application of DPCs in children under the age of 18, a majority cellular or tissue engineering therapies for corneal of parents are not taking their children stromal blindness, the authors concluded. to the dentist before age 1, even though For more, see the fi ndings published in STEM 60 percent of the parents were aware of CELLS Translational Medicine, March 2015, vol. the AAPD’s recommendation. According 4, no. 3, 276-285. to the survey report, of the parents of children who were aware of the recommendation of a dental care by age one, most stated that they did not think S. Martinez, DMD, College of Dental patient relationship by age 1 by all the visit was necessary (67 percent) or Medicine associate dean of Community health professions will be critical to that their pediatrician or doctor stated Partnerships and Access to Care. “Age parents’ knowledge and use of this it was not necessary (22 percent). 1 is a perfect time to get a child into the information,” the authors concluded. “The lack of knowledge parents dental offi ce and begin preventative For more, download the survey have, and the lack of urgency of taking dental care that will minimize decay report at supportcleandentistry.com their children to the dentist by age and early childhood caries.” or visit supportcleandentistry.com/ 1, is very concerning to me,” said lead “Continued messaging on the upload/resources/Western%20Uni%20 author of the survey report Timothy importance of establishing a dentist- Child%20Dental%20Care%20Paper.pdf.

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Smokers in Cessation Program Three Times More Likely to Be Long-Term Quitters In a study published in Anesthesia up study of 168 patients from a previous & Analgesia, researchers report that randomized trial evaluating a “practical patients receiving a brief intervention intervention” to help smokers quit before to help them quit smoking before surgery. Three weeks before scheduled surgery are still more likely to be elective procedures, one group of patients nonsmokers at one-year follow-up. received the smoking cessation program. “Anesthesiologists and perioperative The four-part programs consisted of brief providers have a unique opportunity counseling (less than fi ve minutes) by a to help patients achieve both nurse, brochures on smoking cessation, short-term and long-term smoking referral to a quit-smoking hotline and a cessation,” the authors wrote. free six-week supply of nicotine patches. The researchers performed a follow- The study reports that the simple,

inexpensive cessation program to help Report: Estimated Smoking Costs in California patients quit smoking before surgery triples Average $1.5M Per User the percentage of patients with long-term smoking cessation at one year after surgery. In a recent report organized to encourage the more than 60 million tobacco According to the study, at one year, users in the U.S. to quit the habit, WalletHub gauged the fi nancial cost of 127 patients (76 percent) were available smoking in each of the 50 states and the District of Columbia and found that for a follow-up telephone interview and the average smoking cost per user in California is an estimated $1,508,790. the authors report that smoking cessation According to the feature on WalletHub.com, the report calculated the occurred in just 8 percent of control potential fi nancial losses — including the cumulative cost of a cigarette pack patients compared with 25 percent of per day over several decades, health care expenditures, income losses and patients in the intervention group. other costs — brought on by smoking and exposure to secondhand smoke. “Undergoing surgery can serve California ranked 35th nationwide, with total costs that included as a ‘teachable moment’ that may about $1.06 million in tobacco costs; $188,368 in medical care; motivate patients to engage in $243,352 in income loss; and $14,336 in other costs. permanent smoking cessation,” the authors wrote. “Perioperative care “Direct medical costs to treat smoking-connected health complications are providers have a unique opportunity one of the biggest fi nancial detriments caused by tobacco use,” the report to assist patients in smoking cessation states. The article explains that to calculate related health care costs, state- and achieve long-lasting results.” level data from the Centers for Disease Control and Prevention was obtained, “This study demonstrates that specifi cally the annual health care costs incurred from smoking, and that an intervention designed for a busy amount was divided by the total number of adult smokers in each state. preadmission clinic results in decreased Based on total calculations, the report estimates that $116.4 billion is spent smoking rates not only around the on direct smoking-related health care costs in the U.S., $67.5 billion is spent in time of surgery but also continued workplace productivity losses and $117.1 billion in early deaths related to smoking. benefi t in smoking cessation at For more information, see the report at wallethub.com/ one year,” the study concluded. edu/the-fi nancial-cost-of-smoking-by-state/9520. For more, see the study in the journal Anesthesia & Analgesia, March 2015, vol. 120, issue 3, pp. 582–587.

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Tooth Fairy Leaves Estimated $255 Million Under Pillows in 2014 A recent survey, “The Original Tooth Fairy Poll,” has found that the tooth fairy’s average gift amount has hit a record high, averaging $4.36 per tooth in 2014, up 25 percent from $3.50 in 2013, according to a news release. Bone-Loss Score Could The poll surveyed 1,000 parents and found that in 40 percent of homes, the Indicate Gum Disease in tooth fairy was more generous if a fi rst tooth had been lost, leaving an average Older Women $5.74 for a fi rst tooth (a 27 percent increase from 2013). The survey reported that in the U.S., the tooth fairy visited 81 percent of homes Postmenopausal women whose with children who lost a tooth and found that in 88 Fracture Assessment Risk Tool (FRAX) percent of those homes, cash was left for children, scores suggest major osteoporotic fracture either by itself or in combination with (OPF) risk have signifi cantly more severe other gifts. Kids who received gifts most often got periodontitis endpoints than controls, a toy, game, toothbrush, toothpaste, book, doll, according to researchers at Case Western Reserve University School of Dental stuff ed animal or dental fl oss. Medicine and Case/Cleveland Clinic As for the reasons behind determining how much Postmenopausal Health Collaboration. is left for each child, 44 percent of parents reported In a study published in the it was the amount of spare cash they had on hand journal Menopause, researchers found while 39 percent based the amount on the child’s age. a link between postmenopausal For more information and to see detailed women with high FRAX scores and poll results, go to theoriginaltoothfairypoll.com. symptoms of severe gum disease. “More investigations are needed, but the FRAX Tool score can potentially be used as a way to fi nd women at risk for gum disease,” said Leena Palomo, DDS, be at-risk for gum disease as FRAX scores OPF risk while 98 participants served MSD, in a news release from the school. take into account weight, height, previous as controls, according to the study. After the onset of menopause, lower fractures, rheumatoid arthritis, smoking All women had FRAX scores and estrogen levels impact the mouth and habits, diabetes and other factors. a periodontal checkup that measured cause infl ammatory changes in the body “Many of these factors are also probing depth for the gums, tooth loss that can lead to gingivitis, a precursor to markers for gum disease,” Palomo said. and attachment loss from ligaments gum disease, Palomo said. If untreated, The sample used in the study included holding teeth to bone. Researchers the result is tooth loss. Knowing women between ages 51 and 80 who had found that women with high FRAX how bone loss occurs throughout the gone through menopause within the last scores also showed the strongest signs body in menopause, researchers of 10 years, didn’t smoke and were not on of gum disease, a result that suggests the recent study were also interested hormonal replacement therapy, bone bone-loss scores could provide a in the oral-physical connections. loss medicines for at least fi ve years or reliable indicator of gum disease. Palomo and the team of researchers diabetes medication. Ninety participants For more, see the study in the tested the hypothesis that women who had FRAX scores higher than 20 percent journal Menopause, January 2015, are at-risk for bone fractures might also and were considered to have high vol. 22, issue 1, pp. 75-78.

180 APRIL 2015 Read this issue on your iPad.*

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CDA JOURNAL, VOL 43, Nº4

Labial Veneers: A Multidisciplinary Approach

Aaron Schwartzman, DDS

GUEST EDITOR

Aaron Schwartzman, hallenging esthetic by teaming with an orthodontist. Bodily DDS, is a prosthodontist in treatment often requires a movements of teeth and intentional private practice in Beverly multidisciplinary approach positions may eliminate elective Hills, Calif. He attended New York University College to achieve the goals of both endodontics and even periodontal of Dentistry for his dental the patient and the dentist. treatment. The byproduct of this degree and postgraduate CA detailed diagnosis and treatment treatment course might be an extended prosthodontics program. plan that incorporates the desires of the treatment time, but the superior outcome He has served as a clinical patient and negotiates the limitations makes it a worthy alternative. Traditional instructor at NYU College of Dentistry and the University of the case can be a time-consuming facial metallic brackets may not be of California, Los Angeles, process. Often the clinician is under acceptable to the esthetically conscious School of Dentistry. great pressure to produce an esthetic patient. Our authors defi ne orthodontic Confl ict of Interest treatment plan to meet the patient alternatives ranging from clear aligners Disclosure: None reported. demands in a short time frame. This to computer guided lingual brackets.1 rapid scripting of a treatment plan may Additionally, guidelines are provided for please the patient in the chair and orthodontic retention after treatment increase his or her acceptance, but it and subsequent restorative treatment could compromise the integrity and — a critical and often overlooked step. long-term viability of the treatment. Complex esthetic treatments can In this issue of the Journal of the benefi t from the involvement of the California Dental Association, we explore periodontist. Gingival positions, papilla various viewpoints from periodontists, volume and zeniths can be controlled orthodontists and prosthodontists or changed with appropriate planning. to learn unique approaches to Presurgical treatment diagnostics and successful esthetic treatment. diagnostic wax-ups serve as guides A more minimally invasive for both the periodontist and the restorative rehabilitation may be attained restorative dentist. Procedures such as

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crown lengthening in the esthetic zone Ivoclar Vivadent, Amherst, N.Y.) have many practitioners, today they are require a diagnostic and surgical guide. given the restorative dentist a material becoming increasingly more attainable In the articles to follow, treatment choice that is stronger than any esthetic and quickly shifting the standards of sequencing and suggested healing ceramic to date. The dentist has the care. In this issue, we hope to reinforce times will be discussed to produce choice of making a restoration of lithium strong clinical backgrounds and more predictable soft tissue results disilicate in the offi ce or trusting it to enlighten with fresh approaches. ■ for complex esthetic treatments. the hands of an experienced ceramist. REFERENCES The prosthodontists provide a history While changes in technology are 1. Grauer D, Proffi t WR. Accuracy in tooth positioning with a of veneers, reviewing the current trends creating opportunities for advancing fully customized lingual orthodontic appliance. Am J Orthod and anticipated future advances. As we techniques, there are certain strongholds Dentofacial Orthop 2011;140:433-443. 2. www.zirkonzahn.com/en/products/millable-materials/ will see, innovations in digital treatment left unchanged. In the articles to follow, temp-premiumsuperfl exible. planning and milled provisionals are we look into what technologies may hold gaining popularity.2 Digital design of for our future and how they can help restorations coupled with advances in improve our clinical outcomes. Some 3-D printing and computer-assisted may simplify while others complicate. milling is becoming the new standard Advances in orthodontic treatment of practice for both laboratories and and retention, periodontal surgeries and practicing dentists. The digital industry dental material science hold promise continues to produce innovations in of a new evolution. Digital approaches scanners, milling machines, printers and to orthodontics, impression making software. As the technology evolves, and restoration fabrication coupled start-up costs will decline, allowing with stronger ceramic materials are this technology to be attainable for any paving the way to more predictable practice or laboratory. Material advances results. While these newer technologies such as lithium disilicate (IPS e.max, were at one time not affordable for

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Orthodontic Management of Patients Undergoing Prosthetic Rehabilitation

Varun Acharya, BDS, and Deepak Victor, MDS

ABSTRACT The successful management of a patient’s functional and esthetic dental needs frequently requires a multidisciplinary approach. One such avenue for collaboration is between the orthodontist and the restorative dentist. Orthodontic therapy can also assist the surgeon in preparing a surgical site for implant placement. The practical application of orthodontic therapy in restorative dentistry as well as an approximate time frame for a proposed orthodontic intervention is described in this article.

AUTHORS

Varun Acharya, BDS, Deepak Victor, MDS, he past three decades have and the restorative dentist and briefl y graduated from dental received his dental training seen tremendous advances discusses the different orthodontic school in Chennai, India. at Rajiv Gandhi University in dental technology, appliances available to patients and the He completed postgraduate of Health Science in prosthodontic training Bangalore, India. He was an making it possible to achieve amount of time required post treatment. at New York University orthodontic resident in the beautiful form, function and To accomplish an optimum result College of Dentistry and a department of orthodontics Testhetics in the restorations dentists for complex interdisciplinary patient fellowship in maxillofacial at Meenakshi Academy provide for patients.1-4 Patients are treatment, the clinicians involved must prosthetics and oncologic of Higher Education and more than willing to accept complex develop a problem list that closely dentistry at The University Research in Chennai, India, of Texas MD Anderson where he received his treatment plans if they can be assured examines various challenges associated Cancer Center. He is postgraduate degree in of an optimal esthetic result.5 Adult with dental rehabilitation that can currently the consultant orthodontics and dentofacial orthodontics is now very common, and make treatment more challenging. maxillofacial prosthodontist orthopedics. He then went this adult population is likely to have at Acharya Dental in on to complete a master’s worn restorations, missing or damaged Chennai, India. training program in lingual Periodontal Considerations Confl ict of Interest orthodontics at Kyungpook teeth, dental caries, discoloration of The prevalence of periodontal Disclosure: None reported. National University in teeth and other problems that require disease and loss of attachment increases Daegu, South Korea. the services of a restorative dentist.6 As with age, becoming more common Confl ict of Interest a corollary to this, a restorative dentist is in adults. A patient should undergo Disclosure: None reported. likely to encounter situations requiring a complete clinical and radiographic orthodontic intervention to obtain an assessment of his or her periodontal ideal esthetic and functional result. status before commencing orthodontic This paper discusses indications for treatment.7 An excellent standard of collaboration between the orthodontist plaque control should be attained and

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then maintained throughout treatment, with professional supra- and subgingival scaling as necessary. Previous attachment loss does not preclude orthodontics, but active periodontal disease will require treatment and evidence of stabilization before any appliances are placed.8 Teeth with previous attachment loss and reduced bony support will respond differently to orthodontic force. The center of resistance moves apically FIGURE 1. Vertical maxillary excess FIGURE 2. Correction of gummy smile with and tipping occurs more readily than demonstrating a gummy smile. traditional orthodontics. bodily movement. Similarly, the relative anchorage value is also reduced.9 Increasing age is associated with a invasive way. If these morphological treatment, as it could be due to maxillary reduction in vascularization and collagen factors are compromised, then restoration excess, passive eruption of teeth, short turnover within the periodontium, with with veneers or crowns can be done to upper lip, gingival enlargement or an overall reduction in bone volume. achieve an optimal, esthetic smile line. insuffi cient clinical crown length.14 Initial tooth movement can be slower in adults and light force should be used Gingival Display Buccal Corridor to avoid the risk of root resorption.10 A smile is framed by the lip curtain, The transverse dimension of the smile a term proposed by Lavater to describe plays an important role in achieving Esthetics of the Smile the soft tissue drape of the lips over the ideal esthetics, as demonstrated by Frush teeth.12 Ackermann classifi ed smiles and Fisher. The buccal corridors, when Smile Arc to be either a Stage 1 “posed” smile insuffi cient, lead to the perception of the The smile line plays a vital role in or a Stage 2 “unposed” (spontaneous) smile to be unrealistic. Although the buccal achieving a beautiful smile. Originally smile. A posed smile can be reproduced corridor is traditionally linked to the width proposed by Ackermann, the smile easily and is not generally accompanied of the maxillary arch, there is evidence to arc is an alternative to traditional by any emotion, whereas an unposed show that the anterior-posterior position complete denture anterior tooth position smile is spontaneous, involuntary and of the maxilla also is a determining factor guidelines. Ackermann’s “smile line” or accompanied by feelings of joy. Most in the width of the buccal corridor.12,15 “smile arc” is defi ned as the relationship orthodontists agree that a maximum between the curvature of the maxillary elevation of the lip up to the gingival Orthodontic Management of Partial anterior teeth and the curvature of the zenith of the maxillary incisors to be ideal Edentulism upper border of the lower lip. The key for a posed smile. A total lack of gingival difference between this and traditional display or excessive display of gingiva is Missing Teeth and Impacted Teeth denture tooth position guidelines is considered to be unattractive.11,12 With Missing or impacted teeth can the fact that the incisal edges of teeth orthodontics, extrusion of short teeth adversely affect a favorable esthetic are fl atter in complete denture tooth can be performed to display more tooth outcome when a patient is undergoing arrangements, whereas Ackermann’s structure while smiling (FIGURES 1 and prosthetic rehabilitation. Missing teeth smile arc follows the curvature of the lip 2). Alternatively, if the periodontal have functional and esthetic consequences to achieve an ideal esthetic result.11 If the condition permits, crown lengthening can and can also affect the psychology and teeth have acceptable morphology and be performed with or without restorations confi dence of the patient.16 Impacted do not have discoloration or large missing to achieve the ideal amount of tooth- teeth can cause pain and tenderness spaces, correction of the smile line is to-gingival display.13,14 The etiology of or can compromise neighboring teeth, ideally undertaken with orthodontics to the excessive gingival display needs depending on the type of impaction.17 achieve an ideal result in a minimally to be established before commencing While impacted third molars are generally

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orthodontic intrusion may be the only treatment needed, obviating the need FIGURE 3. Impacted maxillary central incisor. FIGURE 4. Correction of impacted maxillary for any further fi xed prosthodontic central incisor with orthodontics. treatment (FIGURES 3 and 4). Lack of occlusal clearance can frequently be a extracted, removal of any other impacted Adjunctive Orthodontic Treatment in complicating factor in the restoration teeth in the dentition should be executed Fixed Prosthetic and Dental Implant of missing teeth with any type of only after consideration of the esthetic Therapy prosthesis. A minimum of 4-5 mm of and functional challenges such an occlusal clearance is required to make extraction can impose.18 Impacted teeth Path of Insertion a functional and reasonably esthetic are relatively common, with 14.1 percent Aligning teeth to provide a path of restoration on a dental implant. This of individuals in a retrospective study insertion can frequently be achieved by space is frequently compromised due of 4,063 individuals having at least one orthodontics. Fixed dental prostheses to supraeruption of the opposing impacted tooth.19 Management of impacted need an ideal path of insertion to enable dentition. Orthodontic intrusion can teeth orthodontically, restoratively and/ the placement of the restoration on improve such situations and create the or surgically is essential for obtaining a teeth. This is usually achieved during the necessary occlusal clearance to obtain desirable outcome when restoring the preparation of the tooth to receive a fi xed ideal esthetics and functionality of the dentition (FIGURES 3 and 4). Frequently, dental prosthesis. However, in some cases, restored dental implant. Alternatively, these impacted teeth can be managed a tooth may be rotated or tilted in an a full coverage restoration will have orthodontically and brought into an unfavorable direction.5,24-27 If orthodontics to be used for the encroaching teeth ideal location in the dental arch by using are not performed in such cases to in the opposing dentition (frequently various orthodontic appliances and wires.17 upright the tooth, then these teeth will combined with endodontic treatment) to Depending on the severity of impaction, frequently need endodontic treatment obtain this necessary occlusal clearance. varying amounts of time will be required prior to tooth preparation to achieve a Orthodontic treatment is the more to move an impacted tooth to a favorable favorable path of insertion. Tilting of conservative of the two approaches, location in the dental arch. If orthodontic teeth can also affect mesiodistal width and can be carried out after the implant movement is undesirable due to technical available for dental implant placement. In surgery during the healing phase.27 limitations, time constraints or lack of patient general, a minimum of 1.5 mm is required compliance, then it would be advisable to from the outer diameter of each dental Orthodontic Extrusion leave the impacted tooth undisturbed and implant to the adjacent tooth to obtain Orthodontic extrusion has applications manage esthetic and functional concerns ideal results. While minor angulation in restorative and implant dentistry. It using restorative dentistry only.17,20,21 issues can be resolved by enameloplasty, should be remembered that hopeless Transposition of teeth can be performed larger corrections of an angulated tooth teeth are not useless teeth. In certain by an orthodontist to obtain favorable will require orthodontic therapy or a full situations, slow orthodontic extrusion esthetics. This is commonly performed in coverage restoration to provide a path of can be used to migrate the alveolar bone anterior teeth and frequently requires some placement for the implant restoration. to obtain a greater volume of bone for modifi cation of the transposed tooth by In both of these situations, orthodontic implant placement.28 The increased enameloplasty or a restoration to enable therapy is the less invasive way to volume of bone will also serve to enhance the transposed tooth to mimic the tooth provide the necessary corrections.27 the soft tissue profi le under a fi xed requiring replacement. A very common dental prosthesis29 (FIGURES 5–10). indication of orthodontic transposition of Orthodontic Intrusion teeth is the movement of a maxillary canine Orthodontic intrusion has Tilting of Teeth to Permit Dental to the maxillary lateral incisor space.22 In applications in improving form, function Implant Placement such a situation, enameloplasty, a full- and esthetics of the dentition and The three-dimensional nature of coverage restoration or a partial-coverage serves as a means to create occlusal the alveolar bone should be taken restoration may be required to obtain the clearance for dental implant restoration. into account when considering dental ideal form of the transposed tooth.21,23 When used to correct a smile line, implant placement. A dental implant

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FIGURE 6. Periapical radiograph showing compromised bone level of the left maxillary central incisor.

