Dr. Michael DiTolla: Bob, I’ve got to tell you: I use the skills I learned in your class all the time. Hardly ever do I do an anterior case where I don’t have to do some sort of soft tissue recontouring to make the case look a little better. As a dentist, you should know whether you will have to recontour any hard tissue when you do a case. That really would be a great skill for most general dentists to have. Do you still offer that course? And how often do you find that you need to do soft and hard tissue recontouring on your esthetic cases?

Dr. Robert Lowe: First of all, Mike, I want to say thanks for inviting me to do this interview in Chairside^® magazine. It’s always good to talk to you.

It has been a while since we did that first course, but I think the average dentist really needs to look at becoming more skilled at diagnosis and treatment. Minor biologic widths and esthetic crown lengthening issues easily can be handled in the office. With the technologies available to us today, it’s certainly within the scope of the majority of dentists to be able to do it. As far as my courses, we still train in Charlotte. But, as you know, with the economic downturn, dentists’ investments in technology have been a little bit behind the curve. I think we’ll see that change again in the near future. And with that change, I think dentists will start seeking out ways to differentiate their practice, and this will certainly be one of them.

MD: It seems to me if you offered six different courses — say, courses on direct composites, veneers, and soft and hard tissue crown lengthening — the crown lengthening course would probably be the smallest class you’d give. Do you think that’s because dentists are afraid to reflect flaps like this or they think it’s better left to the periodontist, or maybe a combination of both?

RL: Well, you hit it on the head; you pretty much answered the question in the lead-in there. I think, number one, there needs to be a greater understanding among the average dentist about biologic width and the position of the restorative margin relative to the crest of the bone. Many of my mentors — Drs. John Kois, Frank Spear, Dennis Tarnow, Harold Shavell — have been talking about this for years. Dr. Anthony Giardullo, who co-authored the initial article on biologic width more than 30 years ago, was the department chair in perio at Loyola University, where I attended dental school. So this isn’t new information; but I think intimidation is a factor, particularly nowadays when we’ve had electrosurgery for a long time, and now diode lasers and dentists getting into soft tissue recontouring. Without a basic understanding of biologic width and bone position, you can run into some issues — it takes only one bad case and one bad turnout. Dentists are not excited about crown lengthening and are willing to pass it off to a specialist.

I don’t sit and do full-flap crown lengthening surgeries in my office anymore. When you’re young and just out of school, you want to do everything — you push the envelope a bit. After you’ve been around for a while and you get set in doing what you like to do, you realize you don’t have to do those types of procedures — you settle into a comfort level. 

I don’t want it to sound like we don’t need or use our specialists — that’s absolutely untrue. I’m talking about minor procedures that help esthetic outcomes. I don’t sit and do full-flap crown lengthening surgeries in my office anymore. When you’re young and just out of school, you want to do everything — you push the envelope a bit. After you’ve been around for a while and you get set in doing what you like to do, you realize you don’t have to do those types of procedures — you settle into a comfort level. You know, just like Dirty Harry, everybody has to know his or her limitations. I certainly don’t want to make it sound like I don’t use my periodontal specialist. We work together quite a bit, in implant restorative soft tissue recontouring and full-mouth crown lengthening.

MD: That is one of the big changes that occurred for me when I took your course: learning how to recognize when this type of surgery should be referred to a periodontist. And, more importantly, it helped me learn how to have the lab design a BioTemps^® (Glidewell Laboratories; Newport Beach, Calif.) stent, if you will, that reflected the final clinical crown length I wanted for the veneers. This would be a surgical stent, essentially, the periodontist could snap onto the teeth during the surgery, and I could tell him to place the osseous crest 3 mm from these veneers. So I was able to guide the periodontal surgery to help achieve the desired esthetic results. Taking the course for that knowledge alone, and then being able to ensure your periodontist does the surgery the way you want it done, makes it a worthwhile course to take.

