Oral Health April 2020 by Annex Business Media

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APRIL 2020

Restorative Challenges FOUR TEAM MEMBERS, ONE GOAL: A TRANSFORMATION STORY THE MISSING CANINE-A PUZZLE WITH FUNCTIONAL & ESTHETIC PIECES

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WHAT MOTIVATES YOU?

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DATA DRIVEN DENTISTRY

MAKING THE INITIAL PHONE CALL COUNT

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What Motivates You?

EDITO RIAL

Les Rykiss, DMD, Dip. ABAD, FASDA, FIADFE

s I write this editorial I certainly feel how time has flown by. Sitting in front of my computer, I realized that my 30th anniversary of graduating from dental school is approaching in May. I thought to myself, “Wow that’s a lot of years!” I started wondering, what is it that motivates me to keep practicing? Herein lies the topic of my Editorial. What or Who motivates us as practitioners to do what we do on a daily, weekly, monthly, and yearly basis? There are no wrong answers here. In fact I am sure that there are many great motivators in our lives. I asked one colleague, and her answer was very simple and to the point: “Seeing the smile on my patients’ faces is my motivation to do the good work that we do even on the most difficult days”. Good answer! In fact when asking more of my friends, that same answer came up more than once. Another motivator: “Self-worth: I try to be the best dentist I can possibly be, patient after patient, day in and day out”. Wow, another great answer. Dentistry takes a lot out of us daily, patient after patient, to maintain our high standards, and for this dentist, that was his internal motivator. Yet another motivating factor that came up more than a few times was: “Money! I love making money and the better I am, and the harder I work, the more money I make. That motivates me!” Ok, a very honest answer and while that is not a prime motivating factor for me, I can certainly see that this would be a driver for many in their day to day practices. The final common motivating factor upon inquiry was “Earning the respect and trust of my patients”. This (as it was explained to me) comes in various forms: “1. Patients telling me how wonderful I am. 2. Appreciating our office care 3. Referring friends and family to our care.” What a wonderful motivator! This really is something

Continued on page 6 ➜

ORAL HEALTH GROUP

@ORALHEALTHGROUP

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Dr Les Rykiss Graduated in 1990 with his DMD from the University of Manitoba . Since then he has been in private practice in Winnipeg, MB. He has diplomate status with the American Board of Aesthetic Dentistry (dip. ABAD). He has Fellowship Degrees in the International Academy for Dento-facial Esthetics(FIADFE), the American Society for Dental Aesthetics (FASDA), and an Associate Fellowship in Laser Dentistry from the WCLI. He received his Cosmetic Dentistry training and is a graduate and Mentor at the Nash Institute for Dental Learning. Also he has also taught restorative and pediatric at the University of Manitoba. He is a member of the Manitoba Dental Association, Canadian Dental Association, Winnipeg Dental Society, the Canadian Academy for Esthetic Dentistry (CAED), The American Society for Dental Aesthetics (ASDA), and past president of the Alpha Omega Dental Fraternity. He is the current Cosmetic Editor for Oral Health Dental Journal and has written articles and has lectured in North America on cosmetic dentistry, digital dentistry, and hard and soft tissue laser use.

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APRIL 2020

CONTENTS

VOLUME 110 NUMBER 4

AESTHETIC D E N T I S T RY

AESTHETIC DENTISTRY 10. Four team members, one goal: A transformation story Jordan Soll DDS; Yair Lenga, Dip. Perio.; Emily Singer, Dip. Ortho.; Steve Somerville, RDT 22. A multidisciplinary case for smile enhancement Ross W. Nash, DDS; Mark Allen, DDS 29. Case study: The missing canine – A puzzle with functional and esthetic pieces W. Johnston Rowe, Jr., DDS, AAACD

39. When is “Good Enough” good enough? Jack D. Griffin Jr., DMD 48. Selfie culture driving more cosmetic dentistry: A case report of conservative, responsible veneers: delivering the smile Susan McMahon, DMD; Joseph Zwickel 54. Principles of smile design treatment planning Jeffery W. Lineberry, DDS, FAGD 67. The “Single Tooth” dilemma Sunny Virdi, DMD 75. Resin infiltration as treatment for an anterior tooth discoloration of developmental origin Nathaniel Lawson, DMD, PhD; Celin Arce, DDS, MS, FACP

EDITORIAL 3. What Motivates You? Les Rykiss, DMD, Dip. ABAD, FASDA, FIADFE

29 83

PRACTICE MANAGEMENT

Sponsored by:

8. Data driven dentistry 103. Dental marketplace For the latest coverage on COVID-19 as it pertains to the dental industry and profession, please visit www.oralhealthgroup.com/news/

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APRIL 2020

Restorative Challenges FOUR TEAM MEMBERS, ONE GOAL: A TRANSFORMATION STORY THE MISSING CANINE-A PUZZLE WITH FUNCTIONAL & ESTHETIC PIECES

WHAT MOTIVATES YOU?

PLUS

DATA DRIVEN DENTISTRY

MAKING THE INITIAL PHONE CALL COUNT

Cover photo by: Caroline Ryan caroline@carolineryan.com 4 A P R I L 2020

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OFFICE

EDITORIAL BOARD MEMEBERS

CONTRIBUTING CONSULTANTS

Dr. Jordan Soll • Editor/Co-chairman Dr. Randy Lang • Co-chairman/Orthodontics Dr. Gary Glassman • Endodontics Dr. Mark Nicolucci • Implantology Dr. Bruce Pynn • Oral and Maxillofacial Surgery Dr. Peter Birek • Periodontics Dr. Les Rykiss • Esthetics Dr. Mark Lin • Prosthodontics Dr. Janice Goodman • General Dentistry Dr. Peter Nkansah • Pharmacology/Anesthesiology Dr. George Freedman • Dental Materials & Technology Dr. Fay Goldstep • Preventive Dentistry/Healing Dr. David Farkouh • Paediatrics Dr. Marina Polonsky • General Dentistry/Laser Dentistry Dr. Bruno Vendittelli • Orthodontic Dr. James Yacyshyn • Practice Management Expert

Dr. Carlos Ochoa • Endodontics Dr. Angelos Metaxas • Orthodontics Dr. Blake Nicolucci • Implantology Dr. Iain Nish • Oral & Maxillofacial Surgery Dr. Howard Holmes • Oral & Maxillofacial Surgery Dr. Jack Griffin • Esthetics Dr. Reza Nouri • Pediatrics Dr. Ross Anderson • Pediatrics Dr. Carolyn Poon Woo • General Dentistry Dr. Keith Titley • Pediatrics Dr. Robert Lowe • Esthetics Dr. Gary Radz • Esthetics Dr. Mitra Sadrameli • Oral & Maxillofacial Radiology Dr. Bo Kryshtalskyj • Oral & Maxillofacial Surgery Dr. Indra Narang • General Dentistry/Sleep Dentistry Dr. Barry Korzen • Endodontics Dr. Goth Siu • Prosthodontics Dr. Joseph Fava • Prosthodontics Dr. W. Johnston Rowe Jr. • Esthetics Dr. Aviv Ouanounou • General Dentistry Dr. Sherif Elsaraj • General Dentistry

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A NEWCOM Media Inc. Publication

Managing Editors: Jillian Cecchini Catherine Wilson 416-510-5125 jillian@newcom.ca Digital Content Coordinator: Marley Gieseler 416-510-6777 marley@newcom.ca Art Direction: Beverley Richards Catherine McKenny Carolyn Brimer Elaine Borg Circulation: Mary Garufi 416-614-5831 mary@newcom.ca

Advertising Services: Karen Samuels 416-510-5190 karens@newcom.ca Director, Business Development: Tony Burgaretta 416-510-6852 tonyb@newcom.ca Senior Sales Manager: Heather Donnelly 416-614-5804 heather@newcom.ca Account Manager: Holly Power 416-510-6846 holly@newcom.ca Classified Advertising: Karen Shaw 416-510-6770 karen@newcom.ca

NEWCOM MEDIA INC.

Chairman and Founder: Jim Glionna President: Joe Glionna Vice President, Publishing: Melissa Summerfield CFO: Trish Saltys Director of Circulation: Pat Glionna

Oral Health, published by Newcom Media Inc., is an independent, monthly professional journal, written and edited for the practicing dentist in Canada, and supervised by an Editorial Board of Consultants from both general practice and major specialties of the profession. The editorial content consists of clinical articles and abstracts from the world’s finest dental literature and monthly departments.The editorial purpose is to provide information on clinical advances in all phases of dentistry. Oral Health is not responsible for the quality of graphic images submitted by the authors. The Editorial Board of Oral Health does not necessarily agree with the claims made for any product advertised. Nor should it be construed that the appearance of any product advertisement in Oral Health implies that the Board either approves or accepts the product. Oral Health reserves the right to edit departmental submissions for content and length. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. ISSN 0030-4204 Yearly subscription rates: Canada 1 year $64.95 + taxes, 2 years $107.95 + taxes (GST/HST #103862405RT0001); U.S. 1 year $70.95; Foreign 1 year $107.95; Single copy Canada & U.S. $10.00; Single copy Foreign $10.00. Printed in Canada. All rights reserved. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 416-614-5831; Fax: 416-614-8861; E-mail: mary@newcom.ca; Mail to: Privacy Officer, Newcom Media Inc., 5353 Dundas St. W. Suite 400, Toronto, ON M9B 6H8. Oral Health is published monthly + a special issue. CANADA POST Publications Mail Agreement No. 40063170. Changes of address notices and orders for subscriptions are to be faxed to (416) 614-8861 or mailed to Circulation Department – Oral Health, 5353 Dundas St. W. Suite 400, Toronto, ON M9B 6H8.

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E DI TORI A L

➜ Continued from page 3

that I can identify with and certainly motivates me as well. However, is this my prime motivator? It’s a pretty strong motivator and often I think how fortunate I am to have such wonderful patients that trust me with their own, and their family members care. Awesome! So why is this not my prime motivating factor? I really had to think this through. I realized that the only thing that motivates me more than the last sentiment, is the respect shown to me by my colleagues. When people in your own profession recognize you for the work that you do, to me it is a compliment like no other. Whether it is colleagues referring their patients, or family members to my care, or having colleagues nominate you for various accolades noting your contribution to the Profession of Dentistry (including being a member of the editorial board of Oral Health), it amounts to the same thing. It feels amazing to think that your peers show trust in you and respect you for what you do. This is the moment where I would like to thank my friends, my mentors, my colleagues, and of course all of my dear patients, for helping me along this 30 year journey. Our profession provides us all with so much, it is my honour to continue on, helping as many as I can along the way. So here’s to the next decade of Dentistry. I can’t wait to see what is in store for us all. Happy spring everyone.

I N F EC T I O N PREVENTION AND CONTROL

Authors Correction Mary Govoni, CDA, RDH, MBA

In the article in the Feb. 2020 issue, “Managing Records Necessary for Sterilization of Instruments and Devices”, there was an error that requires clarification. On page 61 of the issue, a statement was made about SteriLog™ that described it as a system that was not compliant with infection prevention and control standards. Specifically, it states that SteriLog™, and two other systems did not allow 6 A P R I L 2020

Editorial.indd 6

for labeling of packages prior to their placement in the sterilizer. In fact, SteriLog™ is compliant with these standards and does in fact have autoclave safe labels and meets all the infection prevention and control standards. More information on the SteriLog™ system is available at www.sterilog.ca. This author apologizes for this error and any confusion it may have caused.

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2020-03-23 4:14 PM

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Making the Initial Phone Call Count

espite the digital advancements of email, websites and social media, the importance of phone calls remains. When first contacting a dental office, our data shows nearly 75% of patients would prefer doing so by phone. Therefore, you must make sure you take advantage by making the best first impression you can during that call. With this knowledge, it is obvious you must choose the right staff members to be answering the phones. They must be friendly, personable and be trained thoroughly so they impress your potential patients. In fact, 64% of patients agree friendliness and tone of staff on a first call is the main factor in deciding whether to move forward with a practice or not. However, what might not be as obvious regarding the initial phone call to a practice is the importance of having a prompt and personal response as opposed to an automated one. We have all experienced the frustration of making a call and being met with an automated response menu that forces us to choose from a list of set options, oftentimes with no options that perfectly fit our purpose for calling. This could lead to irritation and the patient eventually terminating the call before ever reaching an actual staff member to speak with. With the busy lives that so many of your patients lead while balancing work, family and other duties, they do not have the time to sit through a list of options when they

simply have a few questions or wish to book an appointment. This is shown in our data when approximately 50% of patients responded saying a non-automated response was a factor in their decision on looking further into a practice or not. With this in mind, it is crucial to have someone at your front desk to not only greet the patients that visit your practice, but also to be answering the phones. In a lot of cases, and especially for larger practices, you may want to train multiple staff members to ensure someone is always available to attend to your phones, along with your in-office patients. This will help ensure no potential or existing patients are being discouraged from your practice when they call. Therefore, no income will be lostâ&#x20AC;&#x201D;only gained. As we have established in previous Data Driven Dentistry articles, trust is extremely important for patients when choosing a dentist. It is hard to build a trusting relationship when you are not able to speak with an actual person but are met instead with an automated, non-personal response. Patients want to get to know the staff at your practice so they can judge whether your office will be a good fit for them. The purpose of communicating by phone rather than email is to have the personal connection with another person and to have an instant response, so why take that away from the initial phone call to your practice?

of patients agree friendliness/tone of staff is a factor in first call to dental practice which aids decision on whether to look further into practice. 8 A P R I L 2020

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3/ 4

reason for looking for a new dentist is dissatisfaction with dentist or team.

NEARLY

APPROXIMATELY

3/ 4

1/ 2

of patients chose friendliness of staff as an important factor in a first impression when arriving at a dental office.

62%

of patients say ease of scheduling appointments is a factor in deciding to move further with a dental practice.

of patients prefer to be contacted by phone.

of patients would make first contact by phone.

30%

of patients look for a new dentist because of dissatisfaction with the dentist or team.

During an initial phone call,

of patients say a prompt personal/ non-automated response is a factor in choosing to move forward with the practice.

52%

of patients would consider writing an online review for a dental practice if they had a positive experience.

AROUND

1/ 2 of patients agree that knowledgeable staff is important during the initial call to a dental practice.

Data Driven Dentistry is sponsored by:

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2020-03-18 4:07 PM

In late October and early November, 2018, Bramm Research, a third-party independent research consulting firm, conducted an online survey on behalf of Oral Health. The study was conducted in English

AESTHETIC D E N T I S T RY

Four team members, one goal: A transformation story Jordan Soll DDS; Yair Lenga, Dip. Perio.; Emily Singer, Dip. Ortho.; Steve Somerville, RDT

10 A P R I L 2020

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AESTHETIC DENTISTRY

AB ST RACT Quite often patients have the desire to improve their oral care and appearance but don’t know where to start. Compounding the problem is that when the patient is seeking solutions, they are often turned away or trivialized because their practioner does not have the knowledge or skill to treatment plan the patient’s needs or is not inclined to investigate and present options for the patient, as was the case with this lady. Her dental transformation began when she was referred to a periodontist who had the vision to refer her to an orthodontist and restorative dentist who shared his outlook on the possibilities for the outcome of this case. Through methodical planning in a sequential fashion and ongoing communication between team members resulted in a final result that exceeded the patient’s dreams. It should be noted that a case of this magnitude could not have been accomplished without the patient’s steadfast resolve and determination to follow through with all appointments over the two-year treatment period.

OVERALL PLAN he patient, a 56-year-old female was referred for overall assessment to determine a predictable treatment plan to create an ideal smile that “would make the patient proud of her teeth again”. Due to complications from Cerebral Palsy, the patient is confined to a wheel chair for her mobility. However, once seated in a dental chair, she was extremely cooperative and there were no limitations to performing her treatment. A thorough discussion with the patient confirmed the referring periodontist’s information. The patient was highly motivated to undertake the recommended treatment sequence and was aware that the length of time of treatment was approximately two years. After listening to the patient’s struggles to find someone who would correct her smile without removing all her teeth, I was comfortable moving forward as part of this team (Figs. 1-7). The sequence of events over the next 24 months were as follows; 1) Initial/pre - orthodontic restorative treatment to allow for orthodontic treatment to occur without fear of further destruction of the dentition. 2) Once the dentition was stabilized, the patient began orthodontic treatment. 3) During this phase the patient was on a strict three-month recare schedule alternating between the general dentist and periodontist. 4) Once the orthodontic/retentive phase was complete, the patient underwent maxillary/

mandibular crown lengthening to allow for proper heights and contours of teeth. 5) A fter eight to 10 weeks of healing, 26 full coverage all ceramic restorations were prepared, fabricated and seated. 6) Upper and lower Essix retainers were fabricated to act as retention with alternating three-month recare appointments between the restorative dentist and periodontist. PRE-ORTHODONTIC RESTORATIVE TREATMENT As the orthodontic procedure would take between 18-24 months it was imperative that all necessary restorations were complete prior to orthodontics to insure uninterrupted treatment. As such the following treatment was performed; a) R oot canal therapy on tooth #11 b) Post and core restorations and temporary crowns cemented with permanent cement on teeth #’s 16, 12, 11, 21, 23 c) Composite restorations to restore teeth #’s 32, 33, 42, 44 Once complete the patient was referred to the orthodontist for treatment. ORTHODONTIC PHASE The goals of orthodontic treatment were aimed at ensuring that the patient’s final restorative outcome would be as minimally invasive as possible requiring the least amount of reduction in tooth structure

Dr. Jordan Soll is a Toronto based general practioner with special interest in appearance related procedures. He is principal of Central Dental Group, Co chairman of the editorial board of Oral Health Journal, and the dental expert for City Line with Tracy Moore. Dr. Yair Lenga is a Toronto based periodontist whose experience includes all periodontal and reconstructive procedures including bone regeneration and periodontal plastic surgery. In addition, he has also completed a hospital-based fellowship in anesthesia. He maintains a full-time periodontal practice in the centre of the city. Dr. Emily Singer received her DDS and Masters of Orthodontics degrees from the University of Toronto and completed her dental residency at Sick Kids Hospital. She maintains a full time private orthodontic practice in Whitby, Ontario. Mr. Steve Somerville is the General Manager of DSG Novo, a lab specializing in cutting-edge digitally focused practices.

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A EST H E TI C DE NT I ST RY

10 while ensuring optimal aesthetic and functional outcomes. Treatment objectives included aligning the dentition (especially the severely crowded lower anterior), expanding the collapsed and lingually inclined arches to fill the buccal corridors and provide a wider final smile, opening up the deep bite and improving the upper dental midline. A decision was also made to try and reduce or completely close the space for the missing upper left premolar to prevent the need for prosthetic replacement and additional cost and treatment to the patient. Closing this space also 12 A P R I L 2020

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facilitated improvement of the skewed upper dental midline. Upper and lower traditional twin fixed appliances (American Orthodontics .022 Mini Masters) were placed with self-ligating Empower (American Orthodontics) appliances placed lower 3-3 to facilitate early complete engagement of all of the rotated incisors except the severely lingually displaced 42. Triad buildups were placed on the upper first premolars to facilitate bite opening mechanics. Initial archwire sequencing in both arches was 0.12 Niti, 18 Niti, 19x25 Niti. Once in rectangular archwires, an upper archwire was placed

in the lower arch to facilitate expansion while coiling open space for the blocked out 42. Once space was created, the wire was dropped back to a 12niti to engage the 42 and align it with rest of the arch. An 18x25 SS wire was placed in the upper arch for control during space closure in the upper left and to begin detailing the gingival margins of the upper incisors. Elastics were used in a Class 3 pattern on the right (upper right 6 to lower right 3) and Class 2 on the left (upper left 3 to lower left 6) to improve the midlines and buccal segment relationships (Figs. 8-12). Continued on page 15 â&#x17E;&#x153;

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AESTHETIC DENTISTRY

â&#x17E;&#x153; Continued from page 12

The patient was referred back to both the periodontist and restorative dentist to confirm that the final orthodontic set up would allow them to execute their treatment plans successfully. Once approval of the set up was obtained, appliances were removed and the patient was placed in temporary upper and lower Essix retainers. Overall treatment time was 21 months (Figs. 13-17). After orthodontic treatment, impressions were taken to make diagnostic models. These impressions were poured and mounted in an articulator. Due to erosion the patient had short clinical crowns which made them look wide and short. Our plan was to open the bite to help gain better proportions and to compensate for the erosion. When the models were mounted for review, we were able to see the patient was showing varied gingival heights on their maxillary anterior teeth (Fig. 18). It was decided that a gingivectomy would be performed

to balance the gingival heights in the anterior. This would give us a bit more length and symmetry for the final restorations. A surgical stent was created to help guide the periodontist during the gingivectomy. The stent was also used on the diagnostic wax-up model to ensure we were creating a diagnostic model similar to what would be in the mouth after the surgery. In addition, matrices of the max/mn wax up were made to assist with the fabrication of the temporaries during the restorative phase (Figs. 19-21). After the bite was opened on the articulator and the gums trimmed on the model, a diagnostic wax-up was completed on the upper and lower models. Ideal occlusion and morphology was created on the models and when complete, forwarded back to the dentist. Upon receiving the completed wax up models, they were viewed by the dentist, periodontist and patient. Once unanimous approval was given, the periodon-

tist met with the patient to plan the next phase of her treatment. PERIODONTAL PHASE The patient was evaluated initially (April 19, 2017) prior to her restorative or orthodontic treatment. This first planning appointment consisted of establishing a tentative rendering for what her final esthetic outcome could potentially look like. A more comprehensive evaluation and consultation of the formalized treatment plan as described above was performed approximately two years later (May 14, 2019) once the orthodontic phase of treatment was completed. Ideal anterior cosmetics necessitates healthy and inflammation-free periodontal tissues. Garguilo1 described various components of the periodontal attachment complex, giving mean dimensions of 1.07 mm for the connective tissue, 0.97 mm for the epithelial attachment and 0.69 mm for the sulcus depth. oralhealthgroup.com

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A EST H E TI C DE NT I ST RY

These measurements are known today as the “biologic width”. Since full mouth restorative treatment was being planned, it was imperative to reverse engineer the periodontal attachment complex based on the restorative dentist’s treatment plan. Failure to respect this biologic width would ultimately result in chronically inflamed tissues that would undermine the natural aesthetic outcome that the team was seeking (Ingber et. al).2 Periodontal treatment was performed under IV conscious sedation using benzodiazepines. Maxillary and mandibular Essix-style clear overlay stents that were fabricated were used to transfer the new diagnostic model gingival positions and contours. The gingival positions were marked onto the tissues using the tip of an explorer, and the stents were subsequently removed for the duration of the procedure. The markings were connected by an inverse bevel incision in a scalloped/ parabolic formation, with the gingival zenith located just distal to the long axes of the teeth. Golden proportions were observed such that the length of the central incisors and canines were matched, while the lateral incisors were approximately 1 mm incisal. In the mandible, the gingival margins were all placed at an even level. Full thickness mucoperiosteal flaps were raised across the anterior sextants. Osseous resection was performed only on the buccal surfaces so as to create 3 mm of root surface from the gingival margin to the alveolar crest in keeping with Garguilo’s1 estimates for biologic width. In the mandible a connective tissue graft was harvested from the right side of the palate and placed over the labial alveolar 16 A P R I L 2020