FIGURE 5. Periodontally compromised left central FIGURE 7. Use of orthodontics to extrude the incisor with poor maxillary anterior esthetics. maxillary central incisor.

FIGURE 8. Radiograph demonstrating coronal movement of the bone surrounding the periodontally compromised tooth. FIGURE 9. Preparation of teeth for full-coverage restorations following extrusion of the left maxillary FIGURE 10. Completion of fi xed prosthodontic work central incisor. following orthodontic extrusion. Note improvement in gingival zenith compared to preoperative levels in the maxillary left central incisor.

should be placed at a minimum Types of Appliances and Limitations represented by the setup of teeth from distance of 1.5 mm from a neighboring which the shape of the archwire is tooth.30 In certain situations, the Lingual Orthodontics derived has been achieved using digital coronal portion of a tooth may be One of the most signifi cant drawbacks superimposition. These computer-assisted ideally positioned to facilitate dental to lingual therapy appears to be the appliance systems are quite accurate in implant placement, but the roots may discomfort to the tongue, and with it, representing the fi nal desired outcome.34 be tilted unfavorably, encroaching diffi culty in speech, both of which usually on potential dental implant space. improve after two to three weeks of Clear Aligner Therapy Placement of dental implants without appliance placement.31 Another major Clear aligner treatment involves considering neighboring tooth root technical diffi culty in lingual orthodontics the production of a series of aligners on position can lead to devitalization and/ is the short span of archwires between stereolithographic casts produced from or loss of the neighboring tooth, as brackets. The distances between the teeth virtual models.35 It is possible to treat some well as compromise the dental implant along the archwire are so short that it can type of orthodontic problems in adults itself due to infection.30 Orthodontic be hard to align severely crowded teeth, with clear aligners if bonded attachments treatment can aid in straightening particularly lower anteriors compared are used appropriately to provide a the roots of these teeth to provide to labial technique.32 Modern lingual fi rmer grip on the teeth that require root an ideal path of surgical placement orthodontics is based on computer movement. By using bonded attachments of the dental implant (FIGURES 11–13). technology (customized low-profi le on teeth, an aligner could grip them The need for this orthodontic interven- brackets) and any type of tooth movement more tightly. Extrusion and rotation are tion can usually be determined by can now be produced quite effi ciently.33 very diffi cult and the amount of root radiographs and CT scans.27 The information on treatment plan, movement needed for root paralleling

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FIGURE 11. FIGURE 12. Panoramic radiograph Placement of showing reduced an orthodontic mesiodistal width appliance between right maxillary to widen the canine and maxillary mesiodistal central incisor for implant width between placement. right maxillary canine and maxillary central incisor.

FIGURE 13. Panoramic radiograph showing the successful placement of a dental implant of adequate width. between the archwire and bracket slot, which can result in an increase of total treatment time. They have excessively high bond strength, which can increase the risk of enamel damage on bracket removal. One fi nal problem is the fact that ceramics are harder than enamel, which can result in signifi cant enamel at extraction sites is almost impossible. present in approximately 10 percent wear if brackets are placed in a position With judicious use of attachments and of Western populations and more of occlusal contact with the natural small amounts of tipping and bodily common in females. It is usually a type dentition, commonly the lower incisors movement, it can be accomplished.36 It IV allergic reaction. Intraoral signs are in cases with an increased overbite.37 seems likely that in the future, a brief nonspecifi c and have been reported period of fi xed appliance treatment will be to include erythema, soreness at the Retention combined with aligners to make diffi cult side of the tongue and severe gingivitis Planning the retention phase of tooth movement more practical in adults despite good oral hygiene.40 Stainless orthodontic treatment is part of the who want the esthetic advantage.37 steel wires and brackets contain a treatment planning process and the relatively low proportion of nickel factors that need to be considered Labial Straight-Wire Appliance and are considered safe to use in a are original malocclusion, type of (Ceramic and Metal Braces) patient with diagnosed nickel allergy retainer and duration of retention.42 The preadjusted edgewise or “straight- although titanium or cobalt chromium If the original malocclusion was wire” appliance has revolutionized fi xed nickel-free brackets are available. In severe, a small amount of relapse following appliance orthodontics and is the most contrast, nickel-titanium archwires treatment may be acceptable, as the popular fi xed appliance system in use have a much higher nickel content and overall esthetic improvement will remain today.38 Each tooth in the preadjusted should be avoided in these patients. good. However, if the patient presented edgewise system has a customized Ceramic brackets are manufactured with only a mild malocclusion, any relapse bracket with built-in prescription from aluminium oxide and are described may be unacceptable. This is especially based around Andrews’ measurements as either mono- or polycrystalline, true when mild labial segment crowding is from the untreated sample of ideal depending upon whether they are made treated.43 The next decision is whether to occlusions. In this preadjusted system, from one or many crystals.41 Although use a removable or fi xed retainer.44 Even the work in accurately positioning the esthetics are signifi cantly improved, with fi xed retainers, some reappearance the teeth is done by the bracket they are not without disadvantages in crowding can appear in the lower prescription, signifi cantly reducing the compared to metal brackets. Ceramic labial segment. Fixed retainers also have amount of wire bending required.39 brackets have low fracture toughness, a high failure rate and, unfortunately, the Metal brackets contain nickel, which can lead to higher bracket patient will often only notice a breakage and nickel allergy is thought to be breakage. There is also greater friction when the lower incisors start moving. In

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some patients, fi xed retainers can also for all patients who are concerned Elsevier, 1996. cause problems with oral hygiene.45 If about any changes occurring following 10. Proffi t WR, Fields Jr HW, Sarver DM. Contemporary Orthodontics Elsevier Health Sciences, 2006. 48 compliance is good, removable retainers removal of their appliances. 11. Passia N. Is the smile line a valid parameter for esthetic will provide as effective retention as Most retention regimes are fairly evaluation? A systematic literature review. Eur J Esthet Dent fi xed retainers, and if worn part time, are arbitrary and there is no evidence that 2011;6:314-327. 12. Sarver DM. The importance of incisor positioning in the generally well tolerated. In addition, any there is any great difference in a period esthetic smile: The smile arc. Am J Orthod Dentofacial Orthop breakages or problems with appliance of full-time as opposed to part-time or 2001;120:98-111. 13. Camargo PM, Melnick PR, Camargo LM. Clinical crown fi t are usually apparent to the patient nocturnal wear following removal of lengthening in the esthetic zone. J Calif Dent Assoc 2007;35:487- before relapse has occurred. However, the active appliances. A period of full- 498. compliance is the unpredictable factor. time wear may result in less chance 14. Jorgensen MG, Nowzari H. Aesthetic crown lengthening. Periodontol 2000 2001;27:45-58. If we accept that the choice for long- of the patient forgetting to wear the 15. Janson G, Branco NC, Fernandes TMF, et al. Infl uence of term retention is made in partnership retainer, but when compliance is not orthodontic treatment, midline position, buccal corridor and smile with the patient, this is not necessarily a a concern, removable retainers can arc on smile attractiveness: A systematic review. Angle Orthod 2011;81:153-161. negative thing. It will give responsibility be worn on a part-time basis from 16. Feingold A. Good-looking people are not what we think. to the patient for his or her retention and the end of active treatment.49 Psychol Bull 1992;111:304. ultimately how long he or she maintains Certain occlusal traits are very prone 17. Frank CA. Treatment options for impacted teeth. J Am Dent Assoc (1939) 2000;131:623-632. it. It will also allow the patient’s general to relapse following correction and the 18. Eckert SE. Sequelae of partial edentulism. Int J Prosthodont practitioner to monitor the retention and only way to prevent any change in tooth 2006;20:356-356. provide further retainers as required.46 alignment following active treatment is 19. Aitasalo K, Lehtinen R, Oksala E. An orthopantomography study of prevalence of impacted teeth. Int J Oral Surg Although many different types by long-term or permanent retention. 1972;1:117-120. of retainers have been described, the These include severe rotations, midline 20. Kurol J. Impacted and ankylosed teeth: Why, when main types include the following: diastema or spacing and periodontally and how to intervene. Am J Orthod Dentofacial Orthop 2006;129:S86-S90. ■ Hawley retainers. compromised teeth with bone loss, etc. 21. Shapira Y, Kuftinec MM. Tooth transpositions — A review ■ Begg retainers. In such cases, permanent retention will of the literature and treatment considerations. Angle Orthod 1989;59:271-276. ■ Vacuum-formed retainers. be needed to maintain the position of 22. Fu PS, Wang JC, Wu YM, et al. Unilaterally impacted ■ Fixed lingual retainers. the teeth, usually in the form of a fi xed maxillary central incisor and canine with ipsilateral transposed The duration of retention required retainer.50 This important consideration canine-lateral incisor. Angle Orthod 2013;83:920-926. 23. Capelozza Filho L, Cardoso MA, An TL, et al. Maxillary following orthodontic treatment is needs to be discussed thoroughly with the Canine — First Premolar Transposition: Restoring Normal Tooth variable. However, the only way to patient prior to the start of treatment. ■ Order With Segmented Mechanics. Angle Orthod 2007;77:167- permanently guarantee stability of 175. REFERENCES 24. Cohen B. The use of orthodontics before fi xed prosthodontics tooth position is to retain it indefi nitely. 1. Spear FM, Kokich VG, Mathews DP. Interdisciplinary in restorative dentistry. Compendium (Newtown, Pa.) When fi tting retainers for patients, often management of anterior dental esthetics. J Am Dent Assoc 1995;16:110, 112, 114 passim; quiz 120-110, 112, 114 following at least 18 months of treatment, 2006;137:160-169. passim; quiz 120. 2. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and 25. Gkantidis N, Christou P, Topouzelis N. The orthodontic- the fi rst question they will ask is, “How systems with clinical recommendations: A systematic review. J periodontic interrelationship in integrated treatment challenges: A long will I have to wear retainers?” The Prosthet Dent 2007;98:389-404. systematic review. J Oral Rehabil 2010;37:377-390. honest answer is for as long as they want 3. Della Bona A, Kelly JR. The clinical success of all-ceramic 26. Spalding P, Cohen B. Orthodontic adjunctive treatment in fi xed prosthodontics. Dent Clin North Am 1992;36:607-629. 47 restorations. J Am Dent Assoc (1939) 2008;139:8S-13S. to keep their teeth perfectly straight. 4. Gehrt M, Wolfart S, Rafai N, et al. Clinical results of lithium- 27. Rose T, Jivraj S, Chee W. The role of orthodontics in implant Not all patients will exhibit relapse disilicate crowns after up to nine years of service. Clin Oral dentistry. Br Dent J 2006;201:753-764. or reappearance in crowding, especially Investig 2013;17:275-284. 28. Korayem M, Flores-Mir C, Nassar U, et al. Implant site 5. Evans C, Nathanson D. Indications for orthodontic-prosthodontic development by orthodontic extrusion: A systematic review. Angle in the lower labial segment, but from the collaboration in dental treatment. J Am Dent Assoc (1939) Orthod 2008;78:752-760. available evidence, it is not possible to 1979;99:825-830. 29. Çomut A, Acharya V, Jahangiri L. Use of forced eruption predict who these patients will be. Many 6. Kokich VG, Spear FM. Guidelines for managing the orthodontic- to enhance a pontic site in the anterior maxilla. J Prosthet Dent restorative patient. Seminars in Orthodontics Elsevier, 1997. 2012;108:273-278. patients have very high expectations 7. Johal A, Ide M. Orthodontics in the adult patient, with special 30. Buser D, Martin W, Belser UC. Optimizing Esthetics for Implant of treatment and even some minor reference to the periodontally compromised patient. Dent Update Restorations in the Anterior Maxilla: Anatomic and Surgical deterioration in the alignment of the 1999;26:101-4, 106-8. Considerations. Int J Oral Maxillofac Implants 2004;19:43-61. 8. Melsen B. Adult Orthodontics Wiley Online Library, 2012. 31. Miyawaki S, Yasuhara M, Koh Y. Discomfort caused by teeth will be unacceptable. Therefore, 9. Thilander B. Infrabony pockets and reduced alveolar bone bonded lingual orthodontic appliances in adult patients as long-term retention is recommended height in relation to orthodontic therapy. Seminars in Orthodontics examined by retrospective questionnaire. Am J Orthod Dentofacial

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Orthop 1999;115:83-88. 39. Andrews L. The straight-wire appliance. Br J Orthod controlled trial. Am J Orthod Dentofacial Orthop 2007;132:730- 32. Grauer D, Proffi t WR. Accuracy in tooth positioning with a 1979;6:125. 737. fully customized lingual orthodontic appliance. Am J Orthod 40. Bass JK, Fine H, Cisneros GJ. Nickel hypersensitivity in 47. Little RM, Riedel RA, Artun J. An evaluation of changes in Dentofacial Orthop 2011;140:433-443. the orthodontic patient. Am J Orthod Dentofacial Orthop mandibular anterior alignment from 10 to 20 years postretention. 33. Buckley J. Lingual orthodontics: An illustrated review with 1993;103:280-285. Am J Orthod Dentofacial Orthop 1988;93:423-428. the incognito fully customised appliance. J Ir Dent Assoc 41. Russell J. Current products and practice aesthetic orthodontic 48. Kahl-Nieke B, Fischbach H, Schwarze C. Post-retention 2012;58:149-155. brackets. J Orthod 2005;32:146-163. crowding and incisor irregularity: A long-term follow-up evaluation 34. Wiechmann D. A New Bracket System for Lingual Orthodontic 42. Uhde MD, Sadowsky C, Begole EA. Long-term stability of of stability and relapse. J Orthod 1995;22:249-257. Treatment. J Orofac Orthop/Fortschritte der Kieferorthopädie dental relationships after orthodontic treatment. Angle Orthod 49. Barlin S, Smith R, Reed R, et al. A retrospective randomized 2003;64:372-388. 1983;53:240-252. double-blind comparison study of the eff ectiveness of Hawley 35. Lee H-F, Wu B, Ting K. Preliminary studies on Invisalign tray 43. Bibona K, Shroff B, Best AM, et al. Factors aff ecting versus vacuum-formed retainers. Angle Orthod 2011;81:404-409. fabrication. Am J Orthod Dentofacial Orthop 2002;122:678. orthodontists’ management of the retention phase. Angle Orthod 50. Bondemark L, Holm A-K, Hansen K, et al. Long-term stability of 36. Kravitz ND, Kusnoto B, BeGole E, et al. How well does 2013;84:225-230. orthodontic treatment and patient satisfaction: A systematic review. Invisalign work? A prospective clinical study evaluating the effi cacy 44. Atack N, Harradine N, Sandy JR, et al. Which way forward? Angle Orthod 2007;77:181-191. of tooth movement with Invisalign. Am J Orthod Dentofacial Fixed or removable lower retainers. Angle Orthod 2007;77:954- Orthop 2009;135:27-35. 959. THE CORRESPONDING AUTHOR, Varun Acharya, BDS, can be 37. Ireland AJ, McDonald F. The Orthodontic Patient: Treatment 45. Zachrisson BU. Clinical experience with direct-bonded reached at [email protected]. and Biomechanics. Oxford University Press, 2003. orthodontic retainers. Am J Orthod 1977;71:440-448. 38. McLaughlin RP, Bennett JC, Trevisi HJ. Systemized Orthodontic 46. Rowland H, Hichens L, Williams A, et al. The eff ectiveness of Treatment Mechanics. Elsevier Health Sciences, 2001. Hawley and vacuum-formed retainers: A single-center randomized

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CDA JOURNAL, VOL 43, Nº4

Periodontal Considerations in Veneer Cases

David Peto, DDS, MSD

ABSTRACT Porcelain veneers are a minimally invasive technique to enhance patients’ smiles. A crucial component in these cases is the supporting periodontal apparatus and its interaction with the restorations. This article addresses basic concepts such as biologic width, altered eruption patterns, appropriate gingival contouring and smile design to give practitioners the tools to diagnose, evaluate and treat cases successfully and predictably.

AUTHOR oday’s patients are esthetically predictable and long-lasting results. David Peto, DDS, MSD, maintains a private practice driven. They are well informed This article will address concepts limited to periodontics and very demanding when in smile design, as well as biologic and implant dentistry in it comes to the results of width, altered eruption patterns and Beverly Hills, Calif. He is a cosmetic dentistry. This appropriate gingival contouring to give diplomate of the American places an enormous responsibility the practitioner the tools to diagnose, Board of Periodontology. T Confl ict of Interest on the dentist and his or her team evaluate and treat veneer cases, Disclosure: None reported. to diagnose, work up and treat these particularly for patients with gummy cases. A very common treatment smiles, successfully and predictably. Most option for the cosmetically driven important, it will highlight the value of patient is the use of porcelain veneers. a team approach to patient care in order Veneers are a minimally invasive to achieve ideal results for the patient. technique to enhance patients’ smiles. Far from being a simple treatment Principles of Smile Design option, veneer cases can present Before beginning a discussion of the many challenging issues. In order periodontal-restorative relationships, it to achieve an excellent result, the is important to establish the ultimate restorative doctor must address the esthetic end points that you are trying tooth-related cosmetic concerns and to achieve. These principles are well the soft tissue must exist in harmony known and have been described by with the restorations. An understanding numerous authors.1-10 These ideas fall of the relationship between the under the broad category of smile design. periodontal tissues and restorations is The rationale behind smile design is to essential in order to achieve esthetic, create a clinical situation where both