RL: I agree with that. You know, this isn’t trying to make a periodontal specialist out of every general dentist, but, again, the key is recognition and diagnosis. As Kois has said many times, the most important thing is: Where is the restorative margin relative to the crest of the bone? How many dentists out there routinely sound when they cut preps? I guarantee you there aren’t enough doing it, and I teach that all the time. Unless you know where the bony crest is, all of a sudden you get under the free gingival crest and into uncharted territory. And maybe that amalgam interproximally goes down just a little bit too far, and you get a little bit of bleeding, and you’re close to the attachment, but you don’t want to send the patient out, and you want to take your impression. All these things come into play. We work in a space where tenths of millimeters are the difference between success and failure. I think you hit the nail on the head there, too. Just knowing that when you run into these issues, either you do something about it or you refer the case. It’s up to each dentist what he or she does. But the technologies exist — hard tissue lasers being one of them — so that with a little bit of knowledge this is not outside the scope of most dentists. Sounding and diagnosis are key.

I want to make one point based on what you said about the BioTemps stent: It is for communication with the specialist. I’ve found that an easy way to communicate with the specialist, if you can even just do soft tissue work with a diode, is to place the margin where it needs to be esthetically and functionally. Do the diode surgery to that point; place your margin on your prep; make your temp. Then you don’t even need a stent. The surgeon just has to reflect the tissue, take out a perio probe, and measure 3 mm from your margin and drop the bone. It becomes very predictable. But your point is well-taken: It’s communication. If you’re not the one doing it, there needs to be an accurate way to communicate with the specialist.

MD: You mentioned you do osseous sounding on every prep. I’m guessing you don’t necessarily do that if it’s tooth #19 with a broken cusp and you’re prepping it and it hasn’t had a prior restoration. But if a tooth has a preexisting PFM with subgingival margins, and on the X-ray it looks like it’s touching the bone — though obviously that’s probably due to some distortion on the X-ray — is that an instance in which you definitely do sounding? Or do you really sound every prep?

RL: To say “every” probably is not a true statement. I would retract that and clarify by saying “most.” For any tooth I’m preparing, whether it’s a virgin tooth or a restored tooth, if I’m planning my margin to be at the level of the gingival tissue or below, I sound.

Here’s another reason why sounding is important. This is something that Kois and Spear and others teach, and something I mention all the time as well, because dentists are always asking about recession. If I put retraction cord in, is it going to recede? If I do electrosurgery, is the facial margin going to recede? If I use a laser, is it going to recede? It’s also important to diagnose whether the patient is a high-crest, low-crest or normal-crest individual because low-crest patients tend to recede more. So even if I’m prepping to the free gingival margin, and I’m planning on retracting or doing something to take an impression, and I’m dependent esthetically on having the margin at the level of the tissue or below, it’s a good idea to sound. Even if it’s a virgin tooth, it’s a good idea to sound. That way, I know ahead of time if it’s a low-crest patient, in which case I’m going to prep slightly more into the sulcus than I normally would because I’m going to plan for recession. And that’s really where the key in the diagnosis is. I don’t think you can go wrong by sounding every tooth. After you’ve done this routinely, do you end up sounding every tooth? Well, no, you probably don’t, but the majority, yes.

MD: Certainly every anterior tooth.

RL: Certainly any tooth in the esthetic zone, anterior especially.

MD: Right. You alluded to it a little bit earlier, and it might be an esoteric argument, but you mentioned using the hard tissue laser for crown lengthening. When I took that course from you, we did it all open flap, where you laid a flap and you did half with a handpiece and a bur and half with a hard tissue laser. There are periodontists who aren’t big fans of closed-flap crown lengthening, not that they don’t like the laser. Most general dentists who have a laser will give it a try and actually like the procedure, which is what makes me think that GPs are afraid of doing the flap, not the actual surgery. What are your thoughts on closed-flap crown lengthening versus open flap?

RL: I love controversial subjects like this because I’ve been doing closed-flap procedures for more than eight years. I’ve done hundreds, maybe thousands. But I trod very slowly into the realm of closed-flap crown lengthening. This is coming from somebody who has been doing open-flap crown lengthening surgeries for the majority of their dental career.

When I saw Harold Shavell doing what he called “combined therapy” on his crown & bridge cases, where he was prepping and finding biologic width issues, flapping, and doing osseous and putting provisionals on as part of his treatment modality, I said: That’s want I want to do for my patients. So I took a residency. I learned from a board-certified periodontist. I wanted to be able to manipulate soft tissue in healthy individuals. I don’t treat periodontal disease. This is not for somebody with Type II, Type III or Type IV perio — that’s number one. Number two: We started the closed flap crown lengthening very, very carefully, a millimeter or two. I’ve seen people doing 10 of them across the front.

