DT U.S.

‘Oral tissue contains a kind of powerful stem cell’ / ‘Your Spitting Image’ Web site / News / Weak economy increases employee theft / Complete maxillary implant prosthodontic rehabilitation with a CAD/CAM-fixed prosthesis / Products / Industry News / COSMETIC TRIBUNE 1/2010

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DENTAL TRIBUNE
The World’s Dental Newspaper · U.S. Edition

January 2010

www.dental-tribune.com

IMPLANT TRIBUNE
The World’s Implant Newspaper · U.S. Edition

The World’s Endodontic Newspaper · U.S. Edition

Endodontic implant algorithm

Facing the facts

Dental CBCT vs. medical CT scans.

ENDO TRIBUNE

u page 1B

Help for the decision-making process.

u page 1C

Vol. 5, No. 1

CHosmetiC
RiBUNe
YGIENE TtRIBUNE
the
Dentistry
Newspaper
· U.s.
edition
TheWorld’s
World’sCosmetic
Dental Hygiene
Newspaper
· U.S.
Edition

Immediate restoration

Central incisors with past trauma are common.

upage 1D

‘Oral tissue contains a kind of
powerful stem cell’
Tissue engineering is based on
the concept that the human body, or
parts of it, can be regenerated using
stem cells. Since the 1980s, several types of tissue and organs have
been generated worldwide using
cultured living cells.
Dental Tribune Asia Pacific, in
cooperation with FDI’s Worldental
Daily, spoke with Dr. Minoru Ueda
from Nagoya University in Japan
about key tissue-engineering strategies and their potential for dentistry.
Dr. Ueda, tissue engineering is a
relatively new approach in regen-

erative medicine. How did it find
its way into dentistry?
The basic concepts and strategies
for tissue regeneration are general.
To regenerate any tissue, we need
stem cells, growth factors and a
scaffold.
In the field of dentistry, we have
made much scientific progress in
terms of materials, which gives us
an advantage over other fields of
medicine. We began with developing high-quality materials and then
expanded to using stem cells.
What are the key tissue-engineer-

Complete maxillary implant prosthodontic
rehabilitation with a CAD/CAM-fixed prosthesis
The authors
explain the use
of high-strength
zirconium oxide
restorations in
the prosthodontic
management of
an edentulous
maxilla with a
failing implant.

ing strategies that are currently
being developed for dentistry and
how do they work?
The most important tissue for dentistry is bone. We are establishing
technologies for bone tissue engineering and apply these clinically to
implant surgery. Secondly, we are
focusing on stem cell science.
Oral tissue contains a kind of
powerful stem cell that can be used
to treat systemic diseases, such as
brain infarction or heart infarction.
The dental pulp stem cell is one
of the most important cells derived
from oral tissue.

Which dental conditions will be
the first to be treated or cured by
tissue engineering?
Atrophied alveolar bone and severe
periodontitis.
g DT page 2A, ‘Oral tissue ...’

‘You’ve taken implant training;
what do you do you do next?’
By Lynn Mortilla, RDH

Integrating implants into a practice
is a job for the whole team as much
as it is for the dentist. It is critically
important to focus on the “other” skills
necessary after clinical competencies
are learned. A necessary step is to
be sure not only the clinician but the
entire team is trained for implant den-

g See page 10A

Dr. Minoru Ueda, Japan

tistry. Everyone in the practice plays
an integral role for successful incorporation of systems, strategies and
techniques to enhance the success of
implant dentistry. These techniques
should be built into daily protocols.
Standardized forms and tools can also
aid the implant-focused practice.
g DT page 2A , ‘You’ve taken ...’
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News

Dental Tribune | January 2010

f DT page 1A, ‘Oral tissue ...’

f DT page 1A, ‘You’ve taken ...’

‘Tissue engineering could provide a new
treatment method for diseases that
have not been treatable thus far.’
Is it possible to reconstruct complex tissue defects made up of
multiple cell types?
Yes, it is. We have succeeded in
reconstructing the structures that
make up periodontal tissues, which
are cementum, bone and periodontal ligament in humans.
There is different legislation
around the world regarding stem
cell research. Would you please
explain how the situation in
Japan differs from other parts of
the world and its effect on your
research?
We can do basic research using
animal cells and human stem cells,
but research using embryonic stem
cells [ES] and induced pluripotent
stem cells [iPS] must be performed
under the control of the ethical committees of each university.
In order to use ES or iPS, we
need special permission from our
university and government. Clinical
studies based on basic research also
require approval from our university and government.
It is actually very difficult to gain
approval compared to other countries. So it is easy to conduct basic
research, but very difficult to conduct clinical studies in Japan.
Current debate in the field of cos-

metic dentistry centers on whether dentists should be allowed to
inject osteogenic cells into patients
for non-dental reasons. What is
your opinion on this matter?
Dentists should not be allowed to
inject any cells by themselves for
non-dental reasons.
However, for cosmetic reasons,
dentists can inject stem cells into
the oral and maxillofacial areas,
especially into the face because cosmetic problems such as wrinkles
are not a disease.
The surface structures of an
implant are very important, but this
is not a main factor for enhancing
the living cell around the fixture.
What effect will tissue engineering
have on dental practice during
the next 20 to 25 years?
Tissue engineering could provide a
new treatment method for diseases
that have not been treatable thus
far, such as severe periodontitis and
atrophied alveolar ridges.
Also, cosmetic therapy using tissue engineering in the oral and
maxillofacial regions will become
commonplace in the dental practice. DT
(This interview is published with
permission by the FDI World Dental
Federation.)

Tell us what you think!
Do you have general comments or criticism you would like to share? Is
there a particular topic you would like to see more articles about? Let
us know by e-mailing us at feedback@dental-tribune.com. If you would
like to make any change to your subscription (name, address or to opt
out) please send us an e-mail at database@dental-tribune.com and be
sure to include which publication you are referring to. Also, please
note that subscription changes can take up to 6 weeks to process.

To assist with the next steps as
a team, I published “Incorporating
Implants Into Your Practice — Team
Strategies for Success.” The resource
guide helps practices learn how to
get the most out of implant training
and start booking more treatments
through staff education, identification
of implant candidates, documentation
forms, case presentation techniques,
patient financial forms and more. The
resource guide was printed as a courtesy of ChaseHealthAdvance financing options.
I was working as a surgical assistant and dental hygienist in a practice that was starting to become
involved in implant dentistry almost
20 years ago. I had no idea of how
the procedures were done or how
to educate patients about implants.
Through some research, I found the
ADIA (Association of Dental Implant
Auxiliaries) and attended a symposium. The ADIA is an integral part
of the ICOI (International Congress
of Oral Implantologists), the world’s
largest professional implant society. The ADIA enhanced my overall
knowledge of implant dentistry, and
in 1996 I accepted the responsibility
of becoming the executive director of
the ADIA.
It is goal of the ADIA to educate
each member of the team in the clinical techniques and communication
skills necessary to provide excellence
in patient care and to also educate the
team as a whole to enhance the practice and each team member’s career.
We focus on the coordination and
management responsibilities related
to implant dentistry.
As the number of implant practices in the world grows and develops,
there is a need for auxiliaries to do the
same. Our society is dedicated solely
to the purpose of educating dental
team members about implants and
associated procedures. The ADIA’s
main purpose is to establish educational criteria and training for certification and provide an organized
vehicle for auxiliaries to contribute to
the field of oral implantology/implant
dentistry.
Implant dentistry can be a dynamic
and productive part of your practice.
If you have completed clinical implant
training, how are you going to continue to evolve with current trends,
techniques and technology in implant
dentistry? Have you developed the
systems, strategies and techniques to
incorporate implants successfully into
your practice? Have you included educating your team in your professional
development? The ADIA is committed
to constant development of our programs to keep current with the evolving realm of implant dentistry.
I encourage you and your team to
look into membership with the ADIA
and ICOI at www.ICOI.org and www.
adiaonline.org. I hope the resource
guide will give you tips and tools to
simplify incorporating implant dentistry into practices for the entire team.
g continued

DENTAL TRIBUNE
The World’s Dental Newspaper · US Edition

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Published by Dental Tribune America
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or for typographical errors. The publisher also does not assume responsibility
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authors are their own and may not reflect
those of Dental Tribune America.

