TDA Texas Dental Journal SEPTEMBER 2026 248 THE MODERNIZATION OF THE DENTAL OFFICE JOSHUA AUSTIN, DDS
250 CLEAR ALIGNERS AND SMILE DESIGN FOR COMPREHENSIVE ESTHETICS JOSHUA AUSTIN, DDS Reprinted with permission, Journal of Cosmetic Dentistry, ©2026 American Academy of Cosmetic Dentistry. All Rights Reserved. 608.222.8583; www.aacd.com.
264 THE MONOLITHIC REVOLUTION MICHAEL C. DITOLLA, DDS, FAGD
274 EVERYDAY WORKFLOWS WITH NEW MULTI-DIRECT CAPTURE SCANNING TECHNOLOGY JOSHUA AUSTIN, DDS, MAGD CINDY LAM-VUONG, CDT Reprinted with permission. Originally published in Dental Economics, August 23, 2025. ©2026 Dental Economics. All Rights Reserved. https://www.dentaleconomics.com/
284 THE NEXT CHAPTER OF DIGITAL DENTISTRY MEENA BARSOUM, DMD
288 EFFICIENT WORKFLOW FOR CLEAR ALIGNER THERAPY APPOINTMENTS MICHELE RANTA, DDS
294 THE CLINICAL ADVANTAGES OF CHAIRSIDE MILLING FOR ESTHETIC RESTORATIONS
241
BUTTERMAN, DDS, FICOI www.tda.org |DAN September 2026
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242 Texas Dental Journal | Vol 143 | No. 6
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243
contents
Editorial Staff Jacqueline M. Plemons, DDS, MS, Editor Juliana Robledo, DDS, Associate Editor Nicole Scott, Managing Editor
FEATURES 248
284
THE MODERNIZATION OF THE DENTAL OFFICE:
THE NEXT CHAPTER OF DIGITAL DENTISTRY: WHY 3D PRINTING HAS FINALLY REACHED CLINICAL MATURITY
INTRODUCTION Joshua Austin, DDS
Meena Barsoum, DMD
Barbara Donovan, Art Director Lee Ann Johnson, CAE, Executive Director
Editorial Advisory Board Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS
250
CLEAR ALIGNERS AND SMILE DESIGN FOR COMPREHENSIVE ESTHETICS:
288
A CASE REPORT Joshua Austin, DDS Reprinted with permission, Journal of Cosmetic Dentistry, ©2026 American Academy of Cosmetic Dentistry. All Rights Reserved. 608.222.8583; www.aacd.com.
264
THE MONOLITHIC REVOLUTION
Michele Ranta, DDS
294
FROM THE SEARCH FOR CAST GOLD IN SHADE A2 TO THE CONSERVATIVE ESTHETIC REVOLUTION
A CASE REPORT ON EVERYDAY WORKFLOWS WITH NEW MULTI-DIRECT CAPTURE SCANNING TECHNOLOGY: FROM HYGIENE TO FINAL
THE CLINICAL ADVANTAGES OF CHAIRSIDE MILLING FOR ESTHETIC RESTORATIONS ILLUSTRATED THROUGH A SAME-DAY CONSERVATIVE ANTERIOR VENEER CASE
Michael C. DiTolla, DDS, FAGD
274
EFFICIENT WORKFLOW FOR CLEAR ALIGNER THERAPY APPOINTMENTS THAT DON’T CUT INTO RESTORATIVE DENTISTRY
Dan Butterman, DDS, FICOI
304
FBI: FOUND BUT NOT IDENTIFIED (YET) Megan E. Lenahan, DDS, MDS
Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS, MS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS
The Texas Dental Journal is a peer-reviewed publication. Established February 1883 • Vol 143 | No. 6 Texas Dental Association 8701 W Hwy 71, Ste 201-M, Austin, TX 78735 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly, except January-February, March-April, July-August, and November-December, which are combined issues, by the Texas Dental Association, 8701 W Hwy 71, Ste 201-M Austin, TX 78735, 512-443-3675. Periodicals Postage Paid at Austin, Texas, and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 8701 W Hwy 71, Ste 201-M, Austin, TX 78735. Copyright 2026 Texas Dental Association. All rights reserved. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors
RESTORATION Joshua Austin, DDS, MAGD
310
Reprinted with permission. Originally published in Dental Economics, August 23, 2025. ©2026 Dental Economics. All Rights Reserved. https://www.dentaleconomics. com/
Michaell A. Huber, DDS
tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated
HIGHLIGHTS
Cindy Lam-Vuong, CDT
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314
Value for Your Profession: 7 Critical Dental Imaging Problems Every Practice Must Solve Classifieds
statement at tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.
Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such
319
Index to Advertisers,
244 Texas Dental Journal | Vol 143 | No. 6
product or of the claims made.
March 2019
TEXAS DENTAL
SPECIAL ISSUE
The President’s Address Elizabeth Goldman, DDS
August 2015
TEXAS DENTAL INSIDE:
Root Fracture as a Complication of Intermaxillary Fixation: A case report TDA Financial Report and Proposed Budget
TDA President
137
www.tda.org | March 2019
March 2018
TEXAS DENTAL
For 143 years, the Texas Dental Journal has served as a trusted source of scientific knowledge,
ORAL CANCER:
Dentistry and an Evolving Disease
professional insight, and the collective voice
Texas Dental Journal l www.tda.org l August 2015 493
August 2014
of organized dentistry in Texas. As the longest
TEXAS DENTAL
continually published dental journal in the Americas, it has documented the evolution of our profession and our Association while educating and connecting generations of dentists. INSIDE:
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182 | DENTIST MATERIAL SELECTION FOR SINGLE-UNIT CROWNS FINDINGS FROM THE NATIONAL DENTAL PRACTICE-BASED RESEARCH NETWORK
With great sadness, the 2026 House of Delegates
202 | TDA BUDGET:
TEXAS DENTAL ASSOCIATION 2017 FINANCIAL REPORT, 2019 PROPOSED BUDGET
www.tda.org | March 2018 165 Texas Dental Journal
APRIL 2023
voted to suspend publication of the Texas Dental
144 KRATOM AND ORAL HEALTH: WHAT A DENTIST SHOULD KNOW DWAYNE EVANS, DDS STEPHEN LAMAN, DDS
Journal at the end of this year. This decision
GARY N. FREY, DDS CLEVERICK (C.D.) JOHNSON, DDS, MS BEN F. WARNER, MS, DDS, MD
146
was not made lightly. The House of Delegates,
April 2016
A COMPLIANCE PROTOCOL
TEXAS DENTAL
FOR OPTIMIZING RESPONSE TO ORAL APPLIANCE THERAPY
Texas Dental Journal l www.tda.org l August 2014 561
FOR OBSTRUCTIVE SLEEP APNEA
comprised of your elected peers from across the state, carefully considered the financial
JEFF PAZ DDS, D-ABDSM EMET SCHNEIDERMAN, PHD
162 WHAT ARE THE ETHICAL
realities facing the Association. After two consecutive years of membership decline,
CONSIDERATIONS OF USING VIDEO SOCIAL MEDIA PLATFORMS SUCH AS TIKTOK IN YOUR DENTAL PRACTICE?
difficult decisions became necessary to ensure the long-term financial stability of the
KATHLEEN NICHOLS, DDS
138 OFFICIAL CALL
Texas Dental Association.
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129
We recognize that the Texas Dental Journal is far more than a publication. It is part of our Association’s history and identity. It has chronicled advances in dentistry, highlighted the work of Texas dentists, and served as a lasting record of our profession. We understand that many members have contributed articles, served on the editorial board, or simply looked forward to receiving each issue. We share your disappointment in this moment. While publication is being suspended, our commitment to advancing the profession and
July 2021
TEXAS DENTAL INSIDE: 242 | DENTISTS AND POPULATIONS IN UNDERSERVED AREAS OF TEXAS
Special Issue Membership Awards Recognition
Texas Dental Journal l www.tda.org l April 2016 225
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Special Issue Recognizing 10-year, 25-year, 30-year, 50-year, and 60-year members of the Texas Dental Association
providing members with timely, high-quality professional information remains unchanged. We will continue to explore meaningful ways to deliver educational content and keep members informed through our evolving communications and digital resources. It is also our hope that as we stabilize and move forward, we are once again able to publish this
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TEXAS DENTAL
significant piece of our history. INSIDE: 286 | Personality Types: Predictors for Pediatric Dentists— Pilotwww.tda.org Study| May 2017 273
The history of the Texas Dental Journal deserves to be celebrated, and we are deeply grateful to the countless editors, authors, reviewers, volunteers, advertisers, and staff
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members whose dedication sustained this publication for more than a century. Their contributions have left an enduring legacy that will continue to influence the profession for generations to come. We would like to expressly thank our current editor, Dr Jaqueline Plemons, our managing editor, Nicole Scott and our long-time graphic designer, Barb Donovan.
INSIDE: DEVELOPING A FAVORABLE DENTAL IMPLANT EMERGENCE PROFILE
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April 2020
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Thank you for your continued support of the Texas Dental Association. Your membership enables us to advocate for the profession, protect organized dentistry, and make thoughtful decisions that position our Association for a sustainable future. Our commitment to serving Texas dentists remains as strong as ever.
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Board of Directors Texas Dental Association PRESIDENT Elizabeth Goldman, DDS 214-585-0268, texasredbuddental@gmail.com PRESIDENT-ELECT Susan Jolliff, DDS 325-597-7441, ladydds13@gmail.com PAST PRESIDENT Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com VICE PRESIDENT, SOUTHWEST Austin Lee, DMD 210-496-1919, austinvincentlee@gmail.com
JKJ Pathology
VICE PRESIDENT, NORTHWEST Annie C. Wilson, DDS 713-626-8843, annie@anniewilsondds.com
Oral Pathology Laboratory
VICE PRESIDENT, NORTHEAST Shane A. Ricci, DDS 972-381-1888, riccidds@hotmail.com
John E Kacher, DDS ¥ Available for consultation by phone or email ¥ Color histology images on all reports ¥ Expedited specimen shipping with tracking numbers ¥ Reports available online through secure web interface
Professional, reliable service with hightechnology solutions so that you can better serve your patients. Call or email for free kits or consultation. jkjpathology.com 281-292-7954 (T) 281-292-7372 (F) johnkacher@jkjpathology.com
Protecting your patients, limiting your liability
VICE PRESIDENT, SOUTHEAST Ron Hill, DDS 713-626-8343, rhilldds@gmail.com SENIOR DIRECTOR, SOUTHWEST Kenneth Gonzales, DDS 361-992-2421, bikerdent@yahoo.com SENIOR DIRECTOR, NORTHWEST Kevin Altieri, DDS 817-294-5513/817-991-1835, altdent@yahoo.com SENIOR DIRECTOR, NORTHEAST Celeste Latham, DDS 214-351-1500, drclatham@yahoo.com SENIOR DIRECTOR, SOUTHEAST Jennifer Hathaway, DDS 979-776-6884, jp.hathaway@yahoo.com DIRECTOR, SOUTHWEST Susan Putthoff, DDS 830-896-6264, putthoffsusan@yahoo.com DIRECTOR, NORTHWEST Georgia Mitchell, DMD 806-221-2240, gmitchelldmd@gmail.com DIRECTOR, NORTHEAST Corbin Gatlin, DDS 254-399-9925, corbingatlindds@gmail.com DIRECTOR, SOUTHEAST Meredith Overstreet, DDS 512-442-1555, moverstreetdds@gmail.com SECRETARY-TREASURER* Oshmi Dutta, DDS 210-888-0700, odutta@gmail.com SPEAKER OF THE HOUSE* Gregory W. Rashall, DDS 936-336-5171, rashdent@sbcglobal.net PARLIAMENTARIAN** Rob Neal, DDS 972-377-7333, robertnealdds@gmail.com EDITOR** Jacqueline M. Plemons, DDS, MS 214-507-0815, drplemons@yahoo.com LEGAL COUNSEL** Carl R. Galant EXECUTIVE DIRECTOR** Lee Ann Johnson, CAE 512-443-3675, ext 134, ljohnson@tda.org *Non-voting member **Non-voting
246 Texas Dental Journal | Vol 143 | No. 6
Anesthesia Education & Safety Foundation Two ways to register: Call us at 214-384-0796 or e-mail us at sedationce@aol.com Visit us on the web: www.sedationce.com
NOW Available: In-Office ACLS & PALS renewals; In-Office Emergency Program
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Two ways to Register for our Continuing Education Programs: e-mail us at sedationce@aol.com or call us at 214-384-0796
OUR GOAL: To teach safe and effective anesthesia techniques and management of medical emergencies in an understandable manner. WHO WE ARE: We are licensed and practicing dentists in Texas who understand your needs, having provided anesthesia continuing education courses for 34 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.
New TSBDE Requirement of Pain Management Two programs available (satisfies rules 104.1 and 111.1)
Live Webcast (counts as in-class CE) or Online (at your convenience)
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OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels. Our continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits.
AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation This is only a partial listing of sedation courses. Please consult our www.sedationce.com for updates and new programs.
Two ways to Register: e-mail us at sedationce@aol.com or call us at 214-384-0796
www.tda.org | September 2026
247
The modernization
of the dental office a letter from the guest Editor Joshua Austin, DDS, magd Every dentist I know can tell you what
weeks of lab turnaround, the afternoon
disappears. The provisional you no
their intraoral scanner cost. Almost none
you lose to a remake. And in the best
longer have to make, seat, and worry
of them can tell you what it saved.
cases, the time a tooth gets to keep
about for 2 weeks. The second visit that
being a tooth.
stops being necessary.
profession full of people who track
You will notice the issue sorts itself into
The second conversation is about
production down to the tenth of a
3 conversations.
capture, and about what happens
That is a strange blind spot for a
when the patient can see what you
percent, and I think it explains a lot about how our relationship with
The first is about manufacturing moving
see. In a case report written with Cindy
technology has drifted over the past
into the building. Dr Meena Barsoum
Lam-Vuong, CDT, I follow a hygiene
twenty years. We have been trained
argues that the interesting development
patient named Chris from a routine
to evaluate equipment the way we
in 3D printing is not the printer at all
recall visit through a delivered crown.
evaluate a truck. Sticker price, feature
but the ecosystem that finally grew up
The clinically interesting moment is not
list, whether it looks impressive parked
around it, to the point that same-day
the seventy-seven-second scan of the
in the operatory. Meanwhile the actual
appliances and definitive restorations
preparation, satisfying as that is. It is the
return shows up somewhere we almost
have become a scheduling decision
moment Chris looked at a photorealistic
never think to look. It shows up in the
rather than a science project. Dr Dan
rendering of the crack on his lower
schedule.