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the dental hard and soft tissues work from the frontal view. In addition, the utilizing the veneers to move the contact harmoniously to create an ideal smile. central incisor is 2-3 mm wider than point more apically can help to improve Dental midline: The dental midline the lateral and 1-1.5 mm wider than the the soft tissue fi ll in those sites. should be perpendicular to the canine. Similarly, the canine is 1-1.5 mm Lip line: When smiling, the inferior interpupillary line. The philtrum of the wider than the lateral incisor. Both the border of the upper lip should be level lip is one of the most accurate anatomical central incisor and canine are longer than with or within 1-2 mm of the gingival landmarks for the midline. The midline the lateral incisor by 1-1.5 mm. Maxillary margin. If there is excess gingival display, should be parallel to the long axis of the premolars also play an important role in a gummy smile will result, compromising face, perpendicular to the incisal plane fi lling up the buccal corridor, eliminating the esthetic outcome. Depending on and should drop straight down from the darks space at the corner of the mouth the extent of gingival display, different papilla between the central incisors. during smiling. The use of temporary treatment modalities exist to correct Incisal lengths: When the mouth is crowns during the restorative phase is the problem. One such treatment — lip relaxed, approximately 3.5 mm of the useful at this point in order to determine repositioning — is described below in maxillary central incisors should be the ideal esthetics for each patient. the section on vertical maxillary excess. visible. Appropriate tooth length is Patient-specifi c factors: Gender, age also important for proper phonetics. and personality are crucial factors when Tooth dimensions: The central Most authors recommend considering smile rehabilitation. Tooth incisors are the most prominent teeth dimension, shape, cusp anatomy and in the mouth. Thus, proper restoration that proper harmony tooth shade are just a few elements of these teeth is crucial in an esthetic be achieved by eye via that are impacted by these issues. smile. The width-to-length ratio of proper adjustment of the the centrals is typically 4:5. The shape Why Do Patients Want Veneers? and location of the central incisors provisionals rather than strict If patients were satisfi ed with their infl uences the appearance and placement adherence to a formula. smiles, they would not be pursuing of the lateral incisors and canines. cosmetic dental treatment. In some Various methods have been used to cases, patients are unsatisfi ed with determine ideal proportions. The golden the shade of their teeth or are trying proportion is perhaps the most well Zenith points: The zenith point to correct mild chipping and uneven known. It is based on the mathematical is the most apical position of the incisal edges. For patients who have ratio of 1.6:1:0.6, a ratio commonly found tooth margin where the gingiva is the excellent oral hygiene, stable occlusion in nature. However, is it diffi cult to apply most scalloped. It is located distally and suffi cient tooth structure, these in practice, as patients have different arch to an imaginary vertical line drawn cases are fairly straightforward. The forms, lip anatomy and facial proportions. through the center of the tooth. conscientious restorative doctor, working In fact, strict adherence to this formula Interdental embrasures: In order to together with the laboratory, can achieve could lead to esthetic failure.11 Other achieve maximal esthetics, soft tissue an excellent, long-lasting result. models exist. Most authors recommend embrasures should be present between the In most cases, however, the esthetic that proper harmony be achieved by eye teeth. Lack of gingiva in this area results defi ciencies are more extensive. What this via proper adjustment of the provisionals in the formation of a black triangle. This means is that when a patient presents for rather than strict adherence to a formula. is frequently seen in patients who have veneers, there are numerous underlying Bhuvaneswaran1 provides the a history of bone loss due to periodontal factors that make treatment more diffi cult. following guidelines for tooth proportion: disease. If the contact point between teeth The restoring doctor must therefore The central incisors should be 10-11 is greater than 5 mm from the crest of the carefully evaluate the patient and the mm in length. Width is 75-80 percent of alveolar bone, black triangle formation type of case that is presented and develop this value. Maxillary laterals are never is likely. However, if the contact point a thorough treatment plan to achieve symmetrical and they infl uence gender is within 5 mm of the osseous crest, a the patient’s goal of a revitalized and characterization. Only the mesial half of papilla will be present almost 100 percent beautiful smile. Often this will require the the maxillary canines should be visible of the time.12 If bone loss has occurred, direct involvement of a periodontist. The

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following sections will detail diagnosis, In cases of extreme wear, a reduction in Altered Passive Eruption surgical and restorative treatment planning, the VDO is likely.14 If there has been a loss Another common cause of short and proper phasing of the esthetic veneer in the vertical dimension, more extensive clinical crowns is altered passive eruption case, specifi cally in the challenging restorative work may need to be done. (APE). APE occurs when the marginal situation of correcting a gummy smile. In these cases, full-mouth reconstruction gingiva is malpositioned on the anatomic There are two main causes of gummy may be necessary to re-establish the VDO. crown. In such cases, the tissue does smiles. The fi rst is short clinical crowns (Guidelines for re-establishing the VDO not approximate the cemento-enamel and the second is vertical maxillary are beyond the scope of this discussion.) junction (CEJ).15-17 During normal tooth excess (VME). In some patients, Once the proper VDO has been eruption, the attached gingiva moves both of these issues are present. established, patients with short clinical apically.18 This process usually continues crowns should be seen by a periodontist into the early or mid 20s.19 In patients Short Clinical Crowns so that he or she can partner with the with APE, the gingival margin fails to One of the most common reasons restoring doctor. Using a team approach, migrate to the appropriate level. Coslet that patients pursue veneer treatment the surgeon will be able to assess the case et al.20 divided patients into two main is for the correction of short clinical types based on the relationship of the crowns. Patients with short teeth are gingiva to the anatomic crown. These often afraid to smile or even speak in Clear communication classes were subdivided according to public. Short teeth give the appearance the position of the osseous crest. of age and wear and because of the during the restorative Type 1 is represented by the presence drastic change in length-to-width ratio, planning stages enables of the gingival margin coronal to the these teeth are very unesthetic. both the restoring doctor and CEJ. There is typically a wide band Short clinical crowns may be the of keratinized tissue from the gingival result of very different processes. A surgeon to develop the ideal margin to the mucogingival junction. The main cause of short teeth is incisal wear, treatment plan for the patient. mucogingival junction is usually apical to where normal-length teeth have been the alveolar crest. Type 2 is represented reduced. A second reason for short by a normal width of keratinized gingiva clinical crowns is altered passive eruption. from the margin to the mucogingival While certain elements of treatment for and determine if surgical intervention junction. In this type, all of the gingiva these conditions will overlap, there are is necessary in order for the dentist and is located on the clinical crown and the important distinctions that emerge. patient to achieve the desired restorative mucogingival junction is located at the outcome. In cases where the VDO did level of the CEJ. Both types are subdivided Incisal Wear not change over time, crown lengthening into A and B. In subgroup A, the normal The loss of tooth structure is a natural may be necessary in order to expose distance of 1.5-2.0 mm from CEJ to consequence of age and wear. In cases suffi cient tooth structure to restore the osseous crest is observed. In subgroup B, of normal physiologic wear, the vertical case in the most ideal way. In cases where the alveolar crest is at the level of the CEJ. dimension of occlusion (VDO) is not the patient’s bite had to be opened to Diagnosis of altered passive eruption changed, largely due to dentoalveolar restore the VDO, there may be no need is accomplished via clinical and compensation.13 In these cases, the for crown lengthening. If there is suffi cient radiographic exam. Because the clinical patient’s profi le has not been affected since space for veneers of appropriate incisal crowns are short, excessive wear must be the vertical dimension and freeway space length, crown lengthening may result in ruled out. This can be accomplished by have been maintained. An easy way to teeth that appear too long because they checking for evidence of parafunction determine if the VDO has been affected now need to meet the lower incisors (i.e., worn cusp tips, linea alba on is by having the patient bring in old at a greater vertical dimension. Clear the cheeks indicating repeated cheek photos and comparing the facial esthetics. communication during the restorative biting, trauma to the lateral borders of If the VDO has been maintained, then planning stages enables both the restoring the tongue). If altered passive eruption there will be no change in the distance doctor and surgeon to develop the is suspected, consultation with a from the patient’s nose to chin. ideal treatment plan for the patient. periodontist is recommended in order to

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determine the proper surgical approach. In order to determine the appropriate FIGURE 1. Preoperative view. (Photo courtesy of FIGURE 2. After gingivectomy. (Photo courtesy treatment for altered passive eruption, the Robin Weltman, DDS, MS.) of Robin Weltman, DDS, MS.) periodontist will perform bone sounding in order to determine the position of the CEJ relative to the osseous crest. This is accomplished by anesthetizing the patient and inserting the probe under pressure until bone is reached. In type 1A cases, the distance from the CEJ to the osseous crest is normal. FIGURE 4. After surgery and veneers. (Photo In these cases, gingivectomy and courtesy of Robin Weltman, DDS, MS.) gingivoplasty are suffi cient to resolve the FIGURE 3. Preoperative view. (Photo courtesy of excess gingival display. (FIGURES 1 and Robin Weltman, DDS, MS.) 2. Note the appearance of Nos. 8 and 9 in FIGURE 1. The teeth are short and positioned fl ap is utilized to maintain tissue attachment to the root surface square and lack the appropriate length- the width of attached gingiva. In type of a tooth.21 The term was based on to-width ratio. In addition, the gingival 2A cases, the fl ap is displaced and work done by Gargiulo et al.22 when margins are level with No. 7 and No. 10, tissue is allowed to heal. No osseous measurements were taken on 30 autopsy further compromising the smile esthetics. recontouring is necessary. In type 2B specimens. They determined that the Following the gingivectomy in FIGURE cases, bone removal is necessary to junctional epithelial attachment to 2, the appearance of Nos. 8 and 9 is establish normal dimensions from the the tooth measured 0.97 mm and the more harmonious. The gingival margins CEJ to the crest and the fl ap is displaced connective tissue attachment measured are at the appropriate heights, and the apically to preserve the attached tissue. 1.07 mm, resulting in a total attachment length-to-width ratio is improved.) distance of 2.04 mm. In addition, the In type 1B cases, there is insuffi cient Biology and Treatment Planning, sulcus above the junctional epithelium space from the CEJ to the osseous crest Presurgical Steps, Surgery and measured 0.69 mm. In order to maintain for the establishment of a proper biologic Healing periodontal health, it is recommended width. In these cases, esthetic crown Once the etiology of the short that at least 3 mm of space exist from lengthening via osseous resection is clinical crowns has been established, the the crest of the bone to the margin necessary to achieve ideal results (FIGURES restorative and surgical team can devise of the restoration. This distance will 3 and 4). Note the short teeth at Nos. 8 a fi nal treatment plan for the patient. account for the epithelial and connective and 9, as well as the peg laterals at Nos. 7 In cases where crown lengthening is tissue attachment to the tooth, as well and 10. In addition, the gingival margins necessary, there are repeatable steps that as the sulcus. Nevins and Skurow23 from Nos. 6-11 are uneven, making both the restoring dentist and surgeon recommend keeping margins within the esthetic defi ciency more acute. In can take to ensure a predictable and 0.5-1 mm of the sulcus in order to avoid FIGURE 4, crown lengthening has been esthetic outcome. Before discussing the impinging on the junctional epithelium. performed and porcelain restorations have specifi c stages of surgery, a review of the It is important to keep in mind that been placed. The tooth length-to-width biologic principles of the periodontal- these numbers are based on cadaver ratios have dramatically improved. There restorative interface is important. studies. In a recent systematic review, is an overall harmonious appearance Schmidt et al.24 noted that mean values of the teeth in the smile. The tissue Biologic Width for biologic width obtained from two margins are appropriately scalloped and One of the most important aspects in meta-analyses were 2.15 and 2.30 mm. the periodontium is pink and healthy. the periodontal-restorative relationship However, large intra- and inter-individual Treatment of type 2 cases requires is the biologic width. The biologic variances were observed (0.2-6.73 mm). a different approach. Because there is width is the distance established by the As a result, 3 mm is generally acceptable, minimal keratinized tissue, an apically junctional epithelium and connective although large discrepancies do exist.

196 APRIL 2015 CDA JOURNAL, VOL 43, Nº4

TABLE Classification and Treatment Options

Degree Gingival and Treatment modalities mucosal display I 2–4 mm Orthodontic intrusion only Orthodontics and periodontics temporary veneers also enable the surgeon Periodontics and restorative therapy to ensure that a suitable biologic width II 4–6 mm Periodontics and restorative therapy has been established. If the tissue is pink Orthognathic surgery and healthy following surgery, then the The choice depends on the remaining amount of root encased temporary veneers are not encroaching in bone and crown-to-root ratio upon the biologic width. However, if the III ≥8 mm Orthognathic surgery with or without adjunctive periodontal tissues appear red and infl amed more than and restorative therapy complete dentofacial harmony two weeks post-surgery, there is a possibility that inadequate osseous reduction was performed. Veneer margins should be Presurgical Steps of full thickness buccal/labial fl aps to expose assessed to ensure a supragingival location, Prior to commencing a case, a diagnostic the supporting alveolar bone. The CEJs of any excess cement should be removed wax-up is essential. A wax-up of the the affected teeth are the coronal landmarks and proper oral hygiene must be reviewed future veneers will enable the dentist to for the osseous reduction. This reduction to rule out potential contributing factors visualize the desired outcome. The wax- is typically carried out with high-speed resulting in soft tissue infl ammation. up also gives the patient the opportunity handpieces under irrigation, and a new Because there is individual variability to evaluate the number of teeth proposed osseous margin is created more apically to in the dimension of the biologic width, it is for veneer treatment, the tooth shape the original level of the crest. Depending on recommended that restorative procedures and position, as well as overall tooth the etiology of the short clinical crowns, soft be delayed at least six weeks until fi nal length. Once that patient approves the tissue removal may accompany the osseous impressions are taken. In many cases, wax-up, a silicon impression can be used reduction. The fl ap is then repositioned and especially in cosmetic anterior cases, a and temporary veneers can be fabricated. sutured in place. The patient is instructed longer healing period is recommended. This will allow the patient to evaluate not to brush or fl oss the area for two Wise25 suggests 21 weeks for soft tissue the appearance of the fi nal veneers in the weeks, and an antibacterial rinse such as gingival margin stability. If a restoration mouth, and to suggest changes before the chlorhexidine gluconate may be prescribed. is placed too early in the healing process, fi nal restorations are fabricated by the lab. As noted above, the generally accepted the gingival margin may migrate, resulting Once the patient has approved the space between the crest and the CEJ is 3 mm in an unsatisfactory esthetic outcome. fi nal shapes of the veneers, the wax-up can to account for the biologic width. However, However, tissue rebound may occur if too also be used as a surgical guide. A vacuum- due to individual variability, the surgeon will much time elapses prior to fi nal restorations. formed stent can be fabricated using the need to assess this for each patient. This can Because of the variability in patient wax-up. This will provide the surgeon with be accomplished during surgery by additional healing, it is diffi cult to assign a strict rule the proposed fi nal tooth length. Once bone sounding of other teeth that are not for placement of fi nal restorations. Both the positions of the veneer margins are being treated. The distance from the gingival the restoring dentist and surgeon must determined, the surgeon can then perform tissue to the underlying bone will give the monitor the patient’s healing. Once they the necessary amount of bone and/or soft surgeon the patient-specifi c distance that feel that tissue stability has been achieved, tissue removal in order to accommodate the exists between the osseous crest and the fi nal restorations may be placed. As a rule, desired restoration. A surgical guide prevents margin of the soft tissue. This distance can anywhere between three26 to six27 months two potential problems: Too much bone then be recreated to ensure that when the may be considered adequate healing time and soft tissue reduction will result in teeth new biologic width is established, it has the in cosmetic crown-lengthening cases. that appear too long, and inadequate hard same dimensions as the presurgical value. and soft tissue reduction will necessitate Vertical Maxillary Excess further surgery to achieve the desired result. Healing Another common fi nding in patients The temporization phase is important in with short clinical crowns and gummy Surgery veneer cases. Firstly, patients can evaluate smiles is vertical maxillary excess (VME). In cases of short clinical crowns due tooth appearance, as well as other important This frequently results from a skeletal to excessive wear or due to APE, crown aspects such as vertical dimension and dysplasia resulting in teeth that are farther lengthening is accomplished via refl ection phonation. During the healing phase, the away from the maxillary base and a display

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of “Golden Proportion” in Individuals With an Esthetic Smile. J Esthet Restor Dent 2004; 16:185-193. 6. Rosenstiel SF, Land MF, Fujjimoto J. Contemporary Fixed Prosthodontics. 3rd ed. St. Louis: CV Mosby, 2001. pp. 598-599. 7. Lombardi R. The principles of visual perception and their clinical application to dental esthetics. J Prosthet Dent 1973; 29:358-381. FIGURE 5. Preoperative view of a gummy smile. FIGURE 6. After a lip-repositioning procedure. 8. Snow SR. Esthetic smile analysis of maxillary anterior tooth width: The golden percentage. J Esthet Dent 1999; 11(4):177-184. 9. Ward DH. Proportional smile design using the recurring esthetic of gingival below the inferior border of repositioning or other surgical therapies dental (RED) proportion. Dent Clin North Am 2001; 45:143-154. the upper lip.28 In cases of slight gingival to achieve an ideal fi nal result. These 10. Chu SJ. A biometric approach to esthetic crown lengthening. Pract Proced Aesthet Dent 2007; 19(10:A-X). and mucosal display (between 2-4 mm), decisions are determined at the diagnosis 11. Levin EI. Dental esthetics and golden proportion. J Prosthet Dent conservative periodontal and restorative and treatment planning stages by 1978; 40:244-52. treatment can be performed. As gingival the restoring doctor and surgeon. 12. Tarnow DP, et al. The eff ect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal and mucosal display increases in severity, As noted, more severe cases of gummy dental papilla. J Periodontol 1992; 63:995-996. more invasive procedures may be necessary, smile will involve the periodontist 13. Davies SJ, Gray RJM, Qualtrogh AJE. Management of Tooth including orthognathic surgery (such as and restoring dentist, as well as an Surface Loss. Br Dent J 2002; 192(1): 11-23. 14. Chu SJ, Karabin S, Mistry S. Short tooth syndrome: Diagnosis, maxillary impaction surgery) to correct orthodontist and oral surgeon. A team etiology and treatment management. J Calif Dent Assoc 2004; 32(2): the skeletal imbalance. The classifi cation approach will allow the practitioners to 143-52. and treatment options are summarized provide the patient with an ideal result. 15. Dello Russo NM. Placement of crown margins in patients with altered passive eruption. Int J Periodontics Restorative Dent 1984; by Garber and Salama in the TABLE. 4(1):59-65. Mild cases of VME that result in a Conclusion 16. Wolff e GN, van der Weijden FA, Spanauf AJ, et al. Lengthening gummy smile may be corrected with a In today’s era of cosmetic dentistry, clinical crowns — A solution for specifi c periodontal, restorative and esthetic problems. Quintessence Int 1984; 25(2):81-8. periodontal procedure to reposition the patients are conscious of the esthetics of 17. Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered passive upper lip. (FIGURES 5 and 6: Note the their smiles. A major reason that patients eruption: The undiagnosed entity. J Am Dent Assoc 1993; amount of gingival display on full smile in seek veneer treatment is to correct the 124(10):107-110. 18. Gottlieb B, Orban B. Active and continuous passive eruptions of FIGURE 5. Also, note that the teeth are well appearance of gummy smiles or short teeth. teeth. J Dent Res 1933; 13:214. proportioned and that the gingival margins Veneers provide a minimally invasive 19. Volchansky A, Cleaton-Jones P, Retief DH. Delayed passive are at their appropriate levels. In this case, way for clinicians to help patients achieve eruption — A predisposing factor to Vincent’s infection. J Dent Assoc S Africa 1974; 29:291-4. there is approximately 10 mm of gingival their goals. It is important to remember 20. Coslet JG, Vandarsall R, Weisgold A. Diagnosis and classifi cation display. In FIGURE 6, note the dramatic that the restorations are part of the total of delayed passive eruption of the dentogingival junction in the adult. reduction in gingival display. By reducing smile, and they must be harmonious with Alpha Omegan 1977; 70(3):24-8. 21. Takei HH, Azzi RR, Han TJ. Preparation of the Periodontium for the movement of the upper lip, the gummy the surrounding soft tissues. They must Restorative Dentistry. In: Newman, MG, Takei HH, Carranza FA smile was reduced. No restorative work was also be appropriate to the patient’s age, eds. Carranza’s Clinical Periodontology. 9th ed. Philadelphia: W.B. necessary in this case.) In this procedure, gender and personality. A multidisciplinary Saunders Company; 2002: 945. 22. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of a split thickness fl ap is elevated, generally approach is essential in the diagnosis and the dentogingival junction in humans. J Periodontol 1961; 32:261-7. from premolar to premolar. The inferior treatment-planning stages, as well as the 23. Nevins M, Skurow HM. The intracrevicular restorative margin, border of the incision follows the contour treatment and postoperative phases. By the biologic width and the maintenance of the gingival margin. Int J Periodont Restor Dent 1984; 4:30-49. of the mucogingival junction. The superior adopting a team approach, the restoring 24.Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, Walter C. border is approximately 8-10 mm from the dentist, periodontist and lab technician Biologic width dimensions — A systematic review. J Clin Periodontol lower border, depending on the amount of can be successful in creating beautiful, 2013; 40(5):493-504. 25. Wise MD. Stability of the gingival crest after surgery and before gummy smile reduction. The strip of mucosa predictable, long-lasting cosmetic results. ■ anterior crown placement. J Prosthet Dent 1985; 53:20-3. 26. Lanning SK, Waldrop TC, Gunsolley JC, et al. Surgical crown is completely removed from the vestibule REFERENCES lengthening: Evaluation of the biological width. J Periodontol and the mucosal margin in the vestibule is 1. Bhuvaneswaran M. Principles of smile design. J Conserv Dent 2003;74(4):468-474. 2010; 13(4): 225-232. sutured to the apical edge. This results in 27. Brägger U, Lauchenauer D, Lang NP. Surgical lengthening of the 2. McLaren EA, Cao PT. Smile Analysis and Esthetic Design: “In the clinical crown. J Clin Periodontol 1992;19(1): 58-63. reduced mobility of the upper lip, thereby Zone.” Inside Dentistry 2009;5(7). 28. Garber DA, Salama MA. The aesthetic smile: Diagnosis and preventing the hypermobile lip from 3. Ratnadeep P. Esthetic Dentistry: An Artist’s Science. 1st ed. treatment. Periodontol 2000 1996; 11:18-28. displaying too much gingival upon smiling. Mumbai: PR Publications; 2002.p.16-36. 4. Sabri R. The eight components of a balanced smile. J Clin Orthod THE AUTHOR, David Peto, DDS, MSD, can be reached at dpeto@ Crown lengthening procedures 2005; 39(3):155-66. weloveperio.com. may need to be combined with lip 5. Mashid M, Khoshvaghti A, Varshosaz M, Vallaei N. Evaluation

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Clinical Aspects of Porcelain Laminate Veneers: Considerations in Treatment Planning and Preparation Design

Andrea Jordan, DDS, FACP

ABSTRACT Making the transition from conventional methods to more modern, perhaps more sophisticated, methods in dentistry can be intimidating. Introduction of new techniques and materials into private practice requires understanding of the current scientifi c literature. Here, a review of the traditional clinical approach to porcelain laminate veneer case planning and intraoral preparation is reviewed. Current research in each of these subjects is also discussed, summarizing some of the literature as well as newer products and technologies.