Editorial Board
Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
Dr. Gorden Christensen
Dr. Rella Christensen
Dr. William Dickerson
Hugh Doherty
Dr. James Doundoulakis
Dr. David Garber
Dr. Fay Goldstep
Dr. Howard Glazer
Dr. Harold Heymann
Dr. Karl Leinfelder
Dr. Roger Levin
Dr. Carl E. Misch
Dr. Dan Nathanson
Dr. Chester Redhead
Dr. Irwin Smigel
Dr. Jon Suzuki
Dr. Dennis Tartakow
Dr. Dan Ward

[3] =>

0A
Dental TRubric
ribune | January 2010

Dental Tribune
| Month 2009
3A
News

Headline ‘Your Spitting Image’ Web site
f continued

Deck

Interactive program explores forensics, saliva and bioengineering through dentistry

By line

Did you know that a person could
be identified from the DNA in saliva
left behind on a postage stamp?
Or that the average person creates enough saliva each day to fill
a soft-drink bottle? That teeth can
survive fires reaching 2012 degrees
Fahrenheit?
“Your Spitting Image,” (www.
dentalmuseum.org/ysi) a new educational Web site from the National
Museum of Dentistry, reveals what
your mouth says about you.
Find out how forensic dentists
use dental records and DNA analysis
to solve real missing person cases,
discover the telling secrets revealed
by saliva and find out how your
mouth is a window to health for
your body.
This interactive Web site features
an in-depth exploration of forensics, saliva and bioengineering as it
relates to science, dentistry and oral
health.
Key scientific topics include DNA,
genetics, the mouth/body connection and stem cells.
Parents and middle and high
school teachers looking for engaging topics in scientific exploration
for use at home or in the classroom
will find plenty of lessons to choose
from on this site.
The lessons can also be used in
conjunction with a field trip to see
the Your Spitting Image companion
exhibit at the National Museum of
Dentistry in Baltimore or at one
of the venues across the country
hosting the traveling version of the
exhibit (currently on view at the
Impression 5 Science Center in Lansing, Mich.).
The Web site features three sections that explore the science of
dentistry and oral health. In “Forensics: Solving Mysteries,” learn how
forensic dentists help law enforcement identify missing persons using
X-rays, bitemarks and DNA testing.
Learn how saliva protects our
teeth and how our mouth is connected to the health of the rest of
our body in “Saliva: A Remarkable
Fluid.” The section “Bioengineering: Making a New You” explores
how stem cells and genes are being
used to grow replacement teeth and
cure disease.
Interactive activities include:
• An exploration into how a few
drops of saliva can be used to determine genetic makeup, diagnose
infections and identify illegal drug
use.
• A step-by-step illustration of
how forensic dentists can extract
DNA from a tooth to learn the identify an unknown victim.
• An animated cartoon that shows
how brushing, flossing and rinsing
lead to a healthy mouth.
• A visual timeline of the various ways humankind has sought to
replace missing teeth for thousands

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dental

Lynn D. Mortilla, RDH, is
executive director of the Association of Dental Implant Auxiliaries (ADIA), a fellow of the ADIA
and a member of the ICOI’s
Board of Directors.
She is also an adjunct clinical
instructor at Temple University,
Department of Periodontics and
Implants and is on the faculty
for the implant preceptorship at
the University of Texas Health
Science Center, San Antonio.
Mortilla is a contributing
author to “Dental Implants:
The Art and Science” (Babbush;
Saunders) and to “Contemporary Implant Dentistry 3rd Edition” (Misch; Mosby).

of years, from the ancient Egyptians
to the future of tooth replacement.
Teacher guides included on the
Web site provide easy-to-understand, illustrated, age-appropriate
lessons for middle and high school
students that can be used in the
classroom.
All materials are designed to
meet the National Science Education
Standards developed by the National
Committee on Science Education
Standards and Assessment and the
National Research Council.
The Web site also provides
detailed information about the Your
Spitting Image traveling exhibit and
how it can be brought to communities nationwide.

About the author

The educational Web site ‘Your Spitting Image’ is a part of the National
Museum of Dentistry’s online offerings.

The Dr. Samuel D. Harris National
Museum of Dentistry, an affiliate of
the Smithsonian Institution, is a lively national center where visitors discover the power of a healthy smile
and the rich history of dentistry.
Designated by Congress as the
official museum of the dental profession in the United States, the museum’s collection of 40,000 objects tells
the story of dentistry through changing and traveling exhibits, school
tours and family days.
Highlights include George Washington’s lower denture, Queen Victoria’s personal dental instruments
and an extraordinary collection of
toothbrushes ranging from the 1800s
to the present.
The National Museum of Dentistry is located at 31 S. Greene St.
in Baltimore. Admission is $7 for
adults, $5 for seniors and students
with ID, $3 for children ages 3–19;
and free for age 2 and under.
Open Wednesday to Saturday
10 a.m. to 4 p.m. and Sunday 1–4
p.m. Closed Mondays, Tuesdays and
major holidays. Call (410) 706-0600
or visit www.smile-experence.org for
more information. DT

Lynn Mortilla published the
resource guide shown above,
“Incorporating Implants into
Your Practice — Team Strategies for Success.”
The guide helps practices
learn how to get the most out of
implant training and start booking more treatments through
staff education, identification of
implant candidates, case presentation techniques, patient
financial forms and more.
The resource guide was
printed as a courtesy of ChaseHealthAdvance and you can
receive a complimentary copy
by calling ChaseHealthAdvance
at (888) 388-7633 or visit www.
advancewithchase.com.

The National Museum of Dentistry

IMP

The Your Spitting Image Web
site was made possible by a generous grant from the Patterson Dental
Foundation.

pattersondental.com

Seit

[4] =>

News

Dental Tribune | January 2010

NYU shares $1.63
million NIH award
Although the destructive effects
of oral bacteria in producing dental
caries (cavities), periodontal disease
and other infectious conditions are
well known, the identities of many of
the microbes responsible for these
conditions, as well as their physical
characteristics and ability to grow
and sustain themselves, remain a
mystery. In fact, only half of the
bacteria residing in the human oral
cavity have been identified.
Now, a NYU College of Dentistry (NYUCD) microbiologist and an
engineer at Sandia National Laboratories, part of the U.S. Department of
Energy, are partnering to develop a
technology that will facilitate bacterial identification. Their study was
recently funded with a three-year,
$1.63 million grant from the National Institute of Dental and Craniofacial Research (NIDCR) of the NIH.
The study’s principal investigator, Dr. Anup Singh, director of biosynthesis research at Sandia, uses
a method for spotting unknown
microbes in saliva dubbed “FISH n’
CHIPs” because it combines fluorescent in situ hybridization (FISH)
with a glass chip less than four centimeters wide.
NYUCD, a subcontractor on the
grant, received a $264,000 award

to acquire saliva samples from
NYUCD’s patient population, prepare the samples for Dr. Singh, and
analyze Dr. Singh’s findings. Dr.
Deepak Saxena, an assistant professor of basic science and craniofacial
biology, is leading the NYUCD study
in collaboration with Dr. Daniel Malamud, a professor of basic science
and craniofacial biology and director of NYUCD’s HIV/AIDS Research
Program.
In their study, Saxena and Singh
take advantage of recent advances in
gene sequencing that enable microbial analysis without lab cultivation.
Using probes composed of small,
incomplete oral bacteria nucleic
acid sequences, the researchers
will locate, or “fish out,” bacterial
cells with matching DNA sequences
from dozens of saliva samples that
have been arrayed on a glass chip.
Probes that bind to complementary
sequences will be marked with a
fluorescent dye so that investigators
can examine them under a microscope to confirm that they have been
properly matched.
The researchers plan to locate
cells from a dozen unknown oral
bacterial species and establish a
bank of cells that can be manipulated in subsequent sequencing studies

Dr. Deepak Saxena, assistant
professor of Basic Science and
Craniofacial Biology at New
York University
designed to fully decode a microbe’s
genome.
“I anticipate that our ‘FISH n’
CHIPs’ model will ultimately also be
used to locate unknown bacteria in
the gastrointestinal and nasal tracts
and in other part of the body,” said
Saxena. “This will help in the development of genetic tests to identify
those at risk for a variety of infectious diseases.”. DT
(Source: New York University)

Long-term cavity protection
from tooth-binding micelles?
A new study suggests that toothbinding micelles (or particles) may
provide long-term cavity protection
by adhering to tooth surfaces and
gradually releasing encapsulated
antimicrobials.
Formulation of a mouthwashbased delivery system is anticipated, ultimately simplifying application and increasing at-home patient
compliance.
AD