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bone in order to establish a band of keratinized attached tissue. The flaps were apically repositioned and sutured with 4-0 chromic gut sling suture. Post-operative management included prescriptions for amoxicillin 500mg tid for one-week and chlorhexidine rinse 0.12% bid for two weeks, and the patient was given appropriate postoperative instructions. A non-steroidal anti-inflammatory drug (ketorolac; 0.5mL of a 30 mg/mL solution) along with a steroidal antiinflammatory drug (dexamethasone sodium phosphate; 1.5mL of a 4mg/mL solution) was injected by IV, and an ice pack was placed extraorally. A week-long course of antibiotics was prescribed along with anti-inflammatories and analgesics. A two-week postsurgical appointment revealed normal healing. After a healing period of approximately eight weeks, when soft tissue shaping was achieved with probable sulcus, the patient was returned back into the care of the restorative dentist for completion of the restorative phase of treatment. After 8-10 weeks of healing from the periodontal surgery, the patient was ready to proceed with the next phase in her treatment plan (Figs. 22 & 23). After a follow-up consult with the patient it was recommended and agreed to that the restorative appointments would take place over three full days. RESTORATIVE PHASE: PREPARATION On the first appointment the Maxillary arch was prepared and a traditional PVS impression was taken (Fig. 24) (3M Corp. Impregum Impression Material, St. Paul, MN.) The Maxillary Arch

was registered for the articulator with a Kois Registration Table (Panadent) and the impression and registration was sent to the lab with instructions to pour and mount with the prepared lower arch to follow shortly. Maxillary temporaries were fabricated in three section 17-13, 12-22, 23–27, using the matrices derived from the diagnostic wax-up (Protemp 3M Corp. St. Paul MN). The occlusion was balanced, and the restorations polished and cemented with Temp ON (Kerr Corp, Romulus MI). One week later the patient attended for preparation of the Mandibular arch in similar fashion and materials to the Maxillary arch (Fig. 25). Lower temporaries were fabricated and balanced with the previously fabricated maxillary temporaries (Figs. 26-30). To maintain Vertical Height of Dimension (VHD) during the preparation stage of both arches the following protocol was adhered to; a) Preparation of 27-23 – fabrication of temporaries and balanced b) Preparation of 17-13 – fabrication of temporaries and balanced c) Preparation of 12-22 – fabrication of temporaries and balanced d) The same sequence was followed when preparing the lower arch e) When registering the occlusal relationship the 2nd/3rd quad temps were removed and registered. Once they were placed back the 1st/2nd quad temps were removed and registered and replaced At the end of the second appointment the Mandibular PVS impression, right and left occlusal relationships, diagnostic wax up, and alginate impressions

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A EST H E TI C DE NT I ST RY

of the Max/Mn arch temporized were sent to the laboratory to complete the mounting process and fabrication of the Max/Mn restorations. The laboratory instructions requested full contour Zirconia restorations for all premolars and molars, and e Max restorations for all the anterior teeth all in the shade 1M1, Vita Masterpan (Vident, Brea Ca.). LABORATORY PHASE In the lab, the impressions were poured, mounted and scanned into our design software. The models of the provisionals were also scanned so that we could overlay the information of what she had in the mouth. By doing this, we could design the final restorations to match the occlusion that the patient was experiencing and comfortable with. By layering scans of the temporaries and the preps in the software, we were able to keep the design of the final crowns close to the provisionals, with improved esthetics (Figs. 31-33). When we had achieved what we wanted in the software for the restorations, we milled the crowns 18 A P R I L 2020

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Materials for the restorations had to be chosen. It was decided to use Emax in the upper and lower 6 anteriors for its superior esthetics, and Zirkonzahn Prettau zirconia with facial cutback from the premolars and molars as this would provide strength and help the zirconia better match the visual characteristics of the Emax crowns. After milling the crowns, they were finished on the bench, taking care to have the zirconia match the crowns made from Emax. When finished, the crowns were returned to the restorative dentist for insert (Fig. 34). RESTORATIVE PHASE: INSERTION When the restorations were returned from the lab the crowns were checked on the models to ensure that the fit was ideal and there were no chips or blemishes. The patient was scheduled for the third full day appointment to insert the 26 all ceramic restorations. The max anterior restorations (12, 11, 21, 22) were removed without LA, so as not to cause the upper lip to droop during the preview, and the permanent crowns were

tried in using Rely X try in paste (3M Oral Care St. Paul, MN) to simulate cement and add retention during the preview. The patient immediately approved the restorations and requested that they be placed with permanent cement. Local anesthetic was then appropriately applied to the Max/Mn arches. The remaining temporaries were removed and all the abutments were cleaned with Na OH and Pumice mixture. The rest of the crowns were tried in and the patient confirmed her approval. At this time the VHD was confirmed that it was not altered. The Max/Mn anterior eMax crowns were bonded with Rely X Unicem 2 cement (3M Oral Care, St. Paul, MN) and the Max/Mn full contour Zirconia crowns were cemented with Rely X Luting Plus cement (3M Oral Care. St. Paul MN.) Once all the restorations were bonded/ cemented, the margins were checked and cleared of any cement remnants and all contacts were flossed. The VHD was re confirmed and using U shaped articulating paper and shim-stock, the occlusion was balanced in CO and that there were

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2020-03-23 4:39 PM

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A EST H E TI C DE NT I ST RY

35 34

37 38

40A

no interferences in anterior and lateral excursions. The occlusal surfaces of the adjusted crowns were polished with porcelain polishing cups and the buccal and lingual surfaces were polished with diamond polishing paste (Soft Shine, Water Pik, Fort Collins, CO). Upper and lower alginate impressions were taken and sent to the laboratory for fabrication of Max/ Mn Essix appliances. The patient was dismissed with instructions to eat soft foods for a few days and to alert us immediately if she felt any interferences when eating. In addition, the patient was to do warm salt water rinses to assist in healing of the gingival tissues (Figs. 35-39). The patient returned one-week later for the final assessment, insert of the Essex 20 A P R I L 2020

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appliances and final photographs. The patient reported mild sensitivity which dissipated after a few days and is able to enjoy her meals without hesitation. The patient was advised that she will be on alternating three-month recare schedule between the periodontal/ restorative dentist office. At this visit we revisited with the patient the photographs when she first attended and her final shots. For all involved, it was quite dramatic to see the transformation that occurred and how the patient’s outward appearance also changed. For all four professionals involved, the end result and seeing the patient’s smile was extremely gratifying. (Figs. 40A & 40B).

40B

Oral Health welcomes this original article. Acknowledgements: The authors would like to acknowledge the outstanding contributions of the following: 1. Dr. Gary Glassman DDS, FRCD(C) for Endodontic treatment 2. Dr. David Shapiro DDS, MSc (Ortho), FRCD(C) for assistance in Orthodontic treatment 3. Vladimir Marinic Certifed Master Technician (Ceramist)

R E F E R E NCES 1. Garguilo AW. Dimensions and relationships of the dentogingival junction in humans. J Periodontology 1961; 32:261-7. 2. Ingber JS, Rose LF, Coslet JG. The “biologic width” — a concept in periodontics and restorative dentistry. Alpha Omegan 1977; 70(3):62-5.

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2020-03-23 4:42 PM

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AESTHETIC D E N T I S T RY

A multidisciplinary case for smile enhancement Ross W. Nash, DDS; Mark Allen, DDS

INTRODUCTION patient presented for orthodontic care with a chief complaint to straighten her front teeth, eliminate her overjet, and balance her lip eversion. Her dental history included annual dental cleanings and root canal therapy on #9. Due to the skeletal class 2 retrognathic profile, the severity of her mandibular asymmetry, the vertical discrepancies in the maxillary dental arch, and her desire for some facial soft tissue changes, a combination of various disciplines within dentistry were discussed. The patient chose to pursue orthognathic surgery in combination with orthodontics, periodontics, endodontics, and restorative dentistry. The patient visited with an oral surgeon prior to starting treatment. Figure 1 shows the patient’s smile as she presented at our initial meeting. In Figure 2, you can see the occlusal view of the maxillary arch. After an endodontist evaluation of the previously traumatized anterior teeth, #9 was retreated and #10 was endodontically treated as well. Figure 3 highlights #9’s apical fracture during the retreatment which was managed with an apicoecotomy allowing the preservation of the proximal 1/3 of the root, thus the ridge height and bone density for this eventual implant site. The patient also established a plan for three to six-month checkups with a periodontist to remain in place throughout treatment.

ORTHODONTIC TREATMENT Figure 3 shows the initial bonding using Ormco Damon D2 and Damon Clear2 brackets along with the immediately placement of an ORMCO VectroTAS 6mm TAD in the anterior region. The TAD allowed for vertical control of the front teeth, as well as control of the yaw, pitch, and roll of the patient’s smile within the face. In Figure 4, you can see the occlusal view of the maxillary arch with the brackets in place. At the two-year mark of treatment, the patient was ready for restorative treatment. The final tooth positions can be seen in the retracted facial view in Figure

5 with the brackets still in place and with patient smiling Figure 6. The patient was referred to a periodontist (Dr. Paul Gibbs, Davidson, N.C.) for the extraction of #9 and immediate placement of a Straumann bone level RC size 4.1 mm x 10 mm with a healing abutment RC 5 mm X 4 mm in the #9 space. The patient was referred to a restorative dentist at this time to confirm the adequacy of the #9 interdental space. Residual space was also left distal to #7 and #10 to allow for establishing golden proportions for the upper anteriors using veneers. Orthognathic surgery was completed 22 months into treatment. Braces were removed six months later. Following a full occlusal adjustment, upper and lower permanent retainers as well as removable thermoplastic indexes upper and lower were generated. RESTORATIVE TREATMENT Figure 7 shows the patient’s smile after her orthodontic and implant treatment. The retracted facial view can be seen in Figure 8. Our treatment plan involved one implant supported crown for the missing left maxillary incisor and ceramic veneers for the other central incisor and both lateral incisors. Later we would place porcelain veneers on the maxillary canines and premolars. We chose 1M1 on the Vita 3D shade guide as the shade (Fig. 9). Maxillary and mandibular preoperative Impressions were taken using an alginate substitute material (Kettenbach). A centric relation occlusal registration was made (Kettenbach). Finally, a facebow record was made (Denar). The maxillary lateral incisors and right central incisor were prepared for eMax veneers with 0.5 mm of facial reduction, 1.5 mm of incisal reduction. Chamfer margins were placed at the height of the tissue and elbow preparations were taken to proximal contacts. All corners were rounded (Fig. 6). An impression abutment was placed for the implant. The preparations and implant impression abutment can be seen ready for the final impression in Figure 10.

Dr. Ross W. Nash, is a graduate of the University of North Carolina School of Dentistry and practices general and cosmetic dentistry in Huntersville, North Carolina. He is cofounder and Director of the Nash Institute for Dental Learning in Huntersville, N.C. He can be contacted on line at rosswnashdds@aol.com. As a graduate of the Roth Williams Center for Functional Occlusion in 2000. Dr. Marc Allen was engineered to manage some of the most challenging adult orthodontics. The University of North Carolina and The University of Texas along with the Spear Center for Dentistry all prepared him to strive for excellence during the past 20 years of private practice in Charlotte and Huntersville, North Carolina. 22 A P R I L 2020

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2020-03-20 9:57 AM

AESTHETIC DENTISTRY

1. The patient’s smile before treatment. 2. Maxillary occlusal view before treatment. 3. Facial view of orthodontic appliances in place. 4. Occlusal view with orthodontic appliances in place. 5. Orthodontic movement finished. 6. The patient’s smile before appliance removal. 7. The patient’s smile after removal of appliances. 8. Retracted facial view before restorative treatment. 9. Shade chosen. 10. Prepared teeth ready for impressions. to place.

Final impressions were taken using Panasil Extra Light body (Kettenbach) around the margins and heavy body Panasil Putty in the tray. Provision restorations were made by using a putty stint made over a model of the preoperative teeth with a composite tooth placed where the missing central was. A bisacrylic provisional material was injected into the stint, placed on the

prepared teeth and allowed to set. Excess bisacrylic material was removed with a small carbide finishing bur and the temporary restorations were left mechanically locked over the prepared teeth. LABORATORY At the dental laboratory, the impressions were poured up and mounted for

fabrication of the final restorations. A zirconia oxide abutment was fabricated for the implant supported crown. A eMax (Ivoclar) crown and three eMax veneers were fabricated. In Figure 11, you can see the four eMax restorations photographed on a mirror surface. Figure 12 shows the implant abutment and crown before placement. Continued on page 26 ➜

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2020-03-20 9:58 AM

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A EST H E TI C DE NT I ST RY

➜ Continued from page 23

17 11. eMax crown and veneers ready to place. 12. Implant abutment and crown ready. 13. Implant abutment in place. 14. Final restorations in place. 15. Six porcelain veneers ready for placement. 16. Retracted facial view of the final result. 17. Retracted view in occlusion after treatment. 18. The patient’s new smile.

DELIVERY The prepared teeth and implant abutment in place can be seen in Figure 13. The implant abutment was placed first. After the torque of the implant screw was accomplished, the screw was covered with a soft light cured resin and the eMax crown was cemented to place. The internal etched surfaces of the eMax veneers were treated with silane primer (Silane Primer, Bisco), which was allowed to dwell for twenty seconds and air dried with an air/water syringe. A self-curing luting composite (Choice 2, Bisco) was added to the intaglio surfaces of the veneers and placed on the prepared teeth. Excess composite was removed with an explored and the luting agent was light cured with a curing light (SPEC 3, Coltene). Excess cured luting agent was removed 26 A P R I L 2020

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with a small carbide finishing bur and the margins were polished using an Enhance cup by Dentsply. The four restorations are shown after placement in Figure 14. MORE VENEERS A few months later, the patient was ready for ceramic veneers for the maxillary canines and premolars to “finish” her smile. After very minimal preparation, final impressions were taken and sent to the dental laboratory where eMax veneers were fabricated for teeth numbers 4,5,6,11,12 and 13. They are shown photographed on a mirror surface in Figure 15. The veneers were bonded to place as before. THE FINAL RESULT The final result can be seen from the retracted facial view in Figure 16. A view in

occlusion is shown in Figure 17. The patients new smile can be seen in Figure 18. CONCLUSION Planning the vertical position of a smile in a face prior to the bonding is critical for all successful treatment plans. The use of TADs to control the vertical by the orthodontists maximizes the outcome for all disciplines involved in interdisciplinary care. Continual communication throughout treatment enabled us to create a stable, esthetic, and functional result pleasing to all involved, especially, the patient. By using a multidisciplinary approach with orthodontics, implant placement and ceramic restorations, we were able to provide this patient with the smile she desired. Oral Health welcomes this original article.

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2020-03-20 10:00 AM

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2020-03-24 10:30 AM

AESTHETIC D E N T I S T RY

Case study: The missing canine – A puzzle with functional and esthetic pieces W. Johnston Rowe, Jr., DDS, AACD

INTRODUCTION ew restorative situations provide more stress for a functionally driven esthetic dentist than one involving a missing canine. A missing cuspid creates not only an esthetic issue, but a functional complication, as well. While group function may be viewed as a viable alternative in the absence of a canine, anterior and cuspid guidance is undisputed as the preferred functional relationship for natural dentition. Improper guidance can lead to muscle hyperactivity, pathologic wear, and symptoms of temporomandibular joint disorder.1 A great opportunity for improvement exists in restoring a missing canine, but great care must be taken to avoid functional risks.

CASE STUDY: DIAGNOSIS An 18-year-old female in excellent medical and dental health presented for restorative consultation stating she maintains annual dental cleanings, has whitened her teeth in the past, and has just had her braces removed following completion of orthodontic treatment. The patient stated that her upper left permanent canine (#11) had been extracted in her youth due to malpositioning of the tooth. As she grew older, the patient had become unhappy with the alignment of her teeth, so she and her father sought out an orthodontist and requested treatment. Prior to initiation of orthodontic treatment, the orthodontist had discussed the patient’s desires for handling her missing canine, and she stated her intention to eventually restore the missing tooth. Upon completion of her orthodontic treatment, the patient asked for a referral to a restorative dentist and was introduced to our office. (Fig 1). The patient was wearing an orthodontic retainer with a prosthetic #11 attached to the acrylic palate (Fig. 2). She was particularly interested to learn her options for restoring her missing cuspid. Options for restoring the patient’s missing canine were discussed including a removable prosthesis, various designs of fixed partial dentures, or the op-

tion of an endosseous dental implant. She expressed her desire to have a beautiful, “natural” smile without pursuing additional orthodontic or periodontal options outside of restoring #11. A panoramic radiograph was made (Fig 3). Other than generalized blunting of tooth roots being noted, there were no significant pathologic concerns found. Adequate space for restoration of the patient’s upper left canine with an endosseous implant was observed. Clinical examination revealed a Class I dental relationship with no significant occlusal interferences. The patient exhibited a maxillary cant and some facial asymmetry. Absence of the maxillary left osseous canine eminence was noted, as well as less than optimal width and height of bone in the area of #11. The angulation of the clinical crown of the patient’s maxillary left lateral incisor was noted to be divergent from her midline (Fig. 4). Several areas of gingival asymmetry were also noted.2 Evidence of mild wear was found on the patient’s anterior teeth, however, the patient exhibited no symptoms of any temporomandibular disorder and appeared asymptomatic during a TMJ evaluation. The patient was then referred to an oral surgeon for a surgical consultation. TREATMENT PLAN After an interdisciplinary case conference between the oral surgeon and the restorative dentist, the patient was asked to return for a planning appointment.2 Following discussion of esthetic restorative options for her smile, the patient elected to pursue restoration of tooth #11 with an endosseous implant and treatment of tooth #10 with a minimal preparation porcelain veneer. The patient emphasized that a natural, conservative, long-lasting result was her primary goal. Proper care for the future restorations was discussed including nightly wear of a hard-protective occlusal guard/orthodontic retainer, and the importance of optimal maintenance including regular cleanings and examinations was stressed.3

Dr. Rowe maintains a private practice dedicated to excellence in general, cosmetic, and complex restorative dentistry in Jonesboro, Arkansas. He is an Accredited Member of the AACD, past member and Chairman of the ABCD, and has served as the AACD’s Chairman of Accreditation. He also serves as an Accreditation Examiner for the AACD. Dr. Rowe has been awarded Fellowships in the International College of Dentists and the Pierre Fauchard Academy. He is a graduate of the University of Tennessee College of Dentistry, and is a formally trained artist having graduated from Washington and Lee University with a BA degree in Studio Art. Dr. Rowe enjoys sharing his passion for cosmetic dentistry materials and techniques, lecturing nationally and internationally, and can be contacted at info@rowesmiles.com or 870.932.4126.

oralhealthgroup.com

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A EST H E TI C DE NT I ST RY

3 1

5 4 1. Preop full face photograph. 2. Orthodontic appliance with prosthetic #11. 3. Preop panoramic radiograph. 4. Divergent angulation #10 and defect #11. 5. Multiple shade tabs for reference.

A comprehensive set of records was made of the patient’s preoperative condition including a detailed lab prescription to allow for proper communication between the dentist and the ceramist. Honigum Pro (DMG America; Ridgefield Park, NJ) polyvinyl siloxane impressions were made of both arches, and study models were fabricated in die stone.3,4,5,6 Occlusion was recorded with a Futar D (Kettenbach; Eschenburg, Germany) polyvinyl siloxane bite registration and a facebow transfer. Digital photographs documenting the preoperative shade, texture, and shape of surrounding teeth were made.3,4,6,7 All records were sent to the lab where the study models were mounted on a Stratos 2000 semi-adjustable articulator (Ivoclar Vivadent; Amherst, NY), and teeth #10 and 11 were waxed to full contour. Careful attention was given to the incisal and lingual contours to ensure that they conformed to the patient’s anterior and canine guidance. A Sil-Tech (Ivoclar Vivadent; Amherst, NY) polyvinyl siloxane stent was then formed to fabricate an incisal reduc30 A P R I L 2020

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tion matrix. A Biocryl X (Great Lakes Dental Technologies; Tonawanda, NY) radiopaque acrylic surgical guide was also fabricated and delivered to the patient’s oral surgeon to assist in implant placement. DESCRIPTION OF TREATMENT The patient was able to view and approve the diagnostic wax up presented on mounted study models prior to any preparation of her #10 tooth.3,4 Under color corrected lighting, digital photographs were made from multiple angles with at least two shade tabs per photograph to assist in shade matching and color mapping (hue, chroma, and value) prior to any dehydration of the teeth (Fig. 5).3,4 A shade map was also produced by the dentist to be used as a complimentary guide for the ceramist. The patient was then referred back to the oral surgeon for implant placement surgery. Profound anesthesia of the #10/11 area was obtained through the use of topical benzocaine and lidocaine HCl 2% and 1:100,000 epinepherine injection (Sep-

todont; Lancaster, PA). The patient’s lips were adequately and comfortably retracted for the entire procedure using an Optragate lip retractor (Ivoclar Vivadent; Amherst, NY). Initial tooth preparation was completed with a 2000.10 Two Striper super-coarse grit diamond bur (Premier Dental; Plymouth Meeting, PA) in a high-speed handpiece under copious water spray. Adequate incisal (1.5 mm) and facial (.75 mm) porcelain thickness needed to provide room for layering, slight color change, and addition of incisal effects in the porcelain was confirmed with the lingual and incisal polyvinyl siloxane stent.3,4 A well defined cervical margin was established with a 703.8F diamond bur (Premier Dental; Plymouth Meeting, PA) to provide a positive veneer stop with a smooth, cleansable, precise porcelain to tooth interface while allowing for development of proper emergence profile.3,4 Abrasive discs (Cosmedent Inc.; Chicago, IL) in a slow speed handpiece were used to eliminate any sharp angles that could provide for internal stress points.3,4 Photographs of the

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9 6. Preparation shade #10. 7. Provisionals #10 & 11. 8. Implant #11 with cover screw. 9. DuraLay abutment seat jig. 10. Seated abutment #11.

preparation were made and a preparation shade of st9 (Ivoclar Vivadent; Amherst, NY) was recorded (Fig. 6). The patientâ&#x20AC;&#x2122;s teeth were cleaned with Consepsis chlorhexidine (Ultradent Corp; West Jordan UT). A polyvinyl siloxane stent made from the diagnostic waxup was filled with B1 Luxatemp Ultra (DMG America; Ridgefield Park, NJ) and placed over the prepared tooth and implant placement site and allowed to cure. After approximately one-minute, the stent was gently removed with the provisionals remaining inside. The provisionals were removed from the stent, trimmed, ovate pontic formed, and then seated with Optibond FL resin (Kerr Corp; Orange, CA) bonding the pontic to the mesial of tooth #12. The lingual aspect of the provisionals were reinforced with B1 Luxaflow composite (DMG America; Ridgefield Park, NJ). They were cured for 30 seconds on each tooth with the Bluephase LED curing 32 A P R I L 2020

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light (Ivoclar Vivadent; Amherst, NY). Excess material was removed with a #12 scalpel blade, and the provisionals were smoothed and finished with abrasive discs (Cosmedent Inc.; Chicago, IL) and a rubber cup polisher (Cosmedent Inc.; Chicago, IL). Occlusion was verified and checked and the patient was appointed for a post-operative check twenty-four hours later. The 24-hour post-operative check appointment was particularly important because it allowed the patient to express feedback based on self-analysis of the proposed shapes and contours of the provisionals (Fig. 7). The patient reviewed and approved the shape of her provisional restorations and the shade tabs selected at the prior appointment. Proper occlusion and anterior guidance were evaluated confirmed utilizing articulating paper and shim stock. Photographs of the approved provisional restorations and shade tabs were made. Other pro-

visional records were made including a Futar D stick bite (Kettenbach; Eschenburg, Germany) in centric occlusion and a Honigum Pro polyvinyl impression (DMG America; Ridgefield Park, NJ) of the approved provisionals. All records were disinfected and sent to the ceramist accompanied by a completed laboratory prescription and all photographs taken to this point. The ceramist was instructed to use the impression of the approved provisionals as a guide for the final shape, size, and contour of the porcelain restorations. The patient was instructed to return to the oral surgeon for implant placement. After placement of a NobelActive NP 3.5x13 implant (Nobel Biocare; Zurich, Switzerland) with a cover screw and osseointegration confirmed by the oral surgeon after three months of healing, the patient was referred back to commence implant restoration. During the healing phase the patient had continued

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2020-03-24 10:05 AM

AESTHETIC D ENTISTRY

into position. A Futar D (Kettenbach; Eschenburg, Germany) stick bite of the teeth in centric occlusion was made and photographed.