Butterman takes 6 maxillary anterior
first molar and said yes. Diagnosis has
veneers from scan to bond in a single
always been the easy part. Explaining
When the Journal asked me to guest
appointment and shows where the
it is the part that used to cost us
edit an issue on the modernization
esthetic work actually happens, which
appointments.
of the dental office, my first instinct
turns out to be at the finishing bench
was to assemble a greatest-hits list of
rather than in the mill. And Dr Michael
The third conversation is about clear
hardware. A printer piece here, a mill
DiTolla traces the arc that made both of
aligners finding their place inside a
piece there, a scanner column, and
those possible, from his old fantasy of
restorative practice, which is a harder
something on artificial intelligence so we
cast gold in shade A2 to the monolithic
problem than the marketing admits.
could all feel appropriately current. I am
restorations that now dominate the
My reprint from the Journal of Cosmetic
glad I talked myself out of it. Because
profession. The symmetry he found is
Dentistry follows a patient through 12
once the articles started arriving, and I
hard to shake. Porcelain-fused-to-metal
months of aligner therapy, esthetic
read every one of them more than once,
held 65.3% of the market in 2007. Full-
crown lengthening, and ten no-
the thread running through them was
strength monolithic zirconia held 65.5%
preparation veneers. The point of that
not what any of these machines are. It
in 2025.
case is what the orthodontics made unnecessary. When you plan tooth
was what they hand back. Read those 3 together and the shared
movement with the final restorative
Time. That is this whole issue in one
benefit is not strength, and it is not
outcome already in view, you can arrive
word. Chair time, appointment slots,
esthetics. It is the appointment that
at a place where there is nothing left to
248 Texas Dental Journal | Vol 143 | No. 6
prepare. That is time given back to the tooth rather than to the schedule, and it is the most durable kind. Then Dr Michele Ranta handles the part nobody puts in a brochure, which is how to keep aligner appointments from eating your restorative day. Delaying attachments so that first delivery becomes a pickup. Finding the one point in treatment where most of your interproximal reduction can happen at once. Using virtual monitoring so a tracking problem surfaces before it becomes a refinement. None of it is glamorous. All of it decides whether aligners strengthen your practice or quietly wreck your Tuesdays. A word about the authors. Several of the people writing here work for the companies whose technology they describe, and each of them has disclosed it. I invited them anyway, and I would do it again, because the people who build this equipment often understand its limits better than anyone else does. Read them the way you would read any expert with a stake in the answer, which is to say with real interest and a little salt. Then go find a colleague who owns the same machine and has no reason to flatter it. What I would ask of you is not that you buy anything. Look instead at the place in your week where the schedule fights you hardest. Maybe it is the two-week provisional. Maybe it is the remake that resurfaces every few weeks, or the aligner appointment that never quite fits between two crown preparations. Pick that one thing, and ask whether something in these pages removes it. Modernizing an office is almost always described as addition. In my experience it is closer to subtraction. The practices that feel modern are not the ones with the most equipment. They are the ones that have quietly taken steps out of the day, and then used the room to do more dentistry, or to go home.
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249
Clear Aligners and Smile Design for Comprehensive Esthetics:
A Case Report Joshua Austin, DDS, magd Reprinted with permission, Journal of Cosmetic Dentistry, ©2026 American Academy of Cosmetic Dentistry. All Rights Reserved. 608.222.8583; www.aacd.com.
Abstract Many patients desire and can benefit from esthetic treatments such as porcelain veneers. However, cosmetic dentists often face difficult decisions regarding tooth preparation and the removal of tooth structure to achieve the desired outcome. In many cases, orthodontic therapy can help move the teeth to a more ideal position to conserve tooth structure. Sometimes, it is possible to achieve a situation in which no enamel or dentin needs to be prepared, providing the patient with the most comprehensive yet conservative treatment. In the past, clear aligner therapy planning was often siloed from restorative dentistry planning, leaving the clinician to integrate the two. However, with advances in esthetic design software, it is now possible to plan orthodontic movements that focus on the outcome of restorative treatment. This holistic approach gives cosmetic dentists the greatest control over treatment planning and design.
Key Words Clear aligner therapy, digital smile design, no-preparation veneers, altered passive eruption, esthetic crown lengthening
About the author Dr Austin is a graduate of the University of Texas Health Science Center School of Dentistry in Houston. He maintains a full-time restorative dentistry practice in San Antonio, Texas. Disclosure: Dr Austin is a consultant for Align Technology. He did not receive any financial compensation for authoring this article.
250 Texas Dental Journal | Vol 143 | No. 6
With advances in smile design software, restorative and cosmetic dentists can now plan a patient’s clear aligner treatment with the final restorative outcome in mind.
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251
Introduction Pre-restorative orthodontics offers many advantages for cosmetic treatment. In an analog bracket-and-wire world, an orthodontist usually performed this treatment. However, clear aligners enable restorative and cosmetic dentists to accomplish this therapeutic intervention as well. Beginning with the end in mind is crucial for a proper diagnosis and effective treatment planning. With advances in smile design software, restorative and cosmetic dentists can now plan a patient’s clear aligner treatment with the final restorative outcome in mind to achieve the best possible result. With proper orthodontic planning, it is often possible to move the teeth to a position that minimizes tooth preparation for esthetic restorations. There is an obvious advantage to conservative, minimally invasive dentistry for both dentists and patients. Patients are increasingly aware of the importance of conserving natural tooth structure, and clinicians know that enamel-bonded restorations are more durable than those bonded to dentin. This case report describes the use of clear aligner therapy, aided by a new smile design software, to achieve an excellent outcome.
Case Report Patient Complaint and Presentation A 37-year-old male presented to the author’s practice for a cosmetic consultation and evaluation. He was unhappy with
Figure 1. Preoperative presentation.
his uneven incisal edges, anterior spacing, and gummy smile (Figures 1, 2). Based on the clinical presentation, it was apparent that orthodontics would help enhance the final outcome. Although the patient would not consider traditional bracket-and-wire orthodontics, he was open to the idea of clear aligners as a means to achieve a better result. In this case, the orthodontic movements needed fell within the scope of clear aligners, which, especially when used with attachments, can close spaces as well as level and align the arches with predictable, simple movements.1
252 Texas Dental Journal | Vol 143 | No. 6
Figure 2. Intraoral preoperative presentation.
Visualization and Diagnosis The patient’s facial lines (midline, inter-canine width, lip line, and occlusal plane) were visualized (Invisalign Smile Architect, Align Technology; Tempe, AZ) to determine the optimal position of the maxillary teeth (Figure 3).2-5 These lines guide the software on where to place the restorations and then instruct it where to orthodontically move the teeth to achieve the desired outcome. This facially driven treatment planning was performed with 3D treatment-planning software (Clin-Check, Align). With this imaging, it was determined that the patient’s excessive gingival display would not be resolved with orthodontics alone, and esthetic crown lengthening would be necessary to achieve a more esthetically pleasing result.6 This was verified by probing the maxillary anterior teeth. It was not possible to feel the cementoenamel junction with an explorer, leading to a diagnosis of altered passive eruption.7
Figure 3. Preoperative visualization of facial lines.
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253
Figure 4. Maxilla digital imaging, pre-orthodontics.
Figure 5. Mandible digital imaging, pre-orthodontics.
Treatment Plan The treatment plan comprised 12 months of clear aligner therapy, followed by esthetic crown lengthening and 10 no-preparation veneers. The orthodontic goals included leveling and aligning the arches, achieving a more positive angulation of the maxillary anterior teeth, and reducing and evening the diastemata. Some retraction of both the maxillary and mandibular segments was also planned using the ClinCheck software.
254 Texas Dental Journal | Vol 143 | No. 6
Figure 6. Maxilla digital imaging, post-orthodontics.
Figure 7. Mandible digital imaging, post-orthodontics.
Treatment Clear aligner therapy: The patient accepted the treatment plan, and therapy was initiated (Invisalign). No interproximal reduction was needed, as there was excessive space to begin with. Some attachments were used to achieve the necessary orthodontic movements; these were placed when the clear aligners were delivered and removed after completion of the orthodontic treatment (Figures 4-7). Optimized attachments were used on the posterior teeth to provide anchorage for the anterior retraction and translation movements. Optimized support attachments were placed on the lateral incisors, which can be the most challenging teeth to track with clear aligners, as they often become “lost” between the larger canine and central incisor on either side.8 Lateral incisors also have less surface area for the aligner to “grab” for movement.
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255
Figure 8. Smile view pre-crown lengthening.
Crown-lengthening surgery: After clear aligner therapy was completed, the patient’s attachments were removed, and he was given a provisional retainer. The patient was then referred to a periodontist for esthetic crown-lengthening surgery. The periodontist reflected a full-thickness flap from the maxillary first molar to the first molar. An ostectomy was performed and the bone was removed and shaped to the ideal anatomy. The flap was apically positioned and sutures were placed (Figures 8-12).9
Figure 9. Maxilla, pre-crown lengthening.
Figure 10. Mandible, pre-crown lengthening.
Figure 11. Maxilla, post-crown lengthening.
Figure 12. Mandible, post-crown lengthening.
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Smile design: The patient healed for eight weeks, after which a digital scan and the traditional AACD photographs were taken and sent to a ceramist for smile design (Figure 13) and a diagnostic wax-up for the 10 no-preparation veneers.10 The goals of the smile design were to even the incisal edges, bring symmetry to the anterior teeth, and fill out the patient’s buccal corridor (Figure 14).11
Figure 13. Digital scan sent for smile design.
Figure 14. Diagnostic wax-up and design.
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Veneer fabrication and placement: Once the patient and clinician approved the design, the lithium disilicate veneers were fabricated (IPS e.Max Press, Ivoclar; Amherst, NY).12 First, the teeth were cleaned by means of guided biofilm therapy (Woodpecker PT-B with glycine powder, Vakker Dental; Rancho Cucamonga CA), and a size 0 cord (Ultrapak, Ultradent; South Jordan, UT) was packed.13 An intraoral fixed restorative scan was performed (iTero, Align) and sent to the laboratory (Figure 15).14 Provisional veneers were fabricated with a self-curing provisional resin (Tuff-Temp Plus, Pulpdent; Watertown, MA) and spot-bonded (3M Scotchbond Universal Plus, Solventum; St. Paul, MN) (Figures 16, 17).15 This technique utilizes a clear polyvinyl siloxane (PVS) stent made from the diagnostic wax-up using a pressure pot for supreme adaptation.16 The more accurate and crisp the clear PVS stent, the less trimming and finishing the provisionals will need, and the more surface anatomy they will have. In this case, clear PVS material (Exaclear, GC America; Alsip, IL) was used. Only basic occlusal adjustments were needed on the provisionals.
Figure 15. Fixed restorative scan.
Figure 16. Intraoral view with provisional veneers.
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Figure 17. Full-face view with provisional veneers.
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After three weeks, the patient’s no-preparation veneers were bonded (Adhese Universal Viva-Pen and Variolink Esthetic neutral shade, Ivoclar) (Figures 18-21).17
Figures 18, 19. Intraoral views with no-preparation veneers.
Figure 20. Smile view with no-preparation veneers.
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Tips
Beginner
intermediate
advanced
Start with simple cases. This
Some of the most suitable
Master use of the “3D controls”
approach will enable you to
orthorestorative cases for facially
within the orthodontic design
understand how the physics of
driven, digitally planned clear aligner
software. This will enable you
clear aligners work and how to
therapy are simple ones where one
to quickly and easily adjust the
utilize the software to achieve the
incisor has wear on the edge and
orthodontic plan and visualize the
desired results.
dentoalveolar extrusion. Learning
amount of tooth reduction required
how to use clear aligners to intrude
after treatment.
Utilize simulation software to
the worn tooth and then restoring
visually demonstrate to patients
it with a small amount of resin
Many ortho-restorative cases
the transformative effect that
composite can teach you skills
need intrusion to make space for
orthorestorative treatment
that will translate to more
restorations. Intrusion of anterior
can have on their smile and
complicated cases.
overall esthetics.
teeth requires a fulcrum, which is best achieved by placing optimized
During the provisional phase, be sure
deep bite attachments
to scan or make an impression of the
on the premolars.
provisional restorations that you and the patient are satisfied with. This model is important for the ceramist to be able to provide the best possible ceramic restorations.
Although the patient
Summary
would not consider
Clear aligner therapy facilitated an excellent outcome
traditional bracket-
and align the occlusion, decreasing the forces being
for this case for several reasons. It allowed us to level loaded onto the veneers, and to position the teeth
and-wire orthodontics,
within the frame of the patient’s face.18,19 Pre-restorative
he was open to the idea
best position to deliver no-preparation veneers.20 This
of clear aligners as
orthodontics also enabled us to move the teeth into the yielded a conservative treatment that should serve the patient well for many years.21
a means to achieve a better result. www.tda.org | September 2026
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Figure 21. Final presentation.
262 Texas Dental Journal | Vol 143 | No. 6
Groody JT, Lindauer SJ, Kravitz ND,
and irradiance transmittance of clear
Carrico CK, Madurantakam P, Shroff
PVS materials used for resin injection
Barashi MA, Habis RM, Alhazmi HA.
B, Darkazanli M, Gardner WG. Effect
molding technique. J Esthet Restor
Predictability of orthodontic space
of clear aligner attachment design
Dent. 2025 Feb;37(2):412-22. doi:
closure using Invisalign clear aligners:
on extrusion of maxillary lateral
10.1111/jerd.13270. Epub 2024 May
a retrospective study. Cureus. 2024
incisors: a multicenter, single-blind
30. PMID: 38817077.
Mar 22;16(3):e56706. doi: 10.7759/
randomized clinical trial. Am J
cureus.56706. PMID: 38646261;
Orthod Dentofacial Orthop. 2023
Talabani R, Abdulateef D. Evaluation
PMCID: PMC11032648.
Nov;164(5):618-27. doi: 10.1016/j.
of the clinical success of four
Parrini S, Rossini G, Castroflorio T,
ajodo.2023.07.011. Epub 2023 Aug
different types of lithium disilicate
21. PMID: 37610383.
ceramic restorations: a retrospective
Robbins JW. Differential diagnosis and
study. BMC Oral Health. 2021 Dec
frontal smile esthetics: a systematic
treatment of excess gingival display.
7;21(1):625. doi: 10.1186/s12903-021-
review. Am J Orthod Dentofacial
Pract Periodontics Aesthet Dent. 1999
01987-1. PMID: 34876103; PMCID:
Orthop. 2016 Nov;150(5):740-50. doi:
Mar;11(2):265-72; quiz 273. PMID:
10.1016/j.ajodo.2016.06.022. PMID:
10321231.
REFERENCES 1.
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8.
Fortini A, Deregibus A, Debernardi C. Laypeople’s perceptions of
27871700. 3.
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5.
Evaluation of the ceramic liner
Eslami E, Zadparvar P, Ansari Lari
bonding effect between zirconia and
H, Mirhadian AH, Sadr-Eshkevari
and the 2D/3D digital smile design
lithium disilicate. J Prosthet Dent.
R. Correlation of maxillary anterior
process. Int J Periodontics Restorative
2018 Aug;120(2):282-9. doi: 10.1016/j.
tooth width and outer intercanthal
Dent. 2017 Mar-Apr;37(2):183-93. doi:
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distance. Gen Dent. 2015 Jul-
10.11607/prd.2911. PMID: 28196157.
Mar 15. PMID: 29551381.
Aug;63(4):39-42. PMID: 26147166.
11. Georg R. Digital smile design: utilizing
Melo M, Ata-Ali J, Ata-Ali F, Bulsei M,
novel technologies for ultimate
Barrett AA, Oliveira ER, Yang MC,
Grella P, Cobo T, Martínez-González
esthetics. Compend Contin Educ
Clark AE, Anusavice KJ. Three years
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Oral Health. 2020 Feb 6;20(1):42. doi:
Al-Johani K, Alam MK, Khurshid
Mar 10. PMID: 22410113; PMCID:
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Z. Novel approach to dental
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biofilm management through
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Câmara CA, Martins RP. Functional
guided biofilm therapy (GBT): a
generated treatment planning.
aesthetic occlusal plane (FAOP).
review. Microorganisms. 2021
Cranio. 2016 Nov;34(6):406. doi:
Dental Press J Orthod. 2016 Jul-
Sep 16;9(9):1966. doi: 10.3390/
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Aug;21(4):114-25. doi: 10.1590/2177-
microorganisms9091966. PMID:
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20. D’Arcangelo C, Vadini M, D’Amario M,
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PMC3570123.