The researchers, from the University of Nebraska Medical Center,
Omaha, and the University of Florida, Gainesville, reported their findings in the November 2009 issue of
the journal Antimicrobial Agents
and Chemotherapy.
One of the main contributing factors to dental cavities is overpopulation of acid-producing bacteria in
the oral cavity that causes localized

destruction of compromised dental
hard tissue.
Due to the episodic nature of
cavities, long-term benefits of periodic treatments administered during routine office visits are minimal. Other delivery systems developed to maintain drug concentrations, including bioadhesive tablets,
patches, films and gels, aren’t very
effective on the tooth surface and
often cause irritation resulting in
poor patient compliance.
Emphasis on the need for therapeutic strategies that target the bacterial aspect of the disease and a
delivery platform that would maintain the drug concentration on the
tooth surface is warranted.
In the study, tooth-binding
micelles (molecular particles) were
developed and encapsulated with
farnesol, an antimicrobial recently
found to be effective against the
cavity causing bacterium Streptog continued

[5] =>

0A
Dental TRubric
ribune | January 2010

Dental Tribune
| Month 2009
5A
News

Cosmetic
Headlinedentist holds video
contest
Deck
By Fred
line Michmershuizen,
By
Online Editor

A
tkcosmetic dentist in Austin, Texas, has thought of an
interesting idea to drum up
interest in his practice, Austin Dental Spa.
Dr. Mark Sweeney is conducting a contest inviting
participants to describe —
on video — why they think
they are “the most interesting dental patient in
the world.”
The winner will be chosen by an online vote
and will be treated to a smile makeover worth
up to $15,000, including a variety of treatments
designed to fix dental issues and improve the
appearance of his or her teeth.
Contestants are asked to create a video that
shows why they are the most interesting dental
patient and why they deserve a smile makeover.
Submissions will be judged by staff members of
Austin Dental Spa for creativity and entertainment
value, and the top three finalists will be uploaded
to the practice’s Facebook and YouTube pages.
Anyone can view the videos and vote on the
contenstant he or she believes best represents the
most interesting dental patient in the world.

Although only the winning submission will
earn the smile makeover prize, Sweeney says
everyone who submits a video will receive from
the practice a teeth whitening treatment valued
up to $600.
Sweeney is asking contestants to keep video
submissions shorter than five minutes — and also
G-rated.
Contestants aiming for a smile makeover,
which can include teeth whitening, dental crowns,
porcelain dental veneers and dental implants in
Austin, are encouraged to check out the contest
rules and details on Austin Dental Spa’s Web site,
located at www.austindentalspa.com.
Videos were submitted through Dec. 31. Online
voting began Jan. 6 and ends on Jan. 22. The winner will be announced Jan. 27. DT

Dentists honor Mingledorff
By Fred Michmershuizen, Online Editor

Fort Washington, Pa., prosthodontist Dr. Tom Balshi and his wife,
Joanne, recently gathered dental specialists born of Philadelphia’s only
graduate program in prosthodontics
to honor its renowned former chair,
mentor and Bryn Mawr resident
Ernest Beckwith Mingledorff.
Beloved by all for his wisdom, gen- Temple University pride was abundant when Dr. Ernest ‘Ernie’
teel southern manner and flowing Beckwith Mingledorff, second from right, was recently honored. Also
good humor, “Ernie” drew a crowd pictured are Amid Ismail, left, Ann Weaver Hart and Dr. Tom Balshi.
of 80 professionals from the greater
ment to reinvigorate prosthodontic education in
Philadelphia and New York area.
In a late summer poolside setting with the the Philadelphia area.
AD
Balshi was the first graduate of the Temvibrant music of live steel drums keeping beat,
dental collegiality was at its best graced by the ple Dental School program in prosthodontics to
presence of Temple University President Ann become certified as a Diplomat of the American
Weaver Hart and newly appointed Dean Amid Board of Prosthodontists. His Fort Washington,
Ismail of Temple’s Kornberg School of Dentistry. Pa., practice boasts a 100 percent success rate in
Both Hart and Ismail spoke of their commit- prosthodontic restorations on dental implants. DT
f continued

AD
1/4 Page
9 1/4 x 3 3/8

coccus mutans UA159. When tested on a model
tooth surface, the micelles were able to swiftly
bind and gradually release the encapsulated
farnesol.
Additionally, biofilm inhibition studies of the
farnesol-containing tooth-binding micelles demonstrated that they were able to inhibit S. mutans
UA159 at much higher levels than untreated
blank control micelles.
“A tooth-binding micelle delivery platform for
the prevention and treatment of dental caries has
been designed and prepared in this study,” the
researchers said.

“It is anticipated that the tooth-binding
micelles have the potential to be formulated
into mouth rinses that may have the merits of
simple application, cultural acceptance and
improved patient compliance.”
If you would like to download a copy of the
journal article, please visit www.asm.org. DT
(F. Chen, X.M. Liu, K.C. Rice, X. Li, F. Yu, R.A.
Reinhardt, K.W. Bayles, D. Wang. 2009. Toothbinding micelles for dental caries prevention.
Antimicrobial Agents and Chemotherapy, 53; 11:
4898–4902.)
(Source: American Society for Microbiology)

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[6] =>

Practice Matters

Dental Tribune | January 2010

Weak economy increases employee theft
By Sally McKenzie, CMC

The stories read like popular fiction. Unfortunately, they are true.
The outwardly stable, unquestionably loyal employee commits a crime
that no one would have expected,
least of all her/his employer. More
puzzling is the fact that often this
member of the staff doesn’t have a
criminal record.
In fact, according to the 2008
report of the Association of Certified Fraud Examiners (ACFE), only
7 percent of those committing fraud
have prior convictions and a mere
12 percent have been fired by a
former employer as a result of fraud
related conduct.
However, what is perhaps most
disconcerting is that many of the
characteristics that make up this
person’s profile would also be the
sketch for your “ideal” team member. “Dedicated, takes very little
time off, first in the office and last
to leave, will even take work home,
is very particular about how things
get done.”
Some may say she/he is controlling while others contend it’s a commitment to doing a job well. Working her/his fingers to the bone, this
devoted employee is quietly slipping
thousands of dollars under the table
and into her/his pocket.
According the ACFE’s most recent
report, U.S. businesses lose an estimated $994 billion in annual revenues to fraud despite increased
emphasis on anti-fraud controls and
recent legislation to combat it.
If that weren’t troubling enough,
the U.S. Chamber of Commerce estimates that 75 percent of all employees steal at least once, and that half
of these steal repeatedly.

Who are the thieves?
Fraudsters are represent by all occupations — CEOs, bank tellers, firefighters, payroll clerks, senators,
even Catholic priests. And, in some
cases, they are shamelessly brazen.
One reported case involved an
employee who routinely crossed out
the employer’s name on checks written from customers and inserted his
own. No Wite-Out®, no fancy chemical concoction to erase the ink, he
just striked through the name on
the check and made it payable to
himself.
AD

And you probably thought the
bank would catch something so blatant, right? However, banks process
literally tens of thousands of checks
per minute so they cannot catch
every suspicious-looking one.
In the case of a parish priest,
he embezzled more than $1 million from two churches. The crime
wasn’t exposed until a donor
requested a receipt for tax purposes
from the church dioceses, which
had no record of the donation. However, the contributor had his canceled check. This led to the arrest
and conviction of the priest.
No organization or business is
immune to employee theft, and
health care businesses, such as dental offices, are among the top three
businesses to be victimized by dishonest employees.
With the average loss per fraud
case among small businesses at
$200,000, that kind of financial hit
can be huge for small dental practices, many of which operate very
close to the margin.
In this economy, any increase in
expenses or reduction in revenue
could be catastrophic. Even more
problematic is the fact that lenders

are less likely to extend additional
credit these days to cover such a
shortfall.