AUTHOR

3-5 Andrea Jordan, DDS, istorically, practitioners design and raw material. They were FACP, is a board certifi ed have strived to preserve thought of as a temporary solution to be prosthodontist and as much tooth structure removed before eating. Composite resin maxillofacial prosthodontist as possible, with the laminate veneers came into popularity in private practice in Palo trends in preparation in the 1970s and 1980s, again employing Alto, Calif. She completed her specialty training at Hdesign oscillating between minimal a minimal-to-no-prep design, but New York University and and “no-prep.” Charles Pincus, DDS, capitalizing on advances in bonding to the University of California, introduced the original “Hollywood provide a more permanent restoration. Los Angeles. veneer” in the 1920s as a method for Direct bonding of the material to Confl ict of Interest improving the smiles of actors of the the tooth was limited and there Disclosure: None reported. time.1 He did not etch and bond his was diffi culty shaping an acceptable veneers into place, but instead used contour, which led to patients often denture adhesive to hold the porcelain experiencing gingival infl ammation as facings in place for photos and fi lm. well as marked marginal deterioration The veneers were no-prep and billed and discoloration.4-5 Acrylic resin as a method for “building personality,” veneers became commercially available as the title of his original publication in 1979 when the Mastique laminate suggests. They were similar to some veneer system (DeTrey, Dentsply) was porcelain laminate veneers used today marketed. The system used a composite in both minimal-to-no-preparation resin that adhered to patients’ teeth.2

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This was part of a larger trend of using and meta-analyses. A PubMed literature by Belser and Magne.24 This tried-and- a preformed veneer (hollow-ground search was completed for each aspect true method is labor intensive and denture teeth, preformed acrylic resin presented below. Further parameters time consuming for the clinician and or custom-made acrylic resin) as an regarding emerging technologies laboratory technician. Because of this, esthetic solution.6 Both direct bonding included a fi lter for date limiting there are emerging technologies that of composite, as well as use of preformed the results to articles published after augment the ability of the restorative acrylic resin, led to disappointing results. 2010, included only articles published dentist to communicate with his or her As reported throughout the literature, in English and required publication specialist team through digital media. The the shortcomings included color in a peer-reviewed journal. The use of digital photography postediting instability, staining, lack of abrasion fi ndings of each search are described and computer-assisted treatment resistance, biological incompatibility and reported, including fi ndings planning are providing new platforms for and poor bonding between the tooth that indicated that further research porcelain laminate veneer planning. and the restorative material.3-7 may be necessary before widespread In the early 1980s, Horn and acceptance of the technology. Digital Photography Calamia showed that etched porcelain Digital photography is indispensable could be adhered to etched enamel in the dental practice. It is used for almost by way of an intermediary composite every patient and is recommended by resin.7,8 They suggested that a no-prep Correct use of the camera many prior to veneer treatment. Proposed technique could be benefi cial and settings, as well as post- updates to the digital photography successful. It conserved tooth structure, editing training, can improve protocol of a standard preoperative and which was paramount to the clinician, postoperative record include the use of since the procedures suggested were lab communication and sophisticated postediting software. elective. Reports of limited esthetics provide impressive McLaren et al. focus on the use of and gingival irritation (like those patient presentations. the digital single-lens refl ex camera reported for preformed facings and direct (DSLR) camera and the use of intraoral composite bonding) were common and photography postediting with Adobe preparations evolved from being “no Photoshop.24,25 The authors explain prep” to “minimal prep” during this Treatment Planning that correct use of the camera settings, time.3,9 Since then, this bonded style and Common knowledge dictates that as well as postediting training, can method of veneering has been the basis proper treatment planning for any improve lab communication and provide for the modern restoration. The style esthetic restoration includes intraoral impressive patient presentations. and extent of the preparation, incisal photography, assessment of the facial The Photoshop software is presented reduction, facial reduction, proximal features and diagnostic wax-ups. for use in more simple capacities reduction and lingual reduction, has Clinicians are assisted by the use of an (polarizing, color correction, etc.) and evolved with the materials and research intraoral mock-up, in which composite for more complex procedures such on the subject. In addition, the method is placed onto the patient’s existing as treatment plan overlays. Goodlin in which cases are planned is evolving, dentition and roughly trimmed to give a covers basic photographic procedure providing the clinician with several guide for the future restorations. This is as well as suggestions for pretreatment options for treatment plan development. used to communicate to the laboratory esthetic records that can be helpful for Here, the current literature is technician, who can fabricate a correct patient communication.26 Goodlin’s investigated in regard to standard veneer wax-up using the predefi ned incisal edge article recommends methods for practices, as well as in reference to position, gingival zeniths and approximate corrections prior to digital transfer some emerging technologies. High-level contour.18 The wax-up is then used to of images, as well as methods for evidence was sought regarding several make silicone matrices for chairside improving and communicating aspects of porcelain laminate veneer provisional fabrication, the benefi ts and treatment plans using Photoshop. treatment planning and treatment, with drawbacks of which have been covered The current literature pertaining to a focus on fi ndings of systematic reviews extensively in the literature, most notably digital photography emphasizes the use

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of DSLR technology, proper settings validity of the no-prep veneer, although the restoration is most likely being and correct accessories (mirrors, block- its popularity has come in and out of favor employed for esthetic reasons, the factors outs and fl ash attachments) in addition with clinicians as new dental ceramics effecting fi nal tooth shade should be to postediting software. The use of have become available.17 Historically, it considered when creating a plan for facial these tools is, and has always been, has been used with mixed results but still reduction, in addition to the minimum indispensable for the esthetic treatment of is maintained as a method of restoration required thickness of the material. patients. The authors noted here advocate to be used judiciously. The resulting the usefulness of combining this newer restorations can appear bulky, create an Proximal Reduction technology with traditional methods overcontoured gingival third and, in some There is no consensus as to a proper for shade matching and treatment cases, alter occlusion if the incisal length is proximal reduction for porcelain laminate presentation.24,25 The benefi ts to these changed.25 In cases where the restoration veneers. If a less radiopaque cement is newer methods are fairly obvious, but may is additive (augmenting the facial bulk used when preparations are fi nished in require extensive training and experience and perhaps length of the natural tooth in the contact zone, caries can be easily with advanced hardware and software its current alignment), a no-prep veneer detected, therefore there is no defi nitive before their usefulness is maximized. recommendation for interproximal fi nish areas.22 Textbook teachings explain the Computer-Assisted Treatment Planning reduction as a continuation of the facial Digital impressioning and The benefi ts to these newer reduction, which should be examined in computer-aided design/computer- methods are fairly obvious, but terms of the line angles and shadows.5 aided manufacturing (CAD/CAM) of may require extensive training Shortening an interproximal margin can restorations is a reality in the modern lead to marginal show as well as shadowing dental offi ce and has been documented and experience with advanced at the gingival third. The only consensus in the literature for use in the fabrication hardware and software before in this respect is that the preparation of porcelain laminate veneers in different their usefulness is maximized. should end in enamel and should not end case studies. The proper protocol for use on existing composite restorations. For of CAD/CAM technology in regard to ease of fabrication, it has been advocated veneer fabrication is unclear, leaving that the preparation extend lingual/palatal much room for research regarding the is considered to be a conservative method to the contact area. This facilitates die longevity and esthetic acceptability for restoration with many benefi ts.25 fabrication and ease of proximal marginal of the restorations.19,20,21,28 Authors In most cases, proper treatment fi nishing for the laboratory technician.23 caution that the thickness of material planning shows that reduction of the required may create gingival contour tooth is necessary. The literature shows Incisal/Lingual Reduction issues and infl ammation; the cost of the that in order to maximize strength against Incisal reduction amount was hardware/software can be prohibitive; material fracture, an increased thickness historically dictated by the material used, and a skilled lab technician must be of porcelain and enamel should be used. with the most common practice to be present to layer porcelain once the Ge et al. urge maximizing this thickness a 1 mm incisal reduction.5 This area of lithium disilicate base is milled. (porcelain/enamel) to avoid catastrophic the restoration experiences greater stress failure, while sacrifi cing the thickness than that of the supported, facial area Preparation of the Tooth of the porcelain as necessary to retain and showed clinical cohesive ceramic enamel structure and contour.13 It is failures.10 A study by Castelnuovo et al. Facial Reduction recommended for traditional feldspathic showed that a lingual butt joint with While minimal-to-no preparations porcelain veneers to create a minimum a maximum incisal reduction of 2 mm are preferred from a philosophical 0.3 mm-0.5 mm facial reduction to showed an increased resistance to cohesive and esthetic standpoint, different maintain contour.5 Pressed ceramics fracture when directly compared to a materials and clinical situations require (Empress, Ivoclar Vivadent, Amherst, chamfer design. In addition, Castelnuovo’s different facial reduction depths.12 N.Y.) require a minimum of 0.6 mm and group showed that with an incisal butt There is no clear consensus as to the necessitate a bilayer design.16 Because joint, there was eased seating of veneers

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and reduced risk of unsupported ceramic.11 ■ Preparations should always be Ceramic Veneers Having Varied Preparation Design. Oper Dent 2014 Sep-Oct;39(5):530-40. A fi nite element analysis by Li concluded fi nished in enamel. If this is not 16. Guess PC, et al. Prospective clinical study of press-ceramic that a chamfer design favored longevity, possible, another restorative overlap and full veneer restorations: Seven-year results. Int J citing data that stresses were concentrated option should be investigated. Prosthodont 27.4 (2013): 355-358. 17. Magne P, Hanna J, Magne M. The case for moderate ■ at the margin of a butt joint in a porcelain Current recommendations “guided prep” indirect porcelain veneers in the anterior laminate veneer, but is obviously limited for incisal reduction dictate a dentition. The pendulum of porcelain veneer preparations: from in application because of the study type.14 maximum reduction of 2 mm almost no-prep to over-prep to no-prep. Eur J Esthet Dent 8.3 (2012): 376-388. Bergoli’s group recently found that there and a lingual butt joint, with 18. Gürel G. Porcelain laminate veneers: Minimal tooth was no difference in load-to-fracture based some other evidence supporting preparation by design. Dent Clin North Am 51.2 (2007): on their in vitro study based on fi nite the use of the chamfer margin to 419-431. 15 19. Schmitter M, Seydler BB. Minimally invasive lithium element analysis. Guess et al. concluded increase surface area bonding. disilicate ceramic veneers fabricated using chairside CAD/ in a prospective study that both marginal ■ Current recommendations for facial CAM: A clinical report. J Prosthet Dent 107 (2012), pp. designs resulted in acceptable wear and reduction differ based on masking 71–74. 16 20. Sun J, Zhang FQ. The application of rapid prototyping in fracture resistance. Countless additional necessity and material thickness prosthodontics. J Prosthodont 21.8 (2012): 641-644. studies report similar fi ndings and seem to requirements, which is determined 21. da Cunha LF, et al. Fabrication of lithium silicate ceramic agree that minimizing the occlusal stresses secondary to the diagnostic wax-up. veneers with a CAD/CAM approach: A clinical report of cleidocranial dysplasia. J Prosthet Dent (2015). ■ at the unsupported porcelain area leads There is no consensus as to the 22. Christensen GJ. Facing the challenges of ceramic veneers. J to a long-lasting restoration secondary to most reliable interproximal Am Dent Assoc 2006 May;137(5):661-664. reduced cumulative stresses at the margin, margin design. ■ 23. Christensen GJ. Thick or thin veneers? J Am Dent Assoc if an incisal reduction is required.11,14,15 2008 Nov;139(11):1541-3. REFERENCES 24. McLaren EA, Garber DA, Figueira J. The Photoshop 1. Pincus CR. Building mouth personality. J South Calif Dent Smile Design Technique (part 1): Digital Dental Photography. Conclusion Assoc 14 (1938): 125-129. Compend Contin Educ Dent 2013 Nov-Dec;34(10):772, 774, The porcelain laminate veneer is 2. Faunce FR. Tooth restoration with preformed laminate 776 passim. veneers. Dent Surv 53.1 (1977): 30-32. 25. McLaren EA, Schoenbaum T. Digital photography one of the most conservative treatment 3. Radz GM. Minimum thickness anterior porcelain enhances diagnostics, communication and documentation. options, subject to modifi cation in restorations. Dent Clin North Am 55.2 (2011): 353-370. Compend Contin Educ Dent 2011 Nov-Dec;32 Spec No philosophy, material and technique over 4. Goldstein RE. Diagnostic dilemma: To bond, laminate, or 4:36-8. crown? Int J Periodontics Restorative Dent 7.5 (1986): 8-29. 26. Goodlin R. Photographic-assisted diagnosis and treatment the years. Regardless of the evolution of 5. Shillingburg HT, et al. Fundamentals of Fixed Prosthodontics. planning. Dent Clin North Am 2011 Apr;55(2):211-27. the clinical techniques, some tried-and- 3rd ed. Quintessence Pub Co (1997): 85-123. 27. Vafi adis D, Goldstein G. Single visit fabrication of a true methods have withstood the test of 6. Boyer DB, Chalkley Y. Bonding between acrylic laminates porcelain laminate veneer with CAD/CAM technology: a and composite resin. J Dent Res 61.3 (1982): 489-492. clinical report. J Prosthet Dent 2011 Aug;106(2):71-3. time and others have been modifi ed as 7. Horn HR. A new lamination: Porcelain bonded to enamel. N research on longevity becomes available: Y State Dent J 49.6 (1982): 401-403. THE AUTHOR, Andrea Jordan, DDS, FACP, can be reached at [email protected]. ■ The case must be carefully 8. Calamia JR. Etched porcelain facial veneers: A new treatment modality based on scientifi c and clinical evidence. N selected and treatment planned. Y State Dent J 53.6 (1982): 255-259. While some patients may benefi t 9. Quinn F, McConnell RJ, Byrne D. Porcelain laminates: A from this minimally invasive review. Br Dent J 161.2 (1986): 61. 10. Friedman MJ. A 15-year review of porcelain veneer failure treatment, others would better — A clinician’s observations. Compend Contin Educ Dent 19.6 served with orthodontics, (1998): 625-8. enamel planing or simple bonded 11. Castelnuovo J, et al. Fracture load and mode of failure of 22 ceramic veneers with diff erent preparations. J Prosthet Dent composite restorations. 83.2 (2000): 171-180. ■ The use of mock-ups, wax-ups 12. Farhan D, et al. Masking Ability of Bi- and Tri-Laminate and provisionals allow for the best All-Ceramic Veneers on Tooth-Colored Ceramic Discs. J Esthet Restor Dent 26.4 (2014): 232-239. esthetic and functional outcome. 13. Ge C, et al. Eff ect of porcelain and enamel thickness on ■ Use of CAD/CAM technology porcelain veneer failure loads in vitro. J Prosthet Dent 111.5 to create porcelain laminate (2014): 380-387. 14. Li Z, et al. A three-dimensional fi nite element study on veneers has been documented, but anterior laminate veneers with diff erent incisal preparations. J requires a high level of laboratory Prosthet Dent 2014 Aug;112(2):325-33. skill and expensive machinery. 15. Bergoli CD, et al. Survival Rate, Load to Fracture and Finite Element Analysis of Incisors and Canines Restored With 202 APRIL 2015 communication

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Improved Communication With the Laboratory for the Fabrication of Labial Veneers

Aaron Schwartzman, DDS, and Alan E. Zweig, DMD, FAGD

ABSTRACT Advances in dental materials and adhesive technologies have changed the way we practice dentistry. Consequently, restorative dentistry has seen the adoption and almost exponential increase in usage of materials like zirconia and lithium disilicate. Unlike the incidence of ceramic failure in the past, these newer materials are paving the road to better looking dentistry. This paper focuses on lithium disilicate and predominantly glassy ceramics, as well as improving communication with the laboratory.

AUTHORS

Aaron Schwartzman, Alan E. Zweig, DMD, ecent advances in dental Background DDS, is a prosthodontist FAGD, a prosthodontist, materials and adhesive Dental ceramics have evolved beyond has been in private practice in private practice in technologies have changed the the metal-ceramic restoration to the Beverly Hills, Calif. He for more than 34 years attended New York in Beverly Hills, Calif. way we practice dentistry, a more current all-ceramic option. The University College of He completed his dental trend that continues to gather goal has always been to bring a functional Dentistry for his dental degree at Washington Rmomentum. Consequently, restorative and highly esthetic restoration that is degree and postgraduate University in St. Louis dentistry has seen the adoption and biocompatible. The challenge has been and his postgraduate prosthodontics program. almost exponential increase in usage to maintain strength while utilizing He has served as a clinical prosthodontics program at instructor at NYU College the Herman Ostrow School of materials like zirconia and lithium ceramics as a restorative material. of Dentistry and the of Dentistry of USC, where disilicate. Dental magazines and product Ceramics have been selected as the University of California, he has served as a clinical publications are laden with ceramic material of choice because of their high Los Angeles, School of instructor. promotions. Implant abutments, esthetics; however, they are inherently Confl ict of Interest Dentistry. full-coverage crowns, fi xed partial weak, especially those with high glass Confl ict of Interest Disclosure: None reported. 1,2 Disclosure: None reported. denture frameworks, fi xed detachable content. A major breakthrough for ACKNOWLEDGEMENT frameworks, partial-coverage crowns dental ceramics was the addition of leucite and labial veneers are being fabricated to strengthen the porcelain without Special thanks to Stefan with high-strength ceramics. Unlike increasing opacity. This has the further Ursu, CDT, for his photographic contributions. the excessive incidence of ceramic advantage of simultaneously controlling failure in the recent past, these newer the thermal expansion.3 This allows the materials succeed and are changing the ceramists to place veneering porcelain foundation of esthetics in dentistry. This over metal frameworks, match the thermal paper will focus on lithium disilicate expansions and place the ceramic into and predominately glass ceramics, as slight compression.4 Since the inception well as improving the communication of ceramics in the 1980s, it has matured with the dental laboratory. to include nonshrinking ceramics. This