11 11. Abutment seat check.

LABORATORY PHASE During the final provisional phase, the patient was able to further reevaluate the provisional restorations. If she had requested any changes, they could have been communicated to the ceramist during this period. No changes were requested during this time. On the ceramist’s receipt of the case, the records were reviewed and the material choice on the prescription was confirmed during a telephone conversation.2 Shape, shade, and characterization were discussed again and finalized in the planning stage. Producing the patient’s desired shade choice dictated e.Max MTBL2 blocks (Ivoclar Vivadent; Amherst, NY) to be milled as a base shade for the veneer and implant crown. Cutback and layering of the milled veneer and implant crown was planned to develop restorations with the requested moderate incisal character and natural gingival staining with a lightly textured, polished gloss finish. Zirconia bonded to a titanium base was used to fabricate a custom implant abutment. Master full arch working die models were fabricated of the prepared tooth and the implant (with a lab analog) and mounted on a Stratos 2000 semiadjustable articulator (Ivoclar Vivadent; Amherst, NY) during the laboratory phase. The custom zirconia abutment was fabricated and tried on the model for appropriate emergence profile. Marginal accuracy of the full contour milled veneer and implant crown was then confirmed on the physical die models. Cutback of each full contour milled unit was performed as needed to allow for hand layering of IPS e.Max Ceram porcelain (Ivoclar Vivadent; Amherst, NY) to develop realistic translucency, depth, and character. Following layering and firing, each unit was hand finished and polished. The ceramist meticulously

Shape, shade and characterization were discussed again and finalized in the planning stage to wear the bonded provisional (Fig. 8). The provisional was removed to visualize the implant. The cover screw was removed and an open tray style impression coping was screwed into the implant. A check film radiograph was made to confirm accurate and positive seat of the impression coping. Expa-syl gingival retraction paste (Acteon Group; Mèrignac, France) was expressed around the gingival margins to provide hemostasis and adequate tissue reflection. After three minutes, the paste was rinsed away with a copious, forceful water spray. The preparation and impression coping were dried and a master polyvinyl impression was made with Honigum Pro Light and Heavy impression material (DMG America; Englewood, NJ). Following set of the polyvinyl material, the impression coping was unscrewed and removed as part of the master impression. The implant cover screw was replaced and the provisional was once again bonded

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A EST H E TI C DE NT I ST RY

13 12. Pre-op and Post-op retracted views. 13. Pre-op and Post-op full smile views.

confirmed fit, esthetics, and function. The intaglio of each porcelain unit was lightly sandblasted and then acid etched for one-minute with 9.5% HCl (Keystone Industries; Gibbstown, NJ). The veneer, crown, and abutment were then steam cleaned and carefully packaged for return to the dentist ready for the seat appointment. CEMENTATION On return from the ceramist, the porcelain restorations and abutment were inspected on the dies for marginal fit and on solid models for proper interproximal contacts. Profound anesthesia was obtained through the use of lidocaine HCl 2% and 1:100,000 epinepherine injection (Septodont; Lancaster, PA). An Optragate lip retractor (Ivoclar Vivadent; Amherst, NY) was placed to assist in isolation. The provisional restoration and cover screw were removed, and the preparation and implant interface were cleaned to remove 34 A P R I L 2020

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any residual resin temporary material or debris. The implant abutment was seated using a DuraLay acrylic (Reliance Dental Manufacturing LLC; Alsip, IL) seating jig (Figs. 9 & 10). Positive seat was confirmed with a radiograph prior to torquing the abutment to place (Fig. 11). The seated abutment was then torqued to 35Ncm per manufacturer’s instructions. The porcelain restorations were then tried into the patient’s mouth and evaluated for fit and esthetics (first individually, then together). The patient was then allowed to view and approve the esthetics of her smile in a hand mirror.8 The approved restorations were removed from the patient’s mouth and carefully cleaned with Ivoclean cleaning paste (Ivoclar Vivadent; Amherst, NY) to remove any possible contamination. They were rinsed, dried, and Monobond silane coupling agent (Ivoclar Vivadent; Amherst, NY) was applied to the intaglio.9 Following one minute they

were air dried, and a thin coating of All Bond Universal bonding agent (Bisco; Schaumberg, IL) was applied to the inside of the veneers and air thinned. Vitique Clear Veneer Cement (DMG America; Ridgefield Park, NJ) was then applied to the restorations and they were immediately placed into a ResinKeeper light-safe box (Cosmedent Inc.; Chicago, IL) to prevent polymerization of the resin.3,4 The implant abutment was retorqued to 35Ncm to compensate for any possible settling and tef lon tape was placed in the implant screw access hole and covered with f lowable composite. The abutment was cleaned with Ivoclean cleaning paste (Ivoclar Vivadent; Amherst, NY) and the #10 preparation was acid etched for 15 seconds with 35% Select HV phosphoric acid gel etchant (Bisco; Schaumberg, IL) followed by rinsing with a copious air and water spray. 3,4 The #10 preparation was lightly dried, but not

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AESTHETIC D ENTISTRY

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15 14. 1:1 Pre-op and Post-op retracted views. 15. Post-op completed case.

dessicated while the abutment was dried thoroughly. 3,4 A thin layer of Z-Prime Plus (Bisco; Schaumberg, IL) zirconia primer was applied to the #11 abutment and air dried. Two coats of All Bond Universal bonding agent (Bisco; Schaumberg, IL) were applied to both #10 and 11 and agitated for 20 seconds prior to air thinning to evaporate solvents. Tooth #10 and abutment #11 were cured for 20 seconds with a Bluephase LED curing light (Ivoclar Vivadent; Amherst, NY). The veneer and crown were then removed from the light-safe box and seated on their respective preparations. Excess cement was removed with a Regular Microbrush (Microbrush International; Grafton, WI) and they were tacked into place for five seconds each with the curing light.10 Additional excess was removed gently with a scaler,

f loss was passed through the contacts in the apical direction only, and the restorations were then cured fully for an additional 30 seconds each.10 The margins were then inspected and any excess cured cement was removed with a #12 scalpel blade.10 Interproximal areas were cleaned with Epitex finishing strips (GC America; Alsip, IL). DeOx oxygen inhibiting gel (Ultradent Corp; West Jordan, UT) was expressed around all margins and the restorations were cured an additional 10 seconds to finalize polymerization. 3,4,9 The lingual aspect was then polished with diamond paste and Flexibuff polishers (Cosmedent Inc.; Chicago, IL) in a slow speed handpiece and isolation was removed. The patient’s occlusion was checked and smooth, proper contacts were verified with dental floss. Post-operative

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home care instructions were given and the patient was scheduled for a followup appointment for radiographic and photographic documentation as well as a follow-up check for function and esthetic evaluation. The patient returned the following day. Her functional occlusion was evaluated, and her teeth were inspected for any residual cement. Maxillary and mandibular alginate impressions were made along with a polyvinyl siloxane bite registration for fabrication of a maxillary full arch bite guard/orthodontic retainer for nighttime wear.3 Post-operative home care instructions were given and the patient was scheduled for a follow-up appointment for radiographic and photographic documentation, a final check for function and esthetic evaluation, and deREF EREN C ES 1. Dawson, Peter E. Evaluation, Diagnosis, and Treatment of Occlusal Problems. The C.V. Mosby Co.: St Louis, MO; 1989. 2. American Academy of Cosmetic Dentistry. Diagnosis and Treatment Evaluation in Cosmetic Dentistry: A Guide to Accreditation Criteria. Madison (WI): The Academy; 2001. 3. Dawson, Peter E. Evaluation, Diagnosis, and Treatment of Occlusal Problems. The C.V. Mosby Co.: St Louis, MO; 1989. 4. Magne, Pascal. Bonded

livery of the patient’s maxillary appliance (Figs. 12 & 13).3 CONCLUSION A missing permanent canine presents a complex esthetic and restorative problem. Meticulous attention to both function and esthetics are essential to achieving restorative success. With careful planning and precise execution, contemporary dentistry is able to deliver beautiful, functional, and long-lasting results that exceed patient expectations (Figs. 14 & 15). Oral Health welcomes this original article. Acknowledgements: The author would like to express sincere appreciation to Wayne B. Payne, MDT, AAACD and Tyler Payne for their technical expertise and beautiful porcelain work.

Porcelain Restorations in the Anterior Dentition A Biomimetic Approach. Quintessence Books: Chicago, IL; 2002. 5. Gurel, Galip. The Science and Art of Porcelain Laminate Veneers. Quintessence Books: Chicago, IL; 2003. 6. Rufenacht CR. Fundamentals of Esthetics. Quintessence Books: Chicago, IL; 1992. 7. Fradeani, Mauro. Esthetic Analysis A Systematic Approach to Prosthetic Treatment Volume 1. Quintessence Books: Chicago, IL; 2004.

8. Goldstein, Ronald E. Esthetics In Dentistry. B.C. Decker, Inc.: Hamilton, Ontario; 1998. 9. Flax, Hugh. Smile Enhancement With Laser TechnologyPredictable and Esthetic: A Case Report. The Journal of Cosmetic Dentistry. 23(1): 92-98, 2007. 10. Touati B, Quintas AF. Aesthetic and Adhesive Cementation for Contemporary Porcelain Crowns. Practical Procedures in Aesthetic Dentistry. 13(8): 611-620, 2001.

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MANUSCRIPT

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2020-03-18 9:41 AM 2019-12-09 10:27 AM

AESTHETIC D E N T I S T RY

When is “Good Enough” good enough? Jack D. Griffin Jr., DMD

”I

always do the best for the patient”. That is noble, we’ve all said it and absolutely should practice that way. However, our ability to deliver on this is often limited by many factors including patient desires, ability to afford treatment, and practice limitations. It’s very rare that a patient comes into the office wanting only the absolute best care possible regardless of what it costs. It’s much more common for a patient to say “do whatever my insurance will pay for”. From a practice management point of view, doing excellent work doesn’t always have to be the most expensive. If fact, with the proliferation of fee cutting insurances, corporate dentistry, increased competition, and managed care, being prudent with office expenditures is more important than ever and perhaps more of a determinant on materials and procedures than ever before. When we can provide excellent service for less cost, that can be a win-win for both the office and the patient. With indirect restorations, we strive for aesthetic, comfortable, and durable consistency. If the goal was to truly do “the best” work possible in every case, we could always hire one of the cosmetic guru ceramists who charge more nearly $1000 (USD) per unit. There are certain cases where that expertise is worth every penny; but not always. What are we willing to pay per unit and what is our (and the patients) return on that investment? When is “good enough” good enough? TRENDY INDIRECT MATERIALS There are generally three materials that dominate crown and bridge materials today; lithium disilicate, anterior zirconia, posterior zirconia. They all have an excellent record of clinical success and can meet the esthetic demands of many clinical situations with or without layering porcelain and customization. For conservative restorations like veneers, where most, if not all, of the adhesion is to enamel, a silicabased ceramic like lithium disilicate is hard to beat. Plus, when bonded to etched enamel with a bonding

agent and composite luting material, the longevity is undeniably excellent. Monolithic lithium disilicate has a flexural strength of 360-400 MPa which is quite good with an excellent history of service if the preparation and cementation are sufficient whether in the anterior or posterior. Zirconia has become the market leader in volume because, simply put, it works well. Anterior (high translucency) zirconia has less flexural strength (750-850 MPa) than its older, more opaque posterior zirconia cousin (1050-1300 MPa) and can often give a more natural vitality because of this. There is now even a choice to have both the more translucent anterior and more strength posterior zirconia blended in one restoration (e.max ZirCAD Prime (Ivoclar) resulting in arguably the best esthetics ever in a non-layered restoration. TO LAYER OR NOT TO LAYER Certainly, all three of these materials can be customized with layering when the situation demands a higher cosmetic standard. In the hands of the right ceramist the beauty and realism can be incredible. So, for those premium cases, a great ceramist and layered restoration can be the ultimate in aesthetics. But there is a significant expense. The two main reasons NOT to layer are strength and cost. No doubt that cutting back and adding characterization porcelain can add beauty, depth, and realism, but may not be as durable as a monolithic one. The flexural strength of the add on materials is weaker than the substructure, generally 150200 MPa, which is the “weak link” compared to the stronger, non-layered material and more likely to chip or break. With that in mind, even in anterior cases, a non-layered lithium disilicate or anterior zirconia restoration may at times be “best”. So, some of you reading this will say, “I never compromise and only do the best”. No one can argue with that. Many of us though, practice in an environment where fees and overhead are a concern and we don’t

Dr. Griffin is a full-time practitioner and has owned multiple practices in the St. Louis area for 30 years. He has earned Diplomate status with the American Board of Aesthetic Dentistry, Accreditation in the American Academy of Cosmetic Dentistry, Masters in the Academy of General Dentistry, and Diplomat International Academy for Dento-Facial Esthetics. He has had the honour of being published many times, contributed to product review and development, is a member of the highly respected Catapult Group of instructors, and is a clinical director for the Pacific Aesthetic Continuum.

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A EST H E TI C DE NT I ST RY

have an unlimited amount to spend on “the absolute best” (whatever that means). The best blend of value, aesthetics, and function depends of course the unique view of each practitioner and with the ongoing development of stronger, more aesthetic materials, that view keeps changing. It hasn’t been that long since we were doing platinum dies and 100% water-powder hand stacked feldspathic porcelain for our high-end cases. Generally speaking, the lab fees for a non-layered restoration is considerably less than one with cut back, layering, and customization. That is fair. With less expenditure of time and often without the help of a certified ceramist, a lab has less investment in time and labor with a monolithic 40 A P R I L 2020

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restoration. Particularly with digital impressions and model-less restorations, the fabrication cost per unit is reduced and turnaround time often faster. That is often “good enough”. MONOLITHIC ANTERIOR ZIRCONIA CASE In this case, the patient had interproximal decay, failing restorations, irritated gingiva, uneven color, and a worn dentition (Figs. 1-3). I forgot to mention that she had a limited budget. She wanted to have her smile improved but her insurance lowered the fee to $739 (USD). Despite wanting to do “the best”, budget and reality made us head towards “good enough” (Figs. 4 & 5). Teeth were prepped, decay removed, build ups done, and impressions taken. Teeth were cleaned with 2% chlorhexidine

(Cavity Cleanser, Bisco) and temporaries placed in the shade closest to what the patient chose for the final restorations (ProV Temp, Bisco). All records were sent to the lab with a complete set of pre-op and procedure photos. After one-week in temporaries the patient returned for a follow up to evaluate color, length, and experience with the temps (Fig. 7). Polishing was done, photos taken, and desired changes communicated with the lab (Fig. 8). The preps were conservative but done in full coverage to cover old restorations, decay, and missing enamel (Fig. 9). To best meet the needs of the patient within the financial constraints, we asked the lab to use monolithic “anterior zirconia” full coverage restorations in shade 0.5M1 as the patient chose (Fig. 10). The

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anterior zirconia, without layering porcelain, is opaque enough to cover the color of the model underneath but transparent enough to maintain vitality (Fig. 11). The lab put facial anatomy and slight character stain in the glaze for an excellent aesthetic result (Fig. 12). BIO-INTERACTIVE CEMENTATION At the insertion appointment, the temps were removed, restorations tried 42 A P R I L 2020

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in, a cleaner applied (ZirClean, Bisco), rinsed, and dried (Fig. 13). Anterior zirconia has the strength to be cemented with almost any material but our preference is to use a regenerative, bio-interactive, self-adhesive, dual cure cement because of its excellent tissue response (TheraCem, Bisco) (Fig. 14). The teeth were isolated, cleaned again with 2% chlorhexidine, and restorations placed two at a time starting with the

central incisors and working posteriorly (Figs. 15-16). We allow the chemical cure to begin first without light curing and start clean up after initial set by pushing up down at each papilla, going around the margins with a CH3 explorer, and removing the semi-set material in several large pieces (Fig. 17). This easy to clean up cement is light cured only after complete clean up including f lossing. Not

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20 18

also the transparency of the anterior zirconia when the curing light is applied (Fig. 18). CRITIQUE The soft tissue response is good (Fig. 19). The noted translucency of these monolithic restorations is good even with this light shade with a slight influence of the preparations underneath in the gingival 2/3 of each one (Fig. 20). To be critical 44 A P R I L 2020

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and honest, the upper left cupid, which was necrotic with a metal post, could have been more opaque or I could have done better hiding the grayness with a more opaque build-up, replacement of the post, or a less translucent restorative material. The value of monolithic restorations can be excellent depending upon the clinical situation and patient circumstances (Figs 21-23). I certainly could have ordered a cut back and several different character

layering ceramics added. That certainly creates more of a “wow” effect for us dentists to look in the journals, but we’ve all probably had patients who weren’t as excited about the incisal translucency and tertiary anatomy as we were. When the restoration provides patient pleasing service for many years, it is always “good enough”. Oral Health welcomes this original article.

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AESTHETIC D E N T I S T RY

Selfie culture driving more cosmetic dentistry: A case report of conservative, responsible veneers: delivering the smile Susan McMahon, DMD; Joseph Zwickel

ocial media has arguably become a global obsession. For teenagers and young adults, Facebook, Twitter, Instagram, and Snapchat have become the most common form of communication. Teens are increasingly posting photos of themselves and friends. Beauty standards have changed significantly over the past several decades. As our social media and “selfie culture” continues to grow, an undeniable obsession to have the perfect appearance has emerged. Youtube, Instagram, Facebook, and Snapchat and other social media platforms facilitate comparison to others in many ways including appearance. Unfortunately, these comparisons are not completely accurate and can lead to “compare and despair” feelings. Editing applications and filters now allow people to digitally enhance their appearances (eg. smoother skin, whiter smiles, more contoured faces). Appearance and self-esteem have long been intertwined. Self-esteem is considered to play an important role in psychological adjustment and educational success.”1 A new occurrence termed “Snapchat dysmorphia” is transpiring at an alarming rate. In an attempt to look more like the filtered versions of themselves, patients are seeking out more cosmetic procedures than ever.2 With this rising pressure to have the ideal esthetic appearance, teens and young adults are more commonly turning to cosmetic dentistry to help create an ideal looking version of themselves. As dentists, we can play a crucial role in their quest to have “social media worthy” smiles. Before we can provide these cosmetic services, we have to understand the patient’s desired outcome. A smile evaluation of the patient should be used to determine the most conservative methods, materials, and techniques to achieve the patient’s desired smile while considering the patients long term dental health. Enamel recontouring, direct composite bonding, minimal prep veneers, traditional veneers, full crowns, gin-

gival recontouring, whitening, orthodontics and combinations of these are all possible treatments. Choosing the most conservative option is especially important for younger patients. For a long time, the material of choice for cosmetic and conservative procedures was composite resin. However, the low durability of this material leads to esthetic damage due to color instability. In addition, its organic matrix degrades and it absorbs water; therefore, the material needs constant maintenance and polishing to prolong the duration of its useful life. Porcelain greatly mimics the natural structure of dental elements and is an excellent option to avoid the various deficiencies of composite resin.3 When preparation of tooth structure is necessary to achieve the desired results, restricting the preparation to enamel is considered to be a critical factor for a favorable bonding strength, thus more durable outcome. Additionally, preserving the interproximal contact is recommended in most of the literature and studies, this is due to preserving more enamel and tooth structure, allowing a positive seat for cementation in a conservative approach.4 The following case exemplifies a young man with a pleasing smile and attractive teeth who was not satisfied and sought cosmetic dentistry to idealize his smile. CASE STUDY: MINIMAL PREP VENEERS, WHITENING, GINGIVAL SCULPTING This young man’s chief concern was, “I do not like the unevenness and color of my teeth. I hate the dark space between my front teeth too. I don’t like the shape of my two front teeth. I want veneers”. This patient had orthodontic treatment as an adolescent and teeth whitening several times. His dentition and periodontium were healthy. In order to ascertain the patient’s desired outcome and assess his clinical situation, a smile evaluation was performed. An ideal smile based on academic considerations may not be

Susan McMahon has enjoyed a successful career for over 25 years in the dental industry. Dr McMahon is an accomplished Cosmetic Dentist, national Key Opinion Leader in the dental industry, educator, and author. She is an entrepreneur with 25 successful years in small business. Developing systems and teams for consistency, providing excellent products and offering unparalleled customer service are the hallmarks of the brands she has created. Dr. McMahon has restaurant experience and understands the process of managing a successful small business. Joseph Zwickel is the President of the Academy of General Dentistry at his dental school and was instrumental in the development of an implant fellowship track program. 48 A P R I L 2020

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2020-03-24 10:58 AM

AESTHETIC DENTISTRY

1. Pre-op Full Face. 2. Pre-op retracted. 3. In-office whitening followed by take home whitening. 4. Shade Mapping post whitening, pre-prepping.

perceived as the most attractive by laypeople. Due to the variation in esthetic perception by each person, participation between providers and patients for decision-making and treatment planning is crucial to generate successful results.5 His smile evaluation revealed uneven gingival contours, asymmetric lengths of the lateral incisors, a small dark triangle between the central incisors, and banding of colors on his anterior teeth (Figs. 1 & 2). After smile evaluation and discussion with the patient, a plan was formed to idealize the smile with and reshape the anterior teeth with straighter incisal edges. To idealize the smile, the gingival heights would be addressed with gingival sculpting, the upper central and lateral incisors would be reshaped, and the

remaining dentition would be whitened again. A conservative treatment option would be to use direct composite bonding to close the dark triangle, reshape the central incisors and lengthen the left lateral incisor. Direct composite bonding was ruled out because adding 2-3 mm of unsupported composite to the incisal edge of the left lateral incisor in composite would have compromised retention. The other restorative option would be porcelain veneers either traditional or minimal prep. The perfecting of current ceramic systems, especially pressed ceramics reinforced with lithium disilicate, has brought us back to the idea of no-prep veneers. Although these veneers achieve thicknesses similar to those of feldspathic ceramics, lithium disilicate

ceramics allow for restorations of up to 0.2â&#x20AC;&#x2030;mm in thickness with greater clinical and laboratory ease. Because of their better mechanical properties, these restorations can be made, finished, tested, and cemented more safely.6 Minimal prep lithium disilicate veneers were chosen to enhance this smile along with gingival sculpting for symmetry, preceded by whitening. Records were taken and a mockup was waxed. Combination whitening was performed and then ten days allotted for shade stabilization (Fig. 3). Preparation day consisted of the following: 1. Shade Mapping (Fig. 4). 2. Gingival Sculpting with diode laser, Continued on page 52 â&#x17E;&#x153;

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➜ Continued from page 49

5. Gingival sculpting with diode laser. 6. Minimally prepared teeth. 7. Digitally scanning with Trios Scanner. 8. Provisionalization for prototype. 9. Provisionals being removed. 10. Try in paste with restorations.

