In part 2 of transitions, we discussed distressed sales where the practice owner is not the sole decision maker, hence causing the due diligence process to be unpredictable and accelerated. Traditional sales, however, allow the purchaser more freedom to gather and analyze the information over a period of time in order to determine if this practice is the right “fit.”

Traditional Sales

In a traditional dental sale, the practice owner(s) has autonomy in the entire process of the sale. As varied as dental practices can be, so can transitions of each practice. 
           
Three Common transition types between seller and buyer

1.  Initial and complete break from the seller.

At closing, the seller introduces the purchaser to the staff and has no further involvement, besides warranty work.
Advantages: 

1. The transition is quick and clean. 
2. The team will need to immediately accept the shift of power. 
3. Purchaser can build a new “tone” in the practice immediately.

Disadvantages:
1.  The patients will not have an opportunity to slowly adjust to the new owner    doctor’s style.
2.  The team may resist changes implemented by the owner. This may lead to animosity and negativity in the work environment.

1.  Seller transitions the purchaser for a limited period of time.

After the sale of the practice, the seller stays a few days a week in the practice to transition the new owner to the patients and the staff for a period of time, typically 30 to 90 days.
Advantages: 

1. The team has an opportunity to get to know the new owner over a period of time and slowly adjust to the changes implemented.
2. The patients have a chance to get introduced to the new provider over a period of time. 
3. The new owner has a chance to become somewhat familiar with the tone set by the previous dentist with the patients and team members.

Disadvantages:
1.  The team may resist direction from the new owner when the previous owner is still in the office
2.  The patients may request treatment from the previous dentist and resist the transition to the new owner.

1.   Seller stays on as an associate for an extended period of time.

The previous owner dentist is retained by the purchaser as an associate for an extended period of time, ranging from 6 months to 5 years. 
Advantages: 

1. The team will not feel any significant pressure to change their routine.
2. The patients have a chance to meet the new provider and not necessarily feel pressured to have treatment rendered by him/her.
3. The new owner becomes completely familiar with the tone set by the previous dentist toward the patients and team members.
4. The new owner can be mentored by the senior doctor, in terms of business practices and patient care.

Disadvantages:

1. The team may resist direction from the new owner when the previous owner is still in the office.
2. There may be a “power struggle” between the new owner and the staff to set a different tone in the office.
3. The patients may request treatment from the previous dentist and resist the transition to the new owner.
4. The new owner doctor may not feel fully in control of the office until the previous owner is completely transitioned out.

Practice Merger

Practice mergers occur when dental practices are physically combined and can be highly profitable for both parties involved. Dentists seek mergers for a variety of reasons, including: to increase the patient base, acquire a different population of patients, decrease nearby dental office competition, and/or acquire a new facility. The transitioning process is similar to a traditional sale.  Most mergers result in an increase in revenue for the purchasing dentist as long as the increase in overhead is well controlled. Before committing to a practice merger make sure that you are not only aware but in control of your practice’s numbers and have set clear goals for the outcome of the merger process.

After the Transition

In the last of the 4-part series, we will discuss the stressors associated with practice ownership. It will include tips on how to help overcome the stressors in dentistry that can weigh down and prevent the achievement of our emotional and financial potential.

Conclusion

There is no right or wrong approach when it comes to transitioning a dental practice. Any type of transition can be successful if the buyer and seller are both on the same page and have realistic expectations. It is important to remember that in any transition, both parties need to walk away from the deal feeling that the process was fair and mutually beneficial. No transition will ever be perfect because the concept of perfection is subjective. If the transition is right for you, then it was the right choice and you should make the best of your new investment.

BIO

Dr. Beyramian, a full-time practicing dentist, graduated from the University of Michigan School of Dentistry, and currently owns two private practices in Phoenix. Dr. Beyramian has started, purchased, operated, managed, and transitioned numerous dental practices in her 12 years of practice. Dr. Beyramian’s vision to promote smart business practices for private practitioners led to the development of coupdoc.com, an online dental supply company. She can be reached at (877) 850-2181 or drb@coupdoc.com.

When talking to groups of dentists about embezzlement, I have noted their first instinct is to deny that it has ever happened to them. Current statistics, however, show that at least 60% of all dentists have already been the victim of embezzlement at least once. In a group of seminars I conducted in Australia and New Zealand, one dentist admitted to being a victim 3 times.

There are published lists of red flags, seminars offered, numerous articles in magazines, and books written on the topic, but the number of incidents keeps climbing. Of 10,000-plus dentists invited to a recent webinar on the topic, only 38 actually attended. Why the denial or lack of interest? Perhaps it is an embarrassment. It shows that you have not been minding the store. Maybe you are not aware it has occurred. In most cases, embezzlement is brushed under the rug and you move on to the next office manager who comes along.

A problem I face as a certified fraud examiner is that I can lead dentists in the right direction, but I cannot force them to implement necessary changes. I don’t know whether the suggestions are implemented when they go back to their offices. You can hang an embezzlement policy in a break room, but it is worthless if the policy is not enforced. When suggestions are not implemented, I get a call from the doctor saying he or she believes someone has been embezzling, and I am not surprised.

Because of your clinical responsibilities as dentists, you often become like an absentee owner. This puts your practice particularly at risk. Solutions require you get more directly involved in the day-to-day activities of the office. There is no easy answer to the problem, but being vigilant in implementing the suggestions below can certainly help.

Of those who do attend seminars or webinars, most ask questions about how to know if it has happened and what to look for. The first thing to do is to review security policies and practices. I help my clients review their systems to make sure their software has the necessary reports to track everything related to money. If their software doesn’t have the right reports, I recommend that they switch to a system that does. One of the systems I recommend is DentiMax because it has the right reports and is one of the few available systems that doesn’t break the bank.

Once I verify the software is up to speed, I discuss the importance of reviewing audit trails, holding team members accountable, and having everyone use his or her own login and password.

Immediately implement the following actions to help prevent embezzlement in your practice:

• Open your mail: Most dentists do not do this. Opening the mail and stamping the back of checks “For deposit only” followed by your account number deters a potential embezzler. You will have a good idea of what should be in the deposit each day, and it only takes a few minutes.
• Take the deposit to the bank daily: It is important for your team to know that you will be taking all the money—cash, checks, and credit card payment slips—out of the office each night. This is another vital deterrent. Even if you don’t get to the bank each day, the potential for theft is greatly reduced by this act alone.
• Change your routine: Arrive at the office at different times. Come in early, leave a few minutes later each day, or come back from lunch early. Come up to the front at different times throughout the day just to break up the routine so a potential embezzler doesn’t know when he or she will be alone in the office. If you see an employee’s car at the office in the evening or on a Saturday or Sunday, find out why. Someone who has to work extra hours may be cooking the books.
• Check the daily reports: Be sure to run daily reports—day sheet, deposit slip, and a copy of the schedule from the end of the day—and take them home with you. Compare them to be sure everyone who came in that day shows up on these reports. Also, make sure everyone in the office knows that you are checking this each day. Ensure that the deposit in your practice management software matches what you are taking to the bank.
• Require vacations: Be sure that each employee takes his or her allotted vacations. Many times embezzlement is discovered when the office manager or front desk person is out of the office. If given the choice, an embezzler will usually not take vacation because he or she needs to be in the office each day to cover the tracks.
• Utilize security settings in your practice management system and review audit reports: Most practice management software programs have security settings. You can give team members a security level and then permit or restrict each from different actions in the software. This reduces access to the money in your practice.