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FIGURE 3. Monolithic e.max veneers on teeth Nos. 7-10. FIGURE 1. Example of direct composite veneers on teeth Nos. 7-10. FIGURE 2. IPS e.max CAD blocks in various shades and translucencies. took us from Cerestone to Dicor, Inceram TABLE to Empress, and most notably now to computer-aided design/computer-aided Flexural Strength Comparison of Common Dental Ceramics manufacturing (CAD/CAM) blue state IPS e.max CAD IPS e.max Press Feldspathic Zirconia IPS e.max CAD (Ivoclar Vivadent, Flexural strength 360 400 90-110 800-1100 Amherst, N.Y.) and green machining (megapascal) zirconia.4 Lithium disilicate and polycrystalline zirconia have been major driving forces for all-ceramic restorations due to the high rates of clinical success. Empress pressed and CAD, InCeram feldspathic ceramic to a homogenous piece Alumina, and lithium disilicate or IPS of lithium disilicate ceramic at 400 MPa Types of Esthetic Veneers e.max Press and IPS e.max CAD.9 While (TABLE). It should be clarifi ed that when Veneers come in a few varieties. dental technicians and dentists have their an IPS e.max restoration is prescribed Ceramic, composite and prefabricated personal preferences, lithium disilicate is through a laboratory there are two options veneers are available to every dentist, fast becoming the material of choice.10 for fabrication, bilayer or monolithic. and each has its ideal applications The bilayer IPS e.max restoration has (FIGURE 1). Composite veneers Lithium Disilicate a compatible veneering layer of 90-110 and prefabricated veneers have Lithium disilicate is a glass ceramic MPa porcelain over the 360 to 400 MPa many applications and an improved composed of quartz, lithium dioxide, lithium disilicate core. A monolithic IPS esthetic.5 Companies like Coltene- phosphor oxide, alumina, potassium e.max restoration is solid IPS e.max. The Whaledent and Dentsply have branded oxide and other components. It can be same can be requested of a labial veneer. prefabricated veneer systems, and most processed by a lost wax technique or As with traditional veneers or dental companies that manufacture milled using CAD/CAM procedures. feldspathic high-glass restorations, lithium composites have an elite anterior line.6 The pressable version is 70 percent disilicate can be etched to allow bonding. Using composites may not be primary, lithium disilicate crystals embedded in When etched, all ceramics with high but they are useful tools when applied a glass matrix with ions disassociated glass content create a microstructure appropriately. The advantages of using in the glass to create its chosen color.11 for a mechanical bond. In full coverage composites or prefabricated veneers The millable blocks are stable in the crowns with proper retention, the are their conservative technique, cost blue state, allowing the milling unit to clinician has the choice whether or effectiveness, chairside application and cut effi ciently. The blue state, however, not to bond the restoration. This is not reversibility.7 The known disadvantages is only an intermediate oxidation the case with veneers — they must be are longer chair time, short clinical lives, state that is much weaker and oddly bonded. Microtensile bond strengths maintenance, lack of color stability, holds a blue color. Once sintered have been observed in the range of about surface degradation, margin staining in an oven at the specifi ed heating 18-20 MPa in aged specimens of lithium and overall clinical challenge.8 sequence, it achieves full strength disilicate to dentin in vitro.15 Etching A ceramic veneer can provide the and desired color12-14 (FIGURE 2). times for lithium disilicate are shorter highest level of esthetics, strength and A monolithic restoration of lithium than for feldspathic veneers, 60 seconds longevity. It is the fi rst choice for a good disilicate has superior properties to compared to 20 seconds, respectively, reason. Currently the common materials traditional veneering porcelain (FIGURE 3). with hydrofl uoric acid. Lithium disilicate are layered glass or pressed ceramic, One only need compare the fl exural is a more robust restorative esthetic including feldspathic porcelains, IPS strength of 90-110 megapascal (MPa) of material and holds the advantage of

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FIGURE 4A. Platinum foil technique for fabrication FIGURE 4B. Layered porcelain placed over the FIGURE 5. Example of a feldspathic veneer failure. of labial veneers with platinum foil adapted to the adapted platinum foil. preparations on the cast. good micromechanical bonding to Wear Communicating the Right Information tooth structure16 (FIGURES 4A–4B). Appropriate attention must be paid When writing a laboratory prescription Failures are usually seen with metal- to veneer preparations and subsequent for labial veneers, the clinician must ceramic bilayer restorations and all- restorations because they play a take care to be specifi c. It is a common ceramic bilayer restoration in the overlay signifi cant role in opposing occlusions. complaint of ceramists and laboratory porcelain (FIGURE 5). The loss of load- Currently, ceramists are favoring lithium technicians that dentists do not bearing capacity of dental ceramics in disilicate or feldspathic ceramic for labial communicate well, which forces them repetitive loading can be attributed to veneer restorations. It is important to to make blind decisions. This results in chemically assisted slow crack growth know the long-term effects the materials frustration for the dentist, the technician or SCG. It has been suggested that can have on natural dentition or even and the patient, and ultimately the not only is there a chemical but also a other restorations. Three-dimensional restoration will have to be redone. mechanical fatigue usually originating laser scanners are used to measure from a defect within the ceramic.2,17 intraoral wear using noncontact optical What to Communicate Natural biting forces can be in the sensors on replicated dental models.23 Color, shape, incisal length, incisal range of 100 N to 600 N, and ceramics These scanners have an estimated plane, translucency, ceramic material, must not violate this at minimum.18 precision of 5 um to 8 um.24 Numerous occlusion, tooth position, embrasures, Crack propagation originates from studies have demonstrated the clinical contacts — the list is endless. Fortunately, the core material and rises up through success of ceramics. A study comparing with advances in technology, relaying the veneering layer. The fi ve-year ceramic inlays to enamel over a four- information to the laboratory can be survival rate of all-ceramic crowns used year period found inlay wear at 78 um expedited. Digital photography, new shade in the posterior is estimated to be 93.3 against enamel at 120 um.25 A controlled guides and spectrophotometers have made percent and 95.6 percent for metal- clinical trial evaluated full coverage data capture easier and more accurate. ceramic crowns.19 A nine-year study crowns opposing enamel antagonists of bilayer lithium-disilicate crowns and the corresponding two contralateral Shade Guides reported a 97.4 percent success at fi ve teeth while correlating bite force. The The typical clinical procedure to select years and 94.8 percent after eight years.20 results of this study comparing metal and reproduce natural teeth color with a In a study targeting lithium disilicate ceramic crowns and all ceramic crowns ceramic restoration is visual comparison restorations, the cumulative survival rates found that the wear was greatest for the using a dental shade guide.28-30 However, of restorations ranged from 95.5 percent contralateral antagonist.26 Esquivel- most dental shade guides cover a limited to 100 percent using 53 monolithic and Upshaw et al. in 2013 found lithium color space of natural teeth and do not 265 layered veneers. More specifi cally, disilicate crowns showed greater surface demonstrate adequate distributions within anterior veneers showed a cumulative roughening and crown wear from the the color range.31 Dental professionals survival rate of 97.9 percent with a second to third year during a three- strive to provide a restoration matching follow-up range of 12 to 72 months.21 year study evaluating metal-ceramic the natural tooth color; nevertheless, color Petridis and colleagues conducted a crowns, core ceramic crowns and replication presents a challenge for the minimum fi ve-year systematic review core ceramic/veneer ceramic crowns. clinician.32,33 Color identifi cation involves and meta-analysis of ceramic veneers and The loss of surface degradation of the multiple challenges such as available found the most frequent complication glaze accounted for increased surface lighting conditions, neighboring teeth and reported was marginal discoloration at 9 roughness, although the tested ceramics tissues, metamerism, tools available and the percent, followed by marginal integrity were proven to be wear resistant and subjective perception of the receiver.28,34-36 at 3.9 percent to 7.7 percent.22 comparable in wear to natural enamel.27 The Vitapan Classical (VITA

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FIGURES 6A. Vitapan Classical shade guide. FIGURE 6B. Vita System 3D-Master. FIGURE 7. Example of shade tabs placed at the same plane as the tooth.

Zahnfabrik, Bad Säckingen, Germany) read refl ected wavelengths of light, crop sensors and approximately 100 mm (FIGURE 6A) continues to be used for the hence allowing for a more objective for full-frame sensors. Focal lengths are ceramic system despite constraints related opinion when choosing a shade. In important because the on-camera fl ash to the color range and distribution of the contrast to conventional shade selection distance will be altered as focal length natural tooth.35 The Vita Toothguide techniques, it was found that the use of changes, resulting in suboptimal lighting 3D-Master guide (VITA Zahnfabrik) spectrophotometers result in a 33 percent conditions. Wide-angle lenses distort (FIGURE 6B) is a relatively new concept increase in accuracy in 93.3 percent of cases.8 reality and should not be used for macro of systematic coverage of natural images. The on-camera lighting setup teeth color space and is based on the Digital Photography should consist of a macro ring fl ash or a colorimetric CIELab* order principle, Out of all the information to provide dual point fl ash system. With the proper providing a more scientifi c approach.28 the laboratory technician, digital hardware in place, the camera settings Many studies have shown the use of the photography is by far the most valuable. should include a fast shutter speed and Vitapan Classical shade guide results in a Photography provides the ceramist small aperture, such as 1/160s at f/22. signifi cantly greater mean color difference a virtual seat in front of the patient. This will allow for the action to be frozen than the use of the Vita Toothguide Current advanced and increasingly and the depth of fi eld to be as large as 3D-Master guide. The color difference affordable technologies make providing possible. For example, both the centrals values between the teeth and the ceramic the laboratory with valuable digital and the second molars could be in focus crowns in one particular study were images a sensible practice. Endless simultaneously. Finally, in regard to 2.33 ΔE units for the Vitapan Classical morphology can be communicated in shade selection, a current custom white guide and 1.62 ΔE units for the Vita a few photos, along with color, shape, balance should be utilized as variations Toothguide 3D-Master guide. This shows size, length and bodily position. in lighting conditions could change the a signifi cant improvement with the use of Specifi cally for shade matching, overall color temperature of an image. the Vita Toothguide 3D-Master guide.35 photography can be used to assist Often the fl ash of the camera will proper illustration of a tooth color hit portions of the tooth with too much Spectrophotometers map (FIGURE 7). The reference shade intensity. This overexposure washes out Many clinicians have adopted the tabs identifying chroma and value are important details of the tooth. It has adjunct use of a spectrophotometer to positioned in the same vertical plane been suggested to bracket the exposures aid in producing a more objective color as the selected tooth and an image is to reveal more detail in the lighter areas measurement. These include Crystaleye captured.37 Because there are variations of the tooth structure (FIGURES 8A–C). (Olympus, Tokyo), Vita Easyshade compact in tooth color and great complexity in However, a potentially superior method (VITA Zahnfabrik), SpectroShade Micro tooth structure, the technician can use to combat these specular highlights is to (MHT Optic Research, Nederhasli, judgment through the images to discern employ cross polarization. This method Switzerland) and Shade-X (X-rite, the subtle changes in the tooth. polarizes the light coming out of the fl ash Grandville, Mich.), to name the more The process is best conducted with and the light coming into the camera lens, recognized products.34 Each of these the proper camera equipment and thus eliminating the specular highlights. spectrophotometers work by producing setup because it can greatly affect the With cross-polarized images, overall an internal source of light, collecting the overall image usefulness. Ideal camera tooth value can be more easily identifi ed. refl ected light from the tooth and then equipment consists of a digital single- The details of the teeth are muted, but displaying a familiar dental color shade on lens refl ex (DSLR) camera with a macro accurate color shade and value can be the digital readout. Spectrophotometers lens around 65 mm in focal length for noted. McLaren describes a method

206 APRIL 2015 CDA JOURNAL, VOL 43, Nº4

FIGURE 8A. FIGURE 8B. FIGURE 8C. FIGURE 8A–C. Bracketed exposures to show subtle details. 8A, 0 EV; 8B, -2/3 EV; and 8C, -1 EV.

utilizing cross-polarized shade selection Conclusion 6. Xu B, Chen X, Li R, Wang Y, Li Q. Agreement of try-in pastes and the corresponding luting composites on the fi nal color of with the assistance of Adobe Photoshop The success of veneers is not purely ceramic veneers. J Prosthodont 2014;23(4):308-12. to identify tooth value at an increased dependent on the materials. Preparation 7. Zhao K, Wei YR, Pan Y, et al. Infl uence of veneer and cyclic accuracy. In this example, the image is design, quality of the underlying tooth loading on failure behavior of lithium disilicate glass-ceramic molar crowns. Dent Mater 2014;30(2):164-71. taken with a shade tab of comparison structure, preparations ending in enamel, 8. Paul S, Peter A, Pietrobon N, Hämmerle CHF. Visual and under cross-polarized light. The image bonding technique and proper isolation are spectrophotometric shade analysis of human teeth. J Dent Res is then opened in Photoshop and the all contributing factors. The clinician must 2002;81(8):578-82. 9. Bagis B, Turgut S. Optical properties of current ceramics overall hue, saturation, brightness (HSB) be aware of sensitive technique parameters systems for laminate veneers. J Dent 2013;41 Suppl 3:e24-30. information is compared between the to ensure long-term survival. Wear of the 10. Zahran M, El-Mowafy O, Tam L, Watson PA, Finer shade tab and the natural tooth. As value opposing dentition must also be considered. Y. Fracture strength and fatigue resistance of all-ceramic molar crowns manufactured with CAD/CAM technology. J tends to be the most important parameter Current studies have raised some concern Prosthodont 2008;17(5):370-7. of color selection and the most perceivable for the long-term surface texture of 11. Tysowksy GW. The Science Behind Lithium Disilicate: A by the patient, this can be a valuable lithium disilicate glazes. As this material is Metal-Free Alternative. Dent Today 2009 Mar;28(3):112-3. 12. Bindl A, Luthy H, Mormann WH. Strength and fracture 38 tool for the laboratory technician. somewhat new to the dental world, more pattern of monolithic CAD/CAM-generated posterior crowns. research will provide dentists with greater Dent Mater 2006;22(1):29-36. Video information to make clinical decisions. 13. Fasbinder DJ. Chairside CAD/CAM: An overview of restorative material options. Compend Contin Educ Dent Video capability is built into the Porcelain laminate veneers require 2012;33(1548-8578 (Print)):50, 52-8. fi rmware of most DSLRs, easily lending thorough communication between the 14. Malo P, de Sousa ST, De Araujo Nobre M, et al. itself to social media. If a camera isn’t practitioner and the laboratory throughout Individual lithium disilicate crowns in a full-arch, implant- supported rehabilitation: A clinical report. J Prosthodont available, a smartphone is usually the treatment process. After all, the detail 2014;23(6):495-500. accessible. Androids and iPhones alike of the restoration is only as good as the 15. Marocho SM, Ozcan M, Amaral R, Bottino MA, Valandro have great video capturing abilities and can details that are provided to the ceramist. LF. Eff ect of resin cement type on the microtensile bond strength to lithium disilicate ceramic and dentin using diff erent test provide the needed gap to communicate Proper shade selection techniques assemblies. J Adhes Dent 2013;15(4):361-8. to the laboratory. Much of the initial benefi t from each of the three branches 16. Guess PC, Selz CF, Voulgarakis A, Stampf S, Stappert diagnostic decision making in complex described. One shade selection system CF. Prospective clinical study of press-ceramic overlap and full veneer restorations: Seven-year results. Int J Prosthodont esthetic cases involved recording the cannot be as strong as the three combined. 2014;27(4):355-8. position of the teeth in relation to the face Advancements in technology will 17. Ge C, Green CC, Sederstrom D, McLaren EA, White SN. and lips. These positions are not static.38 pave the way for more streamlined and Eff ect of porcelain and enamel thickness on porcelain veneer failure loads in vitro. J Prosthet Dent 2014;111(5):380-7. Still images taken to show lips in repose, accurate color identifi cation processes. ■ 18. Demes B, Creel N. Bite force, diet and cranial morphology exaggerated smiles and fricative movements of fossil hominids. J Hum Evol 1988;17(7):657-70. REFERENCES do help to communicate, but a short video 19. Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A 1. Denry I, Holloway JA. Ceramics for Dental Applications: A systematic review of the survival and complication rates of all- 39 of the same exercise is more effective. Review. Materials 2010;3(1):351-68. ceramic and metal-ceramic reconstructions after an observation Cloud-based sharing, larger email fi le size 2. Zhang Y, Sailer I, Lawn BR. Fatigue of dental ceramics. J period of at least three years. Part I: Single crowns. Clin Oral Dent 2013;41(12):1135-47. maximums and sophisticated laboratory Implants Res 2007;18 Suppl 3:73-85. 3. Raigrodski AJ. Concepts of Design for Contemporary 20. Gehrt M, Wolfart S, Rafai N, Reich S, Edelhoff D. Clinical portals have made transferring these fi les Anterior All-Ceramic Restorations. Journal of Cosmetic Dentistry results of lithium-disilicate crowns after up to nine years of possible. Sending an optical scan consisting 2013;28(4):46. service. Clin Oral Investig 2013;17(1):275-84. 4. Kelly JR, Benetti P. Ceramic materials in dentistry: Historical of 16 to 40 megabytes to the laboratory is 21. Fabbri G, Zarone F, Dellifi corelli G, et al. Clinical evaluation evolution and current practice. Aust Dent J 2011;56 Suppl of 860 anterior and posterior lithium disilicate restorations: becoming commonplace. In summation, 1:84-96. Retrospective study with a mean follow-up of three years and a sending a video is not only feasible but a 5. Farhan D, Sukumar S, von Stein-Lausnitz A, et al. Masking maximum observational period of six years. Int J Periodontics ability of bi- and tri- laminate all-ceramic veneers on tooth- Restorative Dent 2014;34(2):165-77. superior option to still pictures alone. colored ceramic discs. J Esthet Restor Dent 2014;26(4):232-9.

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22. Petridis HP, Zekeridou A, Malliari M, Tortopidis D, Koidis correspondence of a ceramic system in two diff erent shade ceramic system. J Prosthet Dent 2012;108(1):9-14. P. Survival of ceramic veneers made of diff erent materials after guides. J Dent 2009;37(2):98-101. 36. Fondriest J. Shade matching in restorative dentistry: The a minimum follow-up period of fi ve years: A systematic review 29. Paravina RD, Majkic G, Imai FH, Powers JM. Optimization science and strategies. Int J Periodontics Restorative Dent and meta-analysis. Eur J Esthet Dent 2012;7(2):138-52. of tooth color and shade guide design. J Prosthodont 2003;23(0198-7569 (Print)):467-79. 23. Mehl A, Gloger W, Kunzelmann KH, Hickel R. A new 2007;16(4):269-76. 37. Tam WK, Lee HJ. Dental shade matching using a digital optical 3-D device for the detection of wear. J Dent Res 30. Dozic A, Kleverlaan CJ, Aartman IH, Feilzer AJ. Relation camera. J Dent 2012;40 Suppl 2:e3-10. 1997;76(11):1799-807. in color of three regions of vital human incisors. Dent Mater 38. McLaren EA, Schoenbaum T. Combine conventional and 24. Heintze SD, Cavalleri A, Forjanic M, Zellweger G, 2004;20(9):832-8. digital methods to maximize shade matching. Compend Contin Rousson V. A comparison of three diff erent methods for the 31. Joiner A, Hopkinson I, Deng Y, Westland S. A review of Educ Dent 2011;32 Spec No 4(1548-8578 (Print)):30, 32-3. quantifi cation of the in vitro wear of dental materials. Dent tooth colour and whiteness. J Dent 2008;36:2-7. 39. Pound E. Recapturing esthetic tooth position in the Mater 2006;22:1051-62. 32. Wang J, Lin J, Gil M, et al. Assessing the accuracy of edentulous patient. J Am Dent Assoc (1939) 1957;55(2):181- 25. Krämer N, Kunzelmann KH, Mehl A, et al. Antagonist computer color matching with a new dental porcelain shade 91. enamel wears more than ceramic inlays. J Dent Res system. J Prosthet Dent 2014;111(3):247-53. 2006;85(12):1097-100. 33. Wee AG, Lindsey DT, Kuo S, Johnston WM. Color THE CORRESPONDING AUTHOR, Aaron Schwartzman, DDS, can be 26. Esquivel-Upshaw JF, Rose WF Jr., Barrett AA, et al. accuracy of commercial digital cameras for use in dentistry. reached at [email protected]. Three years in vivo wear: Core-ceramic, veneers and enamel Dent Mater 2006;22(6):553-9. antagonists. Dent Mater 2012;28(6):615-21. 34. Chu SJ, Trushkowsky RD, Paravina RD. Dental color 27. Esquivel-Upshaw J, Rose W, Oliveira E, et al. Randomized, matching instruments and systems. Review of clinical and controlled clinical trial of bilayer ceramic and metal-ceramic research aspects. J Dent 2010;38 Suppl 2:e2-16. crown performance. J Prosthodont 2013;22(3):166-73. 35. Öngül D, Şermet B, Balkaya MC. Visual and instrumental 28. Corciolani G, Vichi A, Goracci C, Ferrari M. Colour evaluation of color match ability of two shade guides on a