Chiavaroli Z, De Angelis F. Protocol for
Otto RL, Anholm JM, Engel GA. A
Coachman C. Fully digital workflow,
a new concept of no-prep ultrathin
comparative analysis of intrusion of
integrating dental scan, smile design
ceramic veneers. J Esthet Restor Dent.
incisor teeth achieved in adults and
and CAD-CAM: case report. BMC Oral
2018 May;30(3):173-9. doi: 10.1111/
children according to facial type.
Health. 2018 Aug 7;18(1):134. doi:
jerd.12351. Epub 2017 Nov 15. PMID:
Am J Orthod. 1980 Apr;77(4):437-46.
10.1186/s12903-018-0597-0. PMID:
doi: 10.1016/0002-9416(80)90108-6.
30086753; PMCID: PMC6081948.
21. Shrivastava A, Mohanty P, Dash BP,
14. Small BW. Provisional restorations
Jena S, Sahoo N. Proficiency of clear
for veneers. Gen Dent. 2008 Nov-
aligner therapy: a systematic review
Dec;56(7):608-10. PMID: 19014018.
and meta-analysis. Cureus. 2023
PMID: 6928744. 7.
10. Coachman C, Calamita MA, Sesma N.
PMC8650461. 17. Kim SH, Park CJ, Cho LR, Huh YH.
Dynamic documentation of the smile
27653271; PMCID: PMC5029323. 6.
9.
16. Abdulrahman S, Von See Mahm C,
Dolt AH 3rd, Robbins JW. Altered passive eruption: an etiology of short clinical crowns. Quintessence
15. Machado N, Rocha MG, Oliveira D,
29139209.
Sep 11;15(9):e45072. doi: 10.7759/
Int. 1997 Jun;28(6):363-72. PMID:
Reardon KG, Martins E, Lawson NC.
cureus.45072. PMID: 37842499;
9477899.
Compressive modulus, translucency,
PMCID: PMC10568240.jCD
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THE MONOLITHIC REVOLUTION From the Search for Cast Gold in Shade A2 to the Conservative Esthetic Revolution Michael C. DiTolla, DDS, FAGD Valley Dental Esthetics. Lodi, CAlifornia Disclosure: The author practiced and lectured at Glidewell Laboratories from 2001 to 2016 and served as the lead clinician in the clinical development of BruxZir zirconia. His role included placing early restorations in patients, evaluating clinical performance, providing feedback to the research and development team, and contributing to coloring and characterization protocols. The utilization data presented in this article were provided by Glidewell Laboratories. The author has no current financial relationship with Glidewell Laboratories.
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ABSTRACT Background: For much of modern restorative dentistry, porcelain-fused-to-metal crowns represented the dominant tooth-colored fixed restoration. Although clinically successful, these bilayered restorations required greater tooth reduction than cast gold and introduced the possibility of veneering porcelain fracture, overcontoured margins, antagonist wear, and metal display. Beginning with monolithic lithium disilicate and followed by full-contour zirconia, dentistry rapidly returned to restorations fabricated primarily from a single material. Methods: This professional-practice review combines published evidence with the author’s clinical observations during 15 years of practice within a large commercial dental laboratory. Retrospective Glidewell Laboratories utilization data from 2007 through 2025 were reviewed to characterize changes in fixed restorative material selection. The clinical advantages, limitations, preparation requirements, cementation protocols, failure patterns, and retrieval challenges of lithium disilicate and zirconia are discussed. Results: Porcelain-fused-to-metal restorations decreased from 65.3% of Glidewell’s fixed restorative volume in 2007 to 5.0% in 2025. By 2025, zirconia products represented approximately 87.7% of the laboratory’s fixed restorative volume. Monolithic lithium disilicate served as the catalyst for this transition by demonstrating that removing veneering porcelain could improve reliability without sacrificing esthetics. Full-strength zirconia accelerated the transition by providing a tooth-colored restoration capable of functioning with less occlusal clearance and more forgiving preparation geometry. Conclusions: Lithium disilicate and zirconia have replaced many indications formerly assigned to porcelain-fused-to-metal restorations and are likely to remain dentistry’s principal fixed restorative materials for the foreseeable future. Their success should not, however, encourage indiscriminate zirconia use or acceptance of inadequate preparation. Clinical applications: Full-strength 3Y zirconia is favored for molars and destructive occlusions, while lithium disilicate remains the author’s preferred material for most anterior crowns and veneers. Future cement selection should consider eventual retrieval as well as immediate retention. Digital restorative planning and limited orthodontic tooth movement may allow the monolithic revolution to give rise to a new conservative esthetic revolution.
Key words Dental ceramics; zirconium oxide; lithium disilicate; dental crowns; computer-aided design; tooth preparation
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INTRODUCTION For decades, my ideal restorative material was easy to describe and impossible to manufacture: cast gold in shade A2. Cast gold remains difficult to surpass clinically. It provides exceptional longevity, conservative preparation, thin margins, favorable wear characteristics, and a degree of clinical forgiveness that few subsequent materials could match. Its principal weakness was not mechanical, it was cost and appearance, but those disadvantages proved powerful enough to reshape restorative dentistry. The majority of patients simply did not want a visible gold restoration. The generational shift away from gold was dramatic. When my father attended dental school in 1964, all his indirect restorations were partial-coverage or full-cast gold restorations. When I graduated in 1988, 26 of the 27 crowns I completed were porcelainfused-to-metal restorations. The single gold crown was required because the California licensing examination did not permit a PFM crown. PFM became the workhorse of American restorative dentistry, but it achieved esthetics through compromise. It generally required substantially more reduction than cast gold. The technician needed enough room for a metal substructure, metal opaque, and veneering porcelain. When that space was not provided, the resulting restoration could be overcontoured, weak, or both. The layered structure also created the possibility of porcelain chipping or fracture, gray cervical margins, and antagonist wear after the porcelain surface became rough. During my 15 years practicing at Glidewell Laboratories, inadequate preparation was the laboratory’s most persistent clinical problem. Inadequate occlusal reduction was particularly common. The laboratory could request that the patient be reappointed, reanesthetized, and reprepared, but neither the dentist nor patient welcomed that call. Cast gold could function in limited space, but it was no longer acceptable to many patients. Dentistry needed a tooth-colored alternative that could tolerate the preparation actually received rather than the preparation illustrated in a textbook. The conceptual breakthrough occurred for me in 2007, before the introduction of BruxZir. An Ivoclar representative had recently provided Glidewell with ingots of IPS e.max lithium disilicate. A laboratory manager’s wife needed a crown on tooth No. 12 and agreed to receive the new material. The restoration was prescribed monolithically, with no veneering porcelain. That sounded like a poor esthetic strategy. Layering porcelain had traditionally been how technicians made substructures look like teeth. When the crown returned, however, it was beautiful. I accused the technician, Cindy, of placing veneering ceramic despite my instructions. She had not. The restoration was lithium disilicate with only stain and glaze.
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That was the moment I realized dentistry had changed. A monolithic restoration could be strong, etchable, bondable, and sufficiently esthetic for a maxillary premolar.
That was the moment I realized dentistry had changed. A monolithic restoration could be strong, etchable, bondable, and sufficiently esthetic for a maxillary premolar. Lithium disilicate demonstrated that removing the veneering layer did not necessarily diminish a restoration. It could eliminate its most vulnerable interface. Clinical evidence has subsequently supported favorable outcomes for monolithic lithium disilicate and zirconia restorations when appropriately selected and fabricated.1,20
About the author A 1988 graduate of
Lithium disilicate launched the monolithic revolution. Zirconia propelled it through
University of
posterior dentistry.
the Pacific School of
METHODS This article is a professional-practice review based on 3 sources: published dentalmaterials literature; the author’s clinical experience at Glidewell Laboratories from 2001 through 2016; and retrospective internal Glidewell utilization data covering fixed restorations from 2007 through 2025.
Dentistry, Dr Michael DiTolla was awarded his Fellowship in the AGD in 1995. He was in private practice for 15 years before becoming director of clinical education for
Glidewell product categories containing the BruxZir name were classified as
Glidewell Labs for the next 15
monolithic zirconia. IPS e.max restorations were classified as lithium disilicate.
years, giving him an intimate
PFM categories included porcelain fused to base, semiprecious, white high-noble,
knowledge of American dentists’
and yellow high-noble alloys. The data reflect prescriptions received by one large
crown and bridge habits. From
commercial laboratory and should not be interpreted as national market-share
2006 to 2009 he led the clinical
estimates. Clinical observations described in this article include the development and early placement of monolithic zirconia restorations, communication with prescribing dentists, examination of preparations and impressions, review of laboratory failures, and the author’s subsequent private-practice experience.
team that developed and brought BruxZir Solid Zirconia to market. In 2011 he received the “Most Effective Dentist Educator” award in a nationwide survey of dentists. In 2015 he became the Director of
Published literature was used to support principles involving zirconia transformation
Clinical Affairs for Sirona, and in
toughening, differences among zirconia formulations, antagonist wear, contamination
2017 he became the VP of Clinical
and cleaning, adhesive protocols, and clinical performance. Zirconia’s mechanical
Affairs for AEGIS Communications.
behavior arises partly from transformation toughening, in which stress associated
In 2022 he received the Dr Gordon
with a developing crack can cause tetragonal crystals to transform toward the
Christensen Outstanding Lecturer
monoclinic phase, accompanied by local volumetric expansion that may resist further
award from the Chicago Dental
crack propagation.3,4
Society and Dr Christensen. Dr DiTolla has given over 1,000
RESULTS
lectures to dentists worldwide,
Numerical Evidence of a Revolution
viewed more than 20 million
In 2007, PFMs accounted for 65.3% of Glidewell’s fixed restorations. Their share
views by dentists worldwide. He
decreased to 44.9% in 2010, 17.3% in 2013, 10.0% in 2016, and 5.0% in 2025.
also currently maintains a private
and his online videos have been
practice in Lodi, California, focused By contrast, Glidewell’s 2025 restorative mix consisted of 65.5% BruxZir Full-Strength zirconia, 20.4% BruxZir Esthetic zirconia, 1.8% additional cubic zirconia products, 5.6% lithium disilicate, 5.0% PFM, 1.5% full-cast metal, and 0.2% composite. Combined,
solely on Invisalign, veneers, and obstructive sleep apnea.
zirconia products represented approximately 87.7% of fixed restorative volume.
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The symmetry is striking. In 2007, PFM accounted for 65.3% of restorations. In 2025, full-strength BruxZir alone accounted for 65.5%. When I began using the phrase “the monolithic revolution” in lectures around 2013, the transition was still unfolding. The longitudinal data now establish that this was not a temporary product cycle. A restoration representing nearly two-thirds of Glidewell’s fixed volume fell to one case in 20 within 18 years.
Why PFM Dissatisfaction Was Underestimated Glidewell initially questioned whether PFM fracture could be driving the transition because laboratory remake rates were relatively low. Those records did not capture many clinical porcelain fractures. When veneering porcelain fractured during the first five years, insurance often would not reimburse a replacement crown. Many dentists polished the fractured surface and reassured the patient rather than cutting off the restoration, paying the laboratory for a new crown, and charging the patient. Consequently, many clinical fractures never returned to the original laboratory and never appeared in its remake statistics. The speed with which dentists abandoned PFM after monolithic alternatives became available suggests that a substantial pain point had remained hidden because there was no acceptable alternative. Market dominance demonstrates adoption rather than universal clinical superiority, but this was not the cautious sampling ordinarily associated with a new material. Dentists moved rapidly. One educational demonstration helped make the difference understandable. A PFM crown was placed on a wooden board and struck with a sledgehammer. The feldspathic porcelain shattered, leaving the metal coping and opaque layer. A 1.5-mm-thick full-strength zirconia crown was struck similarly. It was driven into the wood, then pried out with a screwdriver without visible fracture. The demonstration was not a scientific test and should never be interpreted as one. Its influence came from making the difference emotionally legible. Dentists initially gasped and, later, applauded. It revealed how strongly clinicians valued freedom from chipping and fracture once a tooth-colored alternative existed.
Lithium Disilicate as the Catalyst Earlier generations of lithium-disilicate systems used the material as a framework covered by veneering ceramic. Their failures frequently involved fracture of that veneering layer. The monolithic e.max concept eliminated the interface and demonstrated that lithium disilicate itself could provide both form and optical vitality. This was the strategic contribution of lithium disilicate: it proved that a restoration did not need to be bilayered to be esthetic. That success encouraged a simple but consequential question: if veneering porcelain could be removed from lithium disilicate, could it also be removed from porcelain-fused-to-zirconia restorations?
When I graduated in 1988, 26 of the 27 crowns I completed were porcelainfused-to-metal restorations. The single gold crown was required because the California licensing examination did not permit a PFM crown.
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Zirconia Raised the Floor The earliest full-contour zirconia crowns were not beautiful. They were opaque enough that cast gold could arguably have been more esthetic. One Glidewell employee received an early crown at no charge, then paid an outside dentist to replace it before the planned recall because she could not tolerate its appearance. BruxZir’s early advertising acknowledged the limitation with the phrase “More brawn than beauty.” Esthetics improved when color was incorporated into presintered zirconia. In its green state, the porous material behaved somewhat like a sponge, permitting color to penetrate rather than merely remain on the surface. Surface stain alone could be removed during occlusal adjustment, exposing the bright underlying material. Despite early esthetic limitations, dentists expanded zirconia from second molars to first molars, premolars, and eventually anterior teeth. Its greatest contribution was not that it made every preparation ideal. It often made a favorable restoration possible from a preparation that was not ideal. Zirconia raised the floor of restorative dentistry. In grading terms, it could sometimes turn a C-minus preparation into a B-plus or A-minus restoration. It tolerated reduced occlusal clearance and localized feather-edge areas better than PFM or lithium disilicate. That forgiveness helped patients receive stronger restorations without being recalled for additional preparation.
DISCUSSION The Right Material for the Right Tooth The success of zirconia should not be mistaken for the obsolescence of lithium disilicate. The market has arguably moved too far toward zirconia, particularly in the anterior region and in the growing enthusiasm for zirconia veneers. My material-selection approach is straightforward. All molars receive full-strength 3Y zirconia. Maximum strength is clinically useful in the posterior region, while the incremental esthetic benefit of more translucent, weaker formulations is seldom necessary. Increasing translucency through changes in zirconia composition reduces transformation-toughening potential and mechanical strength.5,6 Lithium disilicate remains my preferred material for most anterior crowns and virtually all veneers. Its inherent translucency gives the average technician an optical advantage over zirconia. Long-term evidence for lithium-disilicate veneers is also substantially more mature than that for zirconia veneers.2 Premolars occupy the decision zone. Lithium disilicate, esthetic zirconia, or occasionally full-strength zirconia may be selected according to restorative thickness, adjacent materials, esthetic demand, occlusion, and the patient’s history of wear or fracture. Esthetic zirconia may be appropriate anteriorly when the patient has advanced wear, an edge-to-edge relationship, destructive parafunction, or repeated fracture of prior restorations. Full-strength zirconia may be appropriate in extreme anterior-wear cases.