How do they steal?
Dishonest employees are fraudulently writing company checks,
skimming revenue and engaging in fraudulent billing. In small
operations such as dental practices,
internal controls tend to be lax and
accountability slim, thus providing
the ideal environment for employee
theft.
Checks, in particular, present a
veritable smorgasbord of opportunities for the small business embezzler. As another thief discovered, it
was a relatively simple exercise to
write company checks to herself and
then destroy the canceled checks.
Countless fraudsters have discovered the ease of ordering new
checks in the business’ name and
making them out to themselves.
They can steal insurance checks or
sign checks using a signature stamp.
In a multitude of other cases, the
trusted employee accepts payment
from the patient or customer, deletes
the transaction on the computer and
keeps the payment. Many patients
no longer get their canceled checks,
let alone actually look at them.
Then there are the fraudulent
billing schemes. These take a bit
more effort than your typical check
fraud.
One small employer was building
a new office only to discover by accident that a trusted employee, who
just happens to be in charge of paying the bills, had set up a fictitious
painting business and was billing
the employer for work never done.

Motivation to steal
What is it that makes the other-

wise stellar employee turn to crime?
Research indicates that there are
several inducements that can influence someone’s decision to embezzle, but three factors must be present. It’s known as the “fraud triangle.” The employee must have the
incentive, the opportunity and the
rationalization.
Incentive may be a gambling
problem, alcohol or drug addiction,
or a shopping addiction. It can also
be motivated by financial struggles
through an economic downturn
such as we are experiencing now.
The person may be disgruntled
or is stretched beyond his or her
financial means. The employee may
be experiencing a personal crisis
such as a divorce, serious illness or
a death in the family. The employee
becomes desperate, angry and disillusioned, all of which provide incentive to commit the crime.
The opportunity typically comes
in the form of lax internal controls.
One person has total control of practice revenues. There are few, if any,
checks and balances and an almost
total lack of supervision over that
highly trusted employee who seemingly can do no wrong.
Then there’s rationalization. The
employee tells herself/himself that
she or he will just take a little
loan and will pay it back. Then the
employee takes a little more the
next time. Or the employee hasn’t
received a raise and contends she/
he works harder than anyone, so
she/he deserves the money.
Alternatively, perhaps an addiction is taking over his/her life;
medical bills have skyrocketed; the
spouse lost his/her job. “The dentist
makes so much money, she/he will
never notice.” Whatever form the
rationalization takes, often, in the
employee’s mind, she/he is simply
correcting a perceived wrong.
Who’s most likely to be pilfering
from your practice? Fraud experts
refer to it as the 10-10-80 rule: 10
percent of people will never steal,
another 10 percent will steal at any
opportunity, and the other 80 percent will go either way depending
on how they rationalize a particular
opportunity.
The good news is that for those
in the 80 percent category, if they
believe they will be caught, they
won’t take the chance.

Don’t be an easy target
Small businesses such as dental
practices are prime targets for fraud
and embezzlement. Why? Practice
owners can be very naïve and far too
trusting, giving almost total financial control to an employee. In some
cases, dentists don’t even know how
or where to access their financial
reports.
In addition, there is often a
close relationship between clinicians/owners and employees. They
g DT page 8A

[7] =>

[8] =>

8A

Practice Matters

f DT page 6A
become trusted friends, and this,
sadly, encourages dishonest employees to take advantage of their “dentist friends.”
As the ACFE reports, the most
common small business scheme
is check tampering. It frequently
occurs when one individual has
access to the company’s checkbook and also has responsibility for
recording payments and/or reconciling the company bank statement.
Therefore, the first order of business in protecting practice finances
is to divvy up the financial duties.
The practitioner may only want to
do the dentistry, but this attitude is
inviting disaster.
As one Wisconsin dentist discovered not long ago, his trusted
employee of 28 years who had “total
run of the practice’s financial operations” was accused of stealing at
least $41,000, and that was believed
to be just the tip of the iceberg.
Separating billing, collections and
delinquent account responsibilities
is critical. The employee making the
bank deposit should not be the same
employee responsible for checking
the deposit slip that is returned from
the bank.
Consider rotating the responsibility for making bank deposits among
employees, and monitor deposits for
AD

unexplained increases or decreases.
Look at the reports daily. In particular, examine the day sheet and
the deposit. Investigate any adjustments made on the day sheet.
Pay close attention to increases in
refunds or write-offs, large adjustments or missing documents.
Print and review daily an audit
trail report. It reflects every transaction that has transpired in the office
since the last printed audit trail.
In addition, generate a monthly
report listing all patients that have
had changes made to their accounts.
This helps to identify a recurring
problem or detect a discrepancy.
Routinely conduct random checks of
different accounts.
In practices with small staffs,
the dentist must take a much more
active role in monitoring the financials. Ideally, the clinician should
write all the checks and do her/his
own payables.
She or he should reconcile the
bank statement monthly, and canceled checks should be sent, along
with the bank statement, to the clinician’s home.
In addition, monthly credit card
statements should be received
unopened and compared with original receipts of purchases. These
steps enable the practitioner to
know exactly where the money is
going.

Dental Tribune | January 2010
Checks received should be immediately stamped on the back with
the practice’s bank deposit endorsement stamp. Periodically check the
account number to ensure it is the
practice account. Do not use signature stamps.
All employees should be required
to take at least one week’s vacation every year, particularly those in
charge of practice finances.
And, most importantly, don’t let
the work pile up. During that time,
someone else should carry out the
vacationing employee’s duties.
Pay attention to key red flags.
According to the ACFE report,

“Fraud perpetrators often display
behavioral traits that serve as indicators of possible illegal behavior.
The most commonly cited behavioral red flags were perpetrators
living beyond their apparent means
(39 percent of cases) or experiencing financial difficulties at the time
of the frauds (34 percent).”
Finally, take complaints seriously. If patients claim that they’ve paid
but didn’t receive credit, investigate
it. If an employee tips you off that
something isn’t right, check it out.
If you sense that things just aren’t
adding up, don’t dismiss it. Ignorance could cost you thousands, if
not millions, of dollars. DT

About the author
Sally McKenzie is CEO
of McKenzie Management,
which provides success-proven management solutions to
dental practitioners nationwide. She is also editor of The
Dentist’s Network Newsletter
at
www.thedentistsnetwork.
net; the e-Management Newsletter from www.mckenzie
mgmt.com; and The New Dentist™ magazine, www.thenew
dentist.net. She can be reached
at (877) 777-6151 or sallymck
@mckenziemgmt.com.

[9] =>

[10] =>

10A Clinical

Dental Tribune | January 2010

Complete maxillary implant
prosthodontic rehabilitation
with a CAD/CAM-fixed prosthesis
By Neo Tee-Khin, Ansgar C. Cheng,
Helena Lee and Ben Lim, Specialist
Dental Group, Singapore

prosthodontic management of an
edentulous maxilla with a failing
implant prosthesis.

Endosseous implant treatment
has been widely reported as a highly predictable treatment modality
with a low percentage of clinical
complications.
Prudent clinical judgement and
careful consideration of the risks
and benefits of various treatment
options are essential for the treatment planning and long-term success of prosthodontic treatment.1
Traditional implant prostheses
are commonly fabricated using
acrylic resin teeth supported by a
metal framework. Significant space
is designed at the tissue surface
of the prosthesis to enhance oral
hygiene maintenance.
However, application of this
prosthetic design in the maxillary arch is occasionally esthetically inadequate and speech may be
compromised.
Conventional porcelain-fusedto-metal restorations require the
placement of labial restoration
margins below the free gingival
margin in order to mask the hue
and value transition between the
sub-gingival implant sub-structures
and the supra-gingival crown restorations.
From a periodontal point of view,
sub-gingival placement of restoration margins is related to adverse
periodontal tissue response.2–5 As a
result, restoration margins are best
placed coronally from the free gingival margin.4,5
Porcelain-fused-to-metal res torations are commonly used in
the posterior teeth because of their
well-documented long-term clinical
track record.6–13 CAD/CAM ceramic-based materials are prescribed
nowadays, owing to their demonstrated promising physical properties14,15 and clinical longevity.16
This article describes the clinical application of high-strength zirconium oxide restorations in the

Clinical report
A 62-year-old female with an
implant-supported maxillary prosthesis was evaluated at the Specialist Dental Group in Singapore. She
presented clinically with a maxillary fixed complete denture supported by six endosseous implants
(NobelReplace, Tapered Groovy,
Nobel Biocare).
The prosthesis had acrylic resin
teeth supported by a gold alloy
metal framework. The implant at
the patient’s maxillary right canine
area was exposed. The patient
reported no symptoms (Fig. 1).
An occlusal examination revealed
a stable maximal inter-cuspation
position with insignificant centric
relation to maximal inter-cuspation
slide at the teeth level.
A canine-guided occlusal scheme
was noted. No para-functional habits were reported. Sub-optimal maxillary lip support was noted.
A significant amount of dead
space was identified between the
intaglio surface of the prosthesis
and the maxillary soft tissue.
Upon removal of the maxillary prosthesis, all the maxillary
implants were found to be osseointegrated. The patient desired to
correct the failing implant, restore
lip support, masticatory function
and facial esthetics.
The overall treatment plan
included removal of the implant
at the maxillary right canine area,
replacement of a new implant at the
maxillary right canine region and
fabrication of a full-arch, zirconium
oxide-based ceramic restoration in
the maxilla.
Under local anaesthesia, the
implant at the maxillary right
canine area was removed surgically (Fig. 2) and a new 13 mmlong regular platform implant was
placed (NobelReplace, Tapered
Groovy). The new implant was sub-

Fig. 1: Pre-treatment intra-oral frontal view: A large space was noted
between the intaglio surface of the prosthesis and the maxillary tissue, and
there was significant tissue resorption on the labial surface of the implant
over the maxillary right canine area. The patient was asymptomatic.