Review these settings on a routine basis and follow up with employees on any unusual transactions in the log, such as deposits deleted and transactions modified or removed.

By just changing a few things in the office routine, you can help reduce the potential for fraud and embezzlement.

The Fraud Triangle, created by Donald Cressey, an American sociologist and criminologist, tells only 3 things need to be in place for fraud or embezzlement to occur:

• Motive: The need for money due to a drug habit, an illness, divorce, or just for the fun of it.
• Opportunity: If employees are aware of your daily routine, you open yourself up for embezzlement. The following situations create opportunities for employees to take advantage of you: giving someone signature authorization on your checking account, allowing employees access to the office at times other than normal working hours, allowing employees to make deposits, or not taking money to the bank each day. Probably the most important situation to avoid is becoming too friendly with employees.
• Rationalization: Many embezzlers have felt that they were owed money because they were underpaid, or they claimed the dentist was making so much money he or she wouldn’t miss it.

Consider these situations before you join your team members at the next happy hour, let one of them do you a favor and take the deposit to the bank, take cash from the drawer and put it in your pocket in front of team members, or invite team members to your newly remodeled home for dinner. Don’t give employees a reason to steal from you. They can create many on their own.

Remember: people do not tend to steal from someone they respect.

Protect the company you have spent so much time and effort in creating. Being aware of possible dangers and making small, but important, adjustments in your actions can protect your practice and let you do the thing you like best—care for your patients.

Ms. Salzman is a certified fraud examiner with 25 years of accounting experience. She has a degree in finance from Simmons College and a teaching certificate in business education from Salem State College. She has been a trainer in the dental and medical industries for more than 20 years, training clients on DentiMax, Total MD, Advanced MD, Medformix, Medinformatix, Softdent, PracticeWorks and Quickbooks Pro. Mindy’s specialty is helping doctors in the detection and prevention of embezzlement in their practices. With this expertise, combined with her accounting experience, she provides insight to clients about utilizing the software to run their practices in the most efficient way.

The provision of healthcare is changing at a rapid pace as healthcare providers endeavor to maintain maximum efficiency while navigating the technology rich climate. As a result of the reliance on electronic data, dental offices have become vulnerable to cyber security threats. The growing volume and sophistication of cyber-attacks suggest that dental practices will have to grow increasingly vigilant to ward off these threats. A breach of cyber security will inevitably lead to significant expenses, both financial and reputational, which can wreak havoc on a dental practice.

Many dentists believe that cyber criminals are not a threat to their small dental offices. However, when choosing between a large corporation or bank with security teams and firewalls preventing access to databases and a dental office with no firewall or security team, the dental practice will be the chosen target. In fact, many hackers specifically target small dental offices because they believe that the small business may not have the resources for sophisticated security devices and do not enforce employee security policies.

Dental practices are an increasing target for cyber criminals. These offices hold a vast amount of data, including names, health history, addresses, birthdates, social security numbers, and even banking information of hundreds, if not thousands, of patients. The threat of this information being stolen by a staff member or a cyber-criminal is great, and dental practice owners must address this concern before a theft creates a legal nightmare for the dental practice.

Healthcare organizations make up roughly 33% of all data security breaches across all industries and the healthcare industry is the most breached industry in the United States. According to the US Department of Health and Human Services, almost 21,000,000 health records have been compromised since September 2009. It has been shown that human error causes the majority of personal health information data breaches, and that actions of healthcare employees cause 3 times as many breaches as external attacks. The most common causes of data breaches in healthcare organizations are theft, hacking, unauthorized access or disclosure, lost records and devices, and improper disposal of records. A significant proportion of healthcare breaches are a result of lost or stolen mobile devices, tablets and laptops. In addition, security breaches are not solely inflicted upon the large HMOs, as more than half of all organizations that suffer from security breaches have fewer than 1,000 employees.

The Health Insurance Portability and Accountability Act requires healthcare providers to maintain the privacy of patient health information and to take security measures to protect this information from abuse by staff members, hackers, and thieves. The penalties imposed upon health care providers for HIPAA violations are great. The monetary penalties can range from a fine of $100 to a fine of $50,000 per violation, with a $1,500,000 maximum annual penalty. In addition to the federal penalties, dentists may face penalties imposed at the state level as well as lawsuits filed by disgruntled patients whose health information has been compromised.

It is crucial for dentists to take steps to ensure that their practice is in compliance with HIPAA provisions regarding computer security. Because the majority of data security breaches occur when staff members fail to follow office procedures or exercise poor judgment, the location of computers in the dental office is key. All computers should be placed in areas where the computer screens are not visible to patients and visitors, and encrypted passwords should protect access to each computer. Passwords should contain mixed-case letters and include numbers or symbols and should be changed regularly. In addition, passwords should not be written down under keyboards or kept on desks or surfaces where the public may be able to access them. Dentists should ensure that all staff members understand the importance of maintaining the privacy of patient health information.

Every dental practice should have a policy that includes steps for safeguarding patient information and educate staff members as to how to comply with the office policy. A strict Internet and computer use policy should be enforced that prohibits staff members from checking personal e-mail accounts or visiting Internet sites that aren’t work-related. It is also important that dentists ensure that all firewalls, operating systems, hardware and software devices are up to date, strong and secure and that wireless networks are shielded from public view. Antivirus software should be installed on every computer, kept updated, and checked regularly.

When accessing office data remotely, dentists should use only trusted Wi-Fi hot spots and never use shared computers. Smartphones and tablets should be password protected to prevent easy access to patient information in case the device is lost or stolen. In addition, all hard copies of documents with patient information should be shredded. Finally, to ensure that your dental practice is HIPAA compliant, data transmitted to payers, health plans, labs and other healthcare providers may need to be encrypted to ensure that a hacker will not have access to this data.

Because dental practices are subject to heightened government enforcement and the scope of fines and penalties for data breaches have increased, many dental practices have relied on cyber insurance for protection in the event of a breach of cyber security. These insurance policies cover the cost of investigating a theft, compensate the insured for all state and federal fines and penalties imposed, and fund all related lawsuits and legal fees, thus relieving dentists of the financial and time burdens imposed as a result of the breach in security.

It would be prudent for all dentists to invest in data security and in the proper training of staff members as to acceptable use of office computers. If plans and policies are put in place proactively and steps are followed to ensure HIPAA security compliance, a dental practice should be able to prevent the significant cost and headache involved in responding to a cyber-breach.