When dentists come and take our laser courses, Mike, I recommend they first get comfortable with laying a flap and doing open procedures. To me, closed-flap procedures are like driving with your eyes closed: You can drive straight for a few feet, but after a while you get off track.

MD: And it’s a lot easier if you’ve been driving with your eyes open for years and then you do it.

RL: That’s exactly right. I’ve had periodontists and dentists alike come to me and say, “You know, Bob, that closed-flap crown lengthening doesn’t work.” And I say, “Oh, really, how many have you done?” And they say, “Oh, I haven’t done any; I just know it doesn’t work.”

They said that about osseointegration: “Oh, those implants don’t ever work.” That’s what happens with something new, until we find out it does work.

That’s also what they said about total etch. I remember in dental school: “You can’t etch dentin. You’d be the endodontist’s best friend.” But we’ve been putting zinc phosphate all over dentin for years.

MD: In dental school, I remember we actually had something to put on the tooth, and you would rinse it off to show you where the dentin was, so you wouldn’t accidentally etch it.

RL: Yeah, exactly. Those first etches weren’t gel; they were all liquid. How many dentists kept it totally on enamel and never, ever touched dentin? Nobody. But that’s the way we are.

And there’s nothing wrong with being conservative. I started this off as a very conservative thing. But as I tell everybody, if you’re going to do minor closed-flap procedures with a laser, you need to be prepared to flap it and finish it if you get into trouble because you will always do better when you can see.

“I can smooth the bone better.” I’ve heard that argument, too. “The bone is rough when you do a closed-flap crown lengthening. I can smooth it better with hand instruments.” I don’t disagree with that, but I always remind people to check to see what the tissue looks like at two weeks, five weeks, three months. If after several weeks of healing the tissue is pink, there’s no bleeding, there’s a probable sulcus and everything looks good, does it really matter if at the time of surgery it wasn’t quite as smooth as it would have been with hand instrumentation? I think not.

We do get into esoteric issues and turf wars, but we really need to get away from this and think of what’s best for the patient. I mean, how many of us have had a patient where you mention going into surgery and they say: “Well, just pull the tooth. I’m not having my gums cut!” What do you do then? Just do the best you can? Violate the biologic width and let it bleed until the thing exfoliates out of the socket from bone loss after a few years? No!

MD: Yeah, the word “surgery” doesn’t always bode well with patients. For readers who don’t know you, I find you to be one of the most clinically fastidious dentists I know. You were the one who turned me on to Harold Shavell, who, like you, worships at the altar of healthy tissue.

RL: Exactly. And he would say, “Tissue mirrors technique.”

MD: Exactly. And I can’t picture you doing anything in which you wouldn’t see good results or healthy tissue afterward. You just wouldn’t do it because I know you can lay the flap and do the surgery the other way. So, in my mind, if you’re going to do 10 units in the anterior, yes, you’re going to flap it; but if you’re going to do one posterior tooth where you see the amalgam has gone way too far subgingival, and you’re willing to do it closed with a hard tissue laser, I know you would not do that if you’re weren’t fully confident it was going to turn out fine.

RL: Absolutely. We’re not going to dig troughs around the teeth. We’re not doing closed-flap crown lengthening on clinical crowns that are hacked off at the gum line. That is not an indication.

Procedures get a bad name because dentists think: “Oh, wow, now I’ve got this laser, and I’ll never have to lay a flap. I can crown lengthen everything.” And that’s not true. It’s just like anything else: You have to know the proper indications. And I always tell my patients: “You know, every once in a while, this doesn’t work as it’s supposed to. I reserve the right, if things aren’t healing properly, to go in and flap it and do a secondary procedure to correct it.” It’s either that or tell them, “OK, well, we’re going to cut you right away.” I mean, which one will the patient prefer?

MD: Yeah. The patient will probably say: “Let’s try it the easy way. And if that doesn’t work, then I’ll have seven sutures in there.”

RL: Exactly.

MD: Because that sure seems a lot more like surgery than the laser does.