Fig. 2: Full-thickness flap revealed the advanced bone loss on the labial surface of the implant. In spite of the tissue damage, this implant was clinically
firm.

Fig. 3: Maxillary prosthesis before the application of tooth-colored porcelain;
excessive crown length was noted at this stage.

[11] =>

0A
Dental TRubric
ribune | January 2010

Dental Tribune
| Month11A
2009
Clinical

Headline
Deck
By line

Fig. 5
Fig. 4: Completed maxillary prosthesis with gingival-colored porcelain applied to provide adequate lip support; excessive crown
height was reduced. Fig. 5: Anterior view showing the CAD/CAM-
fabricated full-ceramic implant abutments at the approximated
vertical dimension of occlusion.

Fig. 4
merged and primary wound closure
achieved. The existing prosthesis
was re-inserted during the healing period to serve as a provisional
prosthesis.
Once
osseointegration
was
achieved a few months later, the
new implant was exposed and the
maxilla was ready for prosthodontic
rehabilitation after a few weeks of
soft-tissue healing.
Six implant-level impression copings (NobelReplace) were placed
onto the maxillary implants. Highviscosity vinyl polysiloxane material (Aquasil Ultra Heavy, DENTSPLY DeTrey) was carefully injected
around all the impression copings.
A stock tray loaded with putty
material (Aquasil Putty, DENTSPLY
DeTrey) was seated over the entire
maxillary arch to make the definitive impression.
A jaw-relation record at the treatment vertical dimension was made
with a vinyl polysiloxane material
(Regisil PB, DENTSPLY DeTrey).
The maxillary and mandibular
definitive casts were mounted arbitrarily in the center of a semiadjustable articulator (Hanau Widevue, Teledyne Waterpik) using
average settings.17,18
The custom zirconium oxide
abutments with gold-alloy fitting
surface (Procera, Nobel Biocare)
were CAD/CAM fabricated accordAD
ing to the prosthesis design.
The development of the planned
definitive maxillary restoration was
carried out using a CAD/CAM process. The maxillary definitive cast
with the custom full-ceramic abutments were scanned (Zeno Scan,
Wieland Dental+Technik), and the
prosthesis framework was designed
using a software program (D700,
3Shape).
The framework was milled in
zirconium-base material (Zeno Zr
Bridge, Wieland Dental+Technik)
with a milling machine (Zeno 4030
M1, Wieland Dental+Technik). The
prosthesis framework was sintered
according to the manufacturer’s
recommendations.
Subsequently, overlaying lowfusing, tooth-colored porcelain
g DT page 12A

AD
1/4 Page
9 1/4 x 3 3/8

[12] =>

12A Clinical & Meetings

Dental Tribune | January 2010

Headline
Deck
By line

Fig. 6: Occlusal view of the maxillary arch before insertion of the maxillary
prosthesis; favorable anterior-posterior spread allowed the replacement of
posterior teeth with distal cantilevering.
f DT page 11A

Discussion

material (IPS e.max, Ivoclar Vivadent) was manually applied onto
the exterior to create proper anatomic form (Fig. 3). Low-fusing,
gingival-colored porcelain material
(IPS e.max) was applied to create
proper lip support (Fig. 4).
During the delivery clinical
session, the old prosthesis was
removed and the new custom abutments were torqued to 32 Ncm (Fig.
5).
The new prosthesis was tried in
to verify color, occlusion, lip support, teeth form and comfort.
Upon confirmation of the
patient’s acceptance, the implant
abutments were sealed in guttapercha (Fig. 6) and the prosthesis
was cemented in resin-modified
glass-ionomer luting agent (RelyX
Unicem, 3M ESPE).
The patient was evaluated two
weeks postoperatively. Anterior
guided occlusal schemes were verified intra-orally before and after
prosthesis cementation (Fig. 7).
The patient reported no discomfort and she had been functioning
well with the new restorations. No
abnormal clinical signs were noted.

Osseointegration is a well-documented and predictable clinical
treatment option. On the other
hand, management of implant
failure is also a clinical reality.
In this clinical report, the failure
of one implant at a crucial location
indicated the need for re-fabrication
of the entire implant prosthesis.
As the patient desired a high level
of esthetics, full-ceramic restorations were selected. By prescribing
tooth-colored ceramic abutments
and full-ceramic restorations, prosthesis margins were made at the
gingival level and gingival retraction procedures were eliminated
during impression and prosthesis
insertion.
Full-arch prosthodontic rehabilitation using fixed prostheses usually requires longer-term provisional
restoration in order to facilitate a
predictable treatment outcome.
In this patient, the existing maxillary prosthesis served as a longterm provisional restoration for verifying her adaptability, and multiple
professional clinical adjustments of
provisional restorations were not
required.
This
treatment
sequence
increased the margin of safety in

Fig. 7: Completed maxillary implant-supported prosthesis; note the placement
of the supra-gingival margins.

the execution of the definitive fullceramic restoration.
Intra-oral verification of the new
treatment occlusal scheme and
detailed in situ clinical adjustment
of the restorations on the day of
prostheses insertion still formed
the essential foundation for proper
treatment execution.
In any major prosthodontic
treatment, the patient should be
informed of the potential financial
and time implications should the
need for re-fabrication of the restorations arise.

The functional management of an
edentulous maxilla using a fullceramic implant-supported maxillary prosthesis has been reported.
New CAD/CAM-based restorative
materials were used in treating this
case.
The use of high-strength fullceramic res tor ations enhances
overall esthetic predictability and
long-term functional outcome. DT
A complete list of references is
available from the publisher.

Conclusion

Contact information
Dr. Ansgar C. Cheng is a prosthodontist with Specialist Dental
Group™, Mount Elizabeth Hospital,
Singapore, and an adjunct associate
professor at the National University
of Singapore.
Dr. Ansgar C. Cheng
3 Mount Elizabeth #08-10
Singapore 228510
Republic of Singapore
E-mail: drcheng@specialist
dentalgroup.com

‘Sunshine and Sweet Romance’ at the Miami meeting
The 2010 Miami Winter Meeting
promises to deliver an excellent
program for all attending. Headlining the program are Drs. Markus
Blatz and Alan Atlas on esthetic
dentistry from adhesion to zirconia.
Dr. David Schwab will deliver a
program on practice management
to take your practice to higher levels and increase case acceptance.
Staff members may also attend a
course on proper record keeping;
from business records to financial
records to patient records, course
instructor Alyce Norris will deliver concise and expert advice that
attendees will be able to put to use
upon return to their practices.

Dr. Scott Benjamin will present
a lecture on laser dentistry sponsored by the Academy of Laser
Dentistry.
Additionally, many of your preferred dental vendors will be there.
Information on the lectures and
more may be found at www.miami
wintermeeting.org.
The Miami Winter Meeting is
a boutique meeting that is allinclusive. When you purchase your
ticket to any of the lectures or for
the expo only, your food, beverage
and parking are included.
The morning starts with a Mimosa (champagne and orange juice),
and throughout the day, attendees
and exhibitors alike are treated to

beverage breaks as well as a lunch
followed by Miami’s famous Cuban
Cafecito.
In the afternoon, snack trays
filled with baked treats are also
made available for all.
Once the lectures end, everyone
gathers on the Royal Palm Veranda
for the President’s Tropical Sunset
Party.
Local guitarist Juan Areco will
set the mood as guests gather to
watch a spectacular sunset and
take in the views of the cruise
ships at the port of Miami.
Two open bars and a buffet
of roasted pork and steamship
rounds of beef, pasta and salads
are made available to all.