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However, the sledgehammer reputation of 3Y zirconia should not be casually transferred to every zirconia formulation or thickness.
Preparation and Failure Patterns Zirconia’s forgiveness should not lower the standard of preparation. Technicians generally obtain better results from a defined shallow chamfer than from an intentional feather edge. Depth-cut-based preparation techniques remain valuable because they replace freehand estimation with a repeatable sequence based on the selected material. Lithium disilicate is less tolerant of inadequate marginal thickness. A characteristic laboratory failure is a semilunar fracture originating at a thin lingual margin, particularly on mandibular molars. The lingual segment fractures away while the remainder of the crown remains bonded. These failures often reflect inadequate reduction in the gingival third or an unintended feather-edge margin. Zirconia single crowns rarely fractured in early clinical experience. More failures were associated with fixed partial dentures and inadequate connectors. Connector geometry, height, width, material formulation, and adjustment all influence fracture resistance. Experimental evidence confirms that 3Y zirconia provides greater connector fracture strength than more translucent 4Y and 5Y formulations, and that connector design is a critical factor in fixed prostheses.7,8 Glidewell used a practical “rule of 27” for selected posterior 3-unit zirconia bridges: connector height squared multiplied by buccolingual width should equal at least 27, commonly achieved with a 3-by-3-mm connector. The exact requirement must follow the restorative system, location, span, and manufacturer’s instructions. Designers, finishers, and dentists must all understand that reducing a minimum connector to improve contour or occlusion may weaken the prosthesis.
Adjustment, Glaze, and Antagonist Wear Dentists initially feared that zirconia’s hardness would destroy opposing enamel. The more important variable proved to be surface roughness. Highly polished zirconia can produce less antagonist wear than roughened, glazed, or veneered ceramic surfaces. Clinical and laboratory studies have found that polished zirconia causes less opposing-enamel wear than glazed zirconia and substantially less than veneering porcelain.9-11 Posterior zirconia should therefore be highly polished rather than dependent on glaze. For an anterior restoration, the facial surface may be glazed for appearance, but functional lingual surfaces should remain polished. Intraoral adjustment should be performed with water whenever practical. When dry adjustment is unavoidable, the clinician should use brief, light contacts while an assistant directs air toward the restoration. Fine zirconia-adjustment diamonds create shallower scratches and simplify subsequent polishing. Every adjusted surface must be repolished.
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Zirconia single crowns rarely fractured in early clinical experience. More failures were associated with fixed partial dentures and inadequate connectors.
Cleaning, Cementation, and Bonding Early zirconia failures often involved repeated loss of retention rather than fracture. Dentists had been taught that phosphoric acid was an acceptable ceramic-cleaning agent. On saliva-contaminated zirconia, phosphoric acid does not predictably restore resin-bond strength and may perpetuate phosphate contamination. After try-in, zirconia should be cleaned using an evidence-supported zirconia cleaner or renewed airborne-particle abrasion according to the manufacturer’s protocol. Water, alcohol, or phosphoric acid alone should not be assumed to restore the original bonding surface.12,13 When resin bonding is required, airborne-particle abrasion combined with a 10-MDP-containing primer, adhesive, or cement remains among the most supported protocols. Zirconia lacks the glass phase that makes hydrofluoric-acid etching effective for lithium disilicate.14,15 My recommendation is to conventionally cement zirconia whenever preparation geometry permits and reserve adhesive bonding for short, over-tapered, or otherwise nonretentive preparations. This recommendation is influenced not only by retention today but by retrieval years later. Light transmission through zirconia decreases with thickness and opacity, and polymerization of light-dependent resin cements may be compromised beneath thicker restorations.16,17 Self-curing or reliably self-curing dual-cure resin cements should therefore be selected when light transmission is uncertain. Lithium disilicate does not invariably require adhesive bonding when used as a fullcoverage crown on a retentive preparation. Bonding is increasingly important as the restoration becomes thinner, less retentive, or more dependent on adhesive support. Veneers should be bonded, preferably while preserving enamel whenever possible.
Dentistry’s Unsolved Retrieval Problem PFM crowns offered one advantage that should not be overlooked: they were relatively easy to remove. A diamond penetrated the porcelain, a carbide exposed and sectioned the metal coping, and a crown spreader could often release the restoration before complete circumferential sectioning. Zirconia turns its greatest virtue during service into a liability during retrieval. It may require sectioning across the facial, occlusal, and lingual surfaces. There is no metal layer to provide a distinct visual landmark. When adhesively bonded, individual segments may remain tenaciously attached, requiring continued cutting and increasing the likelihood of removing sound tooth structure. Lithium disilicate is easier to cut, but its translucency creates a different danger. The ceramic, translucent resin cement, and tooth may blend optically, making it difficult to identify where the restoration ends. The patient may never see the resulting overpreparation because it will be concealed by the replacement crown, but the iatrogenic loss of tooth structure is real.
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Cement selection has therefore become a decision about the restoration’s entire life cycle. The clinician must ask not only, “Will this crown remain in place?” but also, “What will happen to this tooth when someone must remove it?” Dentistry needs a truly reversible cement or another predictable, nondestructive retrieval method. The anti-curing light I used to request jokingly from the Glidewell research and development team no longer sounds entirely frivolous.
The Conservative Esthetic Revolution The monolithic revolution restored much of what dentistry valued in cast gold: strength, conservation, and freedom from a veneering interface, now in toothcolored materials. It also made same-day dentistry practical. A zirconia crown can now be scanned, designed, milled, sintered, and placed without a temporary restoration or second appointment. Yet the next advance will not be achieved by ceramics alone. Digital restorative-planning software can evaluate proposed tooth movement and restorative contours simultaneously. Teeth that once would have required aggressive preparation to correct rotation, prominence, or arch position may first be moved with clear aligners. After several months of limited orthodontic treatment, thin or no-preparation lithium-disilicate veneers may become possible, with more uniform ceramic thickness and bonding largely or entirely to enamel. For many years, restorative dentistry spoke about conservation while continuing to reduce healthy tooth structure to compensate for tooth position. The ability to move teeth before restoring them creates a more literal form of conservative dentistry.
CONCLUSION Lithium disilicate and full-strength zirconia are likely to remain the workhorse materials of fixed dentistry for the foreseeable future. Lithium disilicate launched the monolithic revolution by proving that a monolithic ceramic could be beautiful. Zirconia accelerated it by providing extraordinary strength while tolerating conservative and sometimes imperfect preparations. The monolithic revolution is not the end of this story. It is giving rise to the conservative esthetic revolution. By combining durable, thin monolithic restorations with digital planning and limited tooth movement, clinicians can ask a better question before beginning an esthetic case: not merely which material should replace the missing tooth structure, but how much tooth structure needs to be removed at all.
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The monolithic revolution restored much of what dentistry valued in cast gold: strength, conservation, and freedom from a veneering interface, now in toothcolored materials. It also made sameday dentistry practical.
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different cleaning measures on
Fukushima S. The effect of core
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Angelis S, et al. Monolithic CAD-
framework designs on the fracture
saliva-contaminated or blood-
CAM lithium disilicate versus
loads of all-ceramic fixed partial
contaminated zirconia. J Dent.
monolithic CAD-CAM zirconia for
dentures on posterior implants. J
single implant-supported posterior
Oral Rehabil. Rosentritt M, Preis V, Behr M,
S, Van Meerbeek B. Meta-analysis
Hahnel S. Effect of connector
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configuration on the fracture load
zirconia ceramics. J Dent Res.
Klein P, Spitznagel FA, Güth JF, et
in conventional and translucent
2014;93(4):329-334.
al. Survival and complication rates
zirconia three-unit fixed dental
of feldspathic, leucite-reinforced
prostheses. J Prosthet Dent. 2023.
to zirconia used for dental
15. Özcan M, Bernasconi M. Adhesion
Dondani JR, Rao SR, Sankhla B,
restorations: a systematic review
et al. Comparative evaluation of
and meta-analysis. J Adhes Dent.
a systematic review and meta-
wear of natural enamel opposing
analysis. J Dent. 2025.
glazed and polished monolithic
Piconi C, Maccauro G. Zirconia as a
zirconia crowns: a clinical study. Int
of the amount of light passing
ceramic biomaterial. Biomaterials.
J Prosthodont. 2023;36(1).
through zirconia: effect of material
9.
10. Janyavula S, Lawson N, Cakir D,
Ardlin BI. Transformation-
Beck P, Ramp LC, Burgess JO.
toughened zirconia for dental
The wear of polished and glazed
inlays, crowns and bridges:
zirconia against enamel. J Prosthet
low-temperature aging on flexural
Dent. 2013;109(1):22-29. 11. Lawson NC, Janyavula S, Syklawer
2015;17(1):7-26. 16. Ilie N, Stawarczyk B. Quantification
shade, thickness, and curing conditions. J Dent. 2014;42(6):684690. 17. Kim MJ, Kim KH, Kim YK, Kwon TY. Degree of conversion of two dualcured resin cements light-irradiated
strength and surface structure.
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through zirconia ceramic disks. J
Dent Mater. 2002;18(8):590-595.
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Alqutaibi AY, Ghulam O, Krsoum M,
lithium disilicate after adjustment,
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et al. Revolution of current dental
polishing and glazing. J Dent.
zirconia: a comprehensive review. 6.
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2022. 14. Inokoshi M, De Munck J, Minakuchi
clinical trial. Clin Oral Implants Res.
1999;20(1):1-25. 4.
13. Tian F, et al. Effectiveness of
Torizuka K, Vult von Steyern P,
glass-ceramic, lithium-disilicate and
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Kokubo Y, Tsumita M, Sakurai S,
De Angelis P, Gasparini G, De
crowns at 3 years: a randomized
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Molecules. 2022;27(5):1699.
12. Ishii R, Tsujimoto A, Takamizawa
Shahmiri R, Standard OC, Hart
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JN, Sorrell CC. Optical properties
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A case report
on everyday workflows with new Multi-Direct Capture scanning technology:
From hygiene to final restoration iTero Multi-Direct Capture offers several advantages for indirect restorations including accuracy, increased margin readability, and photorealistic capture. This case report highlights another advantage—patient education during the hygiene visit.
Joshua Austin, DDS, MAGD Cindy Lam-Vuong, CDT Reprinted with permission. Originally published in Dental Economics, August 23, 2025. ©2026 Dental Economics. All Rights Reserved. https:// www.dentaleconomics.com/
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Digital scanning technology has been present in dentistry in some form since the 1980s. While digital scanning in dentistry has been mostly focused on restorative dentistry, recent developments in scanning technology increase the applications within the practice. The newest scanning technology, iTero Multi-Direct Capture, brings speed, photorealism, and accuracy that make this technology suitable to use in every aspect of a dental practice. Most digital scanners available for purchase as of 2024 use confocal imaging to capture a digital model. This technology has been well researched and developed. Using a single camera, a scanner takes images of dental structures, records them, and maps them using distances between known points.1 This technology produces reliable models, but due to the single-image capture, it can only move at a certain speed. Processing speed of the computer can quicken the process, but it is still a single stream of data being captured. Multi-Direct Capture technology utilizes five different cameras and 6 light sources to expand the field of view and depth of focus. This increases the speed and smoothness of the scanning experience, as well as providing an astoundingly photorealistic digital model.
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I have been using digital scanning technology in my practice since 2009. Initially, we used our digital scanner in the manner that most dentists do—as a replacement for impression material for indirect restorations. Beginning in 2017, we began to change how often we used our scanner. It started with a patient in one of my hygiene chairs for a recall examination. She had a visible fracture line on the distal of her lower right second molar, and I recommended a crown. I was trying to explain to her why she needed this restoration, but she left her hearing aids at home, so she was having trouble hearing me. A picture is worth a thousand words, right? With this in mind, I got out my DSLR camera and attempted to take
Case study: From recall to treatment Our patient Chris presented for his regular routine recall visit with one of our dental hygienists (Figure 1). When she asked him if he had any issues, Chris reported a slight discomfort on his lower left side when chewing. As part of his normal recall experience, our dental hygienist did a “wellness” scan on Chris using our iTero Lumina scanner. During my examination, I noted a large amalgam restoration on the lower left first molar with an apparent crack down the distal marginal ridge. No percussion tenderness was noted on any area in the quadrant except for the distolingual cusp of the lower left first molar. A bite test also showed tenderness in this area and nowhere else. A cold test indicated that the lower left first molar was vital and had no lingering effects. My treatment plan for Chris was simple: a crown and buildup on his lower left first molar. My dental hygienist had the scan loaded on the screen of our iTero Lumina using the Align Oral Health Suite. Align Oral Health Suite is a tool that helps clinicians educate their patients on all aspects of their dental health using the scanner, including tooth health, gum health, bite, and alignment (Figure 2).
a photo. The battery was dead. In haste to get her exam finished and her crown scheduled, I grabbed my iTero Element 2 scanner. We did a quick (four-minute) scan, and I showed her the crack on her tooth. She could immediately see the issue and quickly understood the treatment plan. This serendipitous event led me to a realization. Patients understand more when they can see what we see, especially in three dimensions. We began scanning every new patient. This was an investment in time, but it paid off. Within three months, our practice production was up nearly 30%. When I talk about this idea with other dental practices, I generally get pushback about that investment
Figure 1. Pre-op presentation of cracked tooth no. 19
in scan time during an already rushed dental appointment. With Multi-Direct Capture technology on our iTero Lumina, our scan time is around 35 seconds per arch. The idea that scan time is a barrier from scanning in our new-patient and recall appointments is a thing of the past thanks to this new technology.
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About the authors Joshua Austin, DDS, MAGD Joshua Austin, DDS, MAGD, is a graduate and former faculty member of the University of Texas Health Science Figure 2. Align Oral Health Suite user interface
Center at San Antonio School of Dentistry. Author of Dental Economics’ Pearls for Your Practice
Using Align Oral Health Suite, I was able to show Chris his lower first molar, both on the scan and an isolated intraoral camera photo taken during scanning (Figure 3). He was able to easily see the issue with his tooth, quickly agreed to treatment, and provided consent. The lower left molar was prepared for a full-coverage crown. The old amalgam restoration was removed and replaced with a dual-cured, fiberreinforced opaque buildup. The preparation was refined, and a size 0 cord was packed in the sulcus. The preparation was then imaged using the iTero Lumina scanner.
column, Dr Austin lectures nationally on products, dental technology, online reputation management, and social media. He maintains a full-time restorative dentistry private practice in San Antonio, Texas. You may contact Dr Austin at jaustindds@icloud.com.
Cindy LamVuong, CDT CO-OWNER OF 38 SMILES DIGITAL DENTAL Cindy Lam-Vuong, CDT, is co-owner of 38 Smiles Digital Dental. She has a BA in communications and specialty certificates in LEAN and LEAD. With 30-plus years of experience, her diverse career includes 25 years as a technician specializing Figure 3. iTero Lumina rendering of cracked distal on tooth no. 19
in veneers and smile makeovers. She participated in beta-testing of materials, including the formulations of BruxZir and BruxZir Esthetic, and digital software and intraoral hardware development while acting as production manager and general manager at Glidewell Laboratories.
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The Multi-Direct Capture technology within the iTero Lumina allowed for fast, accurate scanning of the preparation. Total scan time for the prep, operative quadrant, opposing quadrant, and bite was 77 seconds (Figure 4). Using the robust restorative software on the iTero Lumina, I was able to verify adequate occlusal reduction (Figure 5), as well as accurately mark the margins for my laboratory technician (Figure 6). The prescription was filled out and sent to the laboratory directly from the iTero Lumina, while my assistant fabricated and cemented a provisional crown for the patient.