If a security breach in a dental office does occur, it is imperative that appropriate action is taken immediately, which includes determining how the breach occurred, and the extent of the security breach. In addition, if a security breach does occur, the owner of a dental practice must be very careful whom they initially contact and provide information to. Any improper or accidental disclosure to a third-party other than legal counsel for the dental practice owner may be subject to the rules of discovery if litigation occurs, which could increase the liability exposure of the practice owner.

Mr. Oberman, handles a wide range of legal issues for the dental profession including cyber security breaches, employment law, practice sales, OSHA, and HIPAA compliance, real estate transactions, lease agreements, noncompete agreements, dental board complaints, and professional corporations. He can be reached at (770) 554-1400 or at gadentalattorney.com.

In the first part of this 4 part series, we discussed the basics of all practice transitions, the numbers and our emotional need. In this article, we will look at an outside-of-the-norm type of sale, the distressed sale.

Distressed Sales

Distressed sales of dental practices can occur for a variety of reasons. The owner dentist may have a disability, or even death; or they might be going through a personal transition, such as a divorce, and may need to sell the practice quickly. It also may be possible that the owner dentist may be in financial difficulties due to the lack of control of overhead. Whatever the reasons for a distressed sale, the sale needs to happen quickly.

The acquisition of a distressed practice can be an enormous financial gain for the purchaser. Most distressed practices are priced under fair market value and the owners are eager to sell and move on. With the urgency of the sale comes the pressure to close the deal quickly. The purchaser who already has secured funds and is able to evaluate the numbers quickly will be the chosen one.

Three Tips for Closing a Distressed Sale Quickly

1. Have the funds already secured

If you are to take a loan out, not only have yourself prequalified, but also submit all of your paperwork as if you are going to close on the loan. If you are only prequalified, the banks may go back and forth with paperwork that may delay funding for 30 to 45 days; this may result in losing the purchase to another buyer.

1. Know your numbers

Most purchasers of distressed sales are very versed with practice evaluations and numbers. If you are going to be even in the ball game, you have to be able to quickly evaluate all the practice numbers and present a letter of intent to the seller within a few days.

1. Be flexible

Distressed sales are usually very frustrating and stressful for the sellers and their families. You should be sympathetic to their situation by being flexible with your schedule, and understand that the seller, more than likely, has a strong emotional attachment to the practice and, in many cases, would rather not sell the practice, especially at a reduced price.

Understanding the reasons behind a distressed practice will determine your success after acquisition.

Why is the Sale Distressed?

1. Overhead is too high

Is the overhead able to be reduced? The purchaser has to look at the variable versus the fixed overhead and make a nonemotional, purely numbers-based decision. If the fixed overhead is too high, then the success after acquisition will be compromised unless significant revenue increase can be achieved.

1. Location is not visible or marketable

Is the practice located out of the way of the normal flow of traffic for that region? Even if a practice is physically located close to potential patients’ home or work, it does not necessarily ensure capturing new patients in your practice; people tend to gravitate to familiar places. Again, the physical location of the practice is not a variable. If the location has hindered success of the practice in the past, it will continue to hinder success in the future.

1. Seller did not understand the marketing necessary to match the demographics

This is one variable that the purchaser will be able to influence. Marketing is a fluid category with infinite potential. The purchaser will need to fully understand their demographics and purchase this practice with a concrete external marketing plan in place that will eventually lead to solid internal marketing. Due to the nature of distressed sales, internal marketing is virtually nonexistent in the current practice.

1. The practice is profitable, but the seller had to take a large income for personal reasons and the practice could not support his personal financial needs

If the practice is profitable, then this type of distressed sale is the most successful for the purchaser. The purchaser needs to understand the numbers of the practice and find opportunities to lean out the overhead. As I discussed in part 1 of my series, understanding the numbers is the key to success. If you want to take home $250,000 per year, it is much easier to maintain a practice with $500,000 revenue running a 50% overhead than a practice with $1,000,000 in revenue running a 75% overhead.

Sometimes it may be difficult to truly understand the nature of the distress. The staff, the seller, and the broker will give you clues, but in almost all the cases, it is up to the buyer to get to the bottom of the problem. Just think, if the seller and the staff accurately knew where the difficulties lay, then the practice would most likely not go into a distressed situation.

To find a distressed practice it is not only important to have a close-knit relationship with the brokers in your area, but also it is important to develop good relationships with attorneys and banks. By directly communicating with the attorneys, you are able to understand the needs of the seller and close the deal quickly, efficiently, and profitably.

Warren Buffet said it well, “In the business world, the rearview mirror is always clearer than the windshield.” The challenges associated with a purchase of a distressed sale lies within you, capitalizing on your abilities but understanding your limits. You can look at your past successes to determine if a challenge such as this is the right practice acquisition for you.

BIO
Dr. Beyramian, a full-time practicing dentist, graduated from the University of Michigan School of Dentistry, and currently owns two private practices in Phoenix. Dr. Beyramian has started, purchased, operated, managed, and transitioned numerous dental practices in her 12 years of practice. Dr. Beyramian’s vision to promote smart business practices for private practitioners led to the development of coupdoc.com, an online dental supply company. She can be reached at (877) 850-2181 or drb@coupdoc.com.

Studies have been published that up to 50% of all dentists across the country do not even have a Web site. If you are in this demographic, this article won’t be relevant to you, but you can definitely get some takeaways from it, when you get your Web site done. For those of you who do have a Web site for your dental practice, I ask you one simple question. Are you getting the results you had hoped for when you launched your Web site?

This is a question either you or your marketing person should be asking on a monthly basis. The reason being is you invested money into the design of your Web site and, as a responsible business owner, you need to see a return on investment from it. Unfortunately, a big majority of the dentists I speak to have no idea if their Web site is getting them new patients, or even phone calls to their practice. This is the “kiss of death” to your dental practice online.

When evaluating the performance of your dental Web site, have these goals in mind.

Goal No. 1: Getting New Patients

The only reason for even having a Web site is for attracting new patients to call your practice, and get started with treatment. If you are not keeping track of where your new patients are coming from, you’ll be an uninformed business owner, throwing darts in the dark with your marketing. This would be as simple as your front desk staff asking the question, “We appreciate you calling our office, may I ask how you found out about is?” Once they receive the answer, enter it into a call log for tracking.

Goal No. 2: Answering All the Questions a Visitor May Have

When people arrive on your dental Web site, they may have questions in their head. You want to answer as many of them as possible, so they feel assured you are the right choice for them, and possibly their family. Make a list of the top 20 questions you get in your office from new patients. Now create an article around each question, and answer it as thoroughly as possible. This then makes your Web site a valuable resource for the person inquiring about dental work in your locale. The best place to insert these articles is in a blog, or a FAQ section of your Web site. Preferably a blog, as Google does, likes to see Web sites with blogs that are updated frequently with fresh content.