In addition, to cap off the evening, a plentiful dessert table will
have everyone forgetting their
New Year’s diet resolutions.
Make sure you plan to attend
the 2010 Miami Winter Meeting,
Feb. 11 and 12 at Jungle Island in
Miami.
It happens to be a long weekend
and Valentine’s Day is part of it.
You can’t beat C.E. during “Sunshine and Sweet Romance” during
the Miami Winter Meeting.
Registration is now open online
at www.miamiwintermeeting.org,
or call (800) 344-5860.
You must pre-register to attend,
however, there is no on-site registration. DT

[13] =>

0A
Dental TRubric
ribune | January 2010

Dental T
ribune | Month13A
2009
Products

Headline CLEARFIL SE Protect by Kuraray
Deck
By line

FUJIROCK EP
OptiXScan
by GC

Kuraray recently introduced
CLEARFIL™ SE Protect, a selfetch bonding agent with both
antibacterial cavity cleansing and
fluoride releasing properties.
CLEARFIL SE Protect eliminates the cost and extra step of
applying a separate cavity cleanser to kill any bacteria that remain
in cavities, especially “minimal
intervention” cavities.
CLEARFIL SE Protect offers
greater confidence in fighting the
bacteria that remain in almost all
cavity preparations.
Furthermore, it is biologically
safe because the functional mono-

mer, MDPB, will not leak after light
curing.
The sodium fluoride in CLEARFIL
SE Protect is specially coated to
allow release of the NaF while the
bonding layer’s physical properties,
including strength, are maintained.
CLEARFIL SE Protect retains
the outstanding characteristics of
CLEARFIL SE Bond: low post-op
sensitivity, excellent bond strength
for enamel and dentin, application
speed and ease of use.
In fact, CLEARFIL SE Protect
shows even higher long-term bonding durability than CLEARFIL SE
Bond.

For more information about
this and other Kuraray products,
please visit www.kuraraydental.
com. DT

Used in the production of all kinds
of dental prosthetics, GC FUJIROCK®
EP, renowned for its superior GC
quality, is one of the most popular
Type 4 die stones worldwide.
Now you can enjoy the same highquality standard with the non-reflective GC FUJIROCK EP OptiXscan for
all modern scanner systems.
With CAD/CAM and implant technologies gaining importance every
day, GC has developed a special Type
4 stone.
Thanks to its specially adapted
powder composition, GC FUJIROCK
EP OptiXscan is compatible with all
existing scanning devices.
Advantages include:
• compatible with existing scan
devices (laser, optical);
• extremely smooth but non-reflective surface for optimized scanability;
• adaptable working time and short
setting time for fast processing;
• variable mixing ratio without difference in physical properties;
• low setting expansion of less than
0.08 percent for the highest precision;
• high compressive strength of
approximately 53 MPa with less risk
of breakage during removal and handling of the model.
Please visit GC online at www.
GCAmerica.com. DT
AD

GC Initial MC
and GC Initial
ZR-FS Gum
Shades
The GC Initial™ System is a line
of nine specialized ceramics that
can be used to create metal-ceramic and full-ceramic restorations for
every indication using any fabrication process and framework.
To make gingival restorations
with GC Initial even more esthetic
and more natural, the Initial modular ceramic range has expanded
g DT page 14A

AD
1/4 Page
9 1/4 x 3 3/8

[14] =>

14A Products

Dental Tribune | January 2010

Directa
FenderMate

f DT page 13A
to contain a full array of gingival
shades.
The add-on sets, GC Initial MC
and GC Initial ZR-FS Gum Shades,
meet all the requirements for
highly esthetic gingival reproductions.
The product offers naturally
beautiful transitions to the gingival and unlimited creativity. GC
Initial Gum Shades are available
in both the GC Initial MC and
GC Initial ZR-FS line of ceramic
materials.
The new ceramic gingival-colored materials are specially suited for indications in the areas
of implant superstructures, crown
and bridgework techniques. DT

Congratulations to Susan
Burzynski of New York and
Kathy Sinatra of New Jersey.
They are GC America’s winners
of CareerFusion 2010!
They’ve won free tuition to
the CareerFusion Meeting, Jan.
16–20, in Daytona Beach, Fla.

‘Changing the
payments industry’
At Singular Payments, they do many
things differently, but what truly makes
the company unique is their “one flat
rate.” Instead of having multiple rates
that are typically associated with credit
cards, the company takes the time to
do a full evaluation of your business to
give you their best possible rate.
In addition to having just one rate,
Singular Payments also eliminates
monthly fees. No statement fee, no
batch fee, no transaction fees and
especially no “other fees.” Just imagine
spending minutes, rather than hours,
reconciling your monthly statement.
Find peace of mind knowing you’re not
wasting money on any unnecessary
fees or charges, and put money back
in your pocket.
The company’s program does just
that while saving you valuable time,
money and providing PCI compliance.
In fact, the company is so confident in
its program, it has no early termination fees.
At Singular Payments they understand that most merchants are not
experts in all of the various qualifications, card types and entry methods
and how these can affect their costs.
That’s Singular Payments’ job. The
company takes the responsibility of
not only setting you up with the right
solution, but getting rid of all the complicated rates and fees.
AD

For other processors, there is no
incentive to make sure all transactions
are “qualified.” In fact, providers make
much more money on the downgraded
or non-qualifying transactions. At Singular Payments, the company makes
sure all of your transactions qualify
at the best possible rate, and if they
don’t qualify it comes out of the company’s pocket, not yours. If the company doesn’t do its job, it doesn’t profit.
Why pay more because your service
provider isn’t doing its job?
That’s not all. Singular Payments
also offers a wide variety of solutions
so that the company can process for its
merchants in the most efficient manner. These solutions include: virtual
terminals, PCI-DSS secure payment
gateways, terminals and even POS
solutions.
The company’s mission statement says it is “Changing the Payments Industry.” It’s a lofty statement,
but it’s one the company intends to
achieve. By listening to its customers
and understanding their business, Singular Payments can customize the best
solution for their individual needs. The
company’s goal is not only to be the
best merchant service provider you’ve
had, but the last one you’ll ever need.
To get your “one flat rate” evaluation, call (877) 829-2170 and choose
option No. 3. DT

Placing a matrix band to attain
a good contact point and avoiding
interproximal overhang after preparation for Class II fillings can be a
time consuming and laborious procedure. Directa’s new FenderMate®
offers a unique, fast and easy solution by combining a separating plastic wedge and stainless-steel matrix
in its innovative design.
Cervical overhang is easy to overlook when dealing with Class II
restorations. A matrix that does not
perfectly adapt to the cavity margin
under the contact point may cause
overhang, and a control examination with a probe or floss may not
detect this.
Over a period of time occlusal
pressure causes the fracturing of
unbonded excess material, which
creates a trap for food impaction and
plaque retention causing caries and
gingivitis.
Sectional matrix systems consisting of a matrix, wedge and ring may
create a risk of leakage due to lighter pressure of the wedge against
the matrix when a retention ring is
applied to separate the teeth.
With Directa’s FenderMate the
combined matrix and wedge are
inserted as one piece, as easily as a
wedge, and employs a special new
technology in its curved design that
contours and compliments the curvature of the patient’s tooth.
After FenderMate is inserted it
adapts around the tooth and holds
its shape without the use of a retentive ring. FenderMate’s flexible wing
separates the teeth and firmly seals
the cervical margin. A good contact
point is created by the unique preshaped indentation in the matrix. No
burnishing whatsoever is necessary.
FenderMate is available in two
wedge widths, regular and narrow,
and for left or right application. They
are color-coded for ease of identification. The new, innovative design
accommodates most approximal
spaces.
FenderMate aids fast and efficient
restorations and is the fastest matrix
to apply on the market.
The combined use of Directa’s
new FenderMate and FenderWedge® sets a new standard with
a tissue-friendly approach for the
preparation and filling of Class II
restorations. DT

FenderMate, with its optimal matrix
curvature can be placed in only 5 seconds.

Achieve restoration with tight contacts and tight cervical margins.

Restoration complete.

www.dental-tribune.com

Have you read an ePaper yet?
You can access the most recent edition of Dental Tribune, Cosmetic
Tribune, Endo Tribune, Hygiene Tribune, Implant Tribune and Ortho
Tribune as ePaper. Drop in for a “read” anytime!