Figure 4. Scan of prepared tooth no. 19
Figure 5. Occlusal reduction view of prepared tooth no. 19
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Our laboratory purposefully focuses on doctors who utilize digital scanning, Figure 6. Margin marked on prepared tooth no. 19
A dental laboratory perspective As a robust and busy digital dental laboratory, we handle hundreds of digital scans per day. Our laboratory purposefully focuses on doctors who utilize digital scanning, because we find we get better results with them than those who use analog impression materials. Our internal data shows that remake percentages go down when doctors use digital scanning. In addition, adequate reduction occurs more often, which makes for more successful restorations. We all know that smooth margins, adequate tissue management, and clean, dry preparations are vital to success with digital scans; however, some scans are just easier to work with than others. The iTero Lumina produces scans like this. What we notice is a brilliantly lifelike image, startlingly different in detail, color
because we find we get better results with them than those who use analog impression materials.
rendition, and representation of polychromatic characteristics from other confocal imaging scanners. Lumina’s photorealistic capture of detail sets a new standard for imaging quality and communication (Figure 7).
Figure 7. Design software view of buccal of prepared tooth no. 19
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While the definition of the prep and margin is very clear and definable, it is the lifelike rendition of color, textures, and light reflection that gives Lumina scans unequaled clarity and definition. This is important not only for margin detection, but surface details of the preparation and surrounding dentition. The excellent chromatic representation allows for definitive identification of margins against tissue, a feature never before seen in previous scanners (Figure 8). Lumina’s remarkable depth-offield is evidenced by complete interproximal capture (versus missing data) and clear exposure balance, resulting in realistic surface texture and clarity (Figure 9).
Figure 8. Design software view of occlusal of prepared tooth no. 19
Figure 9. Design software view of lingual of prepared tooth no. 19
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The zirconia crown from the lab required no adjustment and was cemented with RMGI luting cement. This Figure 10. Design software rendering of crown no. 19
visit took a total of nine minutes from start to finish.
Figure 11. Design software rendering of crown no. 19
In this case, we were able to design an anatomic, well-contoured crown for Dr Austin’s patient, Chris, which was milled out of traditional 3Y zirconia dioxide (Figures 10 and 11).
The final restoration Chris returned to the practice for his crown insert five days after the preparation. Cindy’s lab, 38Smiles, focuses on producing high-quality zirconia crowns from digital scans within three days of preparation. Allowing a day or two for shipping, we routinely insert single-unit crowns on day five after preparation. We find this increases the ease of the delivery appointment for both the patient and clinician, as well as decreasing the chances for a remake versus the traditional 2 weeks for delivery. Chris’s provisional was removed, and the preparation was cleaned. The zirconia crown from the lab required no adjustment and was cemented with RMGI luting cement. This visit took a total of nine minutes from start to finish. With the accuracy
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of the iTero Lumina scanner, and the expeditious nature of 38Smiles, we find this to be a common occurrence in our indirect restorative procedures. The patient has tolerated this procedure well and reported no pain or discomfort after the restoration was placed (Figure 12).
Figure 12. Post-op view of final crown no. 19
A summary Digital scanning technology is a staple of modern restorative dentistry. Moving from confocal imaging to Multi-Direct Capture offers a number of advantages for indirect restorations, including accuracy, increased margin readability, and photorealistic capture. As restorative dentists, this is what most of us focus on. However, another advantage of scanning with Multi-Direct Capture is the ability to use this technology in the hygiene and wellness visit to help educate and inform our patients of their dental needs. When patients can visualize (in three dimensions with photorealism) what their dental issues are, case acceptance goes up. This can change the trajectory of a dental practice, increasing production, collections, and patient satisfaction. When the financial aspects of a dental practice strengthen, in addition to an increase in patient satisfaction, that will inevitably lead to an increase in dentist satisfaction as well. Reference 1.
Richert R, Goujat A, Venet L, et al. Intraoral scanner technologies: a review to make a successful impression. J Healthc Eng. 2017;2017:8427595. doi:10.1155/2017/8427595
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The Next Chapter of Digital Dentistry: Why 3D Printing Has Finally Reached Clinical Maturity Meena Barsoum, DMD Global Head of Clinical Strategy, SprintRay
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For years, I’ve believed that dentistry wasn’t waiting for another material or another printer—it was waiting for an improved ecosystem. We’ve spent the last decade watching digital dentistry transform diagnosis with CBCT, treatment planning with AI, and restorative dentistry with intraoral scanning. Yet one area consistently lagged behind: chairside manufacturing. While digital workflows became commonplace, the actual production of restorations often remained slow, extremely expensive, and heavily dependent on closed ecosystems. That has changed. Today, we’re witnessing something fundamentally different than simply “better 3D printing.” We’re seeing the emergence of complete digital manufacturing ecosystems capable of producing same-day appliances and definitive restorations with a level of speed, quality, and predictability that simply wasn’t possible even a few years ago. The past year has represented one of the biggest leaps forward in chairside manufacturing that I’ve seen in my career. Digital Press technology unlocks a completely new class or ceramic infused resins, built for definitive restorations. We’re entering an era where digital manufacturing isn’t just an alternative to traditional workflows—it is becoming the standard of care.
Pro 2: A Manufacturing Platform That Continues to Evolve
About the author Dr Meena Barsoum is the Global Head of Clinical Strategy at SprintRay, where he leads the company’s vision for integrating digital technology into everyday dental practice. An internationally recognized dentist, educator, and speaker, he is passionate about advancing digital dentistry and minimally invasive care. Dr Barsoum earned his Doctor of Dental Medicine degree from Case Western Reserve University and most recently earned his MBA from the University of Illinois in 2024. He maintains a private practice in the Chicago area, focusing on comprehensive care, esthetics, and digital workflows. An early adopter of digital dentistry, Dr Barsoum is widely regarded for his expertise in CAD/CAM, 3D printing, and same-day restorative solutions. He has trained thousands of clinicians through live lectures, hands-on programs, and online education. His ability to translate complex concepts into practical, everyday applications has made him a sought-after educator and key opinion leader. In his role at SprintRay, Dr Barsoum works closely with clinicians, researchers, and industry partners to shape the future of 3D printing in dentistry. He also serves as a clinical educator and advisor to leading dental technology
When Pro 2 launched, the objective wasn’t simply to build another
companies, contributing to product development,
printer. The goal was to create a manufacturing platform capable
training, and global education initiatives.
of supporting an expanding ecosystem of applications while continually becoming faster, smarter, and easier to use.
When he is not practicing or teaching, Dr Barsoum enjoys
One of the most significant advancements has been the dramatic
evolving intersections of technology and healthcare.
traveling, mentoring young clinicians, and exploring the
increase in printing speed. Speed isn’t just about saving minutes— it changes the economics of same-day dentistry. Faster production means reduced patient wait times, higher daily throughput, and
Disclaimer:
the ability to integrate manufacturing seamlessly into existing
The information provided regarding SprintRay is for general
clinical schedules rather than designing the day around the
informational purposes only. The Texas Dental Association
printer.
(TDA) and Texas Dental Journal make no representations
The introduction of the Duo Kit further expanded this philosophy. Instead of forcing practices to compromise between flexibility
or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability
and efficiency, clinicians can now optimize production for
with respect to the product or the information contained
different applications while maintaining exceptional reliability.
herein. The reviews and opinions expressed in the following
Whether producing appliances, models, surgical guides, or
article are those of the author and do not necessarily reflect
restorative components, the workflow continues to become more
those of the TDA.
streamlined and more scalable.
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Materials Continue to Drive Clinical Adoption Hardware is only as valuable as the materials it can process. This year has brought one of the most exciting expansions of printable dental materials we’ve seen. NightGuard Flex 2 represent another major evolution in digitally manufactured occlusal appliances. Dentists have long wanted a material that combines comfort, durability, predictable fit, and efficient production. Digital nightguard workflows continue to eliminate traditional impressions, thermoforming, trimming, and remakes while providing practices the ability to reproduce appliances on demand from stored digital files. Equally exciting is the continued expansion of the Apex family of resins.Instead of viewing dentures as individual components, clinicians can now approach removable prosthetics as a complete digital system. Apex Base, Apex Teeth, and Apex Flex work together to simplify fabrication while delivering highly esthetic, durable prostheses with digital repeatability that conventional analog workflows struggle to match. Especially when coupled with DuoKit, clinicians can deliver same day dentures where all the components are printed simultaneously.
Digital Sports Protection Arrives Sports dentistry has traditionally relied on manual impressions, laboratory fabrication, and multiple appointments. SprintRay SportGuard changes that equation. Digital scanning combined with chairside manufacturing allows practices to fabricate custom athletic protection with remarkable efficiency while improving patient experience. As more practices look to diversify services beyond restorative dentistry, sports protection becomes another practical application of in-office manufacturing that fits naturally within existing digital workflows.
AI Has Become the New Clinical Team Member The biggest pain point I’ve seen in my career of educating and training dentists across the globe has been the learning curve with CAD software. Many options exists, but they are either too limited, too complex or too expensive. When Sprintray set out to build the next version of AI CAD design, 3 things were top of mind—it must be accessible to the masses, it must be simple for any user to operate and lastly it must operate in a truly autonomous fashion. Studio AI has undergone a significant evolution, particularly for restorative design. Multi-unit restoration capabilities continue expanding what clinicians can accomplish chairside while simplifying increasingly complex cases. Preoperative copy workflows have also become an invaluable addition. One of the greatest advantages of digital dentistry has always been the ability to preserve nature. Rather than recreating anatomy from scratch, clinicians can now leverage existing tooth morphology to generate restorations that maintain the patient’s original esthetics and occlusion whenever appropriate.
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Crown HT Has Changed Expectations Every new technology reaches an inflection point where early adopters become mainstream users. For Midas, that moment has largely been driven by Crown HT. Material science has always been the limiting factor in chairside restorations. Clinicians wanted strength, esthetics and efficiency. Historically, achieving all three simultaneously required compromise. Practices now have access to a restorative material capable of producing highly esthetic definitive restorations while integrating into efficient same-day workflows. More importantly, Crown HT has helped expand chairside dentistry beyond the traditional CAD/CAM audience. Many clinicians who previously relied almost exclusively on laboratories are now discovering that definitive same-day restorative treatment is not only achievable—it is practical. Crown HT has also helped drive the transition of our profession towards more conservative, partial coverage and adhesive dentistry. Our profession often prepares crowns for convenience and cost, but ask yourself, how many of your crowns could have been an onlay or partial coverage? Not requiring a provisional or expensive lab bill unlocks a completely new wave of adhesive restorative dental options for clinicians using Midas.
Midas Restore Represents the Next Generation of Chairside Restorative Materials By far the biggest news of 2026 will be the market launch of Midas Restore. Built with approximately 70% ceramic filler content, Midas Restore delivers an impressive combination of strength, esthetics, polishability, and wear resistance that directly addresses what clinicians have been asking for. Restore was built for Midas. Or maybe Midas was built for Restore? The classic chicken or egg argument. Restore is extremely viscous and ceramic filled—making it impossible to manufacture on a traditional 3d printer. A digital press like Midas is the only way to manufacture a highly viscous ceramic filled material like Restore. Increasing ceramic content isn’t just for esthetics—it also improves the wear resistance. Initial data supports a 6x improvement in wear resistance over previous generation materials. And this data will keep coming with currently 15 university studies and counting looking at these properties.
Digital Dentistry Is No Longer About the Future Companies move quickly and innovate with the clinician and the patient in mind. Our Biomaterial Innovation Lab builds next generation resins that take full advantage of the hardware and software stack in the practice. Software teams are constantly iterating and building faster and more efficient algorithms leveraging AI to make the user experience that much better. We are not just building products and software—we are literally obsessed with digital dentistry. It’s the culture that brought me to Sprintray in the first place and it’s what keeps my cup full every single day.
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Efficient Workflow for Clear Aligner Therapy Appointments
That Don’t Cut into Restorative Dentistry michele Ranta, dds
As more general dentists add clear aligner therapy to their practices, one challenge quickly becomes apparent: integrating orthodontic treatment into a schedule built around restorative dentistry.
About the author Dr Michele Ranta graduated in her home state with honors for
While clear aligner therapy is an excellent service
her undergraduate and
for patients and a valuable practice builder,
doctorate degrees at the
inconveniently planned appointments for
University of Michigan in 2008. For the past
attachments, interproximal reduction (IPR), or
15 years, she has called
refinement records can disrupt production, increase
Austin home. She has been treating patients
stress, and reduce efficiency.
with Invisalign for 17 years while learning from mentors as well as mistakes. With clear aligner therapy and iTero technology as the forefront
The solution isn’t necessarily adding more appointment time—it’s creating a standardized workflow. By reducing unnecessary visits, planning treatment strategically, and leveraging technology,
of her approach to comprehensive dentistry, she has been successful as an associate and practice owner. She strongly believes in being open with her patients about their oral health and all treatment options. Dr Ranta is an innovator among the Invisalign Global Faculty
practices can improve the patient experience while
and frequently requested to teach across the
protecting productivity.
country.
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Start Before the Consultation
If the patient is seriously considering treatment, there is little benefit to scheduling a separate appointment for photographs or digital scans. Multiple visits create additional scheduling challenges for both the practice and the patient.
An efficient clear aligner therapy consultation begins before the patient ever sits in the chair.
A complete records appointment should include:
The first step is verifying insurance benefits. Every patient, regardless of whether they are in-network or fee-for-service,
•
Intraoral digital scan
should have a complete orthodontic insurance breakdown
•
Extraoral and intraoral photographs
before the consultation. Rather than simply asking if
•
Radiographs as indicated
orthodontic benefits exist, confirm the details that will affect
•
Updated medical and dental history
treatment discussions:
•
Informed consent
•
Age limitations
Collecting everything during one appointment shortens the
•
Coverage for CDT code D8090
overall treatment timeline and creates a smoother patient
•
Lifetime orthodontic benefit
experience from the very beginning. Nobody, including your
•
Payment schedule, including D8670
front office, your assistant, nor your patient, will appreciate
•
Whether predetermination is required
scheduling an additional appointment for 5 minutes of photographs.
Having accurate financial information available allows the team to confidently discuss treatment and avoids delays after the initial chairside conversation. To simplify the financial presentation, many general practices benefit from having orthodontic insurance reimbursements sent directly to the patient instead of the practice. This eliminates the burden of calculating various insurance benefits into the presentation of fees, especially since payment plans are appropriate for ongoing treatment. Patients will still receive all of their entitled insurance benefits while making scheduled payments to the office. Standardizing fees also improves efficiency. Rather than creating customized payment plans for every patient, establish two or three treatment categories with predetermined financing options. The front office can then present treatment confidently without performing calculations for each consultation.
Combine the Consultation and Records Appointment Whenever possible, collect all diagnostic records during the consultation visit.
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Plan Treatment with Efficiency in Mind One of the greatest opportunities to improve workflow occurs before aligners are ever manufactured. Every digital treatment plan should be reviewed carefully before approval. Small modifications to tooth movement, attachment placement, or IPR timing can prevent unnecessary refinements and additional appointments later. Evaluate each case for: •
Tooth movement sequence
•
Attachment placement
•
Timing of IPR
•
Final occlusion
•
Esthetic outcome
•
Areas likely to require refinement
Traditionally, first delivery appointments include aligner delivery, attachment placement, patient education, and sometimes IPR. These visits can easily occupy an hour of doctor time. One simple scheduling strategy is delaying attachment placement until aligner two, three, or four rather than placing attachments on the day treatment begins.