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Gina M. DaRoza 462 Wellington St W, Suite 500 Toronto, ON, M5V 1E3 gdaroza@capplaw.ca www.capplaw.ca Tel: 416 955 9502 Fax: 416 955 9503

Gemini Laser Ultradent. The free gingiva was assessed with consideration to maintaining biologic width. Two millimeters of free gingiva was removed from the free gingival margin of the left lateral incisor. The gingival zenith was sculpted to match the right lateral incisor (Fig. 5). 3. The anterior eight teeth were prepared minimally for lithium disilicate veneers. The extent of the preparing was to scribe a very light chamfer at the gingival margin for a readable finish line (Fig. 6). 4. A prep shade was recorded. The prep shade in this case is the same as the Shade Mapping from step one due to minimal prepping. 5. The preps were digitally scanned (Fig. 7). 6. The teeth were provisionalized based on the prototype wax-up (Fig. 8). The patient dismissed with post op instructions and returned five days later for approval of the prototypes. These provisional veneers allowed the patient to “test drive” his new smile before fabrication of his final veneers. Once approved, the prototypes were digitally scanned for the lab. The restorations were fabricated to the size and shape of the approved provisional prototype. When the patient returned, the provisionals were removed and the restorations were loaded with try in paste and placed for review (Figs. 9 & 10). The patient approved the restorations (Fig. 11) and signed a consent to insert the final. The final restorations were bonded with a light cured adhesive resin cement, Choice 2, Bisco (Fig. 12). Figures 13 and 14 show the post-op results. The patient feels more confident with his smile and is pleased with the results.

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11. Patient approving insert of restorations. 12. Adhesive resin cement bonding restorations in place. 13. Post-op smile. 14. Post-op full Face.

As dentists, conservation of tooth structure is of utmost importance. This is especially true for the increasing younger patient population interested in cosmetic dentistry. Minimal or no-prep veneers, like the ones used in the case study, are an esthetic, yet conservative, option for many patients. Due to their versatility and natural appearance, porcelain veneers are regarded as the gold standard for cosmetic dentistry. These veneers can typically resolve complaints REF EREN C ES 1. Di Biase AT, Sandler PJ. Malocclusion, Orthodontics and Bullying, Dent Update 2001;28:464-66. 2. Is “Snapchat Dysmorphia” a Real Issue? Kamleshun Ramphul, Stephanie G Mejias. Cureus. 2018 Mar; 10(3): e2263. Published online 2018 Mar 3.

of open spaces, alignment of rotated teeth, enamel pathologies, and stain and color issues. New developments in ceramics allow very thin materials to be very durable. Because these veneers bond the strongest to enamel, minimum preparation are desirable for both bond strength and for longterm dental health of our patients. In conclusion, the ultimate goal in dentistry is to restore health and function, as well as esthetics, using the most

3. McLaren E. A., Whiteman Y. Y. Ceramics: rationale for material selection. Compendium of Continuing Education in Dentistry. 2010;31(9):666–668, 670, 672, 680, 700. 4. The Success of Dental Veneers According To Preparation Design

conservative method possible. This is becoming more and more relevant to dentists as the younger population, driven by social media, yearns for ideal and confident smiles. Oral Health welcomes this original article. ORAL HEALTH GROUP

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and Material Type, Yousef Alothman, Maryam Saleh Bamasoud Open Access Maced J Med Sci. 2018 Dec 20; 6(12): 2402–2408. 5. Perception of smile esthetics by laypeople of different ages. Chompunuch Sriphadungporn, Niramol Chamnannidiadha, Prog Orthod.

O R ALH E ALTH G R O U P.CO M

2017; 18: 8. Published online 2017 Mar 20. 6. de Andrade O. S., Borges G. A., Stefani A., Fujiy F., Battistella P. A step-by-step ultraconservative esthetic rehabilitation using lithium disilicate ceramic. Quintessence of Dental Technology. 2010;33:114–131.

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Principles of smile design treatment planning Jeffery W. Lineberry, DDS, FAGD, ICOI, AACD, AAID

INTRODUCTION hen it comes to re-creating a patient’s smile, it is not as simple as placing veneers or crowns on teeth that are whiter and brighter than the patient’s existing dentition (Figs. 1 & 2). The smile is an important reflection of one’s self along with communicating a variety of emotions to those around us and it is unique to each individual person. In fact, there are many factors that must be carefully considered and evaluated in creating a smile that is esthetically pleasing to the doctor and the patient. And even with digital technology having a widespread effect on so many things, including restorative dentistry, as well as allowing for digital simulations of a patient’s final smile, there are many factors1 and principles2 that must be evaluated by the treating doctor. Creating an ideal smile may require orthodontics, orthognathic surgery, periodontal surgery, cosmetic dentistry, oral surgery, and plastic surgery. Likewise, it cannot be stressed enough that if indirect restorations will be a part of the final treatment plan, involving the dental technician that will be doing the final restorations, should be consulted early in the process as they can bring an invaluable component to helping the clinician and patient achieve the desired final result. In this article, we will provide a broad overview, but not all encompassing, of the multitude of factors and principles that a clinician must consider when a patient presents to their clinic for changes and overall enhancement of his or her smile.

PATIENT DESIRES AND EXPECTATIONS One of the most important parts that must be considered before any treatment is begun is the clinician must take the time to discuss and discover the patient’s chief complaint and concerns and whether he or she can achieve or succeed the patient’s desired final result. After a thorough review of the patient’s medical and dental history, a comprehensive dental

examination is completed, including proper radiographs, evaluation of the muscles and temporomandibular joint (TMJ). When it comes to restorative dentistry that involves significant dental treatment, including the patients smile, it is essential to have proper documentation to a achieve proper diagnosis. This will include proper photos that are taken with a digital SLR camera with a macro lens (Fig. 3) that include: full face photos (Fig. 4); 1:2 lip at rest or repose photos (Fig. 5); anterior and lateral photos (Figs. 6-8) and/or video of the patient smiling naturally, dynamically as well as an exaggerated smile; 1:2 retracted anterior and lateral views (Figs. 9-11); retracted views occlusally (Figs. 12-13); 1:1 retracted views of the anterior dentition (Figs. 14-16). The clinician should also obtain impressions (whether digital or analog) as well as a facebow and a bite registration in CR (centric relation), so that the case can be properly mounted and articulated on a semiadjustable articulator (Fig. 17). All of this critical information for the clinician to properly evaluate, review, treatment plan and thus, treat the patient appropriately and effectively. After a thorough assessment, it is critical to review treatment options and expected outcomes with the patient in order for the patient to make an informed decision about treatment choices. This allows for the patient to give input on any compromises in the final outcome should he/she decide to choose less than ideal treatment, and consequently, accepting any result that is less than desired due to such decisions. FACIAL AESTHETICS A basic overall assessment of the smile must start from an outside-in approach and thus, there has to be some evaluation of the patient’s overall facial features, including facial proportions and evaluation of the facial esthetics in the vertical and horizontal planes. Assessment of the patient’s facial thirds

Jeffrey W. Lineberry currently lives in Mooresville, North Carolina and owns and operates Carolina Center for Comprehensive Dentistry, a fulltime complex restorative focused practice. Dr. Lineberry received his Bachelor of Science in Biology from Western Carolina University and his Doctor of Dental Surgery degree from the University of North Carolina at Chapel Hill in 2000. He has obtained his Fellowship in the Academy of General Dentistry and in the International Congress of Oral Implantologists. He currently serves as a Visiting Faculty member, Online Moderator and contributing author for Spear education, a leader in continuing dental education. He is also a Faculty Assistant at the Pankey Institute. He is an Accredited by the American Academy of Cosmetic Dentistry (AACD) and is a member of the AAID and American Equilibration Society. 54 A P R I L 2020

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and whether there are any disproportions present between the superior, middle and lower thirds (Fig. 18). It is important to look for asymmetries in the facial features starting from the facial midline and how it intersects with the dental midline. It is important to assess asymmetries from the right and left hemifacial portions as well assessment of the patient’s interpupillary line and occlusal planes as well as the relation to the horizon (Fig. 19). Notable concerns in these areas can be an indication of skeletal or growth and development issues that may or may not have an impact on the patients’ smile. A good example is a patient who may have a concern over an excessively gummy smile, when in fact, it may be due to the fact the patient has an excessively long middle third of the face and longer facial 56 A P R I L 2020

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height, indicating vertical maxillary excess (VME). Vertical maxillary excess is a skeletal issue, and hence, would require a different treatment modality to successfully treat the patient’s concern. UPPER LIP LENGTH, LIP POSITION, MOBILITY AND SYMMETRY The lips play an important role as they create the boundaries of the smile and play an important role in the complete smile design. Overall lip mobility is simply the movement of the lips at rest to the farthest position that occurs when the patient smiles spontaneously and is directly related to the upper lip length.4 In order to do so, assessment of the upper lip length (Figs. 20-21) and amount of tooth that is displayed at rest must be first assessed and then reassessment at

the farthest position. The average upper lip length in males is 23 mm and 20mm in females, who have an average of 1.5 mm of higher lip line, and thus showing more tooth display at rest. The average lip mobility in general is 7-8 mm, with females (Fig. 22) having slightly more lip elevation than males (Fig. 23), and in turn, show more tooth display during smiling. Overall symmetry of the patient’s lip mobility must be assessed as well since there is a significant portion of the patient population (8.7-22%)5,6 that has asymmetry (Fig. 24) of the movement of upper and lower lips upon smiling and at rest. This can lead to more tooth and/ or gum displayed on one side versus the other, creating a disharmony in the overall smile of the patient. It is important for the clinician to take a series of photos

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TOOTH DISPLAY The amount of tooth that is displayed at rest is greater in females than males by an average of 1.5mm.7 The average 30-year-old female displays 3.5 mm of maxillary central incisors at rest versus 1.9mm in males and as patients age, they display less of the maxillary incisors (1-1.5 mm in females at age 50; 0-0.5 mm in females at age 70 and more mandibular incisors. This is a result of changes in soft tissues to the skeletal base. There is a significant gender difference8 in gingival display upon smiling where females tend to show more gingiva than males. INCISAL EDGE POSITION IN RELATION TO SURROUNDING TISSUES AND HORIZONTAL PLANES The incisal edge position must also be evaluated in relation to the surrounding tissues as well. One landmark to evaluate is the interpupillary line and how the incisal edge is in relation to it.

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Consideration should be taken of how the incisal edge position relates to the interpupillary line in a parallel plane (Fig. 25). It has been shown that there is a significant correlation between the maxillary incisal edge position and the interpupillary line.9 The incisal edge position should be assessed in relation to the occlusal plane and posterior teeth and the incisal edge in relation to the lower lip/wet dry line or smile line. Another consideration is the relationship of the tooth position and what is considered the “buccal corridor”. The buccal corridor is the space that is present between the lateral aspects of the posterior teeth and the corner of the mouth. When there is “dark” space in the buccal corridor, this is considered a “negative space” (Fig. 26). It has been suggested16 that having minimum “negative space” in buccal corridors is preferred esthetically. MIDLINE The position of the teeth, and the dental midline in regard to the facial midline and surrounding tissue is another area that has to be assessed during the smile evaluation (Fig. 27). It is important to evaluate the relationship of the dental midline to the facial midline in addition to the overall angulation of the midline. Studies10 show that most people, including dental professionals will be unable to detect up to a 4 mm dental midline deviation from the facial midline. However, when there are slight changes in crown and midline angulation, it becomes quickly evident to most people. Hence, overall angulation of the midline is more critical than the overall position

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of the midline to create an esthetically pleasing smile. CURRENT TOOTH POSITION WITHIN DENTOALVEOLAR HOUSING Overall current tooth position in the dentoalveolar housing is another important consideration when it comes to developing an ideal new smile. Without proper evaluation, this can lead to the clinician attempting to obtain ideal results unsuccessfully when the tooth and/or root position and angulation are in the improper position. Ideally, tooth position should be assessed in three dimensionally so that the following can be evaluated properly: Facial-Lingual Position Mesial-Distal Position

Apical-Coronal Position Each of these components should be assessed and the following questions should be considered: • Is the tooth tipped or bodily positioned in relation to the adjacent tooth or teeth, roots, arch form, and the interaction with the opposing arch, lips and surrounding tissues? • Is the current position and balance between the “white” (tooth) and “pink” (gingival architecture) esthetics visually pleasing to the eye? • Will the current position compromise the final desired result? If so, can it be managed restoratively alone or will it require repositioning of the tooth, root and/or surrounding tissues with the assistance of orthodon60 A P R I L 2020

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tics, orthognathic surgery, periodontal surgery or a combination? • If managed by restorative options alone, will this lead to aggressive tooth reduction that may compromise the longterm health of the patient’s dentition and/or will it create less than ideal final restorations? (i.e. a tooth that is lingually inclined and the final restoration is too thick facially) • If current tooth position compromises the outcome and/or long-term tooth health, has this been communicated to the patient when he or she is unwilling or unable to commit to a more ideal treatment plan? FACIAL-LINGUAL POSITION Preferably, the facial lingual position should allow the tooth to be in a position that allows for the desired end result in a minimally invasive way. Teeth (Figs. 28 & 29) that are proclined or retroclined can have a direct impact on the restoration and/or the final desired result and thus, the clinician must assess this as well. MESIAL-DISTAL POSITION When assessing current long axis tooth position, and to create an ideal smile, we would like to see the long axis of the teeth be parallel between the two centrals, and a slight mesial inclination in the laterals and even more mesial inclination of the canines toward the midline (Fig. 30). Variation in the inclination of the teeth in a mesial/distal aspect has been shown10 to be a factor that can quickly be visually detected by most people and can be interpreted as unaesthetic.

APICAL-CORONAL POSITION The apical-coronal position of teeth in relation to the adjacent teeth, as well as the full smile, smile in repose is critical to creating an esthetically pleasing smile. If the patient’s lip line exposes the gingival architecture, then it is vital to assess gingival heights and zeniths as well as overall symmetry and proportion to the contralateral side. If this is not the case, this creates asymmetry and disharmony (Fig. 31). The apical-coronal position of the teeth is one aspect that impacts the overall papilla position and overall contact heights, which should be approximately 50 (papilla) :50 (contact length). Obviously, the patients overall periodontal health should be assessed and how it impacts the relationship of the gingival architecture to the current tooth position as well as current papilla position. TOOTH PROPORTIONS AND PROPER LENGTH TO WIDTH RATIOS Overall tooth proportions are another key and critically important assessment that must be made by the clinician during the initial evaluation. The average length of the maxillary central incisor is 10.5-11 mm and average width to be 8.0-9.0 mm, creating an average length to width ratio of approximately 76%. It has been discussed11,12 and suggested that overall assessment of the length to width ratios can be related to the “golden proportions”, a term that related back to ancient Greeks who used the term to related the proportions between large and small in the beauty of nature. However, this has been refuted in studies and Chu13,14 showed a significant correlation

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between the widths of the centrals, lateral and canines. Dentists can easily determine the overall width of the maxillary teeth by allowing the width of the maxillary centrals to be “Y”, the width of the lateral to be “Y

62 A P R I L 2020

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– 2 mm”, and the width of the canine to be “Y – 1 mm”. Completing a simply overlay of ideal tooth proportions can be quickly and easily done to assess length to width ratios (Fig. 32).

ANTERIOR GUIDANCE AND COUPLING An equally important, and sometimes overlooked principle when it comes to smile design, is the importance of function following form and how the

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AESTHETIC DENTISTRY

anterior teeth couple together and help guide the posterior teeth apart. Ideally, canine guidance with immediate posterior disclusion is desired as this has been shown to decrease overall elevator muscle activity.15

OTHER FACTORS TO CONSIDER â&#x20AC;&#x201D; MICROESTHETICS When it comes to designing the ideal smile for our patients, especially with the use of indirect restorations, the clinician needs to assess and discuss the

final color or shade desired by the patient. If possible, a shade that is naturally pleasing but esthetically enhancing to the patientâ&#x20AC;&#x2122;s final desired result is best. The restorative dentist should also communicate to the his or her lab

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A EST H E TI C DE NT I ST RY

SUMMARY This article serves as a brief summary of smile design along with the multitude of assessments and evaluation in order to obtain an ideal smile for our patients that may include interdisciplinary care. It is critical for the practitioner to have experi-

technician about desired facial surface texture, overall incisal translucency, additional tooth characteristics including incisal effects, embrasures, tooth shape, and variations in value, hue and chroma from the centrals to the cuspids (Fig. 33).

REF EREN C ES 1. Davis NC. Smile Design. Dent Clin North Am. 2007 Apr;51(2):299-318, vii. 2. Bhuvaneswaran M. Principles of smile design. J Conserv Dent. 2010 Oct;13(4):225-32. doi: 10.4103/09720707.73387. 3. Benson, Kenneth & Laskin, Daniel. (2001). Upper lip asymmetry in adults during smiling. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 59. 396-8. 10.1053/joms.2001.21874. 4. Roe, Phillip & Runcharassaeng, Kitichai & Kan, Joseph & Patel, Rishi & Campagni, Wayne & Brudvik, James. (2012). The Influence of Upper Lip Length and Lip Mobility on Maxillary Incisal Exposure. The American Journal of Esthetic Dentistry. 2. 116-125.

5. Mathis, Andrew & Laskin, Daniel & Tufekci, Eser & Caricco, Caroline & Lindauer, Steven. (2018). Upper Lip Asymmetry During Smiling: An Analysis Using Three-Dimensional Images. Turkish Journal of Orthodontics. 31. 32-36. 10.5152/ TurkJOrthod.2018.17056. 6. Laskin DM. Upper lip asymmetry in adults during smiling. J Oral Maxillofac Surg. 2001 Apr;59(4):396-8. 7. Vig RG, Brundo Gc. The Kinetics of anterior tooth display. J Prosthet Dent. 1978:39; 502-504. 8. Al-Habahbeh R, Al-Shammout R, Al-Jabrah O, Al-Omari F. The effect of gender on tooth and gingival display in the anterior region at rest and during smiling. EurJ Esthet Dent. 2009 Winter;4(4):382-95.

ence, education and background in evaluating, treatment planning and treatment sequencing in a variety of areas in order to effectively manage, refer and treat patients that have concerns with his or her smile. Oral Health welcomes this original article.

9. Malafaia FM, Garbossa MF, Neves AC, DA Silva-Concílio LR, Neisser MP. Concurrence between interpupillary line and tangent to the incisal edge of the upper central incisor teeth. J Esthet Restor Dent. 2009;21(5):318-22. doi:1111/j.17088240.2009.00283.x. 10. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-24. 11. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent 1978;40:244-52. 12. Lombardi RA. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29: 358-82. 13. Chu SJ. Range and mean distribution frequency of individual tooth

width of the maxillary anterior dentition. Pract Proced Aesthet Dent. 2007 May;19(4):209-15. 14. German DS, Chu SJ, Furlong ML, Patel A. Simplifying optimal tooth-size calculations and communications between practitioners. Am J Orthod Dentofacial Orthop. 2016 Dec;150(6): 1051-1055. doi: 10.1016/j.ajodo. 2016.04.031. 15. Manns A, Chan C, Miralles R. Influence of group function and canine guidance on electromyographic activity of elevator muscles. J Prosthet Dent. 1987 16. Moore T, Southard KA, Casko JS, Qian F, Southard TE. Buccal corridors and smile esthetics. Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):208-13; quiz 261.

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AGEESNT EHRE AT ILC D E N T I S T RY

The “Single Tooth” dilemma Sunny Virdi, DMD

hen it comes to aesthetic dentistry, many clinicians would agree that the “Single Central” cases are the ones that can be the most difficult. Trying to restore a single central brings up many discussion points: • Direct or Indirect? • Full coverage or Partial? • W hat materials should we use? Often, we reach out for the help of our lab technician where aesthetics is controlled in a benchtop manner. Ceramics and porcelains have made huge strides over the years, providing clinicians with access to better esthetic outcomes. As well, digital photography has given us the ability to communicate our goals to the lab technician, which usually provides a result the patient, clinician and technician are happy with However, creating that result with ceramic requires a highly skilled lab technician and the possibility for corrections or remakes. Although we can be extremely conservative in most situations, ceramics usually require some level of tooth preparation as well. Direct materials such as composite resin give the clinician full control over the situation. Composite resin has the ability to mimic the appearance of both enamel and dentin, can be easily repaired and can be completed in a single visit. Composites are often much easier for the clinician to match the shade with the ability to directly mock-up cases before proceeding. Virtually all clinicians have access to composite and the many shades available on the market. Composite is also easily accepted by patients as it is often the least invasive way to complete treatment and has proven to be a long-lasting solution. Composite can also serve as a test-drive in cases where the clinician and patient are determining what the end result should be. Everything in dentistry is “temporary” and the less tooth structure we remove, the better long-term

outcome for the patient. We always have the possibility to remove previous work and progress down the restorative continuum, and by starting with a minimally invasive approach we retain the ability to use different methods later on. If we start off placing a full coverage crown and it fails due to recurrent decay or fracture, our options for future treatment are extremely limited. CASE REPORT A 20-year-old patient (Fig. 1) was referred to our office with a chief concern that her two front teeth did not match. She had dealt with this her whole teenage and brief adult life and wanted to explore options to correct this issue. DENTAL HISTORY This patient had comprehensive orthodontic work following the extraction of the central incisor (1.1) as it was impacted. Unfortunately, the patient’s orthodontist had retired by the time we had seen the patient and we unable to gain complete records regarding the diagnosis. Regardless, the problem presented as is. We were able to obtain some pretreatment photographs and records showing severe crowding as well (Fig. 2). The decision was made to extract teeth 2.4 and 3.4 as well. The lateral incisor 1.2 was moved into the space of the central and the patient had the space closed directly with composite approximately nine years ago. The current restoration shows a smooth emergence from the gingival tissue and tight contact with the neighbouring central. However, the restoration lacks the aesthetic appearance the patient is seeking. Other factors to consider are the facial and dental midline discrepancy, tooth size/space available discrepancy, and high aesthetic demands. There is an excess of tissue between 1.2 and 2.1, yet the bone

Dr. Sunny Virdi graduated from the University of Manitoba in 2016. He maintains a full-time ownership role in a group private practice in Winnipeg, Manitoba. Dr. Virdi has received postgraduate training in the latest techniques regarding isolation, adhesion, materials science and esthetic dentistry. He has received extensive training in the latest restorative techniques with world renowned leaders in restorative and esthetic dentistry. Dr. Virdi is a fan of collective learning and always keen to share his experience by participating in multiple study clubs. Dr. Virdi is a member of the Canadian Dental Association and the Manitoba Dental Association. Dr. Virdi can be reached by email at sunnyvirdi.dr@gmail.com or through Instagram @dmdsunny.