Now that I practice inside a laboratory, I get the great opportunity to see impressions from dentists all over the U.S. of all different ability levels. These impressions could definitely be improved. One of the things I learned from you, which I’ll never forget, is there’s no site as beautiful as an impression that’s about to be made, where you’ve used the two-cord technique; you pull that top cord out, the bottom one is still in place so you don’t get any bleeding, and you get this open sulcus where you can almost throw alginate from across the room in there and get a good impression. To me, it’s such a great technique. It doesn’t really require skill on the part of the operator because the technique is so solid. Are you still using the two-cord technique for your impressions?

I know laser lecturers out there who claim that if you buy this laser or that laser, you’ll never have to pack cord again. They don’t understand tissue.

RL: Absolutely. It’s my No. 1, go-to thing as far as impression taking. But I’ll tell you just the same, in the day of lasers and electrosurgery, I know laser lecturers out there who claim that if you buy this laser or that laser, you’ll never have to pack cord again. They don’t understand tissue. You’re not going to do troughing in a thin perio type in a lower bicuspid or lower cuspid where the attached gingiva is 1 mm and you’re at the mucogingival junction. I mean, it’s just not proper to say that we never need retraction cord. Now, that being said, I use the retraction cord double-cord technique; I use troughing; I use lasers; I use a lot of things for tissue management. But, like you said, the key is seeing that moat around the castle so you can sling alginate from across the room and still get a good impression. Not really, but you know what I mean.

MD: Right.

RL: At the end of the day, it’s not about the margin; it’s about the margin and 0.5 mm of tooth surface below the margin, so the technician can develop a good marginal seal and a proper emergence profile. And I agree with you 100% on the need for better impression taking. I don’t work in a lab, but I’ve been to lots of dental labs. I’ve given a lot of lectures where I get comments on sheets from dentists saying: “You talk about preparation or impressions — that’s just remedial, that’s just too basic. We want to learn the advanced stuff.” Yet, you go into a laboratory and you see so many teeth not prepared properly; either under-reduced, over-reduced, not reduced in planes. You see so many inadequate impressions that could really use help. It’s not that people don’t know how to do this stuff, Mike. We know how to do this. As I say in lectures: “I’ll give you some hints, some techniques that will take you from 90% to 98%.” It’s all about predictability. It’s all about reproducibility. And that’s where as a profession we need help. Let’s call a spade a spade. You don’t pour it up to see what you’ve got. A blind man should be able to trim that die.

MD: Absolutely.

RL: You bring up good points. I mean, it all ties in with tissue management, whether it’s correcting a biological problem or managing the soft tissue for an impression.

MD: That’s one of the things that came up when the digital impression manufacturers originally approached us. (I actually own all the systems and have them here in the operatory and use them on a regular basis.) Initially their pitch to us was: Give us your highest remake doctors, and we will bring their remakes down. It became clear to me early on that using these digital impression techniques requires the dentist to take even better care of the tissue than with traditional impressions. Therefore, our dentists with the highest remake rates — the ones who tended to abuse tissue anyway — were going to have a more difficult time getting an acceptable impression with these digital impressions. The remake numbers here at the laboratory have kind of proven that. But I’d like to hear about your experience with digital impressions and how often you use them.

RL: My experience has been very positive. I have not had the opportunity to use all the systems in a clinical setting, but I have seen the majority of them at least in the developmental stages. I have used Cadent iTero™ (The Cadent Company; Carlstadt, N.J.) in the office and still do. And I’ll tell you my experience with digital impressions has been extremely positive.

Now, one thing you mentioned that’s absolutely correct is: People who think digital impressions are an excuse for not managing tissue have no clue. You still have to manage the tissue. That being said, I find I have fewer problems with seating, with remakes; I have fewer problems in general with restorations made using a digital impression. My only theory on that, Mike, is they’re not being made on a die that expands and contracts; maybe the water-powder ratio is followed, maybe it’s not. The dies are milled out of polyurethane and, in iTero’s case, there’s no shrinkage; there’s no marginal breakage when the technician is working with the dies. I find the fit to be superior overall.