By postponing attachments, patients can begin treatment
•
Verifying aligner fit
immediately when the aligners arrive in office simply by
•
Placing attachments
picking them up. Their next scheduled clinical appointment
•
Reinforcing 24 hours of daily wear
for attachments becomes much shorter. That visit simply
•
Discussing aligner change intervals
focuses on evaluating initial tracking, bonding attachments, and delivering the next series of aligners—an appointment
Because treatment has already begun, these appointments
that fits much more comfortably into a restorative schedule.
are typically shorter, more focused, and easier to integrate into a busy schedule.
The same principle applies to IPR. IPR at aligner 1 or 2 can be too early around crowded teeth and adds inconvenient length to the 1st aligner or attachment appointment. Rather than performing IPR at the beginning or scattering it throughout treatment, evaluate the digital setup for an early- to mid-treatment “sweet spot” where most reduction can be completed during one or two appointments. If there isn’t one point in the treatment when all the IPR can easily be performed, evaluate and work with your CAD designer to condense 3 or 4 possible IPR appointments into two. In this pictured example, the patient can be appointed for attachments at aligner 2. Then the next appointment for IPR is at aligner 8. Coordinating IPR with already scheduled progress visits minimizes interruptions while maintaining excellent treatment efficiency.
Rethink First Aligner Delivery
Use Virtual Monitoring to Reduce Office Visits Routine progress appointments remain an important part of clear aligner therapy, but not every evaluation requires an in-office visit. Most patients are seen every six to ten weeks to assess tracking, reinforce compliance, perform IPR when necessary, and deliver additional aligners. Standardized appointment checklists help ensure consistency across providers and clinical staff.
Virtual monitoring takes this efficiency one step further Today’s AI-assisted monitoring systems—including Invisalign’s integrated virtual care platform and third-party solutions such
Many practices automatically schedule chair time when the
as Dental Monitoring—allow clinicians to evaluate aligner fit,
first aligners arrive. In reality, that appointment often isn’t
tooth movement, oral hygiene, and attachment loss remotely.
necessary. Early detection of tracking issues allows small corrections If attachments have been intentionally delayed, patients can
before they become larger problems requiring refinements or
simply pick up their first aligners during normal business
additional appointments. Patients also appreciate fewer trips
hours. Written instructions or prerecorded educational videos
to the office while still feeling closely monitored throughout
allow the front office to review wear schedules, hygiene
treatment.
instructions, and expectations while the patient schedules the first clinical visit.
For many practices, virtual monitoring improves both efficiency and patient satisfaction.
This approach also eliminates the frustration of trying to predict manufacturing and shipping timelines when scheduling delivery appointments. When patients return for their 2nd aligner visit, the appointment can include:
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Don’t Overlook the Refinement Phase Even with careful planning, many Invisalign cases require refinement aligners. Before ordering refinements, confirm that original treatment goals have been met as closely as possible. Obtain updated digital scans, capture new photographs when appropriate, evaluate the occlusion carefully, and discuss revised expectations with the patient. One clinical recommendation that can significantly improve refinement efficiency is removing all existing attachments before the refinement scan. Although reusing attachments is common, attachments lose precision over time. When refinement aligners are fabricated using scanned attachments, software estimates the underlying tooth anatomy after digitally removing them, introducing small inaccuracies into the next series of aligners. Freshly bonded attachments more accurately reproduce the intended shape and angulation, providing better retention and more predictable force application. While replacing attachments requires additional chair time during refinement delivery, the improved precision of new attachments results in more predictable tooth movement, fewer tracking problems, fewer additional refinements, and higher patient satisfaction.
Build a Workflow, Not Just an Invisalign Schedule The most successful clear aligner practices don’t simply fit Invisalign appointments into an existing schedule—they build a workflow specifically designed for efficiency. Verifying insurance before consultations, collecting complete records during the initial visit, strategically planning attachments and IPR, simplifying aligner delivery, incorporating virtual monitoring, and optimizing the refinement phase all reduce interruptions while improving consistency. As clear aligner therapy continues to grow within general practice, thoughtful scheduling and standardized systems allow clinicians to provide high-quality orthodontic care without sacrificing restorative productivity. Ultimately, a welldesigned workflow benefits everyone: the doctor, the team, and most importantly, the patient.
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Although reusing attachments is common, attachments lose precision over time. When refinement aligners are fabricated using scanned attachments, software estimates the underlying tooth anatomy after digitally removing them, introducing small inaccuracies into the next series of aligners.
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The Clinical Advantages of Chairside Milling for Esthetic Restorations Illustrated Through a Same-Day Conservative Anterior Veneer Case Dan Butterman, DDS, ficoi
Abstract Chairside CAD/CAM systems have advanced to the point where same-day milled restorations can meet the esthetic standard historically reserved for laboratory-fabricated ceramics. This article reviews the principal clinical advantages of in-office milling—workflow efficiency, elimination of provisional-related complications, tighter clinician control over design and shade, and material performance suited to same-day delivery—and illustrates them through a conservative, 6-unit anterior veneer case completed in a single appointment. The case was digitally captured with an intraoral scanner (Primescan 2), designed in CEREC 5.3 software, milled in-office from monolithic lithium disilicate (IPS e.max), and finished with hand contouring, staining, and glazing prior to same-day bonding. The result demonstrates that, with attention to digital design and chairside characterization, an in-office milled esthetic case can be both efficient and esthetically indistinguishable from a laboratory-fabricated restoration.
Keywords Chairside CAD/CAM, same-day dentistry, lithium disilicate, digital veneer design, intraoral scanning, esthetic restorations
Disclosure Author is a KOL for Dentsply Sirona.
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The result demonstrates that, with attention to digital design and chairside characterization, an in-office milled esthetic case can be both efficient and esthetically indistinguishable from a laboratoryfabricated restoration.
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About the author
Introduction Chairside CAD/CAM has moved well beyond single-unit posterior crown replacement, which was its original and most common application. As intraoral scanning accuracy, milling precision, and ceramic materials have matured, the same digital workflow is now routinely capable of producing esthetic anterior restorations that meet the standard patients and clinicians expect from laboratory-fabricated veneers— without the second appointment, temporary restoration, or shade-communication uncertainty that traditionally accompanies indirect esthetic dentistry. The purpose of this article is twofold: first, to review the specific clinical advantages that chairside milling offers over the conventional impression-provisional-laboratorycementation sequence, particularly for esthetic anterior cases; and second, to
dan butterman, dds, ficoi
illustrate those advantages through a representative case—a conservative anterior veneer treatment scanned, designed, milled, characterized, and delivered entirely within a single visit.
Dr Dan Butterman is a 1994 graduate of the University of Maryland School of Dentistry. He also is a graduate of the Misch International Implant Institute, a Fellow of the International Congress of Oral Implantologists, and a member of PEERS Implant Faculty Group. Dr Butterman is an advanced CEREC trainer, Faculty Chair at CDOCS.com., and Chief Dental Officer for Spear Education. He lectures nationally and internationally on all aspects of digital dentistry, and is a hardware, software, and materials Beta tester. Dr Butterman maintains a general practice in Centennial, Colorado with an emphasis on implant and digital dentistry.
Advantages of Chairside Milling for Esthetic Restorations Elimination of the Provisional Phase The most immediate advantage of same-day milling is that it removes the provisional restoration from the treatment sequence entirely. Provisionals for anterior esthetic cases carry well-recognized risks: marginal leakage, debonding, fracture, gingival irritation, and shade or contour compromises that can shift patient expectations before the definitive restoration is ever seated. Same-day chairside milling collapses preparation, fabrication, and delivery into a single visit, removing the window in which these complications can occur and removing the need for a second anesthetic and appointment.
Immediate Verification Against Living Tissue and Occlusion Because the definitive restoration is designed, milled, and delivered while the patient is still in the chair, shade, contour, and occlusal relationships are verified directly against the patient’s own soft tissue, adjacent dentition, and functional movements— not against a stone model or a provisional that may itself have shifted. This shortens the feedback loop between clinician and outcome: contour or contact discrepancies are caught and corrected chairside rather than at a second appointment after a laboratory has already fabricated a final restoration from an impression or scan that may not reflect the current tissue position.
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Clinician Control Over Esthetic Design Digital design software places incisal length, embrasure form, line-angle position, and diastema closure directly under the treating clinician’s control, informed in real time by the patient’s lip line, facial midline, and smile dynamics—rather than relying on a laboratory technician’s interpretation of a prescription and photographs. For conservative veneer cases in particular, where the esthetic result depends on subtle proportion and symmetry decisions, this direct control is a meaningful advantage over indirect communication with an outside laboratory.
Material Performance Suited to Same-Day Delivery Advances in millable ceramics—most notably lithium disilicate (IPS e.max)—have made same-day esthetic milling clinically practical. Full-contour lithium disilicate blocks can be milled to conservative 0.5 mm thicknesses while retaining flexural strength adequate for anterior function, and are available in a range of shades and translucencies that support layered esthetic effects without a separate layering/ porcelain-buildup step. This combination of mill-friendly handling and esthetic range is what allows a same-day restoration to compete with a layered, laboratoryfabricated veneer rather than serving only as an interim or lower-esthetic-demand solution.
Practice and Patient Efficiency From a practice-management standpoint, same-day delivery consolidates what is traditionally two or more appointments (preparation/impression, provisional management, and delivery) into one, reducing chair-time overhead, laboratory turnaround dependency, and shipping/remake risk. For patients, this translates directly into fewer visits, no interim restoration to maintain, and a shorter overall treatment timeline—all of which have become meaningful differentiators as patient expectations around convenience have risen.
A Caveat: The Mill Produces Form, Not the Final Esthetic Result These advantages are only realized when the chairside workflow is executed with the same attention to design and characterization that a laboratory would apply. A milled restoration straight off the mill is dimensionally accurate but esthetically unfinished; hand contouring, staining, and glazing remain necessary steps, and skipping or rushing them is the most common way same-day dentistry falls short of laboratorylevel esthetics. The case below illustrates a workflow in which this finishing step was treated as integral to, not separate from, the digital process.
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Case Report
Digital Impression
The following case illustrates the advantages described above in a conservative,
Following preparation, a full-arch
6-unit maxillary anterior veneer case completed in a single appointment.
digital scan was captured with the Primescan 2. The scanner’s improved
Presentation The patient presented with worn, discolored maxillary anterior teeth and an uneven midline and adjacent diastemas. The existing dentition showed flattened incisal edges, irregular tooth form, and a shade that no longer matched the patient’s esthetic goals. The treatment plan called for conservative veneer preparations on the maxillary anteriors, restoring incisal length, correcting the diastemas, and reestablishing symmetric proportions and line angles, while preserving as much natural tooth structure as possible.
surface capture and color/texture rendering made it straightforward to visualize margins, tissue contours, and adjacent tooth anatomy directly on the acquisition screen—an important check before moving into design, since any voids or pulls at the margin are far easier to correct with a rescan than after milling.
Digital Design The scan was imported directly into CEREC design software, where a biogeneric proposal was generated and then refined tooth by tooth. Because this was a conservative veneer case rather than a full-coverage restoration, particular attention was paid to incisal edge position, facial contour, and interproximal closure of the diastemas—using the adjacent, Figure 1. Pre-operative retracted view showing worn incisal edges, uneven wear pattern, and shade mismatch.
unprepared teeth and the patient’s lip line as reference. The design was adjusted to restore natural incisal embrasures and line-angle symmetry rather than simply filling in the biogeneric default anatomy.
Figure 2. Pre-operative full-arch retracted view. Note the flattened anatomy and midline diastema to be addressed in the design.
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Milling Once the design was finalized, the restorations were milled chairside on the PrimeMill from full-contour IPS e.max lithium disilicate blocks. E.max was selected for this case for the same reasons it has become a default material for conservative anterior veneers: high flexural strength in a monolithic block that can still be milled thin, a range of shades and translucencies that support layered esthetic effects, and a well-documented bonding protocol to enamel. The PrimeMill’s wet-milling process Figure 3. Occlusal scan of the preparations captured with the Primescan 2, showing clean margins and full arch detail used for the CEREC design.
produced smooth, accurate surfaces directly off the mill, which shortened the chairside finishing time considerably.
Figure 4. Second view of the digital scan showing the prepared teeth from the frontal aspect, used to verify tissue contours and margins prior to design.
Figure 5. CEREC design proposal, frontal view, showing the digital wax-up over the prepared teeth used to guide milling.
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Chairside Finishing and Characterization
Delivery
Same-day milled restorations are only as esthetic as the finishing work that follows
The finished veneers were try-in verified
the mill. After crystallization in a Programat CS6 oven, each veneer was tried
for shade, contact, and marginal fit,
in to verify fit, contact, and color before final characterization. Contouring was
then bonded using a standard etch-
performed under magnification to refine facial line angles, incisal translucency,
and-bond resin cementation protocol
and surface texture (perikymata and micro-line angles) so the restorations would
appropriate for lithium disilicate.
reflect light the way natural enamel does rather than looking flat or overly uniform.
Occlusion was checked and refined in
Staining was used selectively to add depth at the incisal third and to blend internal
both static and excursive movements
characterization with the adjacent natural dentition, followed by a controlled glaze
before the patient was dismissed—start
firing to seal the surface and refine gloss.
to finish, in a single appointment.
This contouring and characterization sequence is the step that most distinguishes
Chairside contouring—refining line
an in-office milled restoration that looks milled from one that looks laboratory-
angles, embrasure form, and surface
fabricated—the mill produces the form, but hand-finishing under magnification
texture on the restoration itself under
produces the illusion of natural tooth structure.
magnification—is what converts an accurate milled shape into a restoration that reads as natural tooth structure. The images below show this step being carried out directly on an e.max restoration prior to staining and glaze.
Discussion This case demonstrates each of the advantages discussed above in practical terms. The provisional phase was eliminated entirely, so the patient avoided the marginal, esthetic, and phonetic compromises that interim Figure 6. Chairside contouring of an e.max restoration: identifying anatomical landmarks with a marking pencil and positioning the restoration against the diamond bur to refine line angles and facial contour.
restorations can introduce over a multiweek laboratory turnaround. Shade, contour, and incisal length were verified directly against the patient’s lip line and adjacent natural teeth chairside, with corrections made in the design software before milling rather than after a laboratory-fabricated restoration arrived. Diastema closure and embrasure form—both subtle esthetic judgment calls—were controlled directly by the treating clinician rather than communicated indirectly through a laboratory prescription. IPS e.max was selected specifically because its combination of flexural strength and
Figure 7. Post-operative smile view. Shade, translucency, and surface texture blend naturally with the patient’s unprepared adjacent teeth.