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208 APRIL 2015

Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO COUNTY

CANOGA PARK (GP) – Price Reduced!! Seller is ANAHEIM – Leasehold Improvements & Equipment VISTA - 35 years of goodwill. 4 fully computerized currently working 1 day/wk with ½ day of hygiene. 2 Only! 4 equipped operatories in a 1,680 sq office. equipped operatories. Grossed approximately equipped operatories. Property ID #4357. Property ID #4535. $883K in 2013. Has monthly revenues of $73K. CHATSWORTH (GP) – Price Reduced!! 5 equipped ALISO VIEJO (Pedo) – 3 chairs in open bay, 1 Property ID #4507. operatories. Grossed $918K in 2013. Projecng plumbed not equipped op. Grossed approximately approx. $948K for 2014. Buyer’s net of $398K. $340K in 2014. Great pracce. Property ID #5031. EL CENTRO (GP) – This pracce is located in a Property ID #4537. single story building. Building is for sale. 5 FULLERTON (GP) – Established in 2002. Projecng equipped operatories. Grossed approximately LOS ANGELES – 65 years of goodwill Grossed ap- $304K for 2014. Buyer’s net of $132K. Property ID proximately $350K in 2013. Buyer’s net of $71K. $554K for 2014. Buyer’s net of $189K. Property ID #5023. Please contact your CPS Agent for more details. #5010. Property ID #5008. SAN DIEGO COUNTY - Mul-Specialty pracce. 7 FULLERTON – Leasehold Improvement and Equip- equipped operatories in an approximately 4,464 LOS ANGELES - This pracce with over 30 Years of ment! On one the busiest intersecons of Fullerton. office. Grossed $1,700,000 in 2013 and projecng goodwill, and approximately 60% of it's income 3 equipped operatories. Some paent charts includ- approximately $1,900,000 for 2014 with monthly comes from capitaon. Property ID #5012. ed. Property ID #5028. revenues of $165,000. Property ID #4231. LOS ANGELES (GP) - 3 equipped operatories with GARDEN GROVE – 4 equipped ops and 1 plumbed digital x-rays in a 1,000 sq . office. The recepon (not equipped) op. Grossed approximately $436K in area was recently remodeled. Grossed approxi- 2014 Property ID #5043. mately $277,130 in 2014. Property ID #5040. HUNTINGTON BEACH - Leasehold Improvement and RIVERSIDE & SAN BERNARDINO COUNTY MISSION HILLS - Leasehold Improvements & Equip- Equipment Only! Modern Design. 3 equipped ops, 1 APPLE VALLEY (GP) – 3 equipped ops . Has monthly ment Only! 8 equipped Property ID #5014. plumbed not equipped. Was built in June 2014. revenues of $42K. Property ID #5044. Property ID #5032. MONTEREY PARK (GP) – Leasehold Improvements APPLE VALLEY - 8 equipped operatories. Seller is & Equipment Only! 3 equipped operatories. IRVINE - Leasehold Improvement and Equipment! working 3 days/wk, Associate 1 day/wk and O.S. 1x/ Property ID #4449. 10 equipped ops and 2 recepon areas. Property ID #5030. mo. Grossed $707K in 2013 and Projecng $722K PASADENA (GP) - 3 equipped ops. Grossed approx- for 2014. Property ID#5009. imately $335K for 2014. Property ID #5035. LAGUNA HILLS – 2 equipped ops. Approximately 20- 25 new paents/mo. Ins/Cash/Cap (~$500/mo). HESPERIA (GP) – 4 equipped operatories. Seller RESEDA – 3 equipped operatories (stand up dens- Grossed approximately $319,024 in 2014. Property works 3 days/wk with 3 days of hygiene Grossed try). Projecng approximately $292,796 for 2014 ID #5033. with monthly revenues of $24K. Property ID#5017. $260K in 2013 and projecng approximately $336K ORANGE COUNTY PERIO – Price Reduced!! Grossed for 2014. Property ID #5007. ROSEMEAD – 2 equipped operatories, lab/ approximately $972K in 2013 and projecng approx- sterilizaon room, x-ray room, dark room and imately $1,016,000 for 2014 with a Buyer’s net of INDIAN WELLS – Leasehold Improvements and private office in a 790 sq suite. Projecng approxi- $260K. Please contact your CPS Agent for more Equipment Only!! Great opportunity for a TMJ, mately $119K for 2014. Low Sale Price! Property ID details. Property ID #5005. Sleep Apnea and GP. 4 equipped ops. Property ID #5019. #5041. RANCHO SANTA MARGARITA – Leasehold Improve- SANTA CLARITA (GP) – This turn-key pracce ment Only!! 4 plumbed not equipped operatories. PALM DESERT— 5 equipped ops. Have monthly Reestablished the pracce in September 2013. Property ID #4483. revenues of approximately $28K/mo. Property ID Great opportunity for a 1st me buyer. Property ID #4331. #5013. PALM SPRINGS – 3 equipped operatories with SANTA MONICA - 3 equipped operatories. Grossed Pracce Web soware and digital x-ray. Major $265,485 in 2013 and projecng approximately VENTURA, SANTA BARBARA & KINGS COUNTY equipment is approximately 2 years old. Suite is $265,796 for 2014. Property ID #5022. 1,200 sq . Seller is working 5 days/wk and sees SAN LUIS OBISPO COUNTY – 6 equipped ops. Has approximately 8-10 paents/day. Income source is TORRANCE – 3 equipped operatories, Grossed monthly revenues of $90K. Property ID #5037. approximately 25% insurance, 65% cash and 10% $321,051 in 2013. Pracce is averaging $28K in Den-cal. Does lile adversing. Please contact monthly revenue. Property ID #4477. VENTURA (GP) - 4 fully equipped operatories in a 1,862 (+ free bonus room) sq suite. Each operatory your CPS Agent for more informaon. Property ID TORRANCE – 5 equipped ops. Grossed approxi- has floor to ceiling windows for plenty of natural light . #4487. mately $493K for 2014. Property ID #5036. Grossed approximately $423K in 2014. Property ID RIVERSIDE – 6 ops. Projecng approximately $550K #5039. for 2014. Property ID # 5006.

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Precise Documentation Is a Plus in Veneer Cases TDIC Risk Management Staff

isk management articles the patient called a month later and seminars often look at and demanded a refund. She said problematic cases where Without consistent and another dentist had to “fi x” the things go wrong during thorough record keeping, it is veneers. The dentist called TDIC’s dental treatment, but diffi cult to remember everything Advice Line to discuss options Rlet’s turn the tables and see what about the best way to proceed. happens when a case goes right. for every patient, especially The risk management analyst The following case involves the relating to treatment that may asked the dentist about documentation placement of dental veneers, a procedure have happened several surrounding the case. He had appropriate that generates numerous questions, months or even years ago. chart documentation, photos and the according to risk management analysts informed consent form. He said he at The Dentists Insurance Company. took time to explain the procedure, TDIC reports regular calls to its Advice Line about veneer-related situations, and numbers show that veneer cases are sent to claims more frequently than cases involving other dental issues. In a recent two-month time frame, Advice Line calls revealed 10 of 12 veneer-related calls ended up in the claims department. You are not a policy number. “Veneers cases can be diffi cult,” said a senior risk management analyst with And at The Dentists Insurance Company, we won’t treat you like TDIC. “There is not one easy answer.” Risk management analysts are clear, one because we are not like other insurance companies. We were however, that dialing the Advice Line started by, and only protect, dentists. A singular focus that leads does not mean your call is automatically to an unparalleled knowledge of your profession and how to best sent to claims. Based on the facts of the protect you. It also means that TDIC is in your corner, because with call, the analyst may determine the case is beyond risk management and refer us, you’re never a policy number. You are a dentist. the caller to the claims department. Some veneer cases have a more positive outlook than others. Here’s Contact the Risk Management Advice Line at 800.733.0634. an example: Last October, a Northern California dentist placed fi ve anterior veneers on a 29-year-old patient. The dentist discussed the procedure with the patient, and she signed an informed Protecting dentists. consent form. The dentist also charted ® the discussion and procedure and It’s all we do. took photos, including a fi nal photo thedentists.com of the smiling patient with the new veneers in place. The patient even gave a “thumbs up” in the photo. The dentist was surprised when

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including tooth preparation, and poised for a favorable outcome thanks to noted the conversation in the dental good clinical work and record keeping. Key Recommendations record. This documentation gave the Unfortunately, not all cases go this way. To boost the success of dentist an advantage because he felt “Some would say we preach veneers cases, TDIC strongly the veneers were clinically sound, and documentation,” said a TDIC risk recommends the following: he had the evidence to back it up. management analyst. “Yet, in too many ■ Communicate clearly with the The TDIC analyst recommended cases we fi nd the documentation is patient about the irreversible the dentist tell the patient he was spotty or incomplete. What we see aspect of porcelain veneers. willing to investigate further. The is a lack of signed informed consent Discuss tooth preparation, potential dentist should then ask the patient forms for invasive procedures such consequences and alternatives. for permission to speak with the new as veneers and no documented ■ Ask the patient to sign an informed dentist who fi xed the veneers, so he patient esthetic approval prior to the consent form. Informed consent forms could learn what was allegedly wrong. permanent cementation of veneers.” are available at thedentists.com. In this case, the burden is on the Dentists have told analysts that ■ Chart the informed consent patient to prove there is a complication patients often assume if they do not discussion, treatment plan and with the veneers, and the dentist is like the veneers, then the veneers can progress notes in suffi cient detail. ■ Photograph the procedure from start to fi nish. ■ Prior to cementation of veneers, ask the patient to sign an esthetic When Looking To Invest In Professional approval form. Esthetic approval forms Dental Space Dental Professionals Choose are available at thedentists.com.

just be removed with no consideration of tooth coverage. The issue is whether Linda Brown the doctor was clear during the informed consent discussion that the 30 Years of Experience Serving tooth preparation is irreversible and the Dental Community Proven veneers cannot simply be taken off. Informed consent discussions about Record of Performance veneers include essential information about tooth preparation, potential • Dental Office Leasing and Sales consequences and possible alternatives. • Investment Properties If orthodontics or periodontal surgery For your next move, is recommended but the patient contact: LINDA BROWN • Owner/User Properties chooses veneers instead, be clear • Locations Throughout verbally and in writing about the risks, Direct: (818) 466-0221 benefi ts and alternatives to veneers. Southern California Equally as important are questions Office: (818) 593-3800 about what the patient expects from Email: [email protected] the treatment. Patients may bring Web: www.TOLD.com pictures of celebrities they admire. Often Cal BRE: 01465757 the patient is looking at the overall appearance in the photo rather than CONTINUES ON 214

212 APRIL 2015 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a dental practice is sold? QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

Can I afford not to buy a dental practice? LEE SKARIN 2. INC. & ASSOCIATES

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify for financing the purchase of a practice?

5. Is it possible to purchase a practice without a personal cash investment?

6. What kinds of things should a Buyer consider when evaluating a practice?

7. What are the tax consequences for the Buyer when purchasing a practice? 2IÀFHV Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other 805.777.7707 questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149 APRIL 2015 RM MATTERS

CDA JOURNAL, VOL 43, Nº4

CONTINUED FR0M 212 just the teeth. Other times the patient importance of the dental record for may be seeking a cure-all or miracle is seeking a more youthful appearance. continuity of care and keeping the that even superior dental work cannot As a prominent dental attorney advises, facts straight. Without consistent deliver. You are not obligated to take “There needs to be a meeting of the and thorough record keeping, it is on every case that comes your way. As minds about the patient’s expectations diffi cult to remember everything for one well-known esthetic dentist put and the limitations of dentistry. every patient, especially relating to it, “In one instance, my best cosmetic Communicate what you can accomplish treatment that may have happened case was one that I never started.” ■ compared to what the patient expects, several months or even years ago. and make sure the patient hears you.” Additionally, risk management For more information, call TDIC’s Document the conversation and experts always advise dentists to pay Risk Management Advice Line at include the patient’s comments and attention to any intuition they may 800.733.0634. questions. Keep consistent records have about a patient. This is especially throughout the treatment including true during an informed consent progress notes, fi ndings, patient and discussion about veneers. The desire clinician concerns, and photographs. for cosmetic procedures may be tied in Claims professionals emphasize the with complex emotions, and the patient

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214 APRIL 2015 DENTAL PRACTICE BROKERAGE Making your transition a reality.

Dr. Lee Dr. Thomas Dr. Dennis Dr. Russell Jim Kerri Mario Jaci Steve Thinh Maddox Wagner Hoover Okihara Engel McCullough Molina Hardison Caudill Tran LIC #01801165 LIC #01418359 LIC #0123804 LIC #01886221 LIC #01898522 LIC #01382259 LIC #01423762 LIC #01927713 LIC #00411157 LIC #01863784 (949) 675-5578 (916) 812-3255 (209) 605-9039 (619) 694-7077 (925) 330-2207 (949) 566-3056 (949) 675-5578 (949) 675-5578 (951) 314-5542 (949) 675-5578 25 Years in Business 40 Years in Business 36 Years in Business 33 Years in Business 42 Years in Business 35 Years in Business 35 Years in Business 26 Years in Business 25 Years in Business 11 Years in Business

PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

ANAHEIM: General Practice & Bldg. GREATER SAN JOAQUIN: Pedo N. COUNTY INLAND SAN DIEGO: SANTA ROSA: General Dentistry & 6 Ops, 3 Equipped, 3 Plumbed. Near Practice. Pano, Digital X-ray, 3 chairs. 2014 NEW LISTING! General Practice & bldg, Building. 3 Ops. 2013 GR $542K w/Adj. Disneyland. Est. 39 years. #CA186 GR approx. $700K. #CA230 IN ESCROW! 4 Ops, PPO/FFS, Digital, Pano, Cerec. GR Net $182K #CA200 over $1M. #CA216 ANAHEIM: 4 Ops, 5 add’l available, GREATER SAN JOSE: Perio Practice. SANTEE: NEW LISTING! General FFS/ SoftDent, Digital X-rays and Digital Pano. Fiscal-year GR $1.3M. 5 Ops, 2 add’l NORTHERN CALIFORNIA: Perio PPO Practice, 6 Ops, retail center, Dentrix, 2013 GR 237K. #CA207 plumbed, in same loc. 28 years. #CA219 Practice, Partnership Position. 6 Ops, 1,500 Digital, $780K GR in 2014. 7 days of hyg/ BAKERSFIELD: General Practice. 4 Ops. sq. ft. Dentrix. Owner Financing Available. week, long-term staff. #CA228 Pano. Est. 20+ Years. 2013 GR $521K. HAWAII (MAUI): PRICE REDUCED! #CA168 S. BAY AREA, SAN DIEGO: General #CA193 General Practice. 4 Ops, Approx. 1,200 sq. ft. GR $636K #20101 NORTHERN CALIFORNIA: Endo Dentistry, 3 Ops, 4 days hyg/wk. Retail BALDWIN PARK: General Practice. Practice. 3 Ops, 1 Plumbed, 1,200 sq. ft. center, Dentrix, Digital Pano, PPO & FFS. 5 Ops, 4 Equipped. 2013 GR $286K w/Adj HUNTINGTON BEACH: General 2 Microscopes, Digital. 2013 GR $319K+ Proj. GR 2014 $562K. #CA206 Net $133K. #CA176 Practice., 3 Ops. Dentrix, Digital, Laser, #CA158 IN ESCROW! S. COUNTY SAN DIEGO: General BANNING: General Practice. 6+ Ops. Intra-Oral. Est. 23 Years. #CA194 NORTHERN CALIFORNIA: Endo Practice. 3 Ops, 1,100 sq. ft. Easy Dental, Paperless, Digital, EagleSoft. 8 Days Hyg/ LA MESA: General Practice. 4 Ops. Digital w/3 Sensors. Growth Potential. 2014 Week. 2013 GR $1.5MM+. #CA183 Practice. 4 Ops, 1 Add’l Available, 1,021 sq. Dentrix, Digital, Pano. Est. 28 Years, 2013 ft. 2013 GR $337K #CA169 GR $195K #CA175 BAY AREA: Perio Practice. 2,120 sq. ft. GR $501K. #CA205 IN ESCROW! S. ORANGE COUNTY: General Practice. w/6 Ops, Digital, Endoscope, Piezosurgery, OAKLAND: General Practice. Piedmont 5 Ops. EagleSoft, Schick, Intra-Oral. 2013 Dentrix. #CA167 LA MESA: NEW LISTING! General 'LVWULFW2SVLQVKDUHGRI¿FHZVT GR $400K w/Adj. Net $136K #CA192 Practice. 4 Ops. 3 Equipped, FFS/PPO, ft. GR $453K. #CA217 BEVERLY HILLS: NEW LISTING! Dentrix, Digital. 2013 GR $342K , similar in S. ORANGE COUNTY: NEW LISTING! Small boutique practice, 2 Ops, 1 Equipped, 2014. #CA227 PLEASANTON: Facility Only, Former General Practice/Condo with 4 Ops, 3 Open Dental, Digital, 2014 GR $120K on 3 Endo Ofc, Good GP Startup. 2 Ops, 1 days/wk. #CA215 LA MESA: General Practice. 3 Ops, 2,000 equipped, newer equipment, Dentrix, Plumbed & Partially Eq. 975 sq. ft. #CA195 Digital, FFS/PPO, $192K GR. #CA229 BEVERLY HILLS: NEW LISTING! 5 sq. ft. in a Prof. Bldg. Dentrix, Laser, Ops, EagleSoft, Digital, CEREC. Long-term Digital. 2012 GR $396K w/Adj. Net. $155K PORTERVILLE: NEW LISTING! S. ORANGE COUNTY: NEW LISTING! staff, newer equipment. 2013 GR 1.2M, Adj. #CA127 IN ESCROW! General Dentistry, 6 Ops. 2014 GR $555K, Pedo Practice with 4 Ops, 1 year new 7 year old equipment, retail center. #CA223 Net of $406K. #CA210 LOS ANGELES: General Practice. 9 equipment, digital, Pano/ $236K GR with room to grow. #CA222 CAMARILLO: 4 Ops, 1-2 more available. Ops, 6 Equipped. Dentrix, Digital. Est.16 RIDGECREST: General Practice & Bldg. GR of $568K in a retail location. 34 years of Years. 2013 GR 824K w/Adj. Net $355K 4 Ops, 1,500+ sq. ft. 2012 GR $175K SOUTH BAY, LOS ANGELES: General goodwill. #CA204 IN ESCROW! #CA197IN ESCROW! #CA523 Dentistry. 3 Ops, Dentrix, Dexis, Pano, mostly FFS, 8 days hyg/week. $1.1M GR in CENTRAL COAST: NEW LISTING! LOS ANGELES: General Practice. 4 Ops, SACRAMENTO: General Practice. 7 Ops, 2013. #CA218 IN ESCROW! 6 Ops, 8 days of hygiene/wk. 2013 GR of 3 Equipped, Est. 60+ years in prof. bldg. 1 Plumbed, 2,400 sq. ft. 2013 GR $711K+. $2.3M and $804K in Adj. Net. Dentrix, 2013 GR of $824K with $355K Adj. Net. #CA182 TEMECULA: General Practice. 6 Ops. Digital, Paperless. #CA208 #CA211 EagleSoft, 14 Workstations, Digital, CHULA VISTA: General Practice. 4 Ops, SACRAMENTO: General Practice. 3 Ops, CEREC, Pano. Est. 26 Years, Long-Term 3½ Days/Hyg. Dentrix. 2012 GR $528K. MARIN COUNTY: Mill Valley 1,260 sq. 1 Plumbed, 1,250 sq. ft. 2013 GR $794K+. Staff. #CA174 IN ESCROW! #CA109 ft. 3 Ops, 1 add’l plumbed. Dentrix, Digital #CA177 X-ray, Intra-Oral. #CA224 THOUSAND OAKS: Facility Only. 4 Ops, FOLSOM: FACILITY ONLY 1,200 sq. ft. SACRAMENTO: 4 Ops, 1,177 sq. ft., 1,325 sq. ft. Dentrix, Eq. Business Ofc, w/3 Ops, digital x-rays & pano, new MENDOCINO COAST: General Practice. Digital, new Digital Pan, Dentrix & Demand Sterilization Area. Great Start-Up Location compressor #CA209 4 Ops, 2,376 sq. ft. Dentrix, CAD/CAM. Force 2013 GR $584K. #CA220 RU6DWHOOLWH2I¿FH&$ 2013 GR $1M+. #CA181 FREMONT: 6 Ops 1,760 sq. ft. w/Digital SAN BERNARDINO: General Practice. 4 TORRANCE: NEW LISTING! 3 Ops, 2 X-ray, Pano, Laser, CAD/CAM. 2013 GR N. COAST: Endo Practice. 6 Ops, 5 Ops, 30+ Years Goodwill. Dr. Is Retiring. Equipped. Est 19+ years. 2013 GR of $333K $972K #CA225 plumbed 3,300 sq. ft. Digital X-ray, GR $265K #CA150 with $176K Adj. Net. #CA213 FREMONT: 10 Ops, 3,000+ sq. ft. Digital, Microscopes, EndoVision software. #CA214 Pan. 4,000 Active Pts. PPO/HMO #CA553 SAN DIEGO: General Practice. 3 Ops. TUOLUMNE COUNTY: General Practice IN ESCROW! NEWPORT BEACH: General Practice. 3 FFS, PracticeWorks. Located in Central San & Bldg. 6 Ops, 2,000 sq. ft. 2013 GR Ops, New Equipment. 3½ Days Hyg. 2012 Diego. 2014 GR $187K. #CA161 $1MM+ #CA197 IN ESCROW! FRESNO: General Dentistry Partnership. GR $350K #CAM534 IN ESCROW! 2013 Partnership GR $4.7M. Selling Partner SAN FRANCISCO: General Dentistry. VICTORVILLE: General Practice. 3 2013 Net Inc $368K. #CA196 N.EAST BAY: PRICE REDUCED $77K! 3 Ops, 2 Equipped, 780 sq. ft. 2013 GR Ops, 3 Plumbed, 2,150 sq. ft. Est. 34 Years, General Practice + Bldg. 7 Ops. 2,324 sq. ft. SoftDent. 2013 GR $313K w/Adj. Net FRESNO: General Practice. 5 Ops, 2,000 $854K #CA191 2012 GR $885K. #CA108 $147K #CA149 sq. ft. 23 NP/ Mo. 2013 GR $789K. #CA171 SAN JOSE: Facility Only. 7 Ops, 1,400 sq. IN ESCROW! N. HOLLYWOOD: General Practice. 6 ft. Fully Equipped. #CA190 WALNUT CREEK: PRICE REDUCED! FRESNO: General Practice. 4 Ops, 1,739 Ops, 5 Equipped. Dentrix, Digital, Pano, Prosth Practice. 3 Ops, Full Lab. 2013 GR sq. ft. CEREC, 61% Overhead. 2013 GR Laser, Paperless. 2013 GR $845K. #CA187 SANTA ANA: 6 Ops, Dentrix, Dexis, Pano, $399K w/Adj. Net $143K #CAM540 $740K+. #CA202 IN ESCROW! Laser. GR just over $1M in 2013, higher in N. OF SACRAMENTO: General Practice. 2014. #CA221 WEST LOS ANGELES: NEW LISTING! GREATER LOS ANGELES: Perio 5 Ops 2,050 sq. ft. Dentrix, Intra-oral, General Practice, 4 Ops, newly built- Practice. 5 Ops. 34 Years of Goodwill. Call Digital, Pano.SOLD 2012 GR $1.2M+. #CA106 SANTA CRUZ COUNTY: General out suite, desirable high rise. 50+ years for More Information. #CA173 Dentistry. 3 Ops, 1,100 sq. ft. Schick Digital. goodwill. FFS. 2014 GR $651K. #CA226 N. ORANGE COUNTY: General Practice. Dentrix. GR $338K #CA550 GREATER SACRAMENTO: General 7 Ops, 6 Equipped, 2,700 sq. ft. 3 Day WEST HOLLYWOOD: General Practice, Practice. 7 Ops, 3,079 sq. ft. (Shared w/2nd Work Week. GR $601K w/Adj. Net $244K SANTA MARIA: General Dentistry. 4 Ops, 4 Ops, Mediadent, Intra-Oral Camera, DDS – Separate Practices), 2013 GR $974K. #CA189 1,500 sq. ft. 2013 GR $523K #CA166 Digital, Laser, 5 yr old equip. 2014 GR of #CA140 $613K . #CA212