MD: Yeah. The Cadent models are stunning. In fact, all of the digital impression systems have a model system that goes with them. But the Cadent models in particular are the best models that exist. But you’re kind of making my point: This technology takes really good dentists and makes dentistry more predictable for them. But it doesn’t do what the manufacturers said. It doesn’t take our high-remake doctors and get them to be great doctors all of a sudden and reduce remakes. Digital impression systems give dentists who are already taking good polyvinyl impressions even more predictability because we don’t have things expanding and contracting, and those 69 steps between prep and cementation.

RL: Absolutely. I agree 100% because, when all is said and done, it’s all in the tissue management. Tissue mirrors technique, as Shavell said. Regardless of whether it’s polysulfide or polyvinyl, there’s no magic impression material that you’re going to take an impression with under water. You’ve got to get the tissue out of the way.

MD: Yeah. And try to keep the area kind of dry at the same time.

RL: Correct. Polyvinyls are not hydrophilic.

MD: Right.

RL: There are some that are just less hydrophobic than others.

MD: And they’re not hemophilic either.

RL: No, they’re not hemophilic either.

MD: When we come across a blood-loving one or a tartar-loving one, a calculus-loving one…

RL: Then we’ll have tissue management licked!

MD: I was talking to some engineers from one of the digital impression companies the other day, and they seemed to think within the next five years there’s going to be an intraoral scanner that will be able to differentiate between tooth structure, bone structure, soft tissue and see-through liquids, using a technology called “optical coherence tomography.” Now that might be something where a dentist off the street could point it in there, click it and be able to get a really good impression without having to take care of the tissue at all.

RL: I think you’re right, and I’ve talked about that with many of our colleagues. When the digital impression companies can do that, plus make it a one-click full-arch impression and the scanner costs less than $10,000, I think they’ll have something that will catch on very quickly.

MD: And if the dentist doesn’t have to pay $20 every time he or she uses it, and the lab doesn’t have to pay $20 for the model.

RL: Correct. All of the above.

MD: Let’s say I come into your office tomorrow and I have a standard MOD amalgam — pretty wide, maybe two-thirds the width of the isthmus on tooth #19 — and I break a cusp off. You know I’m going to need a buildup and crown on that tooth. What materials are you going to use on me in your office?

RL: Material questions are always good because we have so many materials to choose from. After practicing for 27 years, I sometimes wish for the days I only had two choices: silver and gold. Today we have an abundance of choices and a lot comes into play. What’s the opposing dentition? How old is the patient? How long is this expected to last? What’s the occlusion scheme like? Is there canine-guided occlusion? Is there mutually protected occlusion? Is there excessive wear? Is the patient a 300-pound bodybuilder with masseters that can’t fit through the front door?

We tend to get so focused on: OK, where’s that magic material that’s going to work and last for everybody? I know of no such thing. I think we’ve got to, again, be doctors and make choices based on a lot of different criteria, including what our patient presents with.

MD: Well, I’m really average. I’m 45 years old. I probably brux, but I do have a cuspid-protected occlusion right now. I’m 170 pounds, so not a bodybuilder. I need something kind of run-of-the-mill, your average crown.

RL: I’d tell you, and this might surprise you and a lot of the readers, but I’m a big fan of laboratory-processed composite. I think it is dentistry’s best-kept secret. Why nobody uses composite? I have my theories. Maybe it’s because reimbursement from insurance companies is less. Maybe it’s because of the old Artless^® (Glastech Inc.; Austin, Texas) debacle. I don’t know.

I just came back from Columbus, Ohio, where we did a live patient demo for Dentistry Today. Actually, I did an article last year on my youngest daughter, using IPS e.max^® (Ivoclar Vivadent; Amherst, N.Y.) no-prep veneers.

MD: I remember that. It was a great article.

RL: Recently, on my oldest daughter, I placed Premise™ Indirect (Kerr; Orange, Calif.) laboratory-processed composite no-prep veneers. I don’t want to spill the whole story on that, but this is a material that’s widely underutilized.

If you came into my office — 45 years old, 170 pounds, not a bodybuilder, with good canine-protected occlusion — and tooth #19 had a broken cusp, and it was not being opposed by ceramic, I probably would look at laboratory-processed composite first. Then maybe a pressed ceramic or IPS e.max, because I still think bonded restorations seal the teeth better. 