Goal No. 3: Where Is Your Practice Located

For any service business, the first question in a person’s minds is your location. How far do they have to go to get their dental work done? If you don’t make it clear on every page of your Web site where you’re located, you will possibly lose that person, as they will get frustrated and leave, never to come back. The most effective way to do this is by inserting a map location of your practice. This must be on the homepage and the contact page at a minimum, but it can be on every page, at the bottom of your Web site, which we call the footer area. The great thing about the Internet is you can create a fantastic Web site that will attract people from other areas looking for a credible and caring dentist. I have dental clients that have patients coming from 45 minutes away.

Conclusion

As in any business, you have investments to sustain and grow your practice. I hope the information in this article, has given you some “food for thought” when it comes to your dental Web site. Your Web site was an investment and, like any investment, you want to get a good return on investment, so you want to make sure you track the results and that your Web site is designed and laid out to get people to take action.

Mr. Pedersen, a 14-year Internet marketing veteran, has built 2 successful online businesses. He now works exclusively with dentists helping them grow their practices using strategic Internet marketing methods. He can be reached at aznetmarketing.com.

The process of acquiring a new practice can become overwhelming. In this 4-part series, we will look at different practice transitions, including distressed and traditional sales, associate buy-in and buy-outs, and practice mergers. For this first part, we will discuss the basics of all practice transitions, the numbers and our emotional need.

Regardless of the type of purchase—traditional, distressed, or transitional—the basic elements of the evaluation process will remain consistent, evaluation of the numbers: new patient flow, hygiene recall, production and collection, and accounts receivable. The fifth, and possibly the most important factor to consider, is personal and emotional needs. What kind of patient population do I want to treat? Not necessarily, where do I want to practice, but what demographic am I most interested in treating? The physical location of a practice may not necessarily determine the type of dentistry you will be practicing. The demographic of the population, age, income status, and dental IQ will determine your practice’s tone. Each transition type will meet different emotional wants and needs of the dentist and for this reason not all practice transitions are the right type of transition for every dentist.

New Patient Flow

New patient flow is one of the most important indicators for practice’s success.

1. Where are the new patients coming from? 
2. How are the patients finding this office? 
3. Are all the new patients coming from the insurance companies, is it based on internal referrals, or is it based on external marketing? 
4. If most of the new patients are coming from external marketing, then how much is each new patient costing the practice based on the expenditures?

In an average practice the attrition rate per month is anywhere between 5 and 15 patients. Knowing this, you have to determine if you are looking for growth in a practice or looking to maintain production.

Number of Patients Actively in Hygiene Recall

Evaluating the number and the frequency of appointments per patient in the last 18 to 24 months provides a good indicator of the active patients in the database and their level of loyalty to the practitioner.

Gross Production/Collection Numbers and Account Receivables

The gross production versus collection numbers determines the baseline of the purchase price. Most practice evaluators base the purchase price between 50 and 75 % of the average collection for the last 3 years.

The production/collection ratio will give insight into the office’s collection policies, as well as the account receivables. The office’s collection policies are important, for it reveals the tone of the practice. Does the practice require payment at the time of procedure or are the patients placed on payment plans and pay as they please?

What Type of Practice is Right for Me?

This leads to the final and most important factor in determining suitability of a particular practice and emotional needs. Determining what type of practice is exactly right for you does not fit into any box or formula. This is a purely emotional and financial decision that can be best made by knowing yourself, your likes/dislikes and your long-term goals. Different transition types will present different opportunities to determine if a particular practice will fit your practice style, hence, it is imperative to research and evaluate as many differing practices and transitions types prior to purchasing a practice.

After looking at all the numbers and the books, then answer these 2 basic questions:

1. Am I able to sustain or grow the previous owner’s production based on my knowledge and skills?
2. Will I have an opportunity to perform the dentistry I enjoy on this patient population?

Once you are able to honestly answer these questions for yourself, then you know this transition type is right for you.

Dr. Beyramian, a full-time practicing dentist, graduated from the University of Michigan School of Dentistry, and currently owns 2 private practices in Phoenix, Ariz. Dr. Beyramian has started, purchased, operated, managed, and transitioned numerous dental practices in her 12 years of practice. Dr. Beyramian’s vision to promote smart business practices for private practitioners led to the development of coupdoc.com, an online dental supply company. She can be reached at (877) 850-2181 or at drb@coupdoc.com.

The increasing expectations of today’s dental patients put additional pressure on the relationships between doctors and their dental technicians. Patients expect a smooth process in the dental office with highly aesthetic results, and they are also expressing a desire for an increased level of comfort during procedures. These factors all contribute to the importance of communication between the dentist and the laboratory.

While any number of factors can contribute to an undesirable result in the restorative process, in many cases “the human element” is likely a major cause. A poor impression or vague instructions on the dentist’s part can start things on the wrong foot, and on the lab side, technique-dependent materials and processes leave a lot to chance. The dental community is discovering that, as in many other industries, reducing some of the human element in the restorative procedure may lead to more predictable and reliable results. At the same time, the technologies used to achieve this goal can also help improve communication between the dentist and the laboratory team.

Capitalizing on Digital Technologies
During the past years, a flood of digital technologies has changed the dental world, many of them offering tools that increase automation and move away from the people-driven techniques that can introduce errors. This is obviously seen in many CAD/CAM technologies and in the newer digital impression-taking systems.

Digital impressions, in particular, can go a long way in improving the team communication between dentists and dental technicians, and in reducing errors. The Lava Chairside Oral Scanner (C.O.S.) (3M ESPE), for example, gives the dentist numerous tools to check and review a digital scan before submitting it to the laboratory, which allows the dentist to ensure that all necessary information has been captured. With digital impression-taking, dentists no longer have to dread receiving calls from their laboratory team with the news that an impression is inadequate; the quality of the impression can be confirmed while the patient is still in the doctor’s chair.

But even with these technologies, the possibility of user error, resulting in restorations being compromised, still exists. One example of this can be seen with certain zirconia crowns. While zirconia itself is known for strength, reports have surfaced in recent years that the porcelain overlays on some of these restorations were prone to chipping. Additional investigation, however, revealed that in most cases, this chipping was due to poor design of the zirconia coping; specifically coping designs that left the overlying porcelain unsupported.¹

Eliminating Variation
A recently introduced laboratory tool offers the potential to further reduce the chance of this human error in designing zirconia substructures and porcelain overlays; the Lava Digital Veneering System (DVS) (3M ESPE) utilizes a standardized CAD/CAM veneering process to better control the variables in the design of a zirconia restoration. With this system, the zirconia coping and glass ceramic veneer are digitally designed, milled separately, and then bonded together with a special fusion porcelain. The system eliminates the need to hand-layer porcelain, increasing productivity for the laboratory teams and reducing the chance of failure due to improper design.

The Lava DVS is designed to maximize productivity for dental laboratories, but the opportunity also exists for dental technicians to apply advanced techniques to enhance characterization. Each of the 3 components of the system is available in multiple shades and translucencies, and both the zirconia coping and inside surface of the glass ceramic veneer can be customized with multiple shades to produce a highly aesthetic restoration. As with natural teeth, the color comes from within using this system.