NORTHERN CALIFORNIA OFFICE NEW SOUTHERN CALIFORNIA OFFICE 1.800.519.3458 www.henryscheinppt.com 1.888.685.8100 Henry Schein Corporate Broker #01230466 “Matching the Right Dentist CARROLL to the Right Practice” &COMPANY CComplete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4064 SANTA CLARA COUNTY DENTAL FACILITY Ample, modern 1,743 sq. ft. general dental facility w/5 fully-equipped ops including state-of-the-art equipment. Located in office complex close to AMD, National Semi, Intel, Applied Material and just seconds from freeways and expressway systems in the heart of Silicon Valley. Lease expires 2018 w/5 year option to renew. Asking $125K. 4070 SAN JOSE GP Beautiful, modern practice established in ideal downtown location. Ez freeway access from Hwys: 101, 880 and 237. Major employers in the immediate area include Cisco, Intel, EBay and Mike Carroll & Pamela Carroll-Gardiner Samsung. Well-designed 1,950 square foot dental office includesPENDING 6 fully equipped ops. Office has 4043 SANTA ROSA GP street front visibility in lovely renovated building Well-established, well respected general dental on a well-traveled street. 750-800 active patients practice located within a lovely professional center with approx. 10 new patients/mo. Last 2 years in the heart of town.

Beautifully landscaped GRs average $377K, with average adj. net of grounds with ample parking, Condo is also $132K. Asking $286K. available for purchase.
Owner/doctor
works 3.5 4051 CENTRAL COAST PROSTHO days a week with 3.5 days of hygiene.


Gross Well-established practice located in California’s receipts average $750-$800K every year with an gorgeous Central Coast area. Beautifully adjstd net of almost $300K.

Seller is willing to appointed, spacious 1,568 sq.ft. office with 4 fully assist Buyer for a smooth transition.

Asking price equipped ops, pros lab and other amenities. for practice only $500K. Situated just minutes from the ocean and <5 4058 SAN FRANCISCO GP miles away from one of California’s historic Sunset neighborhood practice offering 35+ years Mission Cities, this practice is nestled in a highly of goodwill; located on a well-travelled corner, desirable community. 2013 gross receipts were with clearly visible signage. 2014 annualized gross $1.2M+ and 2014 is annualized at $1.3M+ on a 4 receipts SOLD$670K with adjusted net of day doctor workweek, w/4 days of hygiene/week. approximately $210K. Seller relocating out-of- Approx. 15 new patients a month and ~1,500 state, but willing to help for smooth transition. active patients (all fee-for-service). Owner/doctor Asking $515K. is willing to help Buyer for smooth transition. 4063 CENTRAL CONTRA COSTA COUNTY 4054 MID-PENINSULA ORTHO GP This established orthodontic practice is located in desirable centrally located area with a solid Carroll & Company Excellent opportunity with high net profits. 3 fully economic base, numerous amenities & diverse 2055 Woodside Road, Ste 160 equipped ops. in 810 sq. ft. facility. Same location residents. TheSOLD office is state-of-the-art with 5 Redwood City, CA 94061 approx. 40 years. Recently upgraded cabinetry. SOLD (open bay) ops in approximately 1,600 sq. ft. Both Major equipment includes digital x-ray, inter-oral practice and building are for sale. Asking $591K Phone: camera, Diagnodent & Dexis. 4 year avg. Gross practice, $937K building. 650.403.1010 Receipts $809K+. Seller retiring. Asking $617K. 4060 SANTA CRUZ COUNTY GP UPCOMING: Email: Est. practice w/approx. 1,000 active pts. in a 3 op [email protected] 1,070 sq. ft. facility in modern prof. bldg. 4 year • MARIN COUNTY GP avg. GR approx.SOLD $430K+. Seller retiring. Great • SAN JOAQUIN COUNTY GP Website: upside to this practice. Asking $310K. • SANTA CLARA COUNTY PERIO (2) www.carrollandco.info • SANTA CLARA COUNTY GP CA DRE #00777682 Regulatory Compliance CDA JOURNAL, VOL 43, Nº4

Reasons to Read Employment Posters CDA Practice Support

ater this month, local dental societies facial hair or body hair, which are ■ Overtime — Overtime pay is will distribute an updated set of part of an individual’s observance required for nonexempt employees employment posters to members. of his or her religious beliefs. who work more than eight hours Although few changes were made ■ Retaining employment applications in a day or 40 hours in a week. A and one new poster (sick leave) and records of potential candidates description of the categories of Lwas added to the poster set, employers for two years (CDA recommends employees exempt from overtime should make themselves familiar with all retaining employment applications pay is included in the poster. its contents. The content of these posters of hired individuals for four years). ■ Alternative workweek — The poster set employees’ expectations of employer has the rules and election procedures responsibilities. Below are summaries Industrial Welfare Commission Order for establishing an alternative of a few of the included posters. No. 4-2001 — Regulating Wages, workweek schedule. The results of Hours and Working Conditions in any election must be reported to the Safety and Health Protection on the Professional, Technical, Clerical, state within 30 days of fi nal results. the Job Mechanical and Similar Occupations ■ Reporting time pay — An employer Addresses and telephone numbers of This poster was revised to update the is required to pay no less than two Cal/OSHA offi ces throughout the state name of a state offi ce. Otherwise, the rules hours of an employee’s regular rate were updated on this poster. The poster remain the same as they were two years ago. of pay if an employee is required to summarizes what an employer must do in general for workplace safety and describes employees’ rights and responsibilities. The poster mentions the requirement for written plans for injury and illness prevention and for hazard communication. Information on violations, citations and penalties, as well as on compliance assistance through Cal/OSHA consultation, is included on the poster.

California Law Prohibits Workplace Discrimination and Harassment The state enforces laws that protect an employee, job applicant or independent contractor from discrimination and harassment based on any of 13 different categories, such as age or religion, that may be attributed to the employee whether actual or perceived. The poster summarizes these laws, including: ■ Prohibiting employers from limiting or prohibiting the use of any language in any workplace unless justifi ed by business necessity. ■ Requiring employers to reasonably accommodate an employee or job applicant’s religious beliefs and practices, including the wearing or carrying of religious clothing, jewelry or artifacts, and hairstyles,

APRIL 2015 217 APRIL 2015 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 43, Nº4

report to work on a day but is not put to work or works less than half the time scheduled. Exceptions to this rule are described in the poster. ■ Uniforms and equipment — If an employer requires employees wear uniforms (defi ned in the poster; not the same as personal protective Paul Maimone Broker/Owner equipment) or to use tools or VISIT US @ THE CDA CONVENTION equipment at work, the employer IN ANAHEIM BOOTH #359 shall provide and maintain them. ■ Meal and rest periods — These are required for any BAKERSFIELD #29 - (4) op comput G.P. (3) ops eqt’d, (1) add. plumbed. Located in a free stand bldg. Cash/Ins/PPO. Digital x-rays. Annual Gross Collect $300K+ p.t. Seller moving. NEW employee who works a set CANOGA PARK - (5) op comput. G.P. (4) ops eqt’d. Digital x-rays. Located in a strip ctr. w number of hours in a day. excellent exposure, visibility, & signage. 2014 Gross Collections of ~ $250K+ on a (4) day wk. Cash/Ins/PPO pts. In a Denti-Cal area. Can add & easily double or more. SOLD EAST VENTURA COUNTY #2 - Free Standing Bldg. & (3) op comput. G.P. Annual Gross DBC Dental Auxiliary Duties Collect of $560K+. Cash/Ins/PPO/HMO pt. base. Mos. Cap. Ck. of $2K+. (28+) new pts./mos. The poster is updated to add to the ENCINO – (3) op comput G.P. located in a prof bldg. on a main thoroughfare. Annual Gross chart interim therapeutic restoration Collect $165K+ p.t. Cash/Ins/PPO. Below market Lease. Great Starter or Satellite. Seller retiring. LANCASTER – (5) op comput. G.P. & Single Use Bldg. Be your own Landlord. (3) ops eqt’d (ITR) placed by a telehealth-connected (2) add plumbed. Located in a free stand bldg. on a main thoroughfare. Cash/Ins/PPO pts. Gross public health dental team. In addition, Collect $300K+ on a (2) day wk. Digital. Total payment $4K/mos w $30K down. WOW! LA VERNE – (7) op comput. G.P. (3) ops eqt’d (4) add plumbed. Located in a busy shop. ctr. w Business & Professions Code sections exposure/visibility & signage. Cash/Ins/PPO. Digital X-rays. 2014 Gross Collect ~ $390K. 1910.5 and 1926.05 were added to the PASADENA – Nearly New Turnkey Offi ce w some charts. Newer eqt. Gorgeous! registered dental hygienists’ scope of RANCHO CUCAMONGA - (4) op comput. G.P. in a strip ctr. w visibility. (3) ops eqt’d (4th) op plumbed. Annual Gross Collect $185K+ on 2.5 days/wk. Cash/Ins/PPO pts. Seller moving. practice. The chart can be consulted SHERMAN OAKS – (3) op comput G.P. in a well known, easily accessible Med/Dental bldg. to determine if an auxiliary duty is Cash/Ins/PPO. Annual Gross Collect $180K+ p.t. Great Starter or Satellite. Seller retiring. allowed and whether it is duty that SIMI VALLEY #4 - (4) op comput. G.P. w digital x-rays. Located in a busy strip. ctr. w exposure/visibility/signage. Cash/Ins/PPO pts. Annual Gross Collect approx. $600K. is to be performed under general So. KERN COUNTY – (6) op comput. G.P. located in a Bakersfi eld suburb in a small strip ctr. w supervision or direct supervision, exposure/visibility. Pano eqt’d. Limited competition. Cash/Ins/PPO pts. Annual Gross Collect. or if the supervising dentist can Approx. $350K p.t. Seller is moving and is motivated. NEW SANTA ANA - absentee owned (6) op fully eqt’d G.P. First fl oor street front location on a main determine the level of supervision. ■ thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqt’d & Computerized. 2014 Gross Collect. of $549K+ on a (3½) to (4) day Associate run week. NEW Regulatory Compliance appears monthly TUSTIN - (4) op comput. G.P. (3) eqt’d/4th plumbed. Located in a busy shop ctr. on a main thoroughfare. Exposure, visibility & signage. Digital x-rays & CEREC. Annual Gross Collect and features resources about laws and $460K+ on an easy 4½ day week. Cash/Ins/PPO. No Denti-Cal or HMO. Growth potential. NEW regulations that impact dental practices. Visit WEST SAN FERNANDO VALLEY - (4) op comput. G.P. w modern equipt. Located in a smaller prof. bldg. on a main thoroughfare. Cash/Ins/PPO pts. Annual Gross Collect $750K+ on a cda.org/practicesupport for more than 600 (4) day week. Excell. long term lease, outstanding signage, & great off street parking. SOLD practice support resources, including practice UPCOMING PRACTICES: Arcadia, Beverly Hills, Covina, Monterey Park, Montebello, Oxnard, Pomona, San Gabriel, SFV, Temecula, Thousand Oaks, Torrance, Visalia & Valencia. management, employment practices, dental D & M SERVICES: benefi t plans and regulatory compliance. ■ Practice Sales & Appraisals ■ Practice Search & Matching Services ■ Practice & Equipment Financing ■ Locate & Negotiate Dental Lease Space ■ Expert Witness Court Testimony ■ Medical/Dental Bldg. Sales & Leasing ■ Pre - Death and Disability Planning ■ Pre - Sale Planning P.O. Box #6681, WOODLAND HILLS, CA. 91365 Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com Serving CA Since 1994 CA BRE Broker License # 01172430

CA Representative for the National Associaton of Practice Brokers (NAPB)

218 APRIL 2015 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Selling or Buying, Call PPS today! Visit us at CDA Booth #1157 NORTHERNNORT RN CALIFORNICALIFORNIAA SOUTHERNSOUTHERN CALIFORNIACALIF (415) 899-8580 – (800) 422-2818 (714)( ) 832-0230 832 0230 – (800) (800 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6081 SANTA CLARA El Camino Real location. 2014 collected ANAHEIM HILLS Group member wanted. Hi identity. GP has $687,000 on 24-hour week. Available Profits of $305,000. 3-days of space to share with Specialist. Pedo, Ortho? Hygiene. 5-ops in 1,700 sq.ft. BAKERSFIELD AREA Small town. 4-op practice with building. 6080 PLEASANTON - DUBLIN AREA 8+ days of Hygiene. Full price $350,000 includes real estate. Renovations make $450,000 invested in 6-op office. Consistent $900,000+ per year property look new. performer. Attractive transition arrangements available. CLAREMONT-UPLAND Gross $500,000+. Refers $250,000 in 6079 BERKELEY’S ALTA BATES MEDICAL VILLAGE Strong Ortho, OS, Endo. Hi identity. Seller can work back if acquired by performer on Owner’s 24 hour week. 2014 collected $676,500. Patient Specialist. foundation anchored by 4-days of Hygiene. Endo and OS referred. DENTURE PRACTICE Sees 30 patients per day. Perfect for Renowned Medical Village has regional draw. Implant Specialist. 6078 FRESNO Strip center practice on West Shaw Avenue. 2014’s HMO Two practices grossing $4.15 Million. $33,000/month in Collections totaled $383,000 with Profits of $192,000. Practice will cap checks. Call Tom Fitterer at 714-832-0230. do better with Successor who devotes full attention here. 4-ops. HUNTINGTON PARK Hi identity. 65,000 autos/day. 3 ops. Full Price $245,000. Full Price $175,000. Will be Goldmine 6077 PERIO PRACTICE – SAN FRANCISCO’S NORTH BAY IRVINE Low overhead. Established 1981. Grossing $320,000 and Highly regarded and located in desirable family area. On 3.5 day nets 50%. Great Lease. 3 days of Hygiene. Seller refers a lot of work. week, revenues were $1 Million in 2014 with profits of $400,000. Beautiful facility with 4-ops. IRVINE Quality, low overhead practice. 4-ops. Cash, Indemnity & 1 PPO. Gross $300,000 with 50% profit. Great Lease. Full 6076 FREMONT Store front on Fremont Boulevard. Great signage. price $265,000. Beautiful digital & paperless office. 3-ops with 2 more available. Collected $243,000 on limited schedule with Profits of $104,000 in LA JOLLA - HMO $4,000/month in cap checks could be $6,000 2014. Full time Successor shall do well. soon. Beautiful 3-op office. Experienced HMO DDS can take to $500,000 first year. Adec chairs & Hawaiian décor. 1,300 sq.ft. 6075 MONTEREY BAY AREA Digital, paperless and well office leases for $2,500 NNN. Three 3-year Options. Great staff. positioned for future. 2014 collected $1.47 Million with Profits of Full Price $150,000. $690,000. 7+ days of Hygiene. Extremely unique opportunity. LAKE FOREST 7 ops located across street from major employer 6074 FREMONT 2014 collected $643,000. 4 day Hygiene schedule in Orange County. booked 6-months out. Beautiful office. Full Price $325,000. REDLANDS 5-ops with low overhead. Grosses $30,000 per 6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS month. Great Lease at $1.00 sq.ft. Full price $285,000. focuses on restorative. Endo, OS, Perio & Pedo referred. 2014 collected $450,000. Beautiful 4 op office. Full price $175,000. RIVERSIDE HMO grossing $850,000. Low overhead. Established 20-years. 9-ops in 3,000 sq.ft. $1.5 Million potential. 6070 VISALIA Strong foundation and well-positioned for ambitious successor. Strong Hygiene Department, beautiful facility, well SAN DIMAS HMO Hi identity center. Seller refers a lot. equipped. Digital throughout. Not a Delta Premiere practice. $8,000/mth cap checks. Lots of work referred. 6068 KINGSBURG Great family community south of Fresno. Owner SAN FERNANDO VALLEY Shopping center practice grossing works relaxed schedule doing restorative dentistry. Endo & OS $550,000. Call 714-832-0230. referred. 2014 collected $250,000+. Strong Profits. 3 Ops. Full price SOUTH ORANGE COUNTY Prestigious Plaza. Modern 1,450 $135,000. sq.ft. Will be $1.5 Million in 3 years. 6067 MONTEREY - ADVANCED RESTORATIVE PRACTICE SOUTH ORANGE COUNTY Grossed $950,000 in 2013. Strong foundation for DDS desiring quality restorative practice. Gorgeous 5 ops. Full Price $775,000. $310,000 invested here. Digital and paperless. 2014 collected SOUTHERN CALIFORNIA HMO Practice grosses $400,000. "Out-of-network” practice. Considerable transition $4,150,000. Prestigious hi identity. assistance available. Full price $185,000. TEMECULA Partnership leading to ownership. 6065 SAN LEANDRO 2014 collected $438,000 on part-time TORRANCE/GARDENA Established 31-years. Chinese DDS schedule. Attractive 3 Op office with tranquil views of garden setting. retiring. Very profitable. Grosses $200,000. Lots referred out. Digital radiography includes Panorex. VISALIA Performing at enviable levels. Strong Hygiene Department, beautiful facility, well equipped. Digital throughout. **FOUNDERS OF PRACTICE SALES** 120+ years of combined expertise and experience! Well positioned for future. Phone 415-899-8580. 3,000+ Sales - - 10,000+ Appraisals WEST LA Grosses $1.2 Million. Seeks Korean Lady DDS for **CONFIDENTIAL** specialty team. Quality office. PPS Representatives do not give our business name when returning your calls. 800.641.4179 [email protected] WESTERNPRACTICESALES.COM