[15] =>

0A
Dental TRubric
ribune | January 2010

Dental Tribune
| Month15A
2009
Industry
News
AD

Levin Group partners with
pharmaceutical company
Levin Group announced on Dec. 16, 2009, that
it has been engaged by Novalar Pharmaceuticals,
based in San Diego. As the leading international dental practice management consulting firm,
Levin Group works with numerous dental corporations to help them successfully market their
products and technologies and integrate them
into dental practices.
The company will partner with Novalar to
develop a program to demonstrate to dental
professionals the value of OraVerse® as an effective routine treatment in cases where anesthesia
reversal is appropriate. OraVerse is used after
restorative dental procedures where lingering
numbness is problematic. It is the first and only
anesthesia reversal agent that restores normal

sensation twice as fast and accelerates return to
normal function so patients can speak, smile and
drink normally.
A leader in consulting with dentists and dental
companies on practice management systems,
Levin Group has partnered with multiple companies to develop materials to assist in the implementation of unique and innovative products.
Levin Group, an international consulting firm
for dentists, specialists and dental corporations
with 24 years of experience, is based in Owings
Mills, Md., with a second office in Phoenix. Levin
Group provides practice management and marketing consulting programs to thousands of practitioners every year. For more information about
Levin Group, please visit www.levingroup.com. DT

New Zealand prime
minister salutes Triodent
at project launch
New Zealand Prime Minister John Key gave
dental manufacturer Triodent his seal of approval
at an unveiling ceremony on Nov. 21, 2009, to
launch the company’s major expansion project.
Key had been invited to open the Triodent
Innovation Center, the first stage of the company’s
plan to build a new headquarters in Katikati,
New Zealand, about two hours’ drive southeast
of Auckland.
The prime minister unveiled a sculpture to
commemorate the event. Appropriately, it was
made using the company’s new titanium laser
sintering machine, which will be used to manufacture core Triodent products.
The new headquarters will bring all of Triodent’s New Zealand operations, including manufacturing, administration and an international call
center, onto one site for the first time since early
2007.
A new factory is scheduled to open there in late
2010, with the administration wing to follow.
Speaking to invited guests at a garden party on
the planned site, Key said achieving success in the
world market was “ultimately about doing things
a lot smarter.”
“I want to encourage New Zealand companies
to do the things that Triodent is doing, and that
is blazing a trail in international markets, being
creative and investing in science and research
and development, because that is the future of
New Zealand,” Key said.
Triodent founder Dr. Simon McDonald was
delighted to welcome Key to the opening. “This
is a special day for me personally and it is a great
honor to host the prime minister in this wonderful
country I am privileged to live in.”
McDonald said 2009 had been a memorable
year for Triodent, not only for the numerous
awards won but also in the way the company had
consolidated its position and set out the path for
a strong future.
“It has been a hard year for worldwide business, but we have weathered the storm better
than many and we will be the better for it. We
have greatly improved many of our systems this
year and made some big decisions that will bring
huge benefits as we mature.

New Zealand Prime Minister John Key,
center, with Triodent Finance Director
Yashen Jones, left, and Triodent founder and CEO Dr. Simon McDonald.

New Zealand Prime Minister John Key,
right, inspects Triodent’s new laser sintering machine with Triodent founder
and CEO Dr. Simon McDonald.

“With the advantage of our business agility we
have been able to respond quickly to the conditions, and despite the increasing complexity of
our operations, we are as focused on our goals
now as we have ever been,” McDonald explained.
McDonald assured guests that Triodent would
not be resting on its laurels, and more innovative products would follow in the path of the V3
Sectional Matrix System, Triotray and Griptab. DT

[16] =>

[17] =>

Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition

January 2010

www.dental-tribune.com

Vol. 3, No. 1

Immediate restoration of single implants replacing
central incisors compromised by internal resorption
By Susan McMahon Petruska, DMD, and
Jessica Forestier

Central incisors with a history of
past trauma are a common finding
in dentistry today. Many of these
incisors have been endodontically
treated at the time of trauma or
shortly post trauma.
However, failure of these teeth
can occur at a later time as a result
of fracture, internal resorption,
external resorption, decay and other
factors. Sources of trauma often
include sports or automobile related
accidents.
Once it has been determined that
an internally resorbed tooth is failing and non-restorable, a restorative
treatment plan that is both functionally and esthetically acceptable must
be determined and implemented.
The following are two case studies involving maxillary right central
incisors that had sustained trauma,
were endodontically treated and
functioned for a number of years.
Approximately 15 to 20 years later,
the teeth in each case failed due to
internal resorption.

Internal resorption
Dental root resorption involves the
loss of hard tissues that compose
the teeth (dentin, cementum and
enamel).1 Resorption occurs primarily by osteoclasts, large multinucleated cells that originate from the
bone marrow.2
Osteoclasts aid in the process of
bone loss by releasing demineralizing agents and degrading enzymes
that function in the breakdown of a
tooth’s hard tissues.2 Resorption of
the teeth is often difficult to prognosticate, diagnose and care for.1
In most cases, tooth resorption
is the result of trauma or irritation
to the periodontal ligament and/or
tooth pulp.1 These conditions may
occur because of injury, inflammation or chronic infection of the pulp,
periodontal conditions, orthodontic
tooth motility or tooth eruption.1,2
Internal inflammatory resorption,
the type of resorption identified in
the following cases, is characterized
by progressive loss of hard tissue in
the tooth root.1 This degeneration
is typically found in the cervical
region, but has been observed in all
areas of the root canal system.1
Internal resorption is generally
asymptomatic and is discovered
most frequently through radiographic examination.1,2 The loss of
hard tissue is detected radiographically as uniform radiolucent expan-

Fig. 1: Pre-op retracted view, 1:1 (case study
No. 1).
sion of the tooth canal. If internal
root resorption is left to progress
untreated, it may result in extension
to the periodontal ligament through
a crown or root perforation.1

Immediately placed implants/
immediate provisionalization
The clinician faces a great esthetic
challenge in the replacement of single anterior teeth.
In the following cases of internally resorbed incisors with a poor
prognosis, extraction followed by
immediate placement of an implant
is a desirable restorative option. The
failing tooth is located in the esthetic
zone, and therefore an immediate
and esthetic replacement is necessary following extraction.
In the past, the non-restorable
tooth was extracted and a removable partial denture (or flipper) was
fabricated and placed for use during
healing. After an adequate healing
period, an implant was placed and
buried under the gingiva and the
patient continued to wear the flipper
until the implant had osseointegrated and was ready to be uncovered
and restored. The patient would
therefore wear the removable partial denture for upwards of six to
eight months.
This course of treatment often
results in a less than desirable gingival architecture surrounding the
final restoration. There are also
clear indications that partial removable dentures are an important
causative factor in the alveolar bone
resorption process.3
Major cosmetic concerns in
the fabrication of the immediately
placed provisional are the retention
of the interdental papilla and prevention of alveolar bone collapse.4
Research has suggested that
immediate provisionalization following implantation allows for
greater clinical control over the

Fig. 2: Radiograph with
implant in place (case
study No. 1).

regeneration of tissue surrounding
the site of extraction.5 This benefit offers an esthetic advantage of
immediate loading of an implant
with immediate provisionalization
over alternative-staged therapy
treatment options.
Unfavorable alterations to the
alveolar bone structure must be
avoided using ridge preservation
techniques and precautions in terms
of osseous exposure.5 Immediate
placement of the implant into fresh
extraction sockets prevents the postextraction resorption that occurs
commonly with alternate forms of
treatment, preserving the integrity
of the alveolar ridge.6

Case study No. 1
The patient is a 30-year-old healthy
male who was examined in our
office for a failing maxillary right
central incisor. His history involves a
soccer accident in 1993 that resulted
in an elbow to the face with trauma
to the right maxillary central incisor.
Approximately one week subsequent to the accident, the patient’s
tooth was treated endodontically. It
eventually became discolored and
grew increasingly out of alignment
(Fig. 1).
Clinically, all other maxillary
and mandibular teeth were in good
condition. Periodontal examination
revealed healthy gingival tissue.
The patient was concerned that his
anterior tooth would fracture unexpectedly and desired an immediate
replacement.