This system functions very differently from monolithic restorations, which are popular among many laboratories due to their efficient production, but can only be customized via stain and glaze applied to the exterior of the restorations. The aesthetics of monolithic restorations can be compromised if they are adjusted during the seating and cementation phase. In contrast, with the Lava 3-component DVS, the characterization can be applied internally, thus producing a restoration with translucency and shade variances throughout, creating a lifelike appearance.

Because the Lava DVS utilizes a feldspathic porcelain that is condensed into a block and milled, the variability of this process in the laboratory is dramatically reduced. Research2 has shown the variability among ceramists in this process—no 2 ceramists condense at the same density, even on the same day. Even ceramists at high-end laboratories may not be skilled at properly condensing porcelain. With porcelain condensed in an automated process, dental technicians can be assured that there are no imperfections. In turn, this consistency adds to the strength of the restoration. The quality of the laboratory’s product is consistent between technicians and their various levels of experience. Due to the strength² of these restorations, they are indicated for patients requiring a posterior full-coverage option. The results of one study that compared the strengths of CAD/CAM sintered to zirconia to both hand veneered and pressed to zirconia copings produced significant findings; the strength of the CAD/CAM sintered restorations was about 80% stronger than when using the other fabrication techniques.² The following case will demonstrate the use of the Lava DVS system to produce an aesthetic posterior crown, highlighting the simplified communication between the dentist and the dental laboratory team.

CASE REPORT
Diagnosis and Treatment Planning
A patient presented to the office with a fractured buccal cusp on tooth No. 3 (Figure 1). The tooth had originally been restored with a direct filling restoration, followed by a composite inlay when the original restoration failed.

Due to the amount and location of missing tooth structure after this latest break, it was determined that a full-coverage crown would be the best method of treatment.

Preparation Appointment
The tooth was prepped, and a digital scan was captured (Lava C.O.S.) (Figure 2). After scanning the prep and the opposing arch, and reviewing the scan for completion, the case was submitted to the dental laboratory. Photographs, along with a desired shade for the restoration, were also captured to share with the dental laboratory team. A provisional was fabricated using a bis-acrylic material (Protemp Plus [3M ESPE]) and cemented with a provisional cement (Temp Bond Clear (resin) [Kerr]). After checking the occlusion and confirming a balanced bite, the patient was dismissed.

Dental Laboratory Technical Protocol
At the dental laboratory, the Lava Scan ST Design System (3M ESPE) was used to review the scan (Figure 3). The software was used to electronically mark the margins and cut the die, and the digital impression was sent to the Lava C.O.S. model production facility. Concurrently, the laboratory team utilized the software to design the porcelain overlay. Using the data captured in the digital scan, the software designed the crown from the outside in to provide maximum strength (Figure 4). The software indicates with a color scale how thick the overlay material is, and alerts the technician if the thickness is beyond acceptable levels (Figure 5).

Figure 1. Patient presented with a fractured buccal cusp on tooth No. 3.	Figure 2. The prepped tooth, prior to scanning (Lava C.O.S. [3M ESPE]).
Figure 3. The digital scan submitted by the dentist with margins marked.	Figure 4. The software generated the finished crown from the outside in. Once the full-contour restoration was designed, the software cut the design into segments for the zirconia coping and glass ceramic veneer.
Figure 5. The color-coded design of the zirconia core informs the user where overlay material may be too thick.	Figure 6. A very thin layer of fusion porcelain was applied to the coping and fired.

The design was completed and the zirconia coping and glass ceramic veneer components were milled separately in the Lava CNC 500 Milling Machine (3M ESPE).

After the coping was milled, a thin layer of fusion porcelain was applied and the coping was fired to set the color (Figure 6). (This is an optional step in the Lava DVS process, performed in this case to add advanced characterization.) Once the stereolithography model reached the laboratory, the coping was tried on the model to confirm its fit. To fuse the components together, the Lava DVS veneer was placed in water for one minute to allow the water to infiltrate the veneer. Lava DVS fusion powder and modeling liquid were then mixed in a 1:1 ratio and the resulting fusion porcelain was applied to the inside of the veneer, as well as to the occlusal side of the zirconia coping (Figures 7 and 8). The veneer was then seated onto the coping, and the combined pieces were placed on a tissue to allow excess fusion porcelain to be absorbed. Minor corrections were made to the cervical areas with Lava DVS fusion porcelain and the restoration was removed from the die. The crown was then fired on the fusion firing cycle (Figure 9). After firing, the proximal and occlusal contacts were again checked on the die (Figures 10 and 11). Buccal and lingual areas were fine tuned, and occlusal fissures were adjusted. Staining and glazing was then performed, followed by a final firing (Figure 12). The restoration was then returned to the dental office.

Seating Appointment
Once at the office, the crown was tried in for fit and aesthetics. The crown was then cemented using a self-adhesive composite resin cement (RelyX Unicem [3M ESPE]). The dental team and patient were very happy with the fit and aesthetics; and final photos were captured and the patient was dismissed. The restoration is shown in Figure 13 at 5 months postoperatively. It exhibited good function, excellent aesthetics due to customization of the overlying porcelain (after milling and fusion), and the soft tissue was healthy and well-adapted (Figure 13).

Figure 7. The zirconia coping, glass ceramic veneer, and fusion powder.	Figure 8. The fusion powder was mixed with modeling liquid, and then applied to both the occlusal surface of the coping and the interior of the veneer.
Figure 9. The coping shown here, after the components were fired together.	Figure 10. The coping fit precisely on the die after firing.
Figure 11. The die was seated back into the model, demonstrating excellent fit and ample contacts between the mesial and distal surfaces.	Figure 12. The occlusion was adjusted and color was applied to occlusal surfaces.

Figure 13. Restoration shown 5 months after cementation.

CLOSING COMMENTS
The smoothly executed team procedure demonstrated here is typical of restorations fabricated with the new digital tools currently available. Because the restoration was produced digitally from beginning to end, the opportunity for errors to be introduced was minimized, and the restoration fit very well both on the model and in the patient’s mouth. The Lava DVS is designed to offer excellent aesthetics via characterization, without a significant time investment by the dental technician. At the same time, the digital tools used in the case facilitated communication between the dentist and lab, providing clear directions and information.

Many dentists wish that they could have a laboratory technician working alongside them; digital technology is a means to that end. It helps in making the flow of information between the clinical and dental laboratory teams seamless and efficient, as if they were working side by side. In addition, the introduction of digital technologies actually serves to simplify dialogue, rather than complicating matters.

Every clinician who practices restorative dentistry faces the challenge of delivering work that provides long-term function and is consistent in quality, fit, and aesthetics; and dental laboratory teams must also continually strive to provide outstanding technical solutions. By working as a team, and utilizing digital tools designed to facilitate collaboration, dentists and dental technicians can provide patients with the best in restorative outcomes.