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mill-friendly handling allowed the
veneers to be milled to a conservative thickness while retaining the esthetic
Conclusion
depth needed for an anterior case. And
In-office milling of esthetic
the entire sequence—scan, design, mill,
restorations has reached a point
characterize, bond—was completed in
where a conservative anterior veneer
one appointment, consolidating what
case—scanned, designed, milled,
would traditionally require at least two
characterized, and delivered entirely
visits.
within a single appointment—can meet a high esthetic standard while offering
It is worth reiterating that these
clear advantages over the conventional
advantages depend on the chairside
impression-provisional-laboratory
team treating digital efficiency and
sequence: elimination of the provisional
esthetic finishing as complementary
phase, immediate verification against
rather than competing priorities. The
living tissue and function, direct
milled restoration in this case was
clinician control over esthetic design,
dimensionally accurate immediately
and material performance suited to
off the mill, but the natural-looking
same-day delivery. Realizing these
result shown in the final photographs
advantages consistently requires that
came from the subsequent hand
chairside teams treat hand contouring,
contouring, selective staining, and glaze
staining, and glazing as an integral part
firing performed under magnification.
of the digital workflow rather than an
A same-day workflow that skips or
afterthought.
abbreviates this step trades the esthetic advantage of chairside milling for speed alone, which is not a favorable trade for anterior esthetic cases. Limitations of this discussion include that it is based on a single illustrative case rather than a controlled comparison, and that outcomes will vary with operator experience, case complexity, and the specific scanner, design software, mill, and ceramic material used. Broader case selection criteria—including the extent of existing restorations, occlusal scheme, and the amount of tooth structure available for conservative preparation—should continue to guide whether a given esthetic case is appropriate for a same-day chairside workflow versus a laboratory-fabricated restoration.
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FBI: Found But not Identified (yet) A series of articles intended to assist Texas Medical Examiners in giving a name to “unidentified” individuals using postmortem dental evidence.
Do you recognize the dental work/conditions presented? Megan E. Lenahan, DDS, MDS
A Silent Mass Disaster
The National Institute of Justice has described the enduring
The devastation mass disasters bring is familiar to everyone.
“Silent Mass Disaster.”1 The numbers are staggering. In 2025,
Hurricanes destroy homes and communities. Floods wash
nearly half a million missing-person records were entered into
away memories, businesses and lives. Aircraft crashes tear
the FBI’s National Crime Information Center (NCIC), averaging
families apart without warning. Specific dates, events and
more than 1,300 entries each day. Most were ultimately
headlines become etched into memories.
resolved, yet more than 88,000 missing-person records
Texans are no strangers to mass casualty events. The 2021
problem of missing and unidentified persons as the nation’s
remained active at year’s end.2
AstroWorld tragedy, the catastrophic flooding that swept
NamUs—the National Missing and Unidentified Persons
through the Texas Hill Country, and the horrific events in
System—helps bring those pieces together by providing
Uvalde. In each, the loss was immediate and visible, and the
a national platform and forensic support for missing,
response swift and focused. Every person mattered; every
unidentified, and unclaimed-person cases, including forensic
individual needed to be found, identified, and returned home
odontology.3 As of June 2026, NamUs reported 15,504 active
to their loved ones.
unidentified person cases, and the backlog continues to grow.
But across the United States, another mass disaster unfolds much more quietly. There is no single headline, no National Day of Mourning, no single moment when the magnitude of the problem becomes impossible to ignore. People disappear one at a time, across jurisdictions, decades, and generations. Unless it touches one personally, the true scale of that loss often remains invisible. But a tragedy is no less profound simply because it happens quietly.
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Texas represents almost 14% of these cases (as of January 2025), ranking only behind California and Arizona.5 Active NamUs unidentified cases have increased approximately 2-4% over the past few years.3-5 Like a cavity quietly expanding under the enamel surface, the incremental growth can be easy to overlook until the problem becomes impossible to ignore. The growth may be incremental. The impact is not.
How Texas Dental Professionals Can Be a Part of the Solution So, you’re sitting in your office, sipping Jo’s coffee, and you want to help. What can you actually do? First, when a medical examiner, coroner or other authorized investigator requests dental records, send the best records, and send everything. HIPAA should not be a barrier: HIPAA permits disclosure to coroners and medical examiners for the purpose of identifying a deceased person.6 Send the odontogram, clinical notes, every radiograph, photographs, treatment plans, referrals, and the ledger. There is no need to decide beforehand what is or is not important. A forensic odontologist will examine those records tooth by tooth, entry by entry, and quite literally pixel by pixel. Dental records are worth keeping as long as possible. Before an old paper chart is destroyed, practices should consider whether it can be scanned and retained electronically. Texas requires dentists to retain records for at least five years from the date of their last dental service. If the patient was younger than 18 years, records must be maintained until the patient reaches the age of 21 or five years after their last date of treatment, whichever is longer.7 Five years may satisfy the rule, but a radiograph preserved long after the required minimum may someday be the one that matters. And please, do not be embarrassed by your records or by the dentistry in them. Forensic odontologists are not there to audit charting or judge the quality of work. They do not work for the insurance company or the Texas Dental Board. In fact, a dentist’s “bad day at the office” may be a forensic odontologist’s best friend. An unusual restoration, imperfect crown margin, a short endodontic fill, or retained root tip may be the missing piece needed to send a loved one home. This isn’t about the dentistry. This is about helping families during one of the worst times of their lives.
How Is Identification Made? When an individual is found without a presumptive identity, the medical examiner uses the most appropriate identification methods available, depending on the condition of the remains. Each has inherent strengths and limitations. Latent prints (finger, palm, hand) are often the quickest and least expensive route to identification, but usable prints may not be possible, especially in cases involving advanced decomposition, fire, or skeletonization. Medical devices such as pacemakers or joint replacements may contain identifying information or serial numbers, although tracing those devices can require locating the physician or facility responsible for implantation. Dental records can provide a rapid, inexpensive, and highly reliable identification
Author
Megan E. Lenahan, DDS, MDS Dr Lenahan is a board-certified pediatric dentist, private practice owner, and forensic odontologist in St. Louis, Missouri. She earned her DDS at University of Missouri–Kansas City and completed her pediatric residency and Master of Dental Science at the University of Tennessee Health Science Center in Memphis. Dr Lenahan has held numerous leadership roles within organized dentistry, including serving as president of both the Greater St. Louis Dental Society and the Missouri Academy of Pediatric Dentistry, as well as a member of the Missouri Dental Association Board of Trustees. She remains actively involved in organized dentistry, professional education, and advocacy within the profession. In addition to pediatric dentistry, Dr Lenahan has a strong professional interest in forensic odontology. She lectures in both pediatric and forensic dentistry and serves as Dental Team Lead for the Missouri Mortuary Operations Response Team. She completed formal training in forensic odontology through the University of Tennessee–Knoxville and continues advanced education and casework toward board certification in forensic odontology. Dr Lenahan is a Fellow of the International College of Dentists and a member of the American Academy of Forensic Sciences and the American Society of Forensic Odontology.
when a presumptive identity and adequate antemortem records are available.
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When no presumptive identity exists, a forensic odontologist can create a postmortem dental profile to enter into NamUs and NCIC for comparison with missing-person records.
A Call to Texas Dentists Sometimes the missing piece to this puzzle exists outside the medical examiner’s office.
Forensic anthropology can help develop a biological profile and provide additional identifying information from skeletal
It may be sitting in a Texas dental office.
remains. The goal of this series is to place distinctive dental findings DNA testing is another powerful tool. DNA may be compared
from long-term unidentified Texans directly in front of the
with known family members, searched through the FBI’s
dental professionals who may recognize them. Maybe you
Combined DNA Index System (CODIS), and, in long-term
recognize your own work, remember an unusual patient, or
unidentified cases in Texas, submitted for additional testing
recognize a radiograph better than you could ever recall a
and comparison at the University of North Texas Center for
face.
Human Identification. But this isn’t CSI: Houston. This process isn’t done during an ad break. It can take months, sometimes
So take a close look. Texas Dentists, Dental Auxiliaries and
years.
Staff: Can you help the Dallas County Medical Examiner’s Office give a name to the unidentified male decedent
But what happens when all of these methods fail to produce
described on the following pages?
a name? Is this the proverbial end of the road? And is that good enough for the families?
Have You Seen This Premolar? Supernumerary teeth are uncommon, occurring in approximately 0.1–3.8% of the permanent dentition.8 Narrow that down further: how often do you see an extra maxillary premolar? Supernumerary premolars occur in only about 0.075–0.26% of the population and are considerably more common in the mandible than the maxilla.8-9 A solitary maxillary supernumerary premolar is therefore exactly the kind of unusual finding that might stick in your mind.
The Unidentified Individual:
Dallas County Medical Examiner (DCME) Case #26-05071 Decedent found:
March 25, 2026
Body Condition:
Skeletonized
Sex:
Male (DNA confirmed)
Ancestry:
Hispanic/white (anthropological assessment)
Age:
Adult
DNA analysis completed:
CODIS eligible profile has been obtained and entered into the CODIS database.
Dental Evidence Recovered:
Maxilla
Details of Incident:
On 3/25/2026 at approximately 8:45 a.m., a contract crew reportedly located a human cranium while clearing shrubbery in a wooded area near 8200 Mayforge Drive in Dallas, Texas. The location of the cranium was reported to local law enforcement on the same date. The Dallas Police Department conducted additional searches of the wooded area and did not locate any additional remains.
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Dental Postmortem Photographs DCME Case #26-05071
Right Lateral View
Frontal View Left Lateral View
Occlusal View
Supernumerary Occlusal View
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Dental Postmortem Radiographs DCME Case #26-05071
UL PA #12, 13, 63, 14, 15 UL PA #12, 13, 63, 14
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Dental Existing Conditions DCME Case #26-05071: Tooth #
Postmortem Case #26-05071
1
Missing
2
Present
3
Present
4
Present
5
Missing Postmortem
6
Missing Postmortem
7
Missing Postmortem
8
Missing Postmortem
9
Missing Postmortem
10
Missing Postmortem
11
Missing Postmortem
12
Present
13
Present Rotated 180 degrees #63 (supernumerary) present palatally to 13
14
Present
15
Present
16
Missing
Notes: Universal numbering used throughout report. Mandible not recovered.
Closing
References:
If you believe you have dental records, radiographs,
2.
photographs, scans, or other information that may relate to the unidentified male described as DCME Case #26-05071, please contact either Steven Kurtz, Chief Medicolegal Death
1.
Silent Mass Disaster. NIJ Journal. 2007;256.
Office at (214) 920-5900.
Federal Bureau of Investigation. 2025 NCIC Missing Person and Unidentified Person Statistics. 2026.
3.
National Missing and Unidentified Persons System. Monthly Case Report: June 2026. National Institute of Justice. 2026.
4.
Investigator, or Keara St Louis, Deputy Chief Medicolegal Death Investigator at the Dallas County Medical Examiner’s
Ritter N. Missing Persons and Unidentified Remains: The Nation’s
National Missing and Unidentified Persons System. Bi-Annual Report: January 2024. National Institute of Justice. 2024.
5.
National Missing and Unidentified Persons System. Bi-Annual Report: January 2025. National Institute of Justice. 2025.
6.
U.S. Department of Health and Human Services. Health Information of Deceased Individuals; and 45 C.F.R. §164.512(g)(1).
This case has a number. It should have a name.
7.
Texas State Board of Dental Examiners. 22 TAC §108.8(b). Records of the Dentist.
8.
Pasha Z, Choudhari S, Rathod A, Sulabha AN. Bilaterally impacted mandibular supernumerary premolars associated with unusual clinical complications. J Pharm Bioallied Sci. 2013;5(2):166-169. doi:10.4103/0975-7406.111826.
9.
Bandi S, et al. Favorable Outcome of a Maxillary Supplemental Premolar. 2018.
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value
for your profession Provided by:
PERKS
P R OG R A M
7 Critical Dental Imaging Problems Every Practice Must Solve by Balaji Mohanam, Head of Product, Practice at Overjet Dental professionals and support staff encounter imaging errors daily. They can occur at any point from positioning the sensor to interpreting the final image, and they often lead to retakes. But retakes expose patients to additional radiation and consume more chair time. Over time, repeated errors can disrupt schedules, increase costs, and complicate insurance processing. By understanding the most common problems and how to resolve them, teams can target their efforts to minimize disruptions, improve workflow, and maintain accuracy and efficiency. In this article, we’ll cover seven major categories of dental radiography errors—and tips for avoiding them. Let’s take a moment to talk about retake rates.
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What Is an Acceptable Retake Rate? Annual retake rates in dental imaging are tracked as a percentage of total images acquired. For example, if a practice performs 400 images per month and 48 retake exposures monthly are needed, that equates to a 12% retake rate. •
Optimal: Rates under 5%
•
Acceptable: Industry standards suggest a retake rate below 10%
•
Problematic: Rates consistently above 15%
1. Missing Apices on Periapicals Missing apices mean incomplete anatomical coverage on periapical images. They are primarily caused by incorrect X-ray positioning techniques. The sensor may be placed too close to the crowns or not deep enough in the mouth. If the angulation of the X-ray beam is incorrect, the root tip can be cut off, leaving the apex outside the field of view.
Key Positioning Strategies •
Vertical angulation: Align the X-ray beam parallel to the long axis of the tooth to capture the entire root length.
•
Sensor placement: Position the receptor deep enough in the mouth to cover all root tips.
•
Preview verification: Check images for foreshortening or elongation before finalizing exposure.
For anterior teeth, the sensor is placed high in the palate for upper teeth or deep in the floor of the mouth for lower teeth. For posterior teeth, the sensor is placed slightly away from the teeth and parallel to the long axis, using the bite block for support.
2. Overlapping Contacts on Bitewings Contact overlap on bitewing radiographs occurs when tooth surfaces appear superimposed, so the spaces between teeth are not clearly visible. This type of dental radiography error makes it difficult to detect interproximal caries (cavities that form between teeth). Correct X-ray positioning techniques are used to reduce overlap and open the spaces between teeth on the radiograph. The most important technical factor is how the X-ray beam is aimed at the teeth. Aligning the beam perpendicular to the contact points of interest ensures that the spaces between teeth are captured cleanly. Embrasure alignment serves as a helpful visual cue; line up the open area between two teeth (the embrasure) with the central ray of the X-ray beam.
Positioning Device Options •
Bitewing tabs: Simple, low cost, flexible placement, but offer less precise alignment
•
Rinn holders: More consistent results with built-in aiming rings, but are bulkier for patients
•
Digital sensor holders: Maximize stability and fit for specific sensor types
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value
for your profession Continued
Always use a digital preview of the image to verify that contacts are open before finalizing the exposure. Acceptable contact opening means each interproximal space
Dental professionals and support staff encounter imaging errors daily. They can occur at any point from positioning
appears as a radiolucent line without overlap from adjacent teeth.
the sensor to
3. Cone Cut and Collimation Misalignment
interpreting the final image, and they often
Cone cutting occurs when a misaligned X-ray beam leaves blank areas on images. Along with collimation misalignment, these problems prevent full visualization of dental structures and can require retaking the image. The position indicating device (PID) is the part of the X-ray machine that directs the X-ray beam. To avoid cone cuts, line up the center of the PID with the center of the aiming ring on the receptor holder. The PID and the receptor must remain parallel to each other so the X-ray beam covers the full area of the sensor or film.
Pre-Exposure Checklist •
Collimator shape: Match to receptor size (rectangular for digital sensors, round for film).
•
Patient size: Select appropriate settings for pediatric vs adult anatomy.
•
Beam alignment: Verify the collimator covers entire receptor area without blocking.
Common misalignment patterns include the upper or side edges of the image being cut off. Recognize these patterns early and correct them by adjusting the PID position before exposure.