If you came into my office — 45 years old, 170 pounds, not a bodybuilder, with good canine-protected occlusion — and tooth #19 had a broken cusp, and it was not being opposed by ceramic, I probably would look at laboratory-processed composite first. Then maybe a pressed ceramic or IPS e.max, because I still think bonded restorations seal the teeth better.

I’m not of the old school of thought that everything has to be gold. Gold is not a bad material — it’s got a long track record — but remember, when you cement something, it’s only as good as the space between the restoration and the dentin and the seal that the luting agent provides. I’ve been a big advocate of bonded restorations, whether they are porcelain or lab-processed composite.

MD: IPS e.max has been one of our fastest-growing products recently, and it’s interesting to hear you say that in my very average mouth you might choose a laboratory-processed composite crown over an IPS e.max crown. I’m interested to hear why you feel that way.

RL: I’ll give you a very simple explanation: Laboratory-processed composite is easier to place, easier to adjust, easier to polish and easier to repair. It’s easier if you ever have a small little marginal leakage problem; if you ever have a small little breakage problem; if you ever have to do endo through that restoration for some reason. Like materials are going to repair to each other more easily. Porcelain is still a difficult material to repair.

MD: It’s impossible.

RL: You basically have to replace it. So, these are things I’m thinking about. I’m still undergoing psychotherapy for all those years of dental school (27 years ago) because it conditioned us to think everything we do has to last forever or we’re failures. That’s not true. The teeth we’re born with don’t last forever. So why do we think if something only lasts for 20 years, versus 40, it’s not as good? Well, again, everybody is different and everybody has a different idea of success.

Getting back to that tooth and getting back to IPS e.max (the other no-prep case was IPS e.max on my youngest daughter), I think IPS e.max — lithium disilicate — is a tremendously revolutionary product. It’s a thin material that has the esthetics of feldspathic porcelain with four times the strength. Why would you not use it?

MD: I know. In fact, I did some minimal-prep veneers on Jim Glidewell recently. He wanted to try no-prep first, and we used not a feldspathic, but a pressed ceramic, and he broke three of the eight veneers within four months. After that, I placed minimal-prep IPS e.max and he’s been fine — and it’s been nine or 10 months now.

RL: Whether lithium disilicate is the ultimate answer or other materials follow, I still think IPS e.max is a revolutionary material. I’m not surprised to hear that Glidewell Laboratories is doing a lot of IPS e.max because there are so many different ways to use it. You can press it to substrate. The technicians can mill it. It’s a very versatile product. I think that area of the market will continue to grow. Zirconia continues to grow as far as a PFM replacement. Why? Well, what’s the price of gold today? Last time I did a PFM splint with high noble gold, I think the lab bill was $50 million. And that was just for the metal!

MD: In your differential diagnosis of what you would do for my tooth #19, the only other option I didn’t hear was PFM. But it was probably on there somewhere.

RL: If you want a list of every material I’d consider, I would go anywhere from laboratory-processed composite to pressed ceramic to porcelain fused to metal. I’m a big fan of Captek™ (Precious Chemicals Company; Altamonte Springs, Fla). Captek is a great product, and the new Captek Nano™ product is actually a little bit more palladium and platinum and a little bit less gold, so the price structure is a little more favorable than conventional PFMs. There’s nothing wrong with those types of materials. But, again, you didn’t differentiate on your tooth #19. You said the isthmus was about two-thirds the distance and you broke off a cusp. I’m still looking to save the other wall. I’m still looking at doing an onlay on that tooth rather than doing a buildup and a crown. It just depends. I know everything won’t last forever. You’re a young guy, and you’ll probably live another 30, 40, 50 years. Chances are, you’ll need that buccal wall at some point in your future. Again, we’re talking about a differential diagnosis here. It’s not just about the material; it’s about how much of the tooth we can save.

MD: Right. You bring up some great points.

One last question: Let’s say you’re replacing an old PFM. We don’t need to worry so much about the choice of the crown, but let’s say you take it off and there’s an old amalgam in there. As you’re cleaning up the prep, this old amalgam flies out of there and up into the high-speed suction, leaving this huge divot, like a bomb was dropped on the distal half of the prep.

RL: That just happened today!

MD: Of course it did! Usually it happens at 4:55 p.m., after you decide to go around with the bur one last time. And that last time around, it’s like, BOOM, time for a buildup. How are you going to build that up today?