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4 1. Pre-operative view of the patient’s smile. The asymmetry present between the tooth 1.2 (in the place of 1.1) and 2.1 is evident. The shape of the composite does not mimic 2.1 and lacks the desired optical qualities. 2. Pre-treatment records from the patient’s orthodontist dated back to 2010. 3. Pre-treatment radiograph of 1.2 and 2.1. 4. An outline of tooth 2.1 was made using simple computer software (Photoshop CC) and a mirror image was created. It is evident from the image that we need to do something with 2.1 as well to create equal shapes restoratively.

crest is flat in the area as demonstrated by the preoperative periapical radiograph (Fig. 3). This appearance is peculiar, and the tissue almost appears as though it is scar tissue (Fig. 4). Luckily, the patient does not exhibit a high smile line, so any “pink asymmetry” around the zenith of the teeth will not affect the outcome. Before continuing with any anterior composite work, a digital mock-up should be created to assess the final outcome. In this case, a mock-up was used to assess the space available to see if we only need to address a single tooth, or are multiple restorations needed. Based on the mock-up, if we continued to only restore 1.2, we would end up with a larger tooth than 2.1, which will cause too much visual tension. Instead, we proposed an alternative plan, adding a very small amount of resin to the mesial of 2.1 to create equal proportions between the two teeth. The idea of moving the lateral more mesially through orthodontics 68 A P R I L 2020

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was entertained to achieve a better emergence profile. Ultimately, we decided to make an attempt restoratively. THE PROCESS At the initial consultation we typically discuss whitening, however the patient currently is at B1 on the Vita shade guide and there was no perceived benefit in this case. The shade was roughly equivalent to B1 body and dentin custom shade tab using Filtek Supreme (3M) composite. We took photos as well as upper and lower alginate impressions to complete a wax up. Polarized photographs (Fig. 5) were taken to assess the incisal effects and assist in shade matching. Custom shade tabs were fabricated (My Shade Guide, Smile Line) and using Adobe Photoshop we were able to manipulate the photo to compare the teeth and shade tabs. Given the complex anatomy of tooth 2.1, we need to place a layered composite resin restoration trying to mimic the dentin and enamel shades. Whenever

placing a layered composite restoration, the use of transferring the palatal shell with a wax up (Fig. 6) provides more control for a predictable outcome. We created a putty matrix (Genie Putty Fast Set, Sultan) from the palatal surfaces and trimmed it for our use (Fig. 7). Intral oral button try in of composite (Fig. 8) was completed before starting, to verify the shade match and help visualize the layering technique we will use. The previous resin restoration was removed without rubber dam isolation (Fig. 9). Our goal was to assess the soft tissue contour without the restoration in place and decide whether or not to remove soft tissue from the papilla. Once the restoration was removed, we exposed a radiograph to verify the resin was completely removed. From the periapical we could see some small remnants of composite resin on the mesial surface, which we decided to remove once the tooth was isolated. The soft tissue profile presented favourably and we decided to attempt to

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5. The root of the lateral appears to be tipping distal to the midline. Straightening this through orthodontics would allow us to create a better emergence profile both mesially and distally. 6. The custom shade tab shows a close match to tooth 2.1. 7. Wax up completed by Laszlo Benga, CDT (Cerall Dental Laboratory) to mimic 2.1. A small addition was made to 2.1 as well to transfer intra-orally. 8. Trimming the putty matrix with a scalpel for precision. 9. Composite button try in. 10. Previous composite removed and diastema exposed. 11. Isolation in place using modified clamps and heavy latex rubber dam. 12. Palatal putty index in place. 13. Tooth 2.1 resin addition completed.

restore without manipulating the gingiva for now. Composite placement falls under the category of adhesive dentistry, in which isolation and clean working field is paramount. Proper isolation using rubber dam techniques creates a stress-free working environment for clinicians, where we do not have to worry about moisture contamination or materials and water being sprayed intra-orally. Using a heavy gauge rubber dam (6â&#x20AC;?X6â&#x20AC;? Heavy, Nic Tone) with extra retraction using modified clamps (Clamp 212, Hu Friedy), the papilla and gingiva are retracted in a way that provides excellent vision and access to the teeth (Fig. 10). The use of modified clamps is essential here as the putty matrix can only be 70 A P R I L 2020

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placed if the clamps provide access to the palatal surface (Fig. 11). Once isolated, we can begin the adhesive process. Air abrasion is another essential tool for composite placement. Air abrasion achieves a number of things in an efficient manner, such as biofilm removal, removing any remaining restorative materials, and micro mechanical roughening of the enamel surface. Teflon tape is placed over the adjacent teeth to protect them and air abrasion was carried out with 27 Îźm aluminum oxide particles at 40 psi (PrepStart, Zest Dental Solutions). Tooth 2.1 was then etched with 37% phosphoric acid (Super Etch, SDI Limited) for 20 seconds and is thoroughly rinsed and dried. Universal adhesive

(All-Bond Universal, Bisco Dental) was used and applied following the manufacturer instructions. First the 2.1 was restored (Fig. 12), first by placing a small increment in the palatal aspect using the putty matrix. Composite (Filtek Supreme B1B, 3M) was then placed freehand to restore the mesial surface and polished back to ideal contour and finish. Tooth 1.2 was then prepared for bonding in the same manner as 2.1 (Fig. 13). First the palatal shell was created using an enamel shade (Filtek Supreme B1E). The proximal surface was restored (Fig. 14) using a vertically placed posterior matrix (Composi-Tight, Garrison Dental Solutions). Using the matrix in this

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14. The Enamel surface is ready for optimized bond potential through the use of air abrasion and phosphoric acid etch. Teflon tape is used to protect the adjacent tooth that was previously restored. 15. Matrix in place before restoring the proximal surface. 16. Proximal and palatal shell in place. 17. Dentin composite was placed in the necessary areas to mimic the adjacent tooth. 18. A composite sculpting brush is used to feather out the final layer of composite. 19. The four items needed to provide a simplified polish approach. 20. Immediately post-operative. 21. One-week control photograph.

fashion provides superior advantages over traditionally used acetate-matrices in that it creates a natural curvature, whilst also providing a nice seal in the gingival aspect (Fig. 15). Dentin composite replacement was placed in the necessary areas to prevent the restoration from appearing too translucent (Fig. 16). The incisal edge was restored to create a “halo effect”, dentin masses were shaped to help create the appearance of the incisal translucency. The final facial layer (FIltek Supreme B1B, 3M) was sculpted to a reasonable stage to minimize the finishing protocol (Fig. 17). The polishing protocol was carried out using Soflex Discs (3M), polishing 72 A P R I L 2020

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wheels (Footsies, Komet) and goat hair brush (Jiffy Goat Hair Brush, Ultradent) using polishing paste (Diamond Twist SCL, Premier) (Fig. 18). After removing the rubber dam, we verified the excursive movements and occlusion. The patient is instructed to come back in one week to make final adjustments and apply a final polish (Fig. 19). Always remember that after working in the anterior region with composite, rehydration must occur before we can make our final judgment on the outcome. ONE-WEEK CONTROL Adjustments were made to clean up the line angles and again we polished the surface. In summary, the outcome

is a big aesthetic improvement over the previous restoration. The patient’s ecstatic reaction was the most fulfilling outcome we can hope for as health care professionals. A detailed analysis shows that we placed the “halo” incisal edge layer too thick compared to the adjacent tooth (Fig. 20). It is of course possible to correct this by cutting back the incisal third and redoing the layers. However, the patient did not perceive this difference and did not want to undergo any further procedures as they were delighted with the result. Comments like these serve as a reminder for our team that we are ultimately treating a person, and it’s their opinion and final judgement that matter.

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AESTHETIC DENTISTRY

22. Light reflecting off the surface after the creation of secondary anatomy. 23. Natural smile for the patient. 24. Retracted angle view of the finished composite. The soft tissue contour still leaves something to be desired, but it is not visible when the patient is smiling.

CONCLUSION Composite is the most versatile material we have in our armamentarium as clinicians. While you can argue whether or not “no-prep” procedures are “reversible”, the preservation of tooth structure is vital in preventing post-operative compli-

cations and keeping options open in the future. I applaud the previous clinician’s choice for treating this case conservatively, which gave us an opportunity to use a minimally invasive approach again. Had this tooth been cut down for a crown, it would be difficult to recreate the same

outcome. In this age of modern materials and techniques, it’s becoming easier to practice by, “prevention for extension”, as opposed to the traditional mentality, “extension for prevention”. Oral Health welcomes this original article.

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AESTHETIC D E N T I S T RY

Resin infiltration as treatment for an anterior tooth discoloration of developmental origin Nathaniel C. Lawson, DMD, PhD; Celin Arce, DDS, MS, FACP

esin infiltration is a technique that has been available as a commercial product since 2010. The procedure consists of etching the tooth with a 15% hydrochloric acid, drying with an ethanol solution, and applying a TEGDMA-based resin infiltrant. The product (ICON, DMG) was initially developed as a treatment for incipient interproximal caries and anterior white spot lesions. Clinical experience with this technique, however, revealed that it is also effective in masking enamel discoloration of non-carious origin. This article will summarize the diagnosis of discolorations that may be treated with resin infiltration, the mechanism of action of the resin infiltration product, and a clinical protocol for the use of resin infiltration to treat an anterior tooth discoloration of developmental origin.

DIAGNOSIS OF LESIONS TREATABLE WITH RESIN INFILTRATION Discolorations seen on dental enamel can be attributed to either a caries-induced or non-carious etiology. Discoloration from changes in enamel formation initiated by caries are known as “white spot lesions” or “decalcification lesions.” Decalcification lesions typically are located at the cervical aspect of the tooth or surrounding orthodontic brackets because these surfaces are more likely to accumulate acid-producing plaque.1 The incidence of decalcification lesions during orthodontic treatment has been reported to be as high as 50%-97%.2,3 Decalcification lesions also may be suspected based on the patient’s caries risk. Patients with poor oral hygiene, a diet that lowers intraoral pH, a lack of fluoride, or a history of orthodontic treatment may be more likely to acquire decalcification lesions seen as white spots.4 Diagnosing the true etiology of a non-carious tooth discoloration is often difficult. Some clinicians (and patients) will attribute all non-carious tooth discolorations to fluorosis. Fluorotic lesions are brown or white discolorations caused by exposure to excess fluoride during the years of amelogenesis. According to the Centers for Disease Control and

Prevention, the prevalence of some form of fluorosis affected about 23% of Americans during period from 1999 to 2004.5 Severity and manifestation of the fluorosis stain vary, and about 7% of the population were categorized with a form of fluorosis with visibly apparent lesions (mild, moderate, or severe).2 Many discolorations are not caused by fluorosis, and some may be idiopathic white or brown enamel discolorations formed during development. Croll has coined the term “dysmineralization” to describe these disturbances in the formation of the inorganic component of enamel.6 A history of trauma, high fever episodes, or medications taken during childhood may be responsible for altering the enamel mineralization process and lead to discoloration.7 Discolorations attributed to systemic conditions should be present on all teeth mineralizing at the same time during development, whereas those caused by trauma may be limited to a single tooth. Common components of our diet can be extrinsic causes of stains, such as coffee, tea, soy sauce, red wine, or an iron supplement in vitamins, as well as some dental products such as chlorhexidine and stannous fluoride. The clinician should ask the patient about the onset of appearance of the discoloration. A discoloration that has developed during the patient’s span of memory is more likely to be extrinsic staining than is one that has to do with tooth development. In the author’s experience, treatment of extrinsic staining from diet or dental products may be accomplished with a dental cleaning or enamel microabrasion. Resin infiltration has been shown to be able to mask discoloration from both decalcification lesions8-12 and those of developmental non-carious etiology.8,9,13-16 In the clinical trials examining resin infiltration of decalcification lesions following orthodontic brackets, lesions were infiltrated at an average time of 5 months,11 12 months,12 or 21 months9 after removal of orthodontic brackets depending on the trial. One of the trials reported that there was no association between time from debonding to infiltration with the improvement in appearance of the lesion.12

Nathaniel C. Lawson is the Director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry and the program director of the Biomaterials residency program. He works as a general dentist in the UAB Faculty Practice. Dr. Celin Arce is a board certified prosthodontist. He received his dental degree from University Latina of Costa Rica and completed residency in Advanced Prosthodontics at the University of Alabama at Birmingham, and Master of Science in Clinical Dentistry. He is a Diplomate of the ABP and Fellow of the American College of Prosthodontists. He is currently Assistant Professor of the Restorative Sciences Department at the University of Alabama at Birmingham School of Dentistry.

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1. White discolorations present on the labial surfaces of maxillary central incisors. 2. Latex rubber dam placed to protect soft tissue and prevent salivary contamination.

In a clinical trial, 11 out of 18 teeth (61%) with decalcification lesions were completely masked, whereas, only five out of 20 teeth (25%) with non-carious discolorations were completely masked.9 In a laboratory study, resin infiltration was shown to have variable results with different hypomineralized enamel lesions of developmental origin.17 Another clinical trial reported better masking effects for lesions attributed to fluorosis than those attributed to hypomineralization.13 A practical consideration for treating non-carious discolorations is determining the thickness of the discoloration. A thicker discoloration is more visually apparent18 and will be more difficult to infiltrate and mask. A method to help determine the thickness of a stain is to transilluminate the tooth with a dental transilluminator or lightcuring unit (with proper eye protection). If the lesion becomes significantly darker with transillumination, the lesion is likely deeper within the enamel.19,20 MECHANISM OF ACTION OF RESIN INFILTRATION Resin infiltration was developed as a technique to treat enamel caries. The histopathology of enamel caries occurs as acid dissolves inter-crystalline spaces within enamel.21 Since the outermost 10-30 microns of enamel is more resistant to dissolution from the presence of fluorapatite, a more porous subsurface forms.22 The principle of resin infiltration for caries arrest is to occlude the porosity formed during the caries process 76 A P R I L 2020

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and prevent pathways for acid to further dissolve the tooth structure.23 The two basic steps to achieve this goal are to remove the less-porous surface layer of enamel and allow resin to infiltrate the internal enamel porosities through capillary movement. As the surface of a carious lesion may act as a barrier to resin infiltration, several preliminary studies evaluated different acid solutions for removal of the surface layer. A solution of 15% hydrochloric acid applied for 90-120 seconds was shown to almost completely remove the 45-micron thick surface layer of the lesion.24 After removing the surface layer of the carious lesion, the next step is to infiltrate resin into the porosities created during dissolution of intercrystalline enamel. Unfilled resin infiltrants have been shown to penetrate deeper into carious lesions than dental adhesives25 and a TEGDMA resin infiltrant was shown to penetrate deeper than other formulations of infiltrants.26 When applied for three minutes, the ICON TEGDMAbased infiltrant was shown to penetrate 414 microns into non-cavitated interproximal caries lesions.27 The visual change in enamel that arises from enamel caries is due to the air present in the subsurface porosities. The opaque appearance of the white spot lesion occurs because light is scattered within the body of the white spot lesion. Light scattering is caused when light interacts with two substances with different refractive indices. The refractive index of enamel (1.62-1.65) is different than that of air (1.00). Infiltration of the lesions

with an infiltrant that has a refractive index of 1.52 is able to mask the lesion.28 Resin infiltration has also been shown to infiltrate hypomineralized enamel of non-carious developmental origin.17,29 A laboratory study reported infiltration to an average depth of 0.67 +/- 0.39 mm in hypomineralized enamel lesions.17 CLINICAL PROTOCOL FOR TREATMENT OF AN ANTERIOR TOOTH DISCOLORATION OF DEVELOPMENTAL ORIGIN A patient presented to the UAB faculty practice with esthetic concerns of white discoloration on her maxillary central incisors (Fig. 1). An exam revealed that the only discolorations on her teeth were present on her maxillary central incisors. Based on the location and appearance of the lesions, they were determined to be non-carious discolorations caused either by fluorosis or an idiopathic dysmineralization of developmental origin. A transilluminator (Microlux, Addent) was placed on the lingual aspect of the central incisors and the lesions were viewed through transillumination (Fig. 2). The lesions did not appear to become darker, and therefore were determined to be relatively shallow lesions capable of treatment with resin infiltration. The patient was presented with alternative options, including no treatment, bleaching and enamel microabrasion. The patient was given the option to bleach her teeth prior to infiltration as the use of bleaching prior to infiltration has been reported to improve the masking effect.30 The patient refused. The patient was also informed

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A EST H E TI C DE NT I ST RY

3. Transillumination of lesion does not show darkening. 4. Application of ICON Etch hydrochloric acid etchant. 5. After first application of etchant. 6. The ICON dry ethanol solvent is used to re-wet lesion however desired effect was not achieve yet. 7. After second application of etchant. 8. After third application of etchant the surface was re-wet with ICON dry and desired masking affect was achieved. 9. Lesion was infiltrated with ICON infiltrant. 10. Teeth were light cured for 40 seconds.

that the chance of complete or partial masking of the lesion was estimated as 25% and 35% respectively.9 A latex rubber dam was placed on the patient (Fig. 3). Non-latex rubber dams may also be used for the latex allergic patient or clinician, however, prolonged exposure of the infiltrant to non-latex rubber dams may cause partial dissolution of the dam. The use of isolation is critical as salivary contamination of the infiltration process decreased its effectiveness27 and exposure of hydrochloric acid to soft tissue may cause temporary bleaching and chemical burn.6 The hydrochloric acid etchant from the resin infiltration system (ICONEtch) was applied for two-minutes with a gentle scrubbing motion (Fig. 4). 78 A P R I L 2020

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Afterwards, the etchant was rinsed, the tooth was dried (Fig. 5) and the ICONdry ethanol solvent was placed on the tooth (Fig. 6). At this point the tooth was observed to determine if an acceptable color change had occurred. A clinical trial reported that re-wetting the etched lesion with ethanol (after three seconds of waiting) was able to predict the color change that would occur once the lesion was ultimately infiltrated.31 As the desired color change was not achieved, an additional two minutes of etching was performed. The lesion was dried and reviewed (Fig. 7). Following re-wetting, the desired color change was still not achieved. A third 2 minute etching was performed. Following air drying and

re-wetting, an acceptable color change was achieved (Fig. 8). The lesions were infiltrated with the ICON-infiltrant for three minutes (Fig. 9), air dried, flossed, and light cured for 40 seconds (Fig.10). The lesion was infiltrated for an additional 1 minute and light cured for 40 seconds. The esthetic masking effect of the treatment was evident immediately upon completing the treatment (Fig. 11). Prior to removing the rubber dam, the patient was shown her teeth and she accepted the treatment outcome. In the case of more extensive staining that would not have been entirely removed, resin infiltration improves the bond to composite resin of demineralized enamel and has

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AESTHETIC DENTISTRY

11. Teeth display improved outcome immediately following treatment. 12. Teeth display similar outcome at one-week following treatment.

no negative effect on bonding to sound enamel.32,33 A clinical trial reported improved masking at one-week following treatment.9 The patient returned oneweek following treatment and the masking effect looked similar to immediately after treatment (Fig. 12).

CONCLUSION Resin infiltration may be an effective method of treatment for anterior tooth discolorations of developmental origin assuming their depth is not too great. Multiple etching steps may be needed in order to achieve the desired outcome.

Several clinical trials have reported the masking effects of resin infiltration have remained unchanged at follow up times up to 12 months for non-carious lesions16 and 24-45 months for carious lesions.12 Oral Health welcomes this original article.

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REFEREN C ES 1. Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod. 1982 Jul;82(1):62-7. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982 Feb;81(2):93-8. 2. Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, PrahlAndersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res. 2005 Jan-Feb;39(1):41-7. 3. Khalaf K. Factors Affecting the Formation, Severity and Location of White Spot Lesions during Orthodontic Treatment with Fixed Appliances. J Oral Maxillofac Res. 2014 Apr 1;5(1):e4.

4. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. NCHS Data Brief. 2010 Nov;(53):1-8. 5. Croll TP. Enamel microabrasion. Hanover Park (IL): Quintessence Pub.; 1991. 6. Anthonappa RP, King N. Enamel defects in the permanent dentition: prevalence and etiology. In: Drummond BK, Kilpatrick N, editors. Planning and care for children and adolescents with dental enamel defects: etiology, research and contemporary management. Berlin: Springer-Verlag; 2015. p. 15-30. 7. Borges AB, Caneppele TM, Masterson D, Maia LC. Is resin infiltration an effective esthetic treatment for enamel development defects and

white spot lesions? A systematic review. J Dent. 2017 [epub ahead of print]. 8. Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking labial enamel white spot lesions. Int J Paediatr Dent. 2011; Mar;21(4):241-248. 9. Hammad SM, El Banna M, El Zayat I, Mohsen MA. Effect of resin infiltration on white spot lesions after debonding orthodontic brackets. Am J Dent. 2012 Feb;25(1):3-8. 10. Knösel M, Eckstein A, Helms HJ. Long-term follow-up of camouflage effects following resin infiltration of post orthodontic white-spot lesions in vivo. Angle Orthod. 2019 Jan;89(1):33-39. 11. Senestraro SV, Crowe JJ, Wang M, Vo A, Huang G, Ferracane J, Covell DA Jr. Minimally invasive resin infiltra-

tion of arrested white-spot lesions: a randomized clinical trial. J Am Dent Assoc. 2013 Sep;144(9):997-1005. 12. Gençer MDG, Kirzioğlu Z. A comparison of the effectiveness of resin infiltration and microabrasion treatments applied to developmental enamel defects in color masking. Dent Mater J. 2019 Mar 31;38(2):295-302. 13. Mazur M, Westland S, Guerra F, Corridore D, Vichi M, Maruotti A, Nardi GM, Ottolenghi L. Objective and subjective aesthetic performance of icon® treatment for enamel hypomineralization lesions in young adolescents: A retrospective single center study. J Dent. 2018 Jan;68:104-108. 14. Pan Z, Que K, Liu J, Sun G, Chen Y, Wang L, Liu Y, Wu J, Lou Y, Zhao M. Effects of at-home bleaching and resin infiltration treatments on the

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10 Top Management Tools for a Successful Practice PAGE 100

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Dear Dental Community, In recent weeks, Canadians have had to come to grips with the coronavirus (COVID-19) pandemic and the profound impact it has and will have on our country. As an organization, dentalcorp recognizes that in this crisis we have an opportunity to demonstrate leadership in dentistry and help protect the health and wellbeing of patients, dental professionals and Canadians at large. Over the past several weeks, we have created resources to support our dental practices through this pandemic. We want to share these resources with all members of the dental community to help in any way we can. The below COVID-19 resources and more are now available on our website. Please register and share with your team members and colleagues in the dental community, and the public at large. We will continuously add new resources.