4. Under- or Over-Exposure Artifacts Exposure errors in dental radiography occur when the X-ray image is either too light (underexposed) or too dark (overexposed). These artifacts are caused by incorrect selection of exposure variables such as kilovoltage peak (kVp), milliamperage (mA), and exposure time. Underexposed images appear grainy and lack detail, while overexposed images have excessive darkness and reduced contrast. Both make it difficult to see important anatomical structures. Optimal exposure characteristics require a clear differentiation between enamel, dentin, pulp, and surrounding bone, with visible contrast and density appropriate for the region being imaged. Exposure settings are adjusted for each patient depending on the thickness of the dental arch and region being imaged. Maxillary molars may require higher kVp or
312 Texas Dental Journal | Vol 143 | No. 6
lead to retakes. But retakes expose patients to additional radiation and consume more chair time. Over time, repeated errors can disrupt schedules, increase costs, and complicate insurance processing.
longer exposure time than mandibular
manufacturer instructions. Position the
anterior teeth due to increased bone
X-ray tube head close to the patient’s
density.
face, verifying the angle and distance to ensure consistent, sharp images.
Develop standardized protocols by creating exposure charts for each tooth group and sensor type, specifying recommended kVp, mA, and exposure time for different regions and patient sizes.
5. Motion Blur and Unstable Source-toReceptor Distance
6. Inadequate Labeling and DICOM Workflow Breakdowns
7. Missed Incidental Findings from Interpretation Gaps There are legal and ethical responsibilities for dental professionals to conduct comprehensive imaging reviews and to document any significant or potentially harmful findings in the
Accurate labeling is very important
patient record.
because mislabeled or lost images can lead to misdiagnosis, repeat exposures,
A systematic approach can help reduce
treatment planning confusion, or
interpretation gaps. A complete review
insurance claim complications.
of every dental image should include
Incomplete DICOM workflow may also
periapical areas, periodontal bone
Motion artifacts in dental imaging
disrupt data transfer between devices
levels, caries detection, restoration
are caused by movement during
or systems.
margins, endodontic status, anatomical
exposure. This movement can come
landmarks, pathology, implant integrity,
from the patient, the sensor, or the
Current DICOM workflow integration
X-ray tube head. These artifacts
can present challenges, such as
appear as blurriness or double images,
compatibility issues among different
Overjet’s dental AI, for example, is
which reduce diagnostic accuracy
imaging software, practice management
trained to highlight subtle pathologies
and lower the professional quality of
systems, and PACS. Practices may
and high-risk findings, which may go
the radiograph. Distance-related blur
encounter difficulties transferring
unnoticed by human reviewers. When
occurs when the space between the
data seamlessly, leading to workflow
the AI flags possible abnormalities,
X-ray source and the image receptor
disruptions or data silos.
dental professionals can compare
is inconsistent or violates equipment guidelines.
Patient Stabilization Techniques • •
•
and soft tissue evaluation.
these findings with their clinical Solutions to these challenges include
assessment and make decisions about
adopting standardized DICOM
documentation and follow-up.
protocols, leveraging middleware platforms that bridge disparate systems,
This hybrid process supports thorough
Headrest positioning: Keep the
and working with vendors, such as
review and helps meet documentation
patient’s head steady and aligned.
Overjet, that offer robust integration
standards for incidental findings.
Breath-hold instructions: Use
support. These strategies help ensure
a clear countdown method to
smoother, more reliable data exchange
TDA Perks Program-endorsed Overjet
minimize movement.
and promote interoperability across
is a dental AI platform that annotates
Bite blocks: Prevent sensor
dental technologies.
X-rays in real time, automatically writes
shifting inside the mouth during
clinical notes during appointments, and Digital systems use tools like barcode
streamlines insurance verification. TDA
scanners, wristbands, or direct
members receive significant discounts
The recommended source-to-receptor
connections to practice management
on Overjet. Learn more at tdaperks.com
distance depends on the imaging
software to confirm patient identity
(Compliance and Supplies) or call 617-
system. Intraoral radiographs typically
before imaging. A common process
458-7964.
use a distance of 20 to 40 centimeters,
is the two-identifier verification,
whereas panoramic and CBCT systems
which involves matching at least two
have specific, fixed distances set by
unique pieces of patient data before
the equipment. Before taking images,
proceeding with image capture.
exposure.
check and set the distance according to
www.tda.org | September 2026
313
classifieds Opportunities Online at TDA.org and Printed in the
Texas Dental Journal CLASSIFIEDS INFORMATION DEADLINE
PRACTICE OPPORTUNITIES ALL TEXAS LISTINGS FOR MCLERRAN & ASSOCIATES. AUSTIN (ID #745): Established, 2-location GD practice in the Austin area. The practice serves a large, diverse, FFS/PPO patient base with excellent new patient flow, a
Copy text is due the 20th of the month, 2
combined 14 equipped operatories across both
months prior to publication (ie, January issue
locations (with substantial room for expansion
has a due date of November 20.)
at one of the locations). The practice comes fully
MONTHLY RATES PRINT: First 30 words—$60 for ADA/TDA members and $100 for non-members. $0.10 each additional word.
equipped with digital radiography, digital sensors, digital scanners, digital Pano, CBCT, and paperless charts. AUSTIN (ID #762): Established GD office in the heart of central Austin with a majority PPO patient base, 1000+
ONLINE: $40 per month (no word limit). Online
active patients, a robust hygiene recall program,
ads are circulated on the 1st business day of
and a strong reputation online and in the
each month, however an ad can be placed within 24 business hours for an additional fee of $60.
community they serve. The 1,500 sq ft office space contains 3 total operatories, computers throughout, a digital x-ray scanner, and intra-
SUBMISSION
oral cameras. The practice has consistently
Ads must be submitted, and are only
generated revenue of mid-6 figures with
accepted, via www.tda.org/MemberResources/TDA-Classified-Ads-Terms. By official TDA resolution, ads may not quote
abundant upside opportunities to expand roduction/cash flow through launching strategic
specific incomes or revenues and must be
marketing and advertising initiatives, driving
stated in generic terms (ie “$315,000” should
new patient flow, and offering additional
be “low-to-mid-6 figures”). Journal editors
advanced procedures in-house. AUSTIN (ID
reserve the right to edit and/or deny copy.
#790): Established periodontic practice in highly sought after central Austin with abundant upside potential. The well-appointed 1,840 sq ft
314 Texas Dental Journal | Vol 143 | No. 6
space has 5 fully equipped operatories with
#832): Newly renovated GD practice in one of
room for future expansion, computers
DFW’s most prominent suburbs. This 100% FFS
throughout, digital x-ray sensors, and paperless
office features a newly constructed facility with
charts. The 100% FFS practice is built on an
5 fully equipped ops, room for future
impeccable foundation with a diverse referral
expansion, computers throughout, digital x-ray
network, solid hygiene recall, and virtually no
sensors, CBCT, CAD/CAM milling unit, a dental
investment in marketing & advertising. AUSTIN-
laser, intra oral cameras, and paperless charts.
SOUTH (ID #803): GD practice located south of
Rooted in bread-and-butter dentistry, this is
Austin in a high-traffic retail center. 5 fully
rare opportunity to step into a highly profitable,
equipped operatories with an additional ortho
turn-key office, with strong patient
bay set up, digital radiography, intra oral
demographics, and room for growth. DALLAS/
cameras, paperless charts, a digital pano, and a
FORT WORTH-PEDO (ID #849): Rare
digital scanner. Large PPO/FFS/Medicaid patient base with over 1,900 active patients and see 45+ new patients per month. If you are looking
+
for a practice that is primed for continued growth in a growing suburb of Austin with great visibility, reach out to learn more! DALLASWEST (ID #810): Well-established GD practice in a prime location west of the DFW metroplex.
The Premier Sell-Side Advisor for Dental Practice Owners
The 3,800 sq ft facility contains 13 fully equipped operatories with digital x-ray sensors, CBCT, digital scanner, dental laser, intraoral cameras, and room for future growth. The practice supports a large PPO/FFS patient base, has strong cash flow and robust hygiene recall. This office provides a strong clinician and operator the ability to take advantage of the extraordinary foundation built and future upside potential. DALLAS/FORT WORTH (ID
1,200+ Successful Practice Sales Contact us today to schedule a FREE consultation!
$1.5 Billion Closed Transaction Volume
100 Years of Collective Dental Industry Experience Whether you are considering a doctor-to-doctor sale, scaling your business, or exploring a DSO affiliation, our team has the experience and expertise to educate you on your options and guide you through the process.
texas@dentaltransitions.com (512) 900-7989
www.dentaltransitions.com
Ryan Moncrief
Arie Muniz
Principal, President
Partner, M&A
www.tda.org | September 2026
315
classifieds opportunity to purchase a rapidly growing
successful oral surgery practice and real estate
pediatric dental practice ideally located in the
in the Houston area. Large, majority fee-for-
Dallas-Fort Worth metroplex. Established in
service patient base which is supported by
2023, the practice has scaled at an impressive
long-standing referral sources. The office is in a
pace with 7+ figures of collections over the last
large, free-standing building with high-end
12 months. Large, diverse patient base,
finishes throughout that occupies over 4,000 sq
supported by a strong referral network of
ft. The practice has generated over 7 figures in
dentists, stellar online reputation. Beautifully
revenue over the last 3 years with strong
designed, modern approximately 2,000 sq ft
margins of 44%+ annually. The seller is available
retail facility, equipped with excellent
to continue working in the practice for a short-
technology, including a 3D cone beam, digital
or long-term transition to help finish out cases
scanner, dental laser, and digital x-ray sensors.
and ensure a smooth transition to patients and
This turn-key practice is an outstanding
referral sources. HOUSTON-NORTHWEST (ID
opportunity for a pediatric dentist looking to
#843): Legacy, multi-provider GD practice
establish a presence in one of the fastest-
located north of Houston. Large and diverse
growing markets in the country. HOUSTON-
patient base of 4,000+ active patients,
SOUTH (ID #809): GD practice and real estate
approximately 58 new patient appointments
in a highly desirable suburb south of downtown
per month, payor mix of FFS, PPO, and
Houston. The office features modern build-out,
Medicaid. Conveniently situated along a major
occupies just over 2,800 sq ft, and includes 5
thoroughfare, the approximately 2,500 sq ft
fully equipped operatories with digital
facility features 6 fully equipped operatories, is
radiography, intraoral cameras, paperless
fully digital and includes computers throughout
charts, and CBCT. Majority PPO/FFS patient
the office, digital x-ray sensors, a panoramic
base with over 1,300 active patients, strong
x-ray unit, CBCT, a digital scanner, intraoral
hygiene recall program with just over 20% of
cameras, and digital charts. The office has a
production coming by way of hygiene
robust hygiene recall program that supports
procedures. HOUSTON-OMS (ID #835): Rare
consistent patient retention. HOUSTON-
opportunity to purchase an established, highly
SOUTHWEST (ID #844): Thriving GD practice
316 Texas Dental Journal | Vol 143 | No. 6
and real estate southwest of Houston near the
close to 7 figures and has strong net cash flow
coast. 4 fully equipped operatories with digital
annually. The real estate is available for sale or
x-ray sensors, intra oral cameras, paperless
lease, and the outgoing owner is flexible in
charts, a digital scanner and CBCT. Large PPO/
regards to the transition period. SOUTH TEXAS
FFS patient base, healthy new patient flow
COAST (ID #783): Established GD office in a
driven primarily through internal referrals and
quaint town near the Texas Gulf Coast. 100%
an excellent reputation. The practice has
FFS office, multi-generational active patient
realized revenue of 7 figures over the last
base (1,000+). 1,600+ sq ft facility containing 3
several years with strong profit margins over
operatories with computers in each, digital
40% and future opportunities for growth. SAN
x-ray sensors, a Pano, and fully digital charts.
ANTONIO-SOUTHWEST (ID #826): Legacy GD
The practice has impressive net cash flow
located in northwest San Antonio in a high-
margins (75%+) and there are several
visibility retail center along a major
opportunities for post-sale growth. WEST
thoroughfare. The 1,800+ sq ft facility features 6
TEXAS-PEDO/ORTHO (ID #796): Large
total operatories with advanced equipment/
pediatric dentistry and orthodontic practice
technology including a CBCT, x-ray sensors,
located in a large metro area in west Texas.
dental laser, intraoral cameras, and computers
Fantastic reputation in the local community.
in each of the operatories. Serving a FFS/PPO
Large, predominantly FFS/PPO patient base,
patient base, the practice has healthy
strong growth potential, and a massive, turn-
profitability levels with strong historical cash
key facility with 15+ operatories. The owner
flow margins of 40%+. SAN ANTONIO-OMS (ID
doctor would love to continue working part-
#839): Established, successful oral surgery
time for up to 3 years following closing before
practice and real estate, outstanding reputation
eventually transitioning into retirement. TO
in the community. Large, FFS/PPO patient base
REQUEST MORE INFORMATION ON
supported by an expansive, diverse referral
MCLERRAN & ASSOCIATES’ LISTINGS: Please
base. Spacious facility, offering the ability for
register at www.dentaltransitions.com or
the incoming owner to scale and expand the
contact us at 512-900-7989 or info@
practice. The practice consistently generates
dentaltransitions.com.
www.tda.org | September 2026
317
classifieds CENTRAL TEXAS: For sale by owner, this long-
SAN ANTONIO: Well established GD practice
established GD office is located in central
in north-central San Antonio, near Olmos
Texas, with 3 operatories and a hygienist room,
Park and Trinity University, for sale by owner.
3 nitrous, and a dental lab. Perfect for the
Very strong hygiene recall program with great
dentist looking to establish their first practice
potential for future growth. Doctor retiring
ownership. Located near great fishing, 2
after 50 years and is currently working 3 days/
golf courses and a wonderful school system.
week but consistently generates 6-figure annual
After 50 years of practicing, there are more
collections. Tremendous upside opportunities
than 2,000 active case files available to the
for expansion and growth. A true gem for
new owner! Contact Bart Johnson: bartj@
someone to start a practice or relocate. Call or
painterandjohnson.com or 325-642-0721.
text Dr David Masters 210-392-9128.
ODESSA: Established Odessa general dental
WATSON BROWN PRACTICES FOR SALE:
practice with 4 operatories and expansion
Practices for sale in Texas and surrounding
potential. This 100% FFS practice serves 1,840
states. For more information and current
active patients, welcomes 30-35 new patients
listings please visit our website at www.
monthly, and collects almost 7 figures. Owner
adstexas.com or call us at 469-222-3200 to
is open to partnership or full sale. Contact
speak with Frank or Jeremy.
bailey@theptsgroup.com or call: 719-694-8320. Ref #TX11525.
INTERIM SERVICES
SAN ANTONIO: San Antonio family practice for sale in the desired Alamo Heights
HAVE MIRROR AND EXPLORER, WILL TRAVEL:
neighborhood. Low-6 figure production, 3+1
Sick leave, maternity leave, vacation, or death, I
operatories, 1,100 active patients. Practice
will cover your general or pediatric practice. Call
is ideal for growth, startup or satellite clinic.
Robert Zoch, DDS, MAGD, at 512-517-2826 or
Contact my broker Watson Brown at 469-222-
drzoch@yahoo.com.
3200, www.adstexas.com.
318 Texas Dental Journal | Vol 143 | No. 6
YOUR PATIENTS TRUST YOU.
WHOM CAN YOU TRUST?
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JKJ Pathology................................................................ 246
McLerran & Associates............................................... 315
Omni Practice Group.................................................. 283
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TDA Perks........................................... Inside Front Cover
Southwest Sedation Education................................. 303
Watson Brown............................................................. 293
PRN Helpline Visit us online (800) 727-5152 www.txprn.com www.tda.org | September 2026
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