References

1. Komine F, Blatz MB, Matsumura H. Current status of zirconia-based fixed restorations. J Oral Sci. 2010;52:531-539.
2. Beuer F, Schweiger J, Eichberger M, et al. High strength CAD/CAM fabrication veneering material sintered to zirconia copings – A new fabrication mode for all-ceramic restoration. Dent Mater. 2009;25:121-128 [Epub July 11, 2008].

    

Dr. Ringer is a graduate of the University of the Witwatersrand Dental School in Johannesburg, South Africa, and completed a mini-residency program at the University of California, Los Angeles. He received his California dental license in 1979. Dr. Ringer is a member of ADA, California Dental Association, and Orange County Dental Society; an accredited member and board member of American Academy of Cosmetic Dentistry; and the founder and president of Orange County Academy of Cosmetic Dentistry. He is a faculty mentor at Spear Education in Scottsdale, Ariz. During the last 18 years, Dr. Ringer has divided his time among treating private patients, teaching at local dental institutions, and speaking at various dental meetings. He can be reached at drringer@dentalcosmetics.com.

Disclosure: Dr. Ringer reports no disclosures.

Mr. Okon holds a bachelor of science degree in microbiology from University of California in Los Angeles (UCLA) and a degree in dental technology from Pasadena City College. He currently serves as president of the Dental Lab Owners’ Association of California for the 2011-2012 term. He is the principal of Stanley Okon Dental Laboratory, Inc, in Orange County, Calif. Mr. Okon is currently a beta tester for 3M ESPE new products and has completed product evaluations for clinical research. He is also participating with UCLA in a new product research study. Mr. Okon is a member and the preferred lab of the Orange County Chapter of the Seattle Study Club and is involved with several other implant study clubs as well. Mr. Okon has lectured for major dental manufacturers, including 3M ESPE, Straumann, Vita, Zimmer, and others. He can be reached at stan.okon@okonlab.com.

Disclosure: Mr. Okon reports no disclosures.

A good educator is an individual who imparts information and knowledge while using outstanding communication skills. Think back to when you were in college. You probably remember having a professor who had that special gift of sharing information where they not only educated, but inspired. That is the context that I want to address your ability to power educate.

When you are ready to take your cosmetic dentistry practice to the next level, follow these simple suggestions and you will be creating more meaning and significance when you educate patients about the benefits associated with cosmetic dentistry.

1. Never assume patients know what you know. Don’t take for granted that patients know even the most fundamental techniques used when providing elective cosmetic dentistry services. Some may, most do not. Take an extra minute to make sure your patient is on the same page as you are.

2. When it comes to many elective cosmetic dental services, when applicable share the perceived benefit that patients want to hear—that no shots and often no drilling (or minimal cosmetic contouring) is required.

3. Have your team members inform your patients of other real life stories (no names please!) from patients who now have a self-confident smile thanks to your cosmetic dental expertise.

Figure 1. One noninvasive LifeLike Veneer and in-office tooth whitening. Note: Seamless emergence profile and chameleon ability to match adjacent teeth.Cosmetic dentistry done by Dr. Silverman.

4. Some patients associate cosmetic dentistry with teeth that looked like they were “fixed.” Team members need to talk with pride about how natural and lifelike your veneers look. Needless to say, use a dental laboratory or create your own noninvasive veneers that provide you with a gorgeous, real lifelike appearance.

5. Team members should help distinguish the doctor’s artistic skills. Your team needs to describe how you are an artist when doing cosmetic cases. An illusionist when it comes to closing in spaces or making uneven teeth look straight. Needless to say this must be based upon sincere feelings they have about your technical expertise.

6. Show before and after photos of cases that you personally did and have team members describe the positive impact the work had on your patient. Make it relevant.

7. Share before and after photos of how each team member has had some cosmetic dentistry done by you, even if it is bonding or tooth whitening. Have your team fill out my Smile Enhancement Form. From anecdotal studies done over many years I have observed that nearly 8 out of 10 team members still have at least one tooth they would like to have cosmetically enhanced. Surprised? Establish with your patients that your team trusts you enough to do their work too.

8. No selling is ever used or needed. However, power educating requires sincerity, conviction, enthusiasm and a sense of mission. That’s what we focus on when we teach dentists and team members how to power educate patients.

9. Share how your office has a lot of experience when it comes to smile makeovers—from subtle to major transformations. Don’t hold back. Whenever possible show examples of subtle changes. Most patients can relate to subtle improvements than dramatic transformations – and they can afford to have the work done as well. For example providing 1 non-invasive veneer with in-office whitening can make a significant improvement as demonstrated in the above photograph. Our Boot Camp philosophy is “the best cosmetic dentistry is often the least cosmetic dentistry that provides our patients with more self-confidence when they smile.” If you agree with that approach start to implement it as soon as possible.

10. Encourage smile previews using either computer imaging or a chairside mock-up. In either case have your team members inform your patient that they “hope” that the patient will be a candidate and if they are, your team members are confident that your patient will love the final result. One note of caution: conventional mock-ups can take a lot of time to do. That can be frustrating and not very practical when you have a full schedule. In future articles in Denitstry Today I will share with you some suggestions on how to simplify the “Smile Preview” procedure.

The goal of the series, Silverman On Smiles, has been to share with you some of the successful strategies dentists use after participating in my Cosmetic Dentistry Boot Camp Program. I hope that you are able to extrapolate some of the suggestions that work for you and that they ultimately benefit your patients. If you have any questions that you would like me to address in a future article in this series, please send them to me at incrediblesmiles@aol.com.

Dr. Silverman has been successfully coaching dentists on how to expand their cosmetic dentistry practice since 1984. If you want to take your cosmetic practice to the next level or want more information about the Silverman Institute’s Cosmetic Dentistry Boot Camp Program, please contact him at (216) 256-4599 or e-mail him at incrediblesmiles@aol.com.

CASE REPORT
Diagnosis and Treatment Planning
A 42-year-old male presented with porcelain veneers on teeth Nos. 6 to 11 and teeth Nos. 22 to 27 (Figure 1). The original feldspathic units were bonded into place in 2003. During the last 9 years, small chips on teeth Nos. 6, 9, 11, and 22, a complete failure of the restorations on teeth Nos. 24, 25, and 27, and generalized staining at the margins had occurred. These failures were attributed to the patient’s nocturnal bruxism habit, as well as mild occlusal interferences in the anterior region (Figures 2 and 3).
Initially, tooth No. 11 had been bony impacted and was surgically uncovered and orthodontically brought into place. After completion of orthodontics, he was left with an osseous and associated soft-tissue defect. This initial restoration was handled with a direct resin veneer. The upper veneers were selected in 2003 to address this aesthetic issue, and the lowers were added to balance the aesthetic requirements of the patient.

Figure 1. Preoperative: existing veneers on teeth Nos. 6 to 11 and teeth Nos. 22 to 27.	Figure 2. Preoperative: marginal staining and chips.
Figure 3. Preoperative: fractures and complete debonds.	Figure 4. Composite mock-up: aesthetics and occlusion refined for correlation scan.