Patient Resources

Employee Resources

Reference Materials

Continuing Education and Webinar Series

Guides including dentalcorp’s COVID-19 policy and directions for providing care safely in the current environment.

Access free CE courses through DC Institute’s eLearning catalog, which has been made publicly available. Learn from experts in a new webinar series featuring speakers such as Dr. Kevin Katz, Head of Microbiology at Sunnybrook and Dr. Brian Rittenberg, Division head for Maxillofacial Surgery at Mount Sinai Hospital, part of Sinai Health System.

As a healthcare company, our top priority is to provide safe and effective care to our communities. We have kept a number of our clinics open solely to offer emergency care services to patients in need. Visit hellodent.com to see which clinics are open in your area. During this period of uncertainty, it’s all the more important that we be patient, kind and compassionate to one another, especially to our most vulnerable. We hope you will join us in ensuring the health and safety of Canadians as we persevere through this challenging time together.

Graham Rosenberg Founder & CEO

Guy Amini President

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MANAGEMENT SYSTEMS FOR SUCCESS

Lois Banta CEO AND FOUNDER OF

here has never been a more important time than now to implement effective practice management systems. Having a good back up plan is integral to practice success. Keep in mind that focus needs to be on the here and now. Additionally, planning ahead offers peace of mind. Some things to keep in mind:

• Choreograph the schedule to allow for predictable productivity • Utilize dental software to manage unexpected open time. This allows for a good backup plan to call patients who have offered to come in sooner if an unexpected change in the schedule happens • Create fool proof collection strategies to get the money off the books and in the bank • Organize weekly team meetings to address all areas of practice growth, celebrate the successes and identify the challenges • The Morning Huddle is a great way to ensure minimizing hiccups during the day. • Focus on positive ways to offer amazing customer service to make the patients feel special. The best defense is a great offense, so the expression goes in sports. The same can be true in running a successful dental practice. No matter what detailed systems there are in place, special focus needs to be paid to effective communication skills and enhanced customer service. Engage the patient in communication by NOT asking yes/no questions. Instead, offer two solutions to guide

them toward the optimal choice. Using phrases like, “Help me understand…” helps the patient to feel listened to. The “secret” to practice success is quite simple. Treat others the way you would want to be treated. The common denominator is…people want to feel special and be treated with kindness and respect. The more trying the times, the more enhanced customer service needs to be. Focus on the human element. Offer special comfort to the patient for their dental appointment. Offer bottled water and a coffee/tea station in the reception room for patients. Warm blankets in the operatories are a great way to offer patient comfort. School is never out for the pro. Attending continuing education courses helps to keep the skills sharp and knowledge current. There are so many opportunities for learning in the dental industry now. Online learning, podcasts, webinars are all great ways to stay connected and current. In office lunch and learns with specialists and companies that offer goods and services to the practice are also great ways to stay current with knowledge and skills. Creative marketing creates opportunities to enhance customer service and recruit new patients. Think of what the practice can do to create a positive impact, welcome gifts, referral gifts, social media strategies. Ongoing strategies combined with detailed systems, strategies and protocols can ensure long term success. Remember, school is not out for the pro and those that inspect what they expect nurture growth. G

BANTA CONSULTING, INC.

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DENTISTS’ TAX SAVING TIPS STRATEGIES

& 1

Sharing is Caring/Saving

Use family members in the tax savings game. Many dentists have a dentistry professional corporation (DPC). DPC’s if structured appropriately facilitate “sharing of income”. Family members may be eligible to receive dividends provided they work 20 or more hours per week on behalf of the practice throughout the year. A family member could earn $30,000 in dividends from a DPC and pay less than $1,000 in personal taxes, assuming they have no other income. A DPC if structured appropriately enables the lifetime capital gains exemption (LCGE) to be multiplied. Each LCGE of about $883,000 results in tax savings of up to $236,000. LCGE means when the practice (shares) are sold at a gain/”profit”, the first $883,000 of gains will not be subject to regular income tax. Paying family members who work at the practice a reasonable amount (similar to what you would

pay a stranger) results in tax savings. Let’s examine this case. A dentist making $200,000 in personal income pays $70,000 in personal taxes. A dentist making $135,000 and spouse making $65,000 pay $52,000 in personal taxes. In other words, sharing income in this example saved $18,000 in taxes.

Take Advantage of the Accelerated Depreciation Rules

The tax department made changes to allow accelerated tax deductions/write-offs when you buy equipment, computers, software and other capital assets. In light of infectious disease protocol and COVID19, consider upgrading equipment such as sterilizers/autoclaves. Under the accelerated depreciation rules, a $10,000 equipment purchase would provide tax write-offs as follows:

Tax write off on Equipment

Year 1

Year 2

Year 3

Year 4

Old Rules

$2,000 $1,600

$1,280 $1,024

Accelerated Rules

$3,000 $1,400 $1,120 $896

This article was prepared by David Chong Yen*, CPA, CA, CFP, Louise Wong*, CPA, CA, TEP, Basil Nicastri*, CPA, CA and Eugene Chu, CPA, CA of DCY Professional Corporation Chartered Professional Accountants who are tax specialists* and have been advising dentists for decades. Additional information can be obtained by phone (416) 510-8888, fax (416) 510-2699, or e-mail david@dcy.ca / louise@dcy.ca / eugene@dcy.ca . Visit our website at www.dcy.ca. This article is intended to present tax saving and planning ideas, and is not intended to replace professional advice.

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Ensure You Claim All Possible Tax Deductions

Many dentists have annual holiday parties especially in December to celebrate the festive season. Many record these expenses as meals and entertainment which is only 50% tax deductible. The tax department allows 6 meals to be deducted 100% provided all staff are invited. Forgetting to reclassify these expenses into a separate category means you lose out on 50% of the tax deductions. Staff are allowed two non-cash gifts which total $500 tax-free. As an employer, you would not have to withhold any CPP, EI or income taxes from this gift. Make sure these expenses are identified as employee gifts as they may appear personal in nature and recorded as such. Ensure you have the prerequisites for claiming certain tax deductions. For example, child care costs can only be claimed where the lower income spouse has salary or business income. Where a spouse is only receiving dividends, they won’t be able to claim child care expenses.

Claim Your Lifetime Capital Gains Exemption (LCGE) AND Still Own Your Practice If you are concerned that the government may remove the LCGE, there is a maneuver that will allow you to claim the LCGE while still owning your practice. This allows you to take the tax savings off the table and not have to worry about if or when the government might change or remove it.

Make RESP Contributions

Stretch Your Donations

Optimize Your Dividend/Salary Mix

Registered Education Savings Plan (RESP) contributions is a tax efficient way to save and pay for your children’s post-secondary education. The Federal government provides a grant/”gift” equal to 20% of the first $2,500 of annual RESP contributions per child or $500 annually. Gift publicly traded shares, which have risen in value to a charitable organization. You will get a charitable donation receipt for the fair market value of the shares donated. You will not pay any personal taxes on the gain. You will save taxes by optimizing the amount of salaries and dividends you receive from your dentistry professional corporation. For any given individual, depending on your circumstances, there is an optimum level of dividends and salaries which minimizes taxes. Speak with your advisor.

Conclusion Saving taxes, like enhancing your dental care, is a year-round activity. Your financial health depends on it. G

Lend Money to Family at the Low Prescribed Rate

Lend money to “poorer” family members at the current prescribed rate of 2%. Document the loan. Interest on the loan must be paid for each calendar year by January 30 of the following year and all future years. Taxes will be saved provided the money is invested and generates a return greater than 2%. For example, where one spouse who is in the highest tax bracket (53.53%) loans $100,000 to their spouse who is in the lowest tax bracket (20.05%) who invests it and earns 5%, tax savings of about $1,000 (($3000 X (.5353-20.05)) could be achieved.

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LLOYDMINSTER, AB

WARM WELCOME

hen Dr. Terran Strang of College Park Dental in Lloydminster, AB went to expand and build a new practice, he engaged the services of Bold Interior Design Inc. in Edmonton, AB. Design elements requested by Dr Strang included the clinic to be warm, inviting and modern with a sophisticated luxurious presence. After an initial site visit, it was clear that the vast amounts of natural light flowing into the space from three exposures would be a clear defining element. Inspired by the natural light and the existing branding colour of blue, the materials palette was selected using light warm grey floor tones, light hued reconstituted wood veneers with pops of black marble and

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blue glass tile accents in key areas. The branding colour was further incorporated into the design with the selection of simple, modern cylindrical lights to help define space. As the reception desk and waiting area is the heart of a clinic as well as the first and last impression a Client has of the built space, special attention was made to these areas. With the reception desk being at the heart of the clinic and open to all adjacent areas, special attention was paid to the acoustics of the space. TURF Design linear acoustic baffles in a charcoal grey were added above the desk to create a design feature. Adding a touch of blue to the space, custom Lumium Lighting linear lights were used to punctuate the reception area as a focal

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point. Colour-changing RGB lights were used in the kick of the reception desk as well as in the wood bulkhead above. By using RGB lights, College Park Dental has the opportunity to have a bit of playfulness to the space and change colours depending on the season: Halloween, Breast Cancer Awareness, Christmas and more. Lastly is the waiting area which was designed to provide a sanctuary while waiting for an appointment. An open, comfortable and natural light filled area, a custom bench adorned in black marble, grey vinyl and the same wood veneer help provide a sense of luxury and coziness all at the same time. The end result of College Park Dental is a space that truly invites, calms and creates a lasting impression and experience for the staff and patients.G Interior Design: Bold Interior Design Inc. Dental Supplier: Patterson Dental Photograhy: Borsellino Photography

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3/3

THE EXPERIENCED DENTIST POCKETBOOK – A Three Part Series

After Selling –

Finding a New Life Rhythm

t is done, you’ve gone through due diligence, you are done with all lawyers, accountants and consultants. You have inked the agreement and a sigh of relief is noticeable. Welcome to another “first day” of the rest of your life. Similarly to any life milestone, it is always better to have at least one plan for the “day after” you sell your practice. This is true whether you plan on continuing to practice dentistry or retire to Scottsdale, AZ. In this process, you should discuss with yourself and your family the following topics:

1. How would you handle becoming an employee again? Originally, you became an owner not only because of the higher potential earnings, but also because you didn’t want to remain an employee and wanted to do things your way. Well after dozens of years as an owner, you might be looking at becoming an employee again. As things have changed in the industry, you cannot expect that being an employee is the same as it used to be. In fact, you can count on the fact that it is very different. The more resistant to following orders and guidelines you are, the more you’d struggle with adapting to your new reality. In a lot of instances, I recommend for dentists I work with to “swallow their pride”, as new management implements new policies. A controversial point is supplies. Often times, new owners have

a preferred vendor or would eliminate some variety of a product in order to reduce expenses. In this case, you might find yourself outside your comfort zone. As a new owner, they are allowed to make such changes and you would just have to adapt to it and deal with the frustration.

2. Relationships with staff and patients With new ownership comes new rules and procedures. As with any other change, new rules and procedures will create anxiety and stress on you and the staff. If before, you had the power to cut corners and make some concessions, moving forward most of it will not be possible. As patients and staff grew accustomed to this, it might create some friction. Being prepared for this will eliminate the element of surprise at the very least, although may not eliminate the implications. Beyond the fact of how staff and patients will feel in said situation, think about how it would make you feel. “Powerless” is the first word that comes to mind for the dentists I have worked with in this transition period. As with any emotion triggered by events, preparation and awareness are key factors in dealing with it. In my experience, even though everyone knows you are no longer the owner, the habit of turning to you for certain things will not change that quickly.

Alex Zlatin is the CEO of dental practice management software company Maxim Software Systems (MaxiDent). He helps dental professionals take control and reach the next level of success with responsible leadership strategies. He leverages his experience in “Responsible Dental Ownership – Balancing Ethics and Business Through Purpose”, a detailed guide providing practical tools and a unique, proven approach to running a successful dental practice. alexzlatin.com; maxidentsoftware.com

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3. What would you do with the increase in free time? As an owner and a dentist, you are used to not having enough hours in a day. When you sell, you will be planning to “take a step back” and work less hours. This might not occur right away, but will happen eventually. Sometimes, you sell your practice and completely retire right away. At first the excess of time is welcomed. You begin doing all the things that you once dreamed of. But soon, you realize that there has been a void created by the transition and the activities you originally planned do not fill it enough. Keeping busy has not been a problem up until now, but will become an increasingly challenging task. I often recommend dentists to take up speaking/lecturing. Sharing some of your vast experience is a great way to boost your ego, fill in your time with fulfilling activities and support your community. Joining clubs, associations and other charitable activities might be another great suggestion, if that is more your kind of time-spending.

4. Contract obligations and their implications I cannot stress enough how important it is to understand every single item on a contract you are signing. It is true for any transaction throughout life, but especially important in bigger transactions, such as the sale of your clinic. It is important to let your lawyer review the agreement. As with any professional service that is of magnitude, you should get a second opinion from an additional lawyer - it is well worth the money. Also, you should have your lawyer explain every single clause and its potential implications on you, after the transaction has been completed. Through my experience, I’ve seen some

contracts with production levels to be maintained. Although it is not unusual, it can be disastrous if for some reason you cannot continue to produce, such as a medical condition or moving somewhere to care for a family member.

5. How would you ensure that the funds received will be sufficient for your needs moving forward? As with a previous article, you must know the amount of money that you need to live comfortably, attend to all of your commitments and realize some of your life-long dreams. As the transaction has already happened, you are now at a planning phase to ensure the funds received will actually suffice to accommodate all your plans, goals and dreams. Keeping

Making specific investments that are in-line with your risk tolerance are a potential way to ensure money doesn’t run out. a close eye on your expenditures on top of realizing some potential avenues of revenue are good practices to ensure you do not run out of money. Making specific investments that are in-line with your risk tolerance are a potential way to ensure money doesn’t run out. You should keep in mind that even if you planned this out to a “T”, you will still have life events that will change your needs and it is a good idea to make sure you have funds available for those unexpected events. Getting used to a completely new lifestyle is never easy. Luckily for you, you should have enough health and funds to start it the right way, by fulfilling some of your long-time dreams. As in everything in life, planning and preparation are key to provide for not only short-term wellness and happiness but longterm prosperity and fulfillment as well. G

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DATA SECURITY AND YOUR DENTAL PRACTICE T

he amount of data generated from humans and computers continues to grow each day, and with it, the number of data breaches. This holds true for the healthcare industry, including dental practices, which is why having a solid data security policy in place is important to protect your clients and your clinic. To put the significance of data security into perspective, here are some staggering statistics and facts on data breaches from the past year:

With an ever-expanding database of confidential patient information at stake, there’s a great urgency for dental offices to improve their data security measures. A vulnerability in security can lead to the theft of sensitive data that can be used for criminal activities such as blackmail, identity theft, and fraud. In addition to potential damage to the patient, a data breach also leads to various consequences to the dental clinic from losing reputation and money to having lawsuits filed against the practice.

• 88% of Canadian businesses reported having a data breach in the 12 months prior to October 2019 • 82% of Canadian businesses reported an increase in overall attack volume in the 12 months prior to October 2019 • 32M patient records were breached in the first half of 2019 alone, not including the 12M records breached at LifeLabs • Cyberattacks cost small businesses an average of $54,000

Privacy and Data Security Legislations in Canada and Ontario The most common personal data collected includes: age, name, address, medical history, ID numbers, income, ethnic origin, blood type, etc. Fortunately, to ensure that this information is protected from unauthorized usage, there are two main legislations that govern how personal data is handled: PIPEDA (Personal Information Protection and Electronic Documents Act) and PHIPA (Personal Health Information Protection Act, 2004).

Sandro Persia is the Sales Director at Logic Tech Corp, a Canadian dental management software company that has been serving the industry for more than three decades. With over 25 years of experience in the dental field, Sandro has worked with over 1000 dental clinics across Canada to streamline their workflow and increase productivity. To contact Sandro and discuss your dental management needs, email sandro@logictechcorp.com.

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However, “health information custodians” are exempted from the application of PIPEDA as PHIPA is declared substantially similar to PIPEDA. In other words, dentists only need to comply with PHIPA in respect to the collection, use, and disclosure of personal information that occurs within the Province of Ontario.

What is PHIPA? Ontario’s PHIPA came into effect on November 1, 2004 with five main purposes: 1. To set rules for collecting, using and disclosing personal health information about individuals. This protects the information’s confidentiality and the individual’s privacy, while the information is used to provide effective health care. 2. To provide the right for individuals to access their personal health information (with exceptions). 3. To provide the right for individuals to correct or amend their personal health information (with exceptions). 4. To provide for independent review and resolution of complaints regarding personal health information. 5. To provide effective remedies for contraventions of this Act. PHIPA is similar to PIPEDA in that they both: • Incorporate the ten principles in the National Standard of Canada (Model Code for the Protection of Information) with emphasis on principles of consent, access and correction rights. • Provide for an independent and effective oversight and redress mechanism with powers to investigate. • Restrict the collection, use and disclosure to appropriate and legitimate purposes only. PHIPA governs health information custodians and their agents that collect, use and disclose personal health information, whether or not in the course of commercial activities. Dentists and other health care practitioners are considered to be health

The Royal College of Dental Surgeons of Ontario’s guide to compliance with Ontario’s PHIPA outlines that custodians must take steps reasonable in the circumstances to protect personal health information. information custodians, whereas office staff such as receptionists, office managers, dental assistants are considered agents. In some cases, agents may also include accountants, lawyers and record management services. The Royal College of Dental Surgeons of Ontario’s guide to compliance with Ontario’s PHIPA outlines that custodians must take steps reasonable in the circumstances to protect personal health information they have obtained against theft, loss, unauthorized use, disclosure, copying, modification, or disposal. Dental offices must also do their best to satisfy the ten principles to protect patient data. The clinic’s failure to comply with these regulations could result in an investigation by the Privacy Commission and strict penalties. Please note that the above information is intended for reference only and should not replace advice you should be seeking from any formal legal counsel.

How Can You Increase Data Security? As a dental clinic, there are two ways in which data security can be threatened. Physically, the patient data is vulnerable to theft if there are no safeguards to prevent the computers from being stolen. Digitally, if an office neglects to keep their cybersecurity up to par, it leaves the office’s computer network vulnerable to cyberattacks. Here are some ways in which you can increase your data security within the office: Physical Security: Physical theft may not be the first thing to come to mind when you’re thinking of data security, but dental offices do get broken into physically. The thieves often aim for the most valuable

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equipment they can get, which includes office computers holding all the patient data. To keep your data physically secure, set up surveillance cameras around the office so that your computers are always in sight. This keeps your staff accountable and prevents them from taking down any patient information for any unauthorized reasons. At the end of the day, rooms with computers and any paper records should also be locked to deter thieves if the office does get broken into.

Cyber Security With the increase in cyberattack volume over the years, dental offices can no longer rely on basic security measures. Step up your cybersecurity with these tips: Keep Systems Updated: Microsoft had announced that they would be ending support for Windows 7 as of January 14, 2020. What this means is that technical support, software updates, and security updates or fixes will no longer be supported. Keeping your systems updated is the best way to keep your network secure. Since Windows 7 will no longer receive security updates or fixes, this leaves the system vulnerable to new threats (viruses and malware) and allows hackers to easily access your computers. By upgrading your systems to the latest operating system (Windows 10) you’ll receive all the new security updates to ensure that your computers aren’t vulnerable to cyberattacks. Encrypted Electronic Records and Backup: If your office is already backing up data regularly, give yourself a pat on the back – this can save you from a lot of stress and money trying to recover data from a system failure or cyberattack. You can further enhance security by encrypting your backup data. This way, even if this backup data ends up in the wrong hands (e.g. stolen hard drive), the data would not be accessible without the correct decryption key. The software you choose for your practice plays a key role to your data security – such as programs like Paradigm Clinical, which is compliant with the PHIPA, equipped with a security manager and operates a fully encrypted database. Encryption of electronic or digital records is an example of a technical safeguard provided by the Royal College of Dental Surgeons of Ontario’s guide to compliance with PHIPA. This also allows you to create more secure backups, protects a dental office’s electronic records of personal health information and controls access to them.

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Organizations attacked by ransomware have to stop their business due to the disruption, and many end up closing down if they are not able to resolve the attack. It is worth your dental office to invest in anti-ransomware software that continually monitors your systems.

We also recommend keeping an off-site backup (a backup to the backup!) to ensure that you can recover from any data crisis. Anti-Ransomware Software: In the last year, a global wave of ransomware attacks has been hitting Canadian organizations, with a Toronto dental clinic being one of the victims. The staff were locked out of the office computers and the hacker demanded a hefty $165,000 ransom to decrypt the files. This is a prime example of ransomware in action. Fortunately, the office had a good back up system and was able to recover their files without giving in to the demand. Organizations attacked by ransomware have to stop their business due to the disruption, and many end up closing down if they are not able to resolve the attack. It is worth your dental office to invest in anti-ransomware software that continually monitors your systems. A good software should be effective at protecting your system from real-world ransomware, quarantine any ransomware detected and reverse the encryption on the files. A good software should be able to: • Effectively protect your system from real-world ransomware • Detect and quarantine ransomware • Reverse any encryption done to your files • Enterprise Level Firewall

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A firewall monitors and controls the incoming and outgoing traffic from your network, and is an added layer of security against cyberattacks. They can exist on your computer (host-based) or on your network (network-based). You can set up conditions to prevent your computers from accessing certain websites (e.g. social media) or block untrusted network traffic from reaching your computers. An enterprise-level firewall will form a strong barrier between your internal network and any untrusted external networks. As such, your dental office should invest in one to further protect your computers and patient data from cyberattacks.

Cybersecurity Awareness Training The key to effective cybersecurity is employee education, yet only a small percentage get adequate training. If your dental clinic doesn’t already have security training policies in place, now is the time to do so. Even a one-hour session can greatly improve your staff’s ability to recognize potential breaches and disengage with attempted attacks. The most common form of cybercrime is Phishing, which attempts to coax the target to provide sensitive information over email, text or phone calls. Phishing scams often pose as familiar institutions (e.g. banks, internet service providers, post office, etc.) so that the target lowers their defense. Be extra cautious when being contacted if you are asked to provide personal data such

as banking information and passwords. Poorly written emails (bad grammar and spelling) from unknown emails and suspicious links are also a tell-tale sign of a phishing scam.