BAY AREA NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

AC-335 SAN FRANCISCO: Two great practices for the price of one! Call for Info!! EG-363 WEST SACRAMENTO: Top of the Line Pelton Crane and Adec. 3,008 sf & HN-213 ALTURAS: AG-357 SAN FRANCISCO: 450 Sutter! 1,300 sf w/4 ops! Breath-Taking City 10 ops! $600k $115k Views! REDUCED! $295k EG-376 AUBURN: Fantasc Locaon, unprecedented exposure, well-respected. HN-280 NORTHEASTERN CA: AG-053: 3,000 sf w/ 9 ops + 1 add’l. PRIME LOCATION! $595k 2,700 sf w/ 4 + ops $625k $110k BG-362 HAYWARD: Practice AND Real Estate Available! 1,800sf w/ 4 ops! Call EN-340 SACRAMENTO: Large HMO pracce! 3,400 sf w/ 10 ops and Plumbed HN-290 PLACERVILLE: Excellent Merger Op! for Details! for 1 add’l $950k $210k BN-183 HAYWARD: Kick it up a notch by increasing the current very relaxed EN-350 SACRAMENTO: The Perfect Merger Opportunity! Old-fashioned values work schedule! 1,300 sf w/ 3 ops $150k and philosophy! 674 sf w/ 1 op. $85k CENTRAL VALLEY BN-279 CONTRA COSTA COUNTY: Excellent Merger Opportunity! 2-story. 1,350 EN-378 LINCOLN: quality pracce with a wonderful paent base! 1,369 sf w/ 2 sf w/ 3 ops +1 add’l $60k op + 3 add’l. $170k IG-067 STOCKTON: BC-365 CENTRAL CONTRA COSTA: dedicated to restorave & cosmec dens- EN-379 ROSEVILLE: An amazing opportunity in the locaon of your dreams! Steal of the Century! Now ONLY $240k try. 1,757 sf w/ 4 ops. $550k 1,040 sf w/ 3ops. $295k IG-356 MODESTO AREA: Priced at Only 52% of Collecons! BC-361 OAKLAND: Established for over 23+ years! 2,200 sf w/ 7 ops. $430k EN-392 SACRAMENTO: Locaon, excellent exposure & extremely low over- Now Only $395k BC-381 PLEASANT HILL Facility: Open Floor Plan! 1,852 sf w/ 6 equipped ops! head! 1,000 sf w/ 3ops. $125k IG-367 MERCED: RE- Move in Ready! $80k EN-391 SACRAMENTO: Opportunies like this one are “few and far between”! DUCED! $325k CC-390 SOLANO COUNTY: Near Travis AFB! Highly visible location! 950 sf w/ 1,200 sf w/ 4ops. $310k IN-297 MODESTO: 3 ops $200k FG-309 ARCATA: Priced at only 33% of collections! 656 sf w/ 2 ops $95k! PR: $475k / RE : $425k CG-355 NAPA: Looking for Experienced, High-End General Dentist. Collec- FN-181 NORTH COAST: Well respected FFS GP. Stable patient base. 1,000 sf IN-345 MODESTO: tions ~ $1m $725k w/3 ops $150k (25% int. in bldg. avail.) $495k CG-366 SONOMA CO.: Vibrant, growing community! 1,300+ sf w/ 4 ops. Over FN-299 FERNDALE: Live and practice on the beautiful North Coast! 1,300 sf IN-358 MODESTO: $760k in collections! $480k w/ 3 ops $225k (Real Estate: $309k) $350k CN-344 N. SONOMA CO: Long-established, stellar reputaon! 2560 sf, w/ 6 FC-334 NORTHERN CA: Emphasis on prevenon. 1,200 sf w/ 4 ops $480k / JN-295 VISALIA: PR: $185k ops $925k Real Estate Also Available! RE: $300k CC-369 SAN RAFAEL: Perfect starter pracce opportunity! 900 sf w/ 3 ops. FC-343 NORTHERN CA: Quality & locaon are the keys to success! 1,200 sf w/ 3 JC-349 FRESNO $350k ops + 1 add’l & 1 hyg. Op. $500k (Real Estate $375k) Call for Details! DC-287 DUBLIN Facility: Space Share Facility with OS. 2ops + 1 add’l, 1100 sf GG-320 CHICO: Large, Unique, Originally designed for more than 1 dds! 5,000 sf JN-382 FRESNO: $125k w/ 7 ops (+2 add’l) $985k DC-370 SAN JOSE Facility: Available with or without patient charts! Move in GG-386 REDDING: Practice & Real Estate! 2,860 sf w/ 4 ops. Plumbed for 2 Ready! Call for Details! add’l! $360k and $660k SPECIALTY PRACTICES DG-124 MILPITAS: Highly visible. Desirable area. 960 sf w/ 2 ops + 1 add’l GN-201 CHICO: Beautiful practice, major thoroughfare, stellar reputation! $130k 1,400 sf w/ 4 ops & room for another $425k CG-375 WINE COUNTRY Prostho: DG-351 PLEASANTON Facility: Very Appealing and Desirable! 1,000 sf w/ 3 GN-244 OROVILLE: Must See! Gorgeous, Spacious. 2,500 sf w/5 ops! Collec- $725k ops. Now Only: $74k tions over $450k in 2013. Only $315k I-7861 CENTRAL VALLEY Ortho: DG-394 LOS GATOS: Highest Quality of Dentistry! Decades of Goodwill! 850 sf w/ GN-258 REDDING: Prisne and aracve! Conveniently located! 1,050 sf w/ 2 $370k 3 ops ONLY $280k ops. $215k I-9461 CENTRAL VALLEY Ortho: DN-311 PLEASANTON Facility: Three Months’ Rent Free! 870 sf w/ 3 ops + 1 GN-324 YUBA CITY Facility: Newly updated! 1,704 sf w/ 4 ops, Movated Sell- $180k add’l. NOW ONLY: $75k er! $75k EN-203 SACRAMENTO Oral Surgery: DN-312 LIVERMORE Facility: Don’t miss out on this one! 1,070 sf w/ 3 ops. RE- GN-354 YUBA CITY: Well-established pracce and building! 2670 sf w / 6 ONLY $235k DUCED! $75k ops + 1 add’l $325k (Real Estate: $450k) DG-264 SAN JOSE Ortho: DN-353 ALAMEDA: Fantasc Opportunity with view of the estuary 2,060 sf w/ 5 GN-387 CHICO: Streamlined overhead and reasonable rent. 1,000 sf w/ 3 REDUCED! $245k ops. Now Only: $750k ops. $235k GN-304 NORTHERN SACRAMENTO Pedo: DN-388 WATSONVILLE: Locaon, Locaon, Locaon! 2,393 sf w/ 4 ops + 4 add’l.. HG-298 REDDING FOOTHILLS: HEALTH FORCES SALE! Includes Cerec! 2,000 sf $595k $195k w/ 5 ops Pracce $100k / Real Estate $250k AC-325 SF Endo: Call for details! BC-336 CONTRA COSTA CO Perio: Call for Details! What separates us from other brokerage firms? CC-346 SO MARIN CO Perio: $270k As densts and business professionals, we understand the unique aspects of dental pracce sales and offer more praccal knowledge than any other brokerage firm. We bring a crical inside perspecve to the table when dealing with buyers and sellers by understanding the different complexies, personalies, strengths and weaknesses of one pracce over another.

Our extensive buyer database and unsurpassed exposure allows us to offer you a … Beer Candidate Beer Fit Beer Price!

ASK THE BROKER

“That was easy, Doctor.”

BAY AREA NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED Debra was my last patient of the morning. We just finished prepping a couple of crowns, taking impressions, and making temporaries. She was right, it was AC-335 SAN FRANCISCO: EG-363 WEST SACRAMENTO: HN-213 ALTURAS: Close to Oregon Border. FFS practice is 2,200 sf easy. At this point in my career it should be easy. Like most the procedures I AG-357 SAN FRANCISCO: $600k w/ 3ops +1 add’l $115k do daily, I have repeated them thousands of times. Debra wasn’t there for all REDUCED! $295k EG-376 AUBURN: HN-280 NORTHEASTERN CA: “Only Practice in Town” 900 sf w/ 2 ops of the previous procedures, nor was she there for the hundreds of hours of AG-053: $595k $625k $110k Continuing Education that made it easy for her today. BG-362 HAYWARD: Call EN-340 SACRAMENTO HN-290 PLACERVILLE: Excellent Merger Op! Embrace the lifestyle for Details! $950k and build your success story here! FFS. 1,400 sf w/ 4 ops $210k We hone our skills through the years, making even the most difficult BN-183 HAYWARD: Kick it up a notch by increasing the current very relaxed EN-350 SACRAMENTO: The Perfect Merger Opportunity! procedure appear easy. We also assess the patient and procedure to minimize work schedule! $150k $85k CENTRAL VALLEY the possibility of exceeding our professional limitations. The most successful BN-279 CONTRA COSTA COUNTY EN-378 LINCOLN practitioners realize it is better for both the patient and doctor to refer out some $60k $170k IG-067 STOCKTON: Fully computerized, paperless, digital. 5,000 sf procedures to others with more expertise. Throughout our careers, we seek the BC-365 CENTRAL CONTRA COSTA: EN-379 ROSEVILLE w/10 ops Steal of the Century! Now ONLY $240k $550k $295k IG-356 MODESTO AREA: Priced at Only 52% of Collecons! Succeed advice of mentors with skill and experience (Pankey, Spear, Kois, Pride…). BC-361 OAKLAND: $430k EN-392 SACRAMENTO: beyond your dreams! 1,600 sf w/ 4 ops. Now Only $395k BC-381 PLEASANT HILL Facility: $125k IG-367 MERCED: Newly Remodeled, Paperless. 1,550 sf w/4 ops RE- Similar preparation is necessary as you plan for retirement and the transition of $80k EN-391 SACRAMENTO: DUCED! $325k your practice. Now that your professional and financial goals are met, which CC-390 SOLANO COUNTY: $310k IN-297 MODESTO: Prisne, contemporarily designed medical/prof ctr. experts will you turn to assist in transitioning you into retirement? Who will $200k FG-309 ARCATA: $95k! 1,980 sf w/ 4 ops. PR: $475k / RE : $425k make it easy on you? CG-355 NAPA: FN-181 NORTH COAST: IN-345 MODESTO: Long-standing tradion of quality care. 3016 sf w/ I've met with doctors that have started down the road to transitioning their $725k $150k (25% int. in bldg. avail.) 5ops + 1 add’l. $495k practices on their own. While some are successful, I have assisted many CG-366 SONOMA CO.: FN-299 FERNDALE: IN-358 MODESTO: Pracce nets over 50%! 1,200 sf, 3 ops+1 add’l. doctors in the eleventh hour of a chaotic sale and even more who hit road $480k $225k (Real Estate: $309k) $350k blocks resulting in failed transitions. After interviewing the doctors, I realize CN-344 N. SONOMA CO: FC-334 NORTHERN CA: $480k JN-295 VISALIA: Practice & Real Estate 2,000 sf w/ 5 ops PR: $185k many of these transitions would have been much easier and transitions could $925k Real Estate Also Available! RE: $300k have been saved with sound advice from an experienced broker. CC-369 SAN RAFAEL: FC-343 NORTHERN CA: JC-349 FRESNO: Well Respected Specialty Pracce limited to Dental $350k $500k (Real Estate $375k) Sleep Medicine. Call for Details! I recently met with a very successful doctor who “sold” his practice. DC-287 DUBLIN Facility: GG-320 CHICO: JN-382 FRESNO: Successful and highly profitable! 2,452 sf w/ 5 ops. Everything seemed to be ready: there was agreement on price and conditions, $125k $985k $425k date of sale was set, the contract was signed, the doctor had his retirement DC-370 SAN JOSE Facility: GG-386 REDDING: party! However, the sale fell apart for reasons that an experienced broker Call for Details! $360k and $660k SPECIALTY PRACTICES probably could have mitigated, and the buyer has since moved on and DG-124 MILPITAS: GN-201 CHICO: purchased another practice. This sale could have been saved by a few $130k $425k CG-375 WINE COUNTRY Prostho: Call for Details! Collections ~ $1m seemingly easy steps that an experienced broker had learned from performing DG-351 PLEASANTON Facility: GN-244 OROVILLE: $725k similar procedures on many previous occasions. Now Only: $74k Only $315k I-7861 CENTRAL VALLEY Ortho: 2,000 sf, open bay w/ 8 chairs. Fee-

DG-394 LOS GATOS: GN-258 REDDING: for-Service. $370k ONLY $280k $215k I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5 chairs/bays & plumbed The best way to minimize the chance of a tumultuous sale is to start by listing DN-311 PLEASANTON Facility: GN-324 YUBA CITY Facility: Movated Sell- for 2 add’l $180k with a seasoned broker who has a great team backing them up. There is no NOW ONLY: $75k er! $75k EN-203 SACRAMENTO Oral Surgery: Highly efficient. 3,000 sf w/ 4 substitute for experience, someone who has been down the road dozens of DN-312 LIVERMORE Facility: RE- GN-354 YUBA CITY: ops ONLY $235k times and knows where potential potholes lie and how to avoid them before DUCED! $75k $325k (Real Estate: $450k) DG-264 SAN JOSE Ortho: $300-400k in build-outs alone! 1800 sf w/ the sale gets derailed. The process may appear easy, but the seller and buyer DN-353 ALAMEDA: 5 chairs. REDUCED! $245k generally remain unaware of many backroom issues that are resolved before Now Only: $750k GN-304 NORTHERN SACRAMENTO Pedo: Well established, highly they impede the transition of the practice. Every sale is different, with its own DN-388 WATSONVILLE: Locaon, Locaon, Locaon! . HG-298 REDDING FOOTHILLS: HEALTH FORCES SALE! esteemed. 1,800 sf w/ 4 ops $595k unique set of pitfalls, just like every treatment plan has its own unique set of $195k Pracce $100k / Real Estate $250k AC-325 SF Endo: Assoc/ Buy-in Opportunity in upscale SF locaon. issues. Free parking. TDO. Dexis. Central nitrous. Call for details! BC-336 CONTRA COSTA CO Perio: 1,440sf, 4 ops +1 Great Location! Call for Details! This is an excerpt of a longer article recently written by Eric What separates us from other brokerage firms? CC-346 SO MARIN CO Perio: 1,142 sf w/ 3 ops. Meticulously main- Stavoe, DDS, our representative in Arizona. This excerpt has been

tained! $270k used with his permission.

We are a proud member of: Our extensive buyer database and unsurpassed exposure allows us to offer you a … Timothy G. Giroux, DDS is currently the Owner & Broker at Western Practice Sales and a member of the nationally recognized dental organization, ADS Transitions. Beer Candidate Beer Fit Beer Price! You may contact Dr Giroux at: [email protected] or 800.641.4179 Tech Trends CDA JOURNAL, VOL 43, Nº4

A look into the latest dental and general technology on the market

Increase in Large Purchases on Reuters TV (Thomson Reuters, Free) Mobile Devices Reuters TV is a new app for the iPhone that customizes online news video content and live feeds. This app is designed for users who More people are making large fi nancial purchases on their want a digest of daily news that is both interesting and respectful phones, according to a new study. Conducted by Bankrate, the of the amount of time a user has to watch the news. The app is study found that 58 percent of respondents between the ages completely free to use for the fi rst month. After the free month has of 30 and 49 indicated they have made a large purchase over ended, the app requires a $1.99 per month subscription as an their mobile devices at least once, the highest percentage of in-app purchase. Users select the time they have on the top of the any of the age groups surveyed. And close to half of those who main screen from 5 to 30 minutes. Once the available time has been use the Internet on their mobile devices have “made a major selected, the app customizes a series of online news video content fi nancial commitment” on a mobile device. “Major fi nancial that brings all pertinent local, national and world news together in a commitment” can be defi ned as purchases such as mortgages, personalized broadcast format. There are occasional nonintrusive, cars or stocks. Older age groups (65 and older) are less likely to short advertisements between some segments. Users who have limited make such purchases on their mobile devices — the study found cellular data plans or poor signal coverage can download offl ine that more than six in 10 in that age group have not. Millennials content for later viewing by tapping the download button on the upper ages 18 to 29 weren’t that much more likely than any other age right corner of the main screen. The app constantly learns users’ news group to have purchased stock, insurance or another major item preferences to deliver meaningful content. During any personalized on a mobile device, according to the study. Along these lines, broadcast, users can skip news segments that are uninteresting to cellphones continue to be a way for dentists to connect with them by swiping horizontally across the screen. As users continue to patients, with a recent study by Software Advice fi nding that 58 dismiss certain segments, future customized broadcasts become further percent of patients prefer appointment reminders through text catered to their interests. Users can also view Reuters live news video message or email. feeds on the app by swiping to the right on the main screen. Current — Blake Ellington, Tech Trends editor and future scheduled live content can be selected for viewing. — Hubert Chan, DDS SNL (NBCUniversal Media LLC, Free) Saturday Night Live turned 40 this year and as part of that Frequent Social Media Use Doesn’t accomplishment, the show rolled out a new app that off ers fans access to thousands of sketches from the entire show’s existence. Cause Stress When the app opens, users are greeted with the colorful cityscape Much has been made about overuse of social media being shots of New York City that are featured in the show’s opening damaging to someone’s state of mind, particularly when it comes segment. From there, the most recent episodes from that week’s to stress. But the Pew Research Center recently conducted a show appear. Users can scroll through them with a simple swipe to study that found frequent Internet and social media users do not the left. At the bottom of the home screen, select “Explore” to search have higher levels of stress. The study, which involved 1,801 by season or cast member. Each cast member in a given season participants, specifi cally found that women “who use Twitter, email has his or her own photo, which allows the user to narrow down and cellphone picture sharing report lower levels of stress.” Pew skits performed by that person. The top right of the app features a admits, however, “that the data show there are circumstances drop-down button where users can select from “favorites,” get full under which the social use of digital technology increases episodes, download an SNL emoji keyboard and get SNL “exclusive awareness of stressful events in the lives of others.” video.” Fans of the show will enjoy the ease in which the app lets — Blake Ellington, Tech Trends editor them fi nd that one skit they have been telling everyone about.

— Blake Ellington, Tech Trends editor This symbol indicates additional video content in the e-pub version of the Journal.

222 APRIL 2015 Your convention.Your hands-on experience.

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