The patient was a practicing dentist for 16 years who had clear expectations, knowing exactly where he wanted the case to finish from an aesthetic point of view. He did not wish to repeat his last veneer experience, and did not want to have temporaries during the treatment phase because he had previously needed to recement a section of his original temporary veneers twice a day. It was of paramount importance to fully understand what the patient was expecting, and equally important to have him fully understand what was possible and what limitations could be expected. (With regard to the patient’s knowledge and experience as it related to expectations, it should be noted that the patient lectures internationally on the science of color and shade matching.)
Once the treatment goals were agreed upon, I contacted my dental technician, Eddie Corrales, who is a CDT, and we reviewed the preoperative photos and case expectations as a team before scheduling the patient’s next appointment.

TREATMENT DAY
Diagnostic Mock-up
On the day of treatment, we started by reviewing expectations and any limitations or complications we might encounter. I confirmed the shade selection, followed by the dental technician and (most importantly) the patient. A Vita 3D (Vident) Shade 1M1 was selected. Because the case was only extending from cuspid to cuspid, it was extremely importance to obtain an exact color match. The shade was taken at the beginning of the appointment to avoid any errors (especially in value) that can occur after the teeth are dehydrated. It also allows us to do this important procedure before we experience any eye strain (which can weaken our ability to accurately match a shade). The shade was confirmed under 3 light sources: nature, halogen, and florescence. Preoperative pictures were taken on a set sequence. Reproducibility between pre- and postoperative photos requires identical magnification, angle, and exposure to produce a set of pictures that can be accurately used for both future case presentations and self-analysis.
To start, the patient was anesthetized with 2.5 carpules of 4% Septocaine (1:100000 epinephrine) on the upper only. All the teeth were mocked up on both the upper and lower arches with composite, and the incisal embrasures were modified to enhance desired aesthetic qualities. The occlusion was modified to enhance long centric, the patient’s cuspid guidance was restored, and the angle made shallower to provide a freer envelope of function (Figure 4). At this point, the patient was shown changes and reviewed and consented to them. Photos were again taken, in retracted positions only.

Clinical Technique
At this point, the lower arch was anesthetized with 2 inferior alveolar blocks using 4% Septocaine (1:100000 epinephrine). The upper arch was digitally scanned from the mesial of tooth No. 3 to the mesial of tooth No. 14, utilizing the CEREC system (Sirona Dental Systems). Special attention was paid to the all the surfaces of teeth Nos. 6 through 11, assuring accurate detail of both the occlusal surfaces and the facial characteristics. The existing veneers were removed in a conventional manner of incising with a course tapered bur through the facial and extending it into the occlusal reduction area; followed by an oblique force applied by a crown-splitting instrument (CRSPR [Hu-Friedy]). Any areas that would not readily debond were prepped traditionally.

Figure 5. Preparations.	Figure 6. Model try-in: working model utilized for test fitting and contact refinement.
Figure 7. Putty matrix fabricated to assure final contours.	Figure 8. Mild cutbacks.

Figure 9. Layering Vita VM 9 (Vident) porcelain into cutbacks.

The original preparations were quite good and presented with adequate reduction. Only minor additions were added to the line angles to better hide the transitions and support the subsequent cervical embrasures (Figure 5). Due to the patient’s low lip-line and the complete absence of any sensitivity, we agreed to stay supragingival and not attempt to hide the recession. This was considered and agreed upon to sustain natural dentin for the possibility of future grafting, if necessary. The preparations were finished with an ultra-fine diamond bur (NTI Diamond Fine FG, F850-016 [Axis Dental]) to take advantage of the high accuracy of the CEREC scan and milling chamber as well as to maximize the ceramic’s strength after bonding.
We took full advantage of having Mr. Corrales, our dental technician in the office. We had him evaluate that the preparation style and reduction achieved would maximize his ability to deliver the desired product, in terms of both strength and aesthetics. The preparations were then digitally impressed from the mesial of both first molars. A vinyl polysiloxane (VPS) (Imprint 3 [3M ESPE]) impression was also taken for Mr. Corrales. He used that to make a working model to fine-tune the embrasures and interproximal contacts.
At this point, Mr. Corrales began to work on the maxillary veneers as I proceeded on to the lower teeth. He began by moving the digital impressions of both the preparations and the preoperative images into the Correlation software program (which aligns and matches both digital models). Then, the process of digitally replacing what is missing between the preparation and the preoperative models was completed and readied for fabrication in the MC XL milling chamber (Sirona Dental Systems) from a block of porcelain.
The CAD/CAM materials selected for the case were a combination of Vita RealLife (Vident) and Vita Mark II blocks (Vident). Vita Mark II, a fine-grained feldspathic ceramic that is highly aesthetic, has a long history of success for the fabrication of all-ceramic CEREC restorations. The RealLife block was introduced in late 2010 and is fabricated from the same Mark II ceramic material. However, it is stratified with a semispherical dentin layer (porcelain) and a gradient of enamel layering porcelain. The digital restoration is moved within the digital block to obtain the most aesthetic and lifelike restoration. We selected RealLife blocks for teeth Nos. 7 to 10, and Mark II blocks for the remaining teeth.
Moving to the mandibular arch, the preoperative detail and occlusion were scanned from teeth Nos. 20 to 29. The existing veneers were removed and the preparations were refined and polished. Next, the final preparations were scanned and reviewed for accuracy and detail. Any missed areas can be easily added to with additional scans in just a few seconds. The lower veneer program was started and the CEREC AC digital impression was returned to the dental technician. A final VPS impression for the working-model was taken and poured. Temporaries were fabricated using a putty matrix and relined with Integrity (DENTSPLY Caulk). Flash was removed, and the patient was released for 2 hours while the veneers were being fabricated.
At this point, I moved on to my other scheduled patients and hygiene checks and let Mr. Corrales continue the design and fabrication process. Typically, at this point I would do the entire design, milling, test-fitting and finishing (leaving no time for any other patients that day). Having the dental technician perform these vital steps reduced my stress and freed me to increase the office’s production and diagnoses for the day.
Mr. Corrales designed each veneer using the CEREC software and then milled them in the MC XL milling chamber. Once the veneers were finished, he test-fit each individually, then together on the working models to ensure accurate fits and correct interproximal contacts (Figure 6). He added the subtle details in terms of the embrasures, developmental grooves, and incisal-edge positions. Teeth Nos. 7 to 10 received conservative cutbacks (Figures 7 to 9). (A cutback is the process of removing ceramic and then rebuilding it in a traditional manner with various layering ceramics. In this case, a translucent material was added.) All restorations were then stained, glazed, and hand-polished. Then he test-fit all units on the working models again and delivered them to my operatory for try-in.

