Dear Dr. DiTolla,

I am very interested in subscribing to Chairside^®. I came across the 2011 winter issue, and I was fascinated by its concise yet powerful information.

I have worked as a dentist for the past 12 years at a dental health center in New Jersey. Although I am thankful for the stability provided by my job, I must confess: There were times I felt like “half a dentist” because of the type of dentistry I was forced to render. It seemed like it was all about numbers, or the quantity of patients the system demanded I see. I began to wonder, whatever happened to quality instead of quantity?

Over the past decade, I started to hate the profession of dentistry — to the point that I avoided reading anything related to it! (I am ashamed to admit this.) That changed last summer. I was reading the local newspaper and spotted an ad for the practice of a dental school friend. Very happy to have seen his ad, I decided to surprise him at his office. I told him about my big mistake: Going into a health center and getting sucked into the system. Also, I told him that I was intimidated by the idea of leaving the system because I was not up to speed with the latest dental products and procedures. He welcomed me to train in his office, in order to re-acquire skills in cosmetic dentistry and to learn about the newest technologies. In fact, the first thing he did was give me your DVD series. After that, I became your fan.

Today I can say, for the first time, that I am in love with this incredible and lucrative profession. I was in a dormant state for so many years that I often feel overwhelmed — I still have so much catching up to do — but it was time for me to wake up! Because of your mission and vision, dentistry has become easier, cleaner and more fascinating for me!

– Ninoska Fergusson, DMD
Clifton, N.J.

Dear Ninoska,

Thanks for the kind words! I also went through a period where I wondered if I had picked the right profession. I am thrilled that I was able to play a small part in helping you rekindle your love for dentistry — it’s definitely an exciting time to be a part of it. In this issue’s One-on-One interview, I speak with Steve Thorne, founder, CEO and president of Pacific Dental Services. I love how his company is helping dentists find the happiness you’ve already discovered.

– Mike

Dear Dr. DiTolla,

I enjoy and look forward to each new issue of Chairside magazine. I’m writing to you because I am confused by the new types of all-ceramics. I suppose you could call me a “blue-collar dentist,” in the sense that almost all of the crowns I do are standard PFMs. However, I would like to start doing some all-ceramic crowns for anterior and posterior teeth. Where do I start? There are so many all-ceramics to choose from: IPS Empress^® (Ivoclar Vivadent; Amherst, N.Y.), IPS e.max^® (Ivoclar Vivadent), BruxZir^® and probably others.

Will you help me sort through these materials? Which all-ceramic material should I use for anterior crowns & bridges and posterior crowns & bridges? I know this is a lot to ask, but I’m just so confused by all these new products! Also, I just received a New Doctor Kit from Glidewell Laboratories, and I’d like to start sending cases to the lab. However, before I do, I need help determining which all-ceramic material I should be using for crown & bridge cases.

– Robert Israel, DDS
Pleasanton, Calif.

Dear Robert,

Many dentists ask the same exact question. You are not alone! First, know that there is nothing wrong with PFMs. This restoration has served dentistry well for nearly five decades. However, use of PFMs does come with liabilities: As a bilayered restoration, a PFM can be prone to chipping, especially on multiple-unit restorations, such as large bridges. The lab is working to solve this issue by “re-inventing” PFM restorations, by fusing a ceramic that is three times stronger than currently available ceramics to the metal coping. Second, some of the current ceramics used on PFMs cause an unacceptable amount of wear on opposing teeth. We have all seen upper anterior PFMs that have done a number on lower anterior teeth. Third, the average PFM crown is not as esthetic as the average all-ceramic crown. Opaquing a metal coping so that the final restoration looks like a natural tooth requires a skilled technician and ideal reduction from the dentist.

As the strength of all-ceramic restorations has improved, making cementation an option, more dentists have looked to using all-ceramics in anterior situations in hopes of satisfying more patients. Today, two of the fastest-growing products in the lab are monolithic: IPS e.max and BruxZir. A monolithic restoration is fabricated from just one material, whereas a PFM restoration is two materials: porcelain and metal, which are fused together.

The oldest monolithic material we have is cast gold, which scores well in every restorative category except esthetics. Like cast gold, IPS e.max and BruxZir are less prone to chipping than PFMs — and even than porcelain fused to zirconia restorations, which are also bilayered. In the 2011 winter issue of Chairside magazine, Dr. Gregg Helvey compared monolithic and bilayered restorations. You might enjoy reading his article to learn more.

I can tell you that almost every restoration I place today is monolithic — I have that much confidence in IPS e.max and BruxZir. For the last two years, I have been using BruxZir for posterior crowns & bridges and IPS e.max for anterior crowns and 3-unit anterior bridges. As BruxZir becomes more translucent and thus esthetically acceptable, I also have been using it in the anterior for bridges over 3 units. As for IPS e.max, I love the idea that it is three times stronger than IPS Empress. I even did my last three minimal-prep veneer cases in IPS e.max.

If I had to do a single anterior veneer adjacent to a natural tooth, I would still use IPS Empress. If it were a single unit anterior crown adjacent to a natural tooth, I would go with IPS e.max. And BruxZir is catching up esthetically. In fact, in the photo essay, I place a single-unit anterior BruxZir crown that is a pretty darn good match.

That said, I think BruxZir in the posterior and IPS e.max in the anterior is a great place to start. Both restorations can be cemented or bonded into place, based on your preferences or retentive requirements. You will need to place Z-PRIME^™ Plus (Bisco Inc.; Schaumburg, Ill.) into the crown prior to bonding BruxZir. The bonding steps for IPS e.max are the same as typical all-ceramic restorations.

– Mike

Dear Mike,

What anti-snoring device do you recommend for a young woman with no history of sleep apnea? Thanks.

– David S. Hornbrook, DDS, FAACD
La Mesa, Calif.

Dear David,

There are two choices: a mandibular advancement device (e.g., Silent Nite^®) or a tongue stabilizing device (e.g., aveoTSD^® [Innovative Health Technologies (NZ) Limited]). I prefer aveoTSD because I have a hard time sleeping with the Silent Nite appliance in my mouth — it makes me feel claustrophobic. Most people, however, don’t feel that way; Silent Nite outsells aveoTSD by approximately 20 percent (although it had a 15-year head start).

The aveoTSD is pre-made, which means it does not require impressions. It works through gentle suction to hold the tongue forward, thus keeping the airway open. We have also noticed that aveoTSD provides an added benefit: It stops bruxism because the tongue sticks out between the anterior teeth. While aveoTSD looks a little silly, the patient has no bite change issues upon waking. Check out getaveo.com for more information.

Silent Nite also moves the tongue forward, but it does so by moving the whole mandible forward. The downside to this is that it can take the patient a few minutes each morning to “find” centric occlusion. Other patients actually see an improvement in their TMJ symptoms because it moves the mandible downward and forward.

There is a slight learning curve for the patient when using aveoTSD. That’s because the patient is the one who determines how much suction will be on the tongue. Silent Nite, on the other hand, has no learning curve. The patient just puts it in and goes to sleep. If the appliance needs titration, the patient will need to return to his or her dentist.

As for side effects, some aveoTSD users report tip-of-the-tongue numbness from the suction. Many of my patients actually prefer to use both Silent Nite and aveoTSD, alternating between the two to minimize their side effects. I am beginning to think this is the best approach: Present the aveoTSD and Silent Nite together as an anti-snoring package, as opposed to a choose-one-of-these-appliances approach.

– Mike