Dear Dr. DiTolla,

In your most recent issue (Vol. 3, Issue 1), there is an article about making veneer temps with Luxatemp^® (DMG America; Englewood, N.J.). However, nothing is said about what keeps this in place. Can you let me know if cement is used? And, if so, what?

– Dr. Dale Gerber
Lake City, FL

Dear Dale,

There is no cement used in this technique; the temporary veneers are mechanically locked into place. This is a potential shortcoming of this technique, and I have tried many times to remove the temporaries to finish them out of the mouth and recement them, but they break literally every time I try to remove them.

The only exception is when there are only four veneers, such as #7, #8, #9 and #10. In those cases my cement of choice is TempBond^® Clear from Kerr (Orange, Calif.), since there is no cement show through, which can be a big problem with thin veneer temps.

With minimal-prep veneers, the tooth structure under the temps is enamel, so you don’t have to worry about bacterial invasion of dentin. With normally prepped veneers and this technique, some dentists place and cure bonding agent on the tooth prior to mechanically locking the temps into place to provide some protection to the dentin. At the seat appointment the dentist can etch and bond as usual, although I use a fine diamond in an ultrasonic handpiece to freshen the dentin surface prior to bonding. I hope that helps!

– Dr. DiTolla

Dear Dr. DiTolla,

I first want to say I enjoy reading your articles in Dental Economics^®. I have used many of the tips and techniques you have suggested, especially using Profound (Steven’s Pharmacy; Costa Mesa, Calif.). I have a few questions about the product. I currently use full strength Profound mainly for pre-injection of maxillary teeth, and patients love it. Are you using Profound Lite as the topical that you squirt into the furcation? And what does “squirt” mean, exactly? Are you using a plastic syringe to squirt? After it’s placed into the furcation, doesn’t it rub off as you wait for 60 seconds? Is it essentially a PDL injection at the mid-buccal? Seems like it would be difficult to inject one-half to two-thirds of a carpule of Septocaine^® (Septodont; New Castle, Del.) if it was indeed a PDL injection. A lot of questions, sorry…just curious because I like Profound. I would enjoy talking to you sometime. I’ve been thinking of a way to improve the delivery of Profound. I look forward to your response.

– Dr. Eric Resh
Hampstead, MD

Dear Eric,

Thanks for the questions! We use Profound anytime we are placing it on gingival tissue, and Profound Lite anytime we place it in the vestibule.

We syringe the Profound Lite into the furcation in a plastic Ultradent syringe just to get some pre-anesthesia in the furcation. “Squirt” probably isn’t the best word; it makes it sound too liquid. Basically we are trying to place the Profound in the pocket in the area of the furcation. It doesn’t really rub off because it should be placed subgingivally, in the pocket.

Yes, it is essentially a mid-buccal PDL injection, with the added benefit of the anesthetic traveling coronally into the furcation. It is not difficult to inject one-half carpule…it is very slow, though! The good news is I can start prepping as soon as the injection is over. I use the STA™ System (Milestone Scientific; Livingston, N.J.), which gives me constant feedback on the pressure I am experiencing in the PDL. This allows me to know if I am giving a good PDL injection or not. If it is not working well in the buccal furcation, I reposition the needle to the MB and DB corners, as in a typical PDL injection.

I hope that helps, and please ask more questions if I didn’t describe that well enough!

– Dr. DiTolla

Dear Dr. DiTolla,

I just wanted to let you know that using Profound topical has changed my practice! I do a lot of pedo and I can give an injection without the kids even knowing what is happening. Thanks for the great tip!

– Dr. Steve Duffin
Keizer, OR

Dear Dr. DiTolla,

I am a 1973 graduate from the University of Maryland School of Dentistry (practicing and teaching for the last 35 years). Like you, I have followed Dr. Christensen and Dr. Strupp my entire career. I agree that they are two of the “straightest shooters” in our profession and have found their clinical advice and information invaluable. Your articles in the Spring 2008 of Chairside^® (Vol. 3, Issue 1) were wonderful. Thanks!

Would you be so kind as to tell me what are the full coverage restorations “of choice” for Dr. Strupp and what preparation he prefers? He was an advocate of porcelain fused to gold on a shoulder and bevel preparation in years past, and I am interested to know if this is still his first choice in posterior restorations or if he now advocates all-ceramic crowns for bicuspids and molars. If so, could you be specific in letting me know what product or brand name crown he prefers? And do his zirconia copings support interproximal porcelain, or are the copings thimble shape in design? Once again, thank you for your publication.

– Steven Milhauser
Manhasset, NY

Dear Steven,

Thanks for the opportunity to answer your questions.

My full coverage restoration of choice in posterior non-cosmetic zones is cast gold with 1.5 to 2.0 mm occlusal reduction and a 0.5 mm thin chamfer finish line.

For those patients where the cosmetic issue is non-critical, I use porcelain to gold (preferably with a metal collar) or porcelain to zirconia. The reduction requirements are 2.0 mm occlusally with a 1.0 to 1.5 mm deep chamfer finish line.

Where there is a critical cosmetic issue, I use refractory fabricated feldspathic porcelain with the patient fully informed of the higher potential for fracture. The reduction requirements are 2.0 to 3.0 mm occlusally with a 0.2 to 0.5 mm thin chamfer finish line.

All margins are finished at or above the tissue level unless there is a critical cosmetic issue with dark substrates. Subgingival margination is biologically destructive.

There is science to support the use of all-ceramic restorations from bicuspid to bicuspid, and patients should know in advance the potential for fracture when using all-ceramic on molars. With that said, I have seen veneering porcelain fractures on porcelain to gold and porcelain to zirconia restorations in every area of the mouth. Factors that contribute to this are inadequate reduction, improper firing temperature (too low), inadequate porcelain support by the coping (both gold and zirconia must support the porcelain with no more than 2.0 mm veneering porcelain thickness; thimble designs do not work in metal or zirconia), and excessive occlusal loading. Just another reason to choose gold. I have a Procera^® Piccolo scanner (Nobel Biocare; Yorba Linda, Calif.) in my office and use it to scan custom zirconia abutments and zirconia copings. The software allows virtual wax-ups and it is a neat way of handling anterior cosmetic issues with missing teeth.

Because of the superior cosmetic results that most of my patients demand, I usually use refractory fabricated feldspathic porcelain, even on molars, because it is the easiest restoration to replace if it fractures. I usually replace them at no charge for up to five years, and if replacement is required beyond then, I charge a discounted fee to replace it.

I hope this answers your questions, and if you have any more please do not hesitate to email me at Bill@Strupp.com.

– Dr. Strupp