Treatment options
Several treatment options were considered. The first was extraction of
the maxillary right central incisor
and fabrication and placement of a
conventional fixed bridge of porcelain fused to metal or an all-ceramic
system.
The second option was extraction

of the tooth followed by placement
of a removable partial denture. The
next option was extraction, provisionalization with a removable partial denture (flipper) followed by
implant placement, healing while
wearing the flipper and, finally, restoration of the implant.
The best alternative was extraction and immediate replacement of
the extracted tooth with an implant,
followed by immediate loading with
a nonfunctioning provisional. After
adequate osseointegration, a final
restoration would be fabricated.
Advantages and disadvantages
of all options were explained to
the patient. He decided to continue treatment with an immediate
implant restoration. The patient was
then referred to a periodontist for
further evaluation and implant consultation.

Implant evaluation
Implant examination revealed adequate bone height and width for
implant placement immediately following extraction of the failing tooth.
A surgical date was scheduled
with the periodontist for extraction of the tooth and placement of
the implant. An appointment was
coordinated with our office for the
patient directly following the surgical procedure for provisionalization
of the implant.

Surgical protocol
The right central incisor was
removed and a Nobel Replace
Tapered Groovy (internal connection) 5.0 x 13 mm implant was
placed.
An osseous graft of demineralized
freeze-dried bone and a collagen
membrane were utilized to augment the surgical site. The fixture
received an emergence profile-healing abutment. See the radiograph
with implant in place (Fig. 2).

Provisionalization
The patient presented in our office
after the implant placement with
a healing abutment in place. The
healing abutment was removed. A
Nobel Biocare immediate temporary
abutment was placed and a provisional was fabricated.
Care was taken to contour the
emergence of the provisional as
to best support the gingival architecture. The plastic coping for the
immediate temporary abutment was
g CT page 2D

[18] =>

2D Clinical

Cosmetic Tribune | January 2010

f CT page 1D

Fig. 3: Provisional restoration; photo
taken two weeks after surgical placement of implant (case study No. 1).

Fig. 4: Procera zirconia custom
abutment, screw and final restoration (case study No. 1).

Fig. 7: Pre-op photo of lingual view
with fracture (case study No. 2).

Fig. 8: Final restoration before insert
(case study No. 2).

roughened with a 56 carbide bur to
enhance adherence of the integrity
provisional material used.
The provisional was polished and
placed on the immediate temporary abutment with a small amount
of flowable composite to enhance
retention. The provisional crown
was fabricated to be completely out
of occlusion and non-functional to
insure the implant adequate osseointegration time undisturbed by
occlusal forces.
The provisional restoration was
observed periodically during the sixmonth healing process to monitor
gingival adaptation (Fig. 3).

conformity, the zirconium implant
abutment is becoming increasingly
favored by clinicians for esthetically
pleasing anterior implant restorations.8 A Procera zirconia crown was
fabricated for this patient with Noritake CZR porcelain (Fig. 4).
At the time of insert, the provisional crown and immediate temporary abutment were removed. The
Procera zirconia custom abutment
was seated, the screw was hand
tightened and the screw torqued
to 35 Ncm with the manual torque
wrench.
The access was filled with a small
cotton pellet and topped with a thin
layer of flowable composite. The
Procera zirconia crown was then
seated; margins, contacts and occlusion were confirmed; and the crown
was cemented in place with 3M
ESPE RelyX luting cement (Fig. 5).

Final restoration
Six-months post surgery, the patient
was scheduled for placement of the
final restoration. After removing the
provisional crown and the immediate temporary abutment, an implant
impression post was placed, radiographic verification was made to
assure complete seating and a final
impression was taken with a polyether system.
Complex shade mapping was
carefully performed to match the
existing contralateral natural teeth.
The provisional was then reinserted.
A Procera zirconia custom
implant abutment was chosen. Zirconium implant abutments have not
only been noted for their toothlike
color and esthetic appeal, but for
their tissue tolerability, high load
strength and intrasulcular design
enhancement.7
The extraordinary load strength
of the oxide ceramics is not compromised by high bending and tensile
strength, and fracture and chemical
resistance.7 Zirconium abutments
are mechanically equivalent to their
metal counterparts, but boast greater biological compatibility.7
Results of a recent study provide evidence that ceramic oxide
abutments can be safely utilized in
the incisor region of both the maxilla and mandible as determined by
maximal bite forces in the esthetic
zone.7
Due to excellent restorative properties in terms of strength and color

Case study No. 2
This patient, a healthy male in his
late 30s, was examined in my office
for a fractured maxillary right central incisor. The patient had feldspathic porcelain restorations on his
upper central and upper lateral incisors that were placed several years
ago.
He had a history of trauma to the
anterior teeth from a sports injury
and subsequent endodontic treatment. Recent periapical radiographs
showed internal resorption in the
upper incisors (Fig. 6).
The patient sustained additional
trauma to the maxillary right central
incisor through a fall that resulted in
complete fracture of the crown (Fig.
7). The tooth was non-restorable.
After reviewing the different treatment options, the patient decided on
an immediate implant restoration.
Although the maxillary left central incisor also exhibited signs of
internal resorption, it was decided
that treatment of that tooth would be
performed later. Consideration was
given to the poor gingival architecture that results from placing adjacent implants in the esthetic zone.
He was then evaluated by the periodontist for the surgical placement of
the immediate implant for the max-

Fig. 6: Preop radiograph with
internal
resorption
(case study
No. 2).

Fig. 5: Postoperative full-face view
(case study No. 1).

Fig. 9: Occlusal view showing slightly lingual implant placement (case
study No. 2).
illary right central incisor.
The patient’s treatment was similar to that of the patient in case study
No. 1.
The right central incisor was
removed and a NobelReplace
Tapered Groovy (internal connection) 5 x 13 mm implant was placed.
An osseous graft of demineralized
freeze-dried bone was utilized to
augment the surgical site. The fixture received an emergence profilehealing abutment. The patient then
received an immediate non-functioning provisional as the patient did
in case No. 1.

Final restoration
After the six-month healing period,
the final restoration was fabricated.
In this case, a one-piece screwthrough abutment made from a
Nobel Biocare GoldAdapt Engaging
NobelReplace (Fig. 8) was fabricated
in order to obtain the correct emergence profile of the restoration due
to the slightly lingual placement of
the implant (Fig. 9).
The restoration was seated, the
screw was hand tightened and then
torqued to 35 Ncm with the manual
torque wrench. The lingual screw
access was filled with a cotton pellet
and composite restoration (Fig. 10).

Conclusion
As esthetic expectations of patients
and the desire for a convenient
and timely treatment continue to
increase, instantaneous replacement of failing teeth is becoming
more routine.9
In the cases cited above, both
patients had sustained juries to
their anterior teeth as young adults
while engaging in sports. Each of
the patients had been treated endodontically and experienced internal resorption of the traumatized
teeth approximately 15 years later.
Both of the patients’ careers
and lifestyles demanded immediate replacements that were nonremovable and esthetically pleasing.
The failing teeth were extracted and
implants were inserted immediately
and restored the same day with a
non-functional loaded provisional.

Fig. 10: Final restoration in place,
day of insert (case study No. 2).
Immediate placement and restoration of a single implant offers a
highly esthetic and timely treatment
option in the case of internal resorption and tooth failure in the maxillary central incisors.
Furthermore, this treatment eliminates the need for a removable
partial denture while maintaining
the gingival architecture and preventing alveolar bone loss in the
extraction site. CT

Acknowledgements
Custom abutments and porcelain
crowns by Charles Moreno CDT,
Excel Dental Studios.
Implant placement performed by
Dr. Garry Bloch.
A list of references is available
from the publisher.

About the authors
Susan McMahon Petruska,
DMD, has served as a clinical
professor in prosthodontics and
operative dentistry at the University of Pittsburgh School of
Dental Medicine.
She is a guest lecturer in cosmetic dentistry at West Virginia
University School of Dentistry,
and lectures to dentists in the
United States and Europe on
tooth whitening and cosmetic
dentistry. Petruska is a six-time
award winner in the prestigious
American Academy of Cosmetic
Dentistry Smile Gallery competition. You may contact Dr.
McMahon Petruska at:
SouthSide Works Office
2643 East Carson St.
Pittsburgh, Pa. 15203
(412) 381-3969
www.wowinsmile.com
Jessica Forestier was a summer intern in Dr. Petruska’s
office and is now a first year
dental student at the University
of North Carolina at Chapel Hill.

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