Same-Day Delivery of the Final Restorations
The patient was called back and the room was reset for delivery. We removed the temporaries and test-fit each unit clinically, first by themselves and then together. Only minor interproximal contact adjustments were necessary. Translucent try-in paste (Variolink II [Ivoclar Vivadent]) was used so the patient could approve the aesthetics. He loved the appearance and accepted the veneers.
Bonding was carried out with a translucent resin cement (base only) (Variolink II). The bonding sequence was the central incisors (Nos. 8 and 9) first, followed by the right lateral incisor and cuspid (Nos. 6 and 7), and finally, the left lateral incisor and cuspid (Nos. 10 and 11). The etching (Ceramic Etch [Vident]) and silanization (Silane Primer [Kerr]) process was carried out 2 restorations at a time. Once 2 were bonded in, the next 2 would be test-fit to ensure full seating prior to preparing the surfaces for bonding. This sequence does add time to the bonding process, but it also lowers any chance for margins to be inadvertently opened due to interproximal contact interference or incisal edge shifting. Once all 6 units were placed, the same process and sequence was carried out to completion.

Figure 10. Postoperative: Finished and bonded Vita Mark II (Vident) and Vita RealLife Veneers (Vident) utilizing the CEREC system (Sirona Dental Systems).	Figure 11. Postoperative: a 12-unit veneer case started and finished same day with a certified dental technician in the office.
Figure 12. Lateral view—close-up.	Figure 13. Retracted view finished.
Figure 14. Final maxillary restorations.	Figure 15. Final mandibular restorations.

Cement removal was finished using a combination of interproximal scales and rubber cup polishers (Porcelain Polishing Kit [Axis Dental]). Selective polishing on the surfaces of the maxillary veneers was also added to further “break up” the reflective surfaces to obtain an as natural as possible finish. Occlusion was then checked and verified and final impressions were taken for fabrication of an occlusal guard. Final pictures following the initial sequence were taken and postoperative instructions were reviewed with the patient (Figures 10 to 15).

CONCLUSION
Digital dentistry has evolved to such a degree that delivering same-day dentistry is a reality. Large cases present a time-management issue. Scheduling a day of treatment for a single patient in a busy dental practice with a number of hygienists is a difficult task and can be counterproductive to production goals and new patient treatment diagnosis. Bringing in a properly trained and experienced CDT for a day to provide restorations using your equipment can be a cost-effective means of obtaining an excellent result for your patient. In addition, it can be a real practice schedule-saver for your team in a busy office.

Dr. Hatch, an alumnus of the University of Maryland Dental School, worked as an instructor in the laboratory after graduation. He has served on the board of the Academy of CAD/CAM Dentistry and has been involved in CAD/CAM dentistry and education for more than 7 years. He started and developed 2 practices in the United States, first in Columbia, Md, and most recently in San Diego, Calif, both with full integration of CAD/CAM technology. Dr. Hatch has taught and mentored other doctors on how to integrate this technology into their practices as well as many other aspects of practice growth and leadership. He can be reached at numbgum@gmail.com.

Disclosure: Dr. Hatch is a Vident Advocate and does receive financial compensation for speaking engagements.

Mr. Corrales’ education as a ceramist began at Dental Technology Institute, where he graduated with high distinction at the early age of 18 years. After gaining industry experience and becoming a Certified Dental Technician, he opened the doors of his state-of-the-art lab, Downtown Dental Designs, in 1997 where he practices the art of smile design. As a Las Vegas Institute and PAC-Live graduate, he constantly seeks industry excellence. He has volunteered with Scottsdale Center for Dentistry sharing his knowledge in CAD/CAM Technology for 2 years. His dental laboratory is now part of the CEREC Connect Network, a Web-based digital impression transmission from the dental office to the laboratory. An innovative educator and active advocate of advancements in technology, he has founded CAD Smiles, a unique service cater to CEREC doctors. He can be reached via e-mail at ecorrales@downtowndentaldesigns.com.

Disclosure: Mr. Corrales reports no disclosures.

In the last edition of Silverman On Smiles: Cosmetic Dentistry SOS,I described the art and science behind effectively co-diagnosing cosmetic dentistry needs. In this article I want you to sharpen your co-diagnostic ability to solve a cosmetic dilemma – in this case it was one that required immediate attention

This patient came into my office and told me that he wanted to improve the appearance of his teeth (see figures 1 and 2). He was excited because he was getting married. He was a very friendly, outgoing individual who wanted to have a nicer smile for the wedding.

Let’s take a closer look at his teeth and decide how you could help him solve his problem.

This is a challenging case. I am sure you agree. First thoughts immediately go to orthodontia. However, he is getting married in a couple of weeks. Finances are an issue – and he really wants you to do something to help him out. In addition to the alignment issue, he also has a congenitally missing left lateral incisor. So, what would you suggest?

Here’s a hint: The patient ruled out orthodontia as well as porcelain veneers due to his upcoming wedding as well as the time / expense. So what would you recommend to this patient?

Lesson Learned: By now you probably know the answer —which is
“I don’t know—until I have a chance to learn more about what my patient wants to have done.” If you did not automatically say this, please go back and read the last 2 articles that I wrote in Dentistry Today about co-diagnosing cosmetic wants with your patient.

Figure 1. Full-face before photo.	Figure 2. Close up before photo.
Figure 3. Performing cosmetic contouring. No local anesthetic needed.	Figure 4. After minimal cosmetic contouring.
Figure 5. “I cannot believe it!” exclaims the patient as he looks into a mirror and sees how 4 LifeLike Veneers dramatically changed his smile.	Figure 6. Looking good and feeling great at the end of the appointment.

Therefore, to know what your patient wants to have changed, review his smile analysis form and supplement that with a chairside smile analysis before making a decision.

Next, perform a Smile Trial directly on the patients’ teeth. This provides you with a sense of what the final outcome will be as well as to determine if the patient is a candidate for in-office veneers. Conventional bonding is also a possibility but bonding is far more technique sensitive and has its own unique set of problems and challenges. In this case I chose to use the in-office LifeLike Veneer System.

Note: while the LifeLike Veneer technique is typically a noninvasive treatment modality, for this case I had to do some cosmetic contouring on #7 to help create room to achieve the final illusion effect with the veneers.

In the introduction to the last 2 articles I said that I would share with you a valuable technique to help determine patient’s cosmetic dental needs through co-diagnosing. From many years of doing on-site coaching with dentists I can reassure you that using this co-diagnostic technique will be seamless in your daily routine after you practice it for 30 days—with the caveat that you never prejudge patient needs.

The take away from this article is to always give your patient an opportunity to share changes they want before deciding if they are a candidate for a specific elective cosmetic dentistry procedure—and then provide your patient with the appropriate cosmetic dentistry service to have a brighter, more self-confident smile. If you are looking for simple “bread and butter” solutions for your cosmetic cases and are interested in taking your elective cosmetic dentistry practice to the next level please feel free to contact me.

Dr. Silverman has been successfully coaching dentists on how to expand their cosmetic dentistry practice since 1984. If you want to take your cosmetic practice to the next level or want more information about the Silverman Institute’s 24 Hour Cosmetic Dentistry Boot Camp Program, please contact him at (216) 256-4599 or e-mail him at incrediblesmiles@aol.com.