Expect Data Crisis Hackers are becoming craftier by the day so have a crisis management protocol in place so that you can act quickly to mitigate damages caused by a data breach. With a strong backup system in place, your dental office is less likely to experience as much down-time in the case of a cyberattack. Another aspect you should keep in mind is the possibility of system failures. Computer hardware and software don’t have an infinite lifespan and will break down after years of everyday use. Plan to replace hardware and upgrade systems to prevent a sudden breakdown that can cost you a day (or more) to fix. For system upgrades, you can even have your technician come in after the clinic closes to do the necessary backup and updates. With the rising number of data breaches and costly consequences of cyberattacks, dental offices need to be on their best defense to protect their patient data and ensure that their systems comply with PHIPA requirements. It is important to take action now to put physical and digital safeguards in place, as well as training staff to be aware of attacks. With solid safeguards and protocols in place, you’ll be able to keep the hackers at bay. G

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3 Ways

can be a Marketing Tool for Dentists

lthough LinkedIn might not have caught on as quickly as other platforms such as Instagram, Facebook, or Pinterest, in recent times, it has experienced significant growth, with a broad user demographic. With over 675 million users worldwide, of which 16 million-plus are in Canada, it is a social media platform every dental business within Canada should get on. So, what's in it for your dental practice? Cost-efficient marketing opportunities, reaching out to an extensive network of professionals and an all-round platform to meet, retain, and expand the client base of a dental clinic. However, most often, a lot of people create a LinkedIn account and abandon it almost immediately, because they don't have a good grasp on how to use it to grow their profile or business. They are not aware of the strengths of LinkedIn marketing opportunities and as a platform with a broader clientele for a small business such as a dental practice. In this article, I will be guiding you on the three ways you can use LinkedIn as a marketing tool for your dental clinic.

Maximize the Benefits of LinkedIn Advertising

LinkedIn offers very affordable advertising that is similar to what you have on Facebook. You have the option of traditional ads and sponsored updates; these two forms of advertising can be beneficial for dental offices. The traditional advert pop-ups are those that appear on your LinkedIn profile or home page. Here, you can advertise your services using images, written content, and images, or video clips, to link to your LinkedIn company page and your website. For the sponsored ads, these are similar to Twitter promoted tweets: simply create a LinkedIn post, and then pay for your post to appear on the feed of users not connected to your LinkedIn profile. LinkedIn advertising is a great way to focus on those who are most likely to need your services by allowing you to target them based on their interests. So as a dental practitioner, your advertising campaign can target clients based on aspects such as location, gender, and age. For example, your target audience might be older people in the same area

Frank Hamilton is a blogger and translator from Manchester. He is a professional writing expert in such topics as blogging, digital marketing and self-education. He also loves traveling and speaks Spanish, French, German and English.

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as your clinic who have gum problems. Or it could be younger families within your location who may need orthodontic services for their kids. LinkedIn advertising prices are determined by auction from a pool of other advertisers you're in competition with and want to reach a similar audience. You can control your advertising expenditure either by a daily budget, a total budget, or maximum bids. You can customize your settings to the maximum price and number of bids you're willing to pay for impressions and clicks, so it is easy to stay within your budget.

Maximize Your LinkedIn Personal Profile

Besides being an asset for Business-to-Business (B2B) organizations, LinkedIn is likewise efficient when it comes to Business-to-Consumer (B2C) services such as your dental practice. Using your LinkedIn personal profile is a great way to connect with prospective patients by telling them how your qualifications and background has shaped your practice culture and ideals. The tip here is to ensure that your profile has the relevant content and keywords so that you can boost the Search Engine Optimization (SEO) for your dental clinic. The use of keywords will enable your profile to appear in the top of the search engine results pages of Google, Yahoo, Bing, or any of the top browsers your potential clients are likely to use when looking for dental services. Other features of your profile that will help to broaden your clientele include endorsements that point to your expertise, recommendations from peers and existing clients, etc. You can also include a business page to promote your practice. On this page, you can give details of all your different dental services and areas of specialization, staff profiles, images of before and after dental services, post updates on services, etc. Another great thing is that LinkedIn comes in over 24 languages, so it gets easier to reach a broad audience and translate clients' results in a language they understand. And where LinkedIn does not cover a language you wish to use, you can engage The Word Point for accurate medical translation services. The LinkedIn company page is very similar to business pages across other social platforms. It is a great way to consolidate your brand, gain new followers, and engage with potential patients via content that is relevant and informative.

Maximize the benefits of Discussion Groups

LinkedIn discussion groups can be very beneficial for dental practices. You get a space where you can share ideas with fellow dental professionals, network, get up to speed with novel developments in health and technology. You can also get to showcase your professionalism and expertise as you interact with others on relevant topics in your field. There are over two million discussion groups on LinkedIn that have an extensive range of topics for discussion so it is easy to get a group that covers your business idea. There is a limit to the number of groups you can join, which is set at 100 groups. You need to make sure you pick the groups that are relevant and add value to your business. Examples of groups you can join include: • • • • • •

Dental Technology Canadian Dentist Network Innovations in Health Networking for Business Professionals & Doctors. Sedation Dentistry Marketing and Networking for Dentists

These groups expand your networking pool, allow you to share business ideas, and also give you room to establish yourself as an expert in the industry. It is also essential to listen to conversations first before engaging in any group discussions. With this, you can post recommendations about other dentists and likewise get endorsements for the clinic. Suggestions are great for building your professional rapport and establishing your services as trustworthy in the eyes of potential clients, especially when these referrals come from your peers. Remember, if you can't seem to find a group that suits your brand ideas and goals, you can always take the lead and create your own, invite old and potential clients and other service providers. LinkedIn allows you to setup up to 30 groups at a time.

Conclusion A dental practice can get quite competitive, so it is essential to stay ahead of the game with innovative marketing strategies that can help you to connect with old and potential clients. Having a LinkedIn presence is a step in the right direction to having a trustworthy reputation and expanding the client base. G

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It’s Not Just About New Patients – Tips for Increasing Retention N

ot everyone will come back. It’s a simple fact that every business owner must come to terms with, but the percentage for dental practices is higher than many industries. According to some reports, an attrition rate above 201 percent is normal. Of course, that means it is higher in some offices, and lower in others. Improving patient retention not only improves your bottom line, but also makes every new patient more valuable, which increases marketing ROI. Here are six simple strategies to help you do just that.

Answer the phone We’ve all been there. You have a scheduling conflict or urgent question and need an answer now. It is within business hours, so you call. After navigating a lengthy menu, you end up with automated voice mail. Whether the issue is an auto repair appointment or a delayed supply order, the frustration is real and reflects poorly on the business. Just imagine how your patients must feel when the issue at hand is their oral health, or unbearable tooth pain. To optimize your patients’ calling experience, you need to consider both the people and technology involved. Make sure you have adequate

staffing, and that they prioritize answering the phone as soon as it rings. They should be well versed in your services and policies so that they can answer simple questions promptly and accurately. Additionally, phone systems should be up-to-date and adequate to handle call volume. If there is anything worse than voicemail, it is a glitchy system that drops calls.

Upgrade your office You might say that you’ve invested heavily in equipment and devices, your office is already state-of-the-art. However, your perspective is very different from that of your patients. Clinical care is only a portion of the patient experience, which begins long before a person meets you. Take a walk around your office, trying to see it through your patients’ eyes. Is there enough parking? Is the reception area welcoming, stark, or shabby? Are the chairs comfortable? How reliable is the Wi-Fi? Do you have refreshments or snacks available? If you see kids, do they have a play area? Continue this line of thinking to the treatment rooms. Are they comfortable and aesthetically appealing?

Naren Arulrajah, President and CEO of Ekwa Marketing, has been a leader in medical marketing for over a decade. Ekwa provides comprehensive marketing solutions for busy dentists, with a team of more than 180 full time professionals, providing web design, hosting, content creation, social media, reputation management, SEO, and more. If you’re looking for ways to boost your marketing results, call 855-598-3320 for a free strategy session with Naren.

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Improve scheduling Dentists are at a distinct disadvantage compared to many types of businesses. People might be eager to return to a good beauty salon or restaurant. However, virtually no one is excited about a dental cleaning, no matter how good the service is. The first step to getting a patient back is scheduling another appointment. Ideally, this should happen in your office, before the person leaves. Don’t count on a text, email, or postcard reminding the patient that it’s time for a checkup. There is a good chance he or she won’t bother picking up the phone and calling. In fact, failure to pre-schedule can increase patient attrition by 15 to 18 percent2 , according to the Levin Group Data Center.

Provide customer service training for your staff The dentist is one of the last people a new patient will meet and interact with. The first impression usually comes from the initial phone call when the appointment is scheduled. Next is the receptionist who greets the person upon arrival, likely followed by a hygienist or assistant. If the person is already disgruntled or offended, you have an uphill battle to turn things around and have a happy patient. When you hear your office or clinical staff interacting with patients, pay attention to their mannerisms, tone of voice, and actions. Are they friendly and respectful? Does the receptionist answer questions accurately and encourage people to schedule? Are your clinicians gentle and attentive?

Make people feel important No one likes to feel ignored, especially when their health, comfort, and appearance are at stake. Although multi-tasking is the norm in a busy dental office, patients need to feel like they are seen and heard. If your receptionist never stops typing or looks up from the computer when greeting a patient, and you are discussing supply orders with your assistant while performing an exam, the patient is going to feel slighted. During treatments and exams, try to give the patient your undivided attention. If there are questions (even nonsensical ones), answer them seriously and respectfully. Similarly, the office staff should warmly greet people as soon as they walk in, as well as offering assistance or information when needed. Last, but certainly not least, express your gratitude. Let patients know that their patronage is appreciated.

Expand your marketing efforts The number one goal of dental marketing is new patient acquisition. However, that should not be your only goal. If you want to keep your existing patients, you should be marketing to them as well. An opt-in newsletter is a great way to keep them apprised of new staff members, changing office hours, added services, and other news from your office. It also helps keep your name fresh in their minds. Although email marketing has declined in popularity over the years, it remains effective. In fact, about 80 percent3 of small and midsize businesses rely on email as their primary customer retention strategy.

Final thoughts – making patient retention a priority When creating financial projections, it is prudent to consider your current attrition rate as standard, and plan for it to continue. However, when evaluating your marketing and practice management strategies, you should take your attrition rate as a challenge – a number to beat. Review your records to see which patients you are losing and try to determine the reason. Did the front office try to pre-schedule during the person’s last visit? For the patients who refused to schedule: did they give a reason? For those who scheduled and canceled: what efforts were made to reschedule? For no-shows: were appointment reminders sent in advance, and were attempts made to re-schedule? Another great source of information is patients themselves. Don’t automatically discount complaints, bad reviews, or lukewarm responses on patient surveys. Ask yourself if you or your team could have done anything different to provide a better experience. Even better, ask that question from the unhappy patient, if you have the opportunity. Also engage in conversation during appointments. Be open to feedback and suggestions. Find out what patients want and make an effort to deliver it. If you succeed, they will come back. G 1. Gerry McGoldrick, Still think you need new patients? https://www.dentaleconomics.com/practice/article/16386275/ still-think-you-need-new-patients 2. Roger Levin, How to Cut Patient Attrition by 50% https://www.dentistrytoday.com/news/todays-dental-news/ item/5061-how-to-cut-patient-attrition-by-50 3. Maryam Mohsin, 10 Email Marketing Stats You Need to Know in 2020 https://www.oberlo.com/blog/email-marketing-statistics

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10 Top Management Tools for a Successful Practice I

n dental practice management… it takes a “total team” to run a “practice”. This article will reveal the 10 key management tools for running a successful dental practice. There is a domino effect that takes place in running a practice. I have outlined these key management tools in this article.

1. Design systems and protocols for a good foundation of production and collections. Strategically plan the success of the practice by designing effective systems for Production, Net Collections, Adjustments, Accounts Receivables Ratio, open time and treatment acceptance. One of the most important statistics to track is the Accounts Receivables Ratio. A healthy ratio is less than 1.0. 2. Hire and train for positive attitude and acquire great teams with a dedication towards customer service and effective communication. If a practice wants team members with great attitudes, write the ad to attract the person with the best attitudes. Then, inspect what is expected of the team by checking in with them often. A simple “thank you for the hard work”, “great job” and positive recognition for a job well done will go a long way in reducing turnover and can add longevity to a team. 3. Hold a “morning huddle” every day to check in on the pulse of the practice and address day to day concerns before they become major issues. Many times the morning huddle or morning meeting becomes a chart review. It is important to address all areas of the practice to avoid unpleasant surprises during the day.

a) Discuss previous day with what went right and what were the challenges, to identify celebrations and areas to improve. b) Report on next available production block to ensure consistent scheduling. c) Identify any overdue hygiene patients, family members overdue for hygiene, patients with diagnosed dentistry needing to be scheduled, and where to schedule emergency patients. d) Determine which patients to identify for marketing possible practice referrals. e) Measure status of numbers compared with goals and how close practice is to meeting the goal. f) Offer a leadership statement which helps to start the day on a positive note.

4. Strategize each week by holding team meetings. Set a theme for each week of: Week 1: Cross training – Set aside this team meeting to cross train departments Week 2: Analyzing monthly numbers – Reveal the previous month’s statistics, percentage of goal and trends identified Week 3: Continuing Education – Take advantage of continuing education opportunities. You could review a recent conference attended, invite a specialist to the practice to review their specialty, invite a product or services organization to review new and updated products and services, in-office training on dental software in the practice. Week 4: Role play – Practice communication for

Lois Banta is CEO, and Founder of Banta Consulting, Inc. established in 2000. Ms. Banta is also the owner and CEO of The Speaking Consulting Network. Banta Consulting specializes in all aspects of dental practice management. Lois has over 47 years of dental experience. To contact Lois for a personal consultation or to invite Lois to speak to your organization: Office-816-847-2055, Address: 33010 NE Pink Hill Rd ~ Grain Valley, MO 64029, Email: lois@bantaconsulting.com Website: www.bantaconsulting.com

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patient questions – this is very helpful in improving communication with patients. Week 5: Sometimes there will be a 5th week in the month. During these weeks, hold an “attitude adjustment” lunch. The rules for this meeting… don’t talk work. Hold the team meetings at a set time each week for 1 hour. Develop written action plans. Bring these action plans to every team meeting. The action plan would have four columns: Column 1: Item to be addressed Column 2: Name of facilitator taking on the project…a project coordinator Column 3: Target completion date Column 4: Celebration/Completion date I recommend setting the production goals this day as if it were a full day which means raising the hourly goal slightly to accommodate for the one hour less seeing patients. This way, the productivity is not reduced. 5. Choreograph schedule for optimal productivity. Choreograph the schedule in blocks of time based on the preferences of the producers in the practice. Key communication skills are also needed to predict optimal success. This means not asking “yes” or “no” questions. In addition, always offering “two options”. Asking “yes” or “no” questions puts the practice at risk for the patient not accepting optimal dentistry. Also, offering the patient two options makes the patient feel in control, however; the “practice” is actually in control because they offer the two appointments that work best in the schedule. a) Do say: We are calling to let you know you are on our schedule. Don’t say: Remind or Confirm. b) If the patient needs to cancel, never offer them the very next appointment. Instead, schedule them in 4-6 weeks. Then, offer to place them on the “priority list” if a “change in schedule” happens sooner.

c) Have a 2-3 strikes and out “failed appointment” guideline. If the patient fails 2 or 3 appointments in a row, release them formally from the practice. 6. Get the money off the books and into the bank quickly. Collection strategies are a crucial element of a successful practice. Detailed strategies and systems must be in place. a) First, be sure all financial arrangements are in place and patients fully understand their responsibility. b) Second, have a written protocol in place for following up on overdue accounts. Send statement cycles weekly to offer consistent collections through the mail. c) Third, set aside private time to consistently follow up on accounts that need phone calls and special overdue balance communication. d) Fourth, take action on all accounts deemed uncollectable. 7. Utilize excellent customer service…patient’s impression of you begins on the phone. Patients make decisions about the quality of their care by how they feel treated when they walk through the doors of a dental practice. Of all the top management tools in a practice, this is one of the most important tools. 8. Sharpen your clinical and practice management skills often by attending and participating in select continuing education. The practice that invests in learning together is a team that grows in the right direction. Attending continuing education together reinforces consistency. The team that stops learning…stops growing. Continuing education doesn’t mean having to leave the practice to learn. 9. Inspect what you expect. Create an infectious environment to keep learning and growing. Involving the team in this process creates a sense of ownership and offers a practice ultimate success. 10. Have more professional fun and find your “internal giggle”. Look for opportunities to make a positive impact in your practice by treating your patients and team with respect, care and empathy. Find your “internal giggle” and keep the focus about positive results. G

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“I realized that the future of dentistry is changing, and I wanted to drive the bus— not be taken over by it! This group is comprised of the best dental practitioners in Canada. And I’m proud to be part of it.” —Dr. Don MacRae, British Columbia, Partner since 2015

Get back to doing what you love. Visit dentalcorp.ca to learn more.

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Dental Marketplace

OPPORTUN ITIES IN TH E DEN TISTRY PROF ESSION

Contact: Karen Shaw | 416-510-6770 | 437-991-7187 | karen@newcom.ca fax: 416-510-5140 | toll free CDA & USA: 1-888-639-2669

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Dental Practice Advisory Services • Practice Purchase Consulting • Financial Planning • Professional Corporation • Review of Dental Practice Tax and Investment Strategies Appraisal Reports Victor Staniewski CA victor@fgsaccountants.com 416-222-3221

Alglobe

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• Dental Practice Sales and Purchases • Incorporation of dentistry professional corpoHoward Kutner rations • Estate planning for dentists • Associate, employment, partnership and cost sharing agreements • Lease and real estate transactions. Tel: (905) 479-2524 50 Acadia Ave., Suite 307 Markham, Ontario L3R 0B3 www.kutnerlaw.ca Michael Kutner

ORALHEALTH GROUP Construction Company

20 years construction experience • Dental office construction and design + cabinet making. • Provide turn key operation to dental office. • Reliable construction timing, • Good following up service after construction. Call: Stanley • New dental location and lease negotiation. Tel: (416) 321-3313 • Save time, save money. www.alglobe.com

HYG I E NI STS HYGIENISTS WANTED We are looking to hire hygienists to join our busy and well-established practices in Ontario, Saskatchewan, Alberta, and Manitoba. What you will benefit from: • Excellent remuneration • Mentorship and access to a large network of dental professionals • Work life balance with evenings/ weekends off • Additional perks for the right candidate New grads welcome! If interested please send your resume and cover letter: Recruitment@dentalook.ca

CA R E E R S GP DENTIST AVAILABLE 19 years Experienced GP dentist available to work in Toronto and GTA. Monday,Wednesday and Saturday. All types of dentistry including all endo, surgical exo and impactions. Please contact sidhumehboob@hotmail.com

The Oral Health Group of publications offer classified advertising sections in each and every issue. We carry more classified ad pages than all other Canadian dental magazines combined.

O B I T UARY

Dr. Peter StePhen rockman On Monday, January 6, 2020, Peter passed away surrounded by family. We will remember him as a devoted husband to Mary for 39 years; a loving father and father-in-law to Cathy and Joel Dubrofsky, Mike Rockman and Garth Morris, Jenny Rockman and Codye Jolley; a proud grandfather to Abby and Cory; a dear brother to Laurie Rockman and Joseph Rockman; a loving uncle to many nieces and nephews and a devoted friend. Peter passionately served the dental community for over 50 years as both a family practitioner and locum dentist. He was an avid sports fan, especially tennis, hockey, and golf. He was generous of spirit and a selfless, thoughtful, compassionate man who always put his family first.

P RACT I C ES & OFFICES HAMILTON, ON PRACTICE FOR SALE Well established 5 operatory dental practice in a strip mall location with great exposure, great potential, and ample free parking. 1,900 patients seen over last 12 months. Strong, sustainable hygiene program. Owner will stay during transition. Please contact for more details: dp4sale2020@gmail.com

WHY LOSE 10% TO A BROKER? NO PRODUCTION GUARANTEES! Looking to sell your practice for full market value? We welcome the owner staying on too. Confidentiality is guaranteed. E-mail: gtadentist@yahoo.com

NORTH ALBERTA PRACTICE FOR SALE Well established 4 operatory dental practice in a strip mall location with great exposure, great potential, great parking. Good opportunity for one or more dentists. Owner will stay during transition. Please contact for more details: g_christoffel@hotmail.com

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Grad-RetireAd.qxp 2020-03-14 6:59 AM Page 1

PROVIDING DENTAL PRACTICE SOLUTIONS FROM GRADUATION TO RETIREMENT

OPTIMIZATION OF GROWTH

PRACTICE ENHANCEMENT VALUATION AND SALES

1-866-638-6194

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WHO WILL BUY YOUR PRACTICE? Over 45 years of experience speaks for something. We know and understand the business of buying and selling dental practices.

Discretion, Privacy, Practice Preservation Call 1.844.ROI.2020

Subscribe to our New Listing Service at roicorp.com

Are you contemplating selling your practice?

Our purchasing clients pay our fee. No fee is charged to the selling dentist.

As a practicing CA for over 30 years with my practice restricted to dentists across Canada, I am very familiar with the professional needs of dentists at this point in their careers. We are retained by many dentists to locate and assist in the acquisition of a practice, who pay our fee. Their needs range from single practices to multiple locations. The transition period ranges from immediate to several years.

If you are interested in selling or purchasing, please contact us for a confidential discussion.

MacKenzie & coMpany (Practice restricted to dentists)

e-mail: mackenz@telus.net â&#x20AC;˘ www.mackenziecompany.com cell: (604) 312-3780 Any real estate services will be provided by a licensed real estate agent.

EVALUATIONS SEPARATELY AVAILABLE

VANCOUVER (604) 685-9227 EDMONTON (780) 424-9294 TORONTO

(905) 270-7454

EVALUATIONS ALSO AVAILABLE

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Purchase. Prosper. Sell.

LOCATION

NUMBER OF PATIENTS

NUMBER OF OPERATORIES

GROSS REVENUE

SELECTED LISTINGS – VISIT PPSALES.COM TO VIEW ALL OF OUR LISTINGS! EAST TORONTO – NEW!

KITCHENER

LONDON – PATIENTS ONLY!

~500

~550

510

REF. # 997

3+1

REF. # 960 GENERAL FAMILY PRACTICE

REF. # 983 GENERAL FAMILY PRACTICE

$355,000

Conditionally

WEST TORONTO – NEW!

EAST YORK

2300+

2000+

REF. # 996 GENERAL FAMILY PRACTICE

3+1

$1MM+

SOLD

$1.125MM+

SCARBOROUGH – NEW!

SOUTHEAST TORONTO

1250

3400+

REF. # 994 GENERAL FAMILY PRACTICE

2+1

$600,000

SOLD

1800

4+3

$1.1MM+

20 MIN. FROM VANCOUVER

REF. # 986 GENERAL FAMILY DENTAL PRACTICE

REF. # 976 GENERAL FAMILY PRACTICE

GREATER VANCOUVER – NEW!

REF. # 988 GENERAL PRACTICE W/REAL ESTATE-RETAIL

REF. # 977 GENERAL FAMILY PRACTICE

900

$1.95MM

2+2

$850,000

Conditionally

SOUTH WESTERN ONTARIO

KING TOWNSHIP – NEW!