RL: Well, a lot of it’s going to depend on coronal tooth structure. I still believe in ferrule effect; on posterior teeth with anterior guidance, it’s not as critical, but you still have to have resistance and retention form, regardless of buildup material. That being said, if I’ve got ferrule effect, I’m probably going to use a bonded type of material as a buildup, unless I’m replacing four walls.

I don’t do a lot of pin-reinforced buildups anymore, but I won’t tell you I don’t do any. If I don’t have a lot of coronal tooth structure and I feel like a pin is necessary, I’ll place a pin. Or I’ll have intentional endo done and do a fiber post resin buildup.

On the other hand, I don’t do a lot of metal post cores anymore because they crack roots. I remember working for a dentist when I first got out of dental school who was proud of the fact that he’d have to use a little hammer to tap his posts into the teeth — they fit so well. That scares me!

MD: It reminds me very much of an extraction.

RL: Yeah.

MD: And no wonder because it’s probably going to cause one.

RL: But for an endodontically treated tooth, I’ll use fiber-reinforced Flexi-Post^® (Essential Dental Systems; San Pedro, Calif.). Flexi-Flange^® by Essential Dental Systems is a nice post alternative if you don’t have a lot of coronal tooth structure because you actually get an internal sink into the root canal space as it prepares a countersink for the post.

We’re talking about doing anything from a little bit of buildup to help reinforce the crown to doing herodontia. In the old days, we bent over backward to save a root. Now we’ve got a thing called implants. At some point you have to know where to let go, too.

MD: Right. Exactly. You have to consider what’s in the best interest of the patient’s overall detention, not just this one tooth. It’s not like they’re going to lose the rest of their teeth if they lose just this one.

Well, Bob, I want to thank you for your time today. Until somebody comes along to knock you off, you’re still my favorite dental educator. I need to get out to Charlotte and spend a little more time with you to sharpen my skills.

For readers who want to come out or see what courses you guys are putting on, what’s the best way for them to find that information?

RL: The best way is to email me at boblowedds@aol.com, and I will reply with a rundown of what we’re doing. I try not to stick to a course schedule anymore because I prefer to work more with a small group. I don’t have time between my office and my travel schedule to mark it and worry about putting 20 people in a course, making it successful and bringing in sponsorships and partners. I like to get down and dirty with the dentists and find out what they want to learn. I’ve found lately that the best approach is getting people to email me. I get a group of five to eight people who can agree on a weekend, and we sit down, roll up our sleeves and have a good time. But, for you, Mike, I’ll do courses anytime. Just call me and come on out.

MD: I’m not even going to call. I’m just going to show up at your office one day.

When these dentists email and get in touch and pick a weekend, do they actually come out and watch you do a case? And then do you lecture one day? Or can it be any kind of combination? Is it kind of freeform depending on what they want?

RL: All of the above. I think a free-form course is best. The minute you try to stick to an agenda, you’ve got somebody saying, “Well, why didn’t you talk about inlays?” or “Why didn’t you talk about tissue management?” or “I would have wanted to see this …” I’ve got a certain amount of information I like to give, but I like to customize based on what the dentists need and what they want to learn. If it’s something that I can teach them, I’m more than willing to share. That’s what it’s all about. The teacher wants the student to become the teacher.

MD: That’s right. And I do still maintain that you are the most well-rounded educator out there. And that’s why if you’re going to give your blessing to do closed-flap crown lengthening, I’ll feel a lot better when I do it tomorrow, if it’s one of those situations you mentioned where it is in fact indicated.

RL: I appreciate that. Also, I will tell you that I hear a lot of really positive comments about your work with Chairside magazine as well as the quality of your work at Glidewell Laboratories. Keep it up. Anytime you need something, just give me a call. I’m happy to contribute.

MD: Thanks, Bob. I have been spending a lot of time on that and have slacked off a little on my own CE. Whether it’s the end of this year or the first half of next year, I do want to come out because I learn so much every time I’m with you, and I’d love to get a chance to do it again.

Dr. Robert Lowe maintains a private practice in Charlotte, North Carolina. He lectures internationally and publishes in well-known dental journals on esthetic and restorative dentistry. Contact him at boblowedds@aol.com.