~1000

1350+

REF. # 987 GENERAL FAMILY PRACTICE

3+1

$590,000

SOLD

REF. # 975 GENERAL FAMILY PRACTICE W/REAL ESTATE

4+1

$950,000

20 MIN. FROM VANCOUVER REF. # 981 DENTAL PRACTICE

825+

$700,000

SCARBOROUGH – NEW!

NORTH YORK – PATIENTS ONLY!

DOWNTOWN VANCOUVER

3300

420

~1200

REF. # 984 25% PARTNERSHIP

David Lind

Broker of Record

$1.5MM

Colin Ross

Partner/Sales Representative

REF. # 961 MATURE PRACTICE

Gerry Crandles

Partner/Sales Representative

$320,000

Mike Suffield

Sales Representative

REF. # 980 IDEAL FOR CONSOLIDATION W/NEARBY OFFICE

$700,000

Linda OConnor

Sales Representative

Nicky Saini Broker

If you’re buying or selling a practice, we’re here to help. See all available practices and subscribe to our new listing service at www.ppsales.com or call 1.888.777.8825 today!

B R O K E R AG E

PRACTICE VALUATION | PRACTICE BROKERAGE | BUYER REPRESENTATION | NEGOTIATIONS

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MBC BROKERAGE

What Every Doctor Should Know About Appraising and Selling Practices

Introducing

Maria Turner Sales Representative

Tom Schramm Broker

Irv Handler Sales Representative

Jon Walton General Manager Sales Representative

David Schramm Sales Representative

Sandie Baillargeon Transition Consultant Business Analyst

Eric Humes Sales Representative

How can we help you? • •

Professional practice appraisal Professional practice sales and legacy preservation and transfer

• •

Practice purchasing preparation and advice Business, financial and day-to-day practice consulting

Don’t leave any of your money on the table. Contact us to maximize the value of your practice, without harming your legacy.

905-825-2268 • mbc@mbcbrokerage.ca • mbcbrokerage.ca

What You Don’t Know Can Really Hurt You™

Canada’s HR Law Firm for Doctors

The Appraisal and Brokerage Name You Can Trust

MBC LEGAL What Every Doctor Should Know About HR Law

Cheryl Hutchings-Sharron Legal Services Manager

• • • •

Amanda DeGeer Paralegal

Mariana Bracic Founding Lawyer

Dirk de Lint Partner

Chris Stienburg Associate Litigation Lawyer

How can we help you?

Practice Protection Package™ (PPP™) Litigation Health and Safety Programs & Training Consultations (Telephone, Email, or in Person)

• • • •

Maria Turner Director Health & Safety Programs and Training

Optimizing your practice for sale Workplace Investigations Discipline and Terminations Wills, Powers of Attorney, Estate Litigation

The Practice Protection Package™ (PPP™) The only judicially approved, industry recognized, gold standard for staff contracts and policies that will protect you while you own your practice and maximize its value when you sell it.

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P RACT I C ES & O F F I C ES PRACTICES FOR SALE

Alan Kaluta President Specialists for your Dental Practice Valuations Brokerage • Consulting • Mediations

•

Calgary (403) 201 - 1231

•

Edmonton (780) 423 - 3695

TA-1263 Edmonton: NEW LISTING 5 operatory practice located in South Edmonton. Ground floor strip-mall location. Practice boasts 1900 active charts. Great opportunity for above average earnings. Valued at $1.8 million. C/SOLD

TA-1271Southeast Calgary: NEW LISTING Well established 5 operatory practice in strip mall location. Great exposure, great parking. Over 1600 active charts and billings in excess of $1.6 million. Owner will stay on as an associate. C/SOLD

TA-1264 Edmonton: Digital, paperless , well established 5 operatory practice in north Edmonton. Main floor practice with good parking. Over 1800 active charts and over $2.1 million of production. Valued at $2.55 million. C/SOLD

TA-1272 South Edmonton: NEW LISTING This well established 6 operatory non assignment office is located in a visible stand alone building with plentiful parking. Go to our website for more details about this excellent opportunity. $922,290.00

TA-1270 North Calgary: 4 operatory practice/ 3 operatories equipped. Strip mall location with new mall services being added. Great location. Great opportunity. Owner will stay on to associate. Valued at just over $800.000.00 C/SOLD

TA-1273 Central Alberta: NEW LISTING This 4 operatory practice is located in a strip mall boasting over 1,700 active charts and excellent profit margins. Valued at $1,874,000.00

TA-1270 North Calgary: NEW LISTING 4 operatory practice/ 3 operatories equipped. Strip mall location with new mall services being added. Great location. Great opportunity. Valued at just over $800.000.00 C/SOLD Pending: .4 operatory practice in the clgary area. Great reviews... Great staff.

TA-1279 Northern Alberta: NEW LISTING This well established 7 operatory practice is in a stand alone building. with great parking with over 2200 active charts. Great potential and great opportunity ....some great practices never make this page. call or email to be put on our call list...... ........ "A SHIP IN THE HARBOUR IS SAFE, BUT THAT IS NOT WHAT SHIPS WERE BUILT FOR "......

• •

•

Transitions

"Visit our website for additional information about these practices and more!" Contact us at: info@practicesolutionscanada.com

www.practicesolutionscanada.com

ASSO C I AT ES H I P S KAMLOOPS, BC Dental Associate Needed in Beautiful British Columbia. We are looking for a motivated dentist to join our busy family dental practice in Kamloops, BC. We are a paperless, digital office with a busy recall system in place. Kamloops is home to world renowned skiing, golf, fishing, and mountain biking. Our practice is team orientated. The position is full time and is available for July 2 2020. New Graduates welcome.

SASKATCHEWAN We are looking to hire an Associate Dentist to join our busy and well-established practice in Saskatchewan! What you will benefit from: • Excellent remuneration • Mentorship and access to a large network of dental professional • Work life balance with evenings/ weekends off • Additional perks for the right candidate New grads welcome! If interested please send your resume and cover letter: Recruitment@dentalook.ca

Please call 250-398-0532 or email vitoratos@shaw.ca

TORONTO, ON

REXDALE ON (Kipling and Steeles)

Busy downtown family dental clinic is looking for a F/T or P/T General Dentist and Periodontist. Please send resume to Davidkourosh@hotmail.com

Family practice looking for a p/t associate for Saturdays. More days to be offered to the right candidate. Friendly and good communication skills a must. Familiar with all aspects of dentistry. Please send resume to amdentalinfo@gmail.com

ORILLIA, ON Looking for a part time associate. Please send resumes to dental_2010@live.ca

MID AND DOWNTOWN GTA LOCATIONS FULL-TIME ORAL AND MAXILLOFACIAL ASSOCIATE This fast paced, full-scope oral surgery practice has an immediate need for a full-time associate. May lead to possible partnership opportunity. This high-volume multi-doctor practice with mid- and downtown GTA locations has a wellestablished referral base and potential hospital availability. Onsite CBCT/digital X-rays. The position requires a BoardCertified or Board-Eligible oral and maxillofacial surgeon who has ambition! Email: admin@metropolitanoms.com

WHITEHORSE, YT Full time associate required. We enjoy a modern clinic and our excellent team is focussed on patient centered care. Come and join us and experience a northern lifestyle second to none. Tel: 867-633-4401 Fax: 867-633-4402 E-mail: office@murrayadental.ca

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ASSO C I AT ES H I P S OTTAWA, ON

CRANBROOK, BC

CORNWALL, ON

ASSOCIATE DENTIST OPPORTUNITY WITH A LEADING PRACTICE

Nestled in the Rocky Mountains surrounded by world class skiing, fly fishing, hiking, biking and views is an established full time practice waiting for you! The successful applicant will have a higher than average income potential with the full patient base, and no other dental practices in town. This hidden gem is a short 3 hour drive to Calgary and 45 min to Fernie Alpine Resort. Please send CV to elkforddental@gmail.com

FULL-TIME ASSOCIATE DENTIST

Join our large customer-oriented multi-disciplinary group dental centre and build your practice through referral and extraordinary new patient flow. Let us help you rapidly advance a career to be proud of. Centrally-located in a major retail plaza, we offer extended hours and supply superb support staff, state-of-the-art equipment, and committed colleagues.

Great opportunity to Associate for a well established Brampton Group Practice. Call Kathy at 905-457-3606 to set up a visit, if interested.

business@adcottawa.com

STONEY CREEK/BRANTFORD, ON

THE PAS, MB

Looking for a highly motivated dentist. PT/ FT skilled in most aspects of dentistry for a busy, modern practice with an established patient load. Excellent remuneration. Please reply to pwdentist3@gmail.com

Awesome opportunity for full/part time associate or locum. Principal wanting to take some much needed time off. Come and practice stress free dentistry in a state of the art, modern clinic. Be as busy as you want to be. License, travel, accommodations and even a car for you to travel around in all provided! Just show up and start working! Contact dentris2012@yahoo.ca or (204) 978-1158 for more details.

TORONTO, ON PART TIME ASSOCIATE NEEDED Looking for experienced, motivated associate. Seeking permanent part time-associate for 2-3 days per week (Wednesday/(Thursday or Friday)/ and 2-3 Saturday per month). Working in modern paperless office with great staff! Must be skilled in most aspects of dentistry. Email: Dr.Hassanein@2000YongeDental.com

OTTAWA DENTIST Busy Ottawa practice is seeking a full time general dentist to join our experienced team of Dental Professionals and Mentors. E-mail: mentortopartner@gmail.com

ORAL SURGEON NEEDED Oral and Maxillofacial Surgery looking for a part-time associate. Tremendous opportunity in the GTA. Apply to oralsurgerygta@gmail.com 110 A P R I L 2020

BRAMPTON, ON

Whether you’re just starting out, already have years of quality experience, or somewhere in between, if you want to love where you work, please contact us today!

SARNIA, ON Established family practice with loyal patients, located in the downtown core. Looking for an associate dentist 2-3 days per week to start, with the potential to grow. No evenings or weekends. The ideal candidate is enthusiastic and caring with good communication skills and would enjoy working in a team setting. Please email resume to eltantydentistry@hotmail.com

MONDAY P/T ASSOCIATESHIP OPPORTUNITY IN OAKVILLE Est. family practice looking to replace existing associate for Mondays 12-7. Applicants should be mature, gentle and caring with excellent communication skills to go along with proficiency in basic dentistry including molar endodontics and extractions. Minimum of one year experience required. Please send resume to oakvilledentists@gmail.com

OSHAWA, ON Part time Associate Dentist needed for 2 days per week, possibly more, to take over for retired dentist. Busy established general dentist clinic. We are looking for a motivated and experienced dentist to join our team of professionals. English proficiency is a must. Apply to: oshawadentist1@gmail.com No phone calls please.

We are looking for a full time, team oriented associate dentist to join our practice. The office is modern and spacious, with a small town friendly atmosphere and an outstanding team. We are a full-service dental practice focusing on general dentistry, cosmetic services, endodontics, implant placement and restoration, orthodontics and sedation dentistry. Cornwall is located along the beautiful St Lawrence River, nestled between Montreal Quebec and Ottawa the Nation’s Capital offering all the charm and amenities. Candidates must have accredited DDS/ DMD program or completion of NDEB Equivalency Exam. Certified with NDEB. Licensed and in good standing with ODA. Please forward resume to: kim@smilesonseventh.com

KITCHENER, ON Well established modern practice is seeking an ENDODONTIST for 1 day a month. Our practice has a strong patient base, experienced and long-term staff, and a friendly work environment. We provide an experienced Endo assistant, all the armamentarium and global microscope. Please reply with your resume or CV to monica@dentistryinfo.com

HIGH PRAIRIE, AB Wanted! Full time associate to start May 2020 in a busy Northern Alberta Practice. Please email resumes to manager@hpdentalcentre.ca or call Nola @ 780-523-4448.

BURLINGTON, ON EXCITING OPPORTUNITY FOR EXPERIENCED DENTIST!!! Established and thriving Burlington practice looking for the right ‘fit’ with a part-time moving to full-time associate. Must be available to commit to 2 days/ evenings and alternate Saturdays. If you are DRIVEN, PASSIONATE ABOUT DENTISTRY and interested in growing and establishing a consistent patient load and are committed, we would love to hear from you! Please reply to 1stdentalteam@gmail.com

DOWNTOWN TORONTO, ON Part-time associate dentist required. General dentistry practice. Close to subway. E-mail: JHeron96@outlook.com

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Are you a

ASSOC I AT ES H I P S PETERBOROUGH, ON

ASSOCIATE WANTED IN WELL ESTABLISHED OFFICE

DENTAL ASSOCIATE POSITION

Looking for a part time associate, leading to full time in a busy well established preventative/conservative patient focused dental office. Looking for someone to care for our long standing loyal patients in a friendly family dental clinic. Experience Preferred. Send resumes to: dentistryinpeterborough@gmail.com

Modern state of that art dental office with a loyal patient base seeking associate dentist Tuesday-Friday. No evenings or weekends. Excellent systems in place to facilitate comprehensive treatment planning. Incredible opportunity for the right candidate. A commitment to continuing education and quality of care is essential.

MISSISSAUGA/MILTON, ON

Please reply in confidence to: BurlingtonAssociate2020@gmail.com

Part-time associates required for modern busy dental office. Effective communication skills are required. Looking for a general dentist, and a periodontist to add to our growing team. Email resumes to 905dentistry@gmail.com

MILTON, BRAMPTON, MISSISSAUGA & VAUGHAN Associates needed for our busy dental practices. Our locations are surrounded by thousands of newly built homes. We have in-house specialists servicing our patients. Mentorship program available for new grads. Please email dentist@thedentalteam.ca

GTA & SURROUNDING AREAS, ON Associate opportunities available across the GTA and surrounding areas including Scarborough, Mississauga, Brantford, Hamilton, Barrie, Dundas, Brampton, Etobicoke, Oakville, Waterloo, and Owen Sound. E-mail: yourdentaldream@gmail.com

GATINEAU, QC Full time associate needed for extremely busy modern practice in large shopping mall in the heart of Gatineau. Just minutes from Ottawa. New dentist will have a full schedule and will be taking over existing patient base with over 1500 patients and 100+ new patients a month. Email: Gatineaudental@yahoo.ca

BRADFORD, ON

Seeking associate dentist to add to our expanding office located in Bradford. Tuesday 8am to 5pm (maybe extended). Fridays 8am to 4pm. Saturdays 9am to 4pm. Must be easy going and well versed clinically. Send resume to mightymolars@live.ca

dentist or

BURLINGTON, ON

specialist with extra days available?

the

BELLEVILLE , ON Busy non-corporate family practice with sole owner and over 7200 active recall patients seeks a full time associate. Work schedule can accommodate up to 4 days per week. Owner works 4 days per week. No weekends required. Remuneration 42.5% of billings. Strong communication skills an absolute must. Clinical experience an asset. Newly renovated clinic with great staff and work environment. Immediate start available if suitable. Email: toothdoc911@gmail.com

associates on demand on-call talent pool Needs Ortho

LONDON, ON

Perio

PART TIME ASSOCIATE REQUIRED FOR BUSY, WELL-ESTABLISHED OFFICE

and pediatric specialists

Looking for a part time associate for Mondays 8-5 and Wednesdays 1-5 in a busy general practice clinic in the London area. Candidate must have at least 1-year experience. The ideal candidate should be proficient in all aspects, particularly oral surgery and endodontics. Please send your resume to: info@525dental.com

GTA-TORONTO, ON Multiple offices in GTA looking for associates, weekdays and alternating Saturday. Please email: henrywong_dds@hotmail.com

Apply now! Contact us today â&#x2DC;&#x17D;

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BRAMPTON, ON Seeking associate for part time, Fridays and Saturdays, leading to a full time position in a well established practice. Please send resume to docjoef@gmail.com

MARKHAM, ON

ORANGEVILLE, ON

Associate required Monday and Saturday for well established practice. Chinese language an asset. New graduates welcome. Please forward resume to Email: dr.c.lau@on.aibn.com

Busy Practice of over 3000+ patients in search of an experienced Orthodontist and Endodontist to work out of our office one to two days a month depending on demand. Please email resumes to emilydufferindental@rogers.com

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ASSO C I AT ES H I P S CALGARY, AB

PERMANENT OPPORTUNITY IN A WELL ESTABLISHED ORTHODONTIC PRACTICE

ASSOCIATE REQUIRED FOR A BUSY CALGARY DENTAL OFFICE

This is a two (2) days per week position. The right candidate will enjoy working with a great team of professional and support staff, while enjoying all that beautiful Sarnia-Lambton region has to offer. If you are passionate about building strong patient relationships while providing them with exceptional care and are looking for an opportunity to work alongside and learn from some of the industry’s leading clinicians, then this is an opportunity for you. This position comes with the opportunity to grow and work at our other Ontario locations. Candidate must have graduated from an accredited orthodontic program and passed the Canadian National Board Exams (licensure in 2020 is acceptable). No experience necessary – grad students welcome to apply. Position available immediately. Starting per diem rate: $2,000 Please submit your CV and cover letter if interested in the opportunity. Candidates must be legally eligible to work in Canada. We thank all applicants, but only suitable applicants will be contacted. Job applicants with a disability who require a reasonable accommodation for any part of the application or hiring process can contact our HR team at HR@ritebite.ca. Reasonable accommodations will be determined on a case-by-case basis and your request will be responded to as soon as possible.

We are currently seeking either a full or part time general dentist to complete our team. Our office has recently moved to a new store front location in south Calgary. We are a growth oriented practice that puts emphasis on personal and professional development as well as providing an exceptional patient experience. The successful candidate will be experienced in all areas of general dentistry. Please leave a detailed voice message about yourself at 403-836-3235. No resumes. Only the most qualified candidates will be contacted.

WHITBY/OSHAWA, ON

General Dentist and Paedodontist needed. Multi-disciplinary clinic, Ortho, Perio, Endo, Dental Anesthetist specialists. Experience an asset, new graduates welcomed. CEREC Primescan, Primemill in transit, willing to train. Growing community in North Oshawa by Ontario Tech University. Dr. Viet Nguyen, Clinic Admin. airportdentalcentre@rogers.com www.airportdental.ca

DOWNTOWN TORONTO, ON ALBERTA

www.oralhealthgroup.com 112 A P R I L 2020

Highly productive Dental Practices seeking Full Time General Dentists, Orthodontists and Pediatric Dentists in major cities in Alberta, including Grande Prairie, Fort McMurray, Calgary and Edmonton. This is an exciting opportunity for dentists interested in above average remuneration and expanding clinical experience. Mentorship is provided, and opportunities for partnership and fixed salary will be offered to the right candidate. General Dentist candidates must have experience in working with patients of all ages and must be proficient in performing complex dental procedures including cosmetic dentistry, implants, sedation, endodontics and surgery. Qualified applicants with strong communication skills and in search of a long-term career opportunity in a cutting edge practice are encouraged to submit a resume today to albertadentalopportunities@gmail.com

Dentist needed two days per week to provide general dentistry in a well established, modern Union Clinic in downtown Toronto. Monday 10am – 6pm and Thursday 9am – 6pm Please send resume to: drrandy@yongeeglintondental.com

THOMPSON, MB ASSOCIATE DENTIST WANTED Our team at City Dental clinic is looking for motivated team player and experienced dentist in endodontics and oral surgery. To apply email: alln1963@yahoo.com

LONDON, ON

A female associate with at least 2 years experience needed for part time position in a modern and busy office. Please e-mail resume to m_atiya @hotmail.com or call #519-619-1113.

EQ U I P M E NT SARNIA, ON E4D, scanner, milling unit and furnace for sale. Very lightly used over its 4 year life. Not being used by associates is reason for sale. Great opportunity to acquire at fraction of new cost. Best offer. Contact Dr Tim Pringle 519 339 6619.

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dentalCorp �� 84, 102 Dentsply Sirona �� IFC DMG America �� 21 GC America �� 19 Glidewell �� 41 Hill Kindy Dental Practice Sales �� 43

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AT T H E ROOT T H E L AST WOR D ON TEC H N OLO GY

Inspiration, innovation and successful implementation Four steps to ensure new technology lives up to its potential Lou Shuman, DMD, CAGS, CEO and Founder of Cellerant Consulting

nspiration can get a bad wrap. Whether in school or conferences, inspiration can get the short shrift, coded as soft skill that is nice to have, but not a leadership essential. My experience as a clinician, businessman and consultant proves that just isn’t the case. The word “inspire” comes from the Latin word spiro, which means “to breathe.” This seems especially appropriate in considering how you as a practice leader discuss and integrate new technology. You can bring new life into your practice and enthusiasm to your team. It is critical to remember that you are more than just the purchaser-in-chief or signature on the check. You need to involve and motivate your team members in decisions around new products – and technology in particular – since they will be integral in its implementation, patient experiences, and overall success. There are four core components to inspiring your team in the mastery of new technology: 1. COMMUNICATE YOUR VISION The goal for any transition shouldn’t be perfection, but preparation. Before you purchase new technology, you need to establish a “practice persona” that can compel your team to be committed and enthusiastic, even when faced with the inevitable bumps in the road. If you convey passion in providing stateof-the-art technology and clinical processes, your team members will sense this and be proud that the office and they as individuals represent the leading edge of dentistry. After all, the technology you choose may be a key differentiator between you and your competitors. This vision serves as your guidepost. It will answer questions about why you are doing this, how it will help your staff, how it will improve patient care and enhance the practice as a whole. Your vision statement about technology represents your values, your goals and your picture of success. 2. PARTNER WITH YOUR TEAM One mistake many dentists make is to go off to a conference, purchase new technology on impulse and announce its imminent arrival on Monday morning. Understanding that team members are often the ones who will use the new technology and communicate about it to your patient base, incorporating them in the decision-making process and

providing them with that level of ownership mentality is very often the make-or-break point for integration success. Invite your team members to meet with you and vendors, if possible. Share information about the options and your criteria. The more involved your team is in the purchasing phases, the more invested they will be in the implementation phase. 3. TRAIN YOUR TEAM EFFECTIVELY If you want your investment in technology to succeed, you also need to make sure your team is provided with excellent training. You are both the leader of the practice and the role model for your team, so it is essential that you be present for all on-site or off-site training. What do I mean by “effective” training? It should be organized around specific learning outcomes. It should be hands on. Ideally, it should be delivered in half-day increments as opposed to one long, intensive day. In addition, you will need training on updates so your team remains current and you can maximize the technology to its fullest extent. 4. APPOINT A TECHNOLOGY LIAISON Choose a team member who will be the information leader for each piece of technology. This person would act as the liaison between the technology vendor/ trainers and you and your team. This strategy gives the team ownership and responsibility and helps develop self-directed leaders among your team members. It is a way to communicate both to your team and to your vendor that you trust and empower your team. As you are doing the crucial work of inspiring your team, remember how important it is that you be inspired in the process. Look for the products and technology that breathe new life into your approach to clinical care and practice management. It is my hope that this column will become a source of new ideas and innovations that will get you excited about what is next in our industry. Your excitement will be contagious. Note: As a columnist for Dental Products Report and Dental Economics, some of these technologies or concepts may have been discussed in other platforms. All content for Oral Health readership is original.

Contact me with your feedback on this new feature at: catherinew@newcom.ca and let’s start talking. 114 A P R I L 2020

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