Predictable Cosmetic and Restorative Dentistry

Mike Malone, DDS

In this interview conducted by Dr. Damon Adams, editor-in-chief of Dentistry Today, Mike Malone, DDS, an accredited member and past president of the American Academy of Cosmetic Dentistry, candidly discusses matters of interest and relevance to all practicing dentists who are interested in improving their own restorative and aesthetic dentistry skills.

Many dentists seem to have recurring problems with adhesive ceramic dentistry and/or resin dentistry. Mike, you have been placing adhesive restorations for many years and also teach continuing education (CE) courses on the subject. How do you achieve predictable results in your own practice?
Dr. Malone: Believe me, I did not always achieve the results that I wanted! In my first year in private practice, I found out that my skill level was not at all where I thought it was. After attending a local Pankey Study Club meeting, I was embarrassed to even show my work. I immediately asked for help, and my colleagues suggested that I consider attending the Pankey Institute. Well, I signed up right away. In the next few years I also attended courses by Drs. Pete Dawson and the late Alvin Filastre (1923-2011). That early CE training, with both lecture and hands-on experience, helped me with concepts in practice and patient management, occlusion, and gaining precision in fixed and removable prosthodontics.

When I was a senior dental student, I had a life-changing event. I removed 2 old and discolored resin restorations from the central incisors of a very nice middle-aged woman. I was able to perform my first adhesive dentistry case with a light-cured resin restorative (Nuvafill). The final restorations resulted in my getting an A for that procedure. However, it was much more than the good mark that got me motivated; when I gave my patient a mirror and watched her eyes glow with excitement, I knew right then that I wanted to do that again and again. I continued to learn more about bonding and took some courses, reading as much as I could about any new developments. However, real changes and improvements in my aesthetic dentistry came in 1988 when I joined the American Academy of Cosmetic Dentistry (AACD) and started attending the annual AACD meetings. That helped me tremendously with getting and staying updated on information about all phases of aesthetic dentistry.

No dentist is failure-free, but we minimize our failure rate by using certain protocols or systems, many of which I learned about in those early CE courses. Of course, these must be continually updated as materials and techniques change. One of the most important steps any dentist must take to ensure success is isolation and moisture control. I did not learn how to use a rubber dam properly when I was in dental school, but a classmate gave me some tips a few months after graduation that changed my restorative life. For approximately 38 years, I have used a rubber dam on every restorative case, from occlusal resins to full-arch crown and bridge cases, for both prep and insertion. Fortunately, for those who will, for some reason, not use a rubber dam, there are new isolation aids that can also be very effective, such as the Isolite system. Of course impressions must be ideal, and I always take multiple impressions for complex cases to verify accuracy. I use several different types and brands of impression material as well as the CEREC Omnicam (Sirona Dental Systems) and they all work well. The main thing to remember is that often the material is not nearly as important as the technique! Impressions cannot be ideal without great tissue management. A combination of radiosurgery, tissue lasers, and mostly supragingival margins make tissue management easy. No adhesive dentistry will succeed without predictable adhesion. There are many excellent adhesives available today, but they do not all have the same requirements for success. Above all, it is imperative to follow the manufacturer’s directions for all adhesives and cement systems.

Let’s also not forget that one of the most overlooked reasons for ceramic failure is poor occlusion. Any dentist placing adhesive ceramics must be trained to consider and/or control occlusion. We start all patients with a complete examination, with study models mounted in centric relation. I’m convinced that understanding and controlling occlusion is critical for achieving predictable, long-term success for all restorative dentistry.

With all the changes in materials and techniques throughout the years, have you modified your preparations?
Dr. Malone: Absolutely, Damon! There has been a major paradigm shift in tooth preparation due to adhesive cements that do not require the degree of retention once required in our preps. With predictable adhesion using dentin primers and resin cements, we no longer need to prep in the same ways. For example, this means that we can use ceramic onlays instead of full crowns. An important outcome of this shift in how we approach prep design is the new emphasis on minimal tooth reduction and supragingival margins. With anterior teeth, we routinely prep for veneers as well. If we need lingual coverage because of decay or enamel loss, we can use 360° veneers that allow for maximal tooth preservation and strength.

One of my favorite books on adhesive dentistry, published in 2002 and authored by Pascal Magne and Urs Belser, is Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. The authors explain how we can achieve strength similar to a healthy tooth by using minimal preparation and predictable resin bonding of the ceramic restoration. Magne’s concept of biomimetics is based on providing bonded porcelain restorations that mimic natural teeth in aesthetics and strength.

Figures 1a to 1d. Centric relation bite (Vanilla Bite [DenMat]) taken at a predetermined and an open vertical dimension of occlusion using a composite anterior deprogrammer.

What is your favorite new technology and why?
Dr. Malone: Without a doubt, our CEREC CAD/CAM system (Sirona Dental Systems) is something we simply could not live without. The concept of minimal prep and adhesive ceramic restorations works perfectly with this CAD/CAM system. For cases of one to 4 units, we use CEREC routinely. With the proper work flow, the system saves us time and eliminates a second appointment, including, of course, the need for temporization. Our patients love the concept of having just one appointment and not having to put up with a temporary restoration for a number of weeks. 

Figure 2. Study models mounted in centric relation are vital to achieve predictable results with complex reconstructions.

Speaking of challenges with provisional restorations, many dentists complain about the strength, fit, and retention of their temporaries with veneer and onlay restorations. When you have to use these, what do you do in your practice to solve those retention and breakage problems?
Dr. Malone: Many of my large cosmetic cases require temporization for one to 3 months. I have developed systems using strong composite resin materials made indirectly on a stone model to overcome strength and retention problems. In my hands, Triad and Radica (DENTSPLY USA) provisional materials are my personal favorite temporary products. I take a quick and inexpensive impression with alginate, or an alginate substitute, and then have my assistant pour it up with a quick-setting stone, like Snap-Stone (Whip Mix). While my patient relaxes in a massage chair in our recovery room, I can make the custom temps directly on the model. This not only gives me a strong and great fitting temp, but this technique also takes the stress out of the process since the temps are not made directly in the patient’s mouth. By using this indirect technique, these materials can be also be layered with an enamel shade to give them more natural aesthetics. These thin and aesthetic temps are then luted securely to the preps so they are not dislodged or lost. I have been teaching hands-on courses utilizing this technique for more than 15 years.

Figures 3a to 3d. Isolation can make our work easier and more predictable. Demonstrating the use of a rubber dam during onlay and veneer preparation.

With all the advances in materials and technology today, many young dentists feel they need help with advanced learning. What do you recommend for them?
Dr. Malone: Fortunately, there is a plethora of CE opportunities for dentists to choose from these days. Sometimes it is hard to choose! However, I feel that most, especially young dentists, would benefit from one of the excellent hands-on teaching programs choices available. For example, I would highly recommend the Dawson Academy, the Pankey Institute, the Kois Center, or Spear Education. These programs teach dentists all aspects of restorative and aesthetic dentistry, from patient management to occlusion. Any dentist who wants to keep current with the latest in adhesive and cosmetic dentistry should also consider joining the AACD.

You were president of the AACD a few years ago, and I know that you are still involved with them. What is new with the organization and what does the future look like for the AACD and its members?
Dr. Malone: The future for the AACD looks bright! With great leadership and an extremely dedicated staff, our organization is in the right place at the right time. Anyone can be a member of the AACD and learn to enjoy the many benefits in joining. The majority of its members—more than 6,300—are general members, but all have the opportunity to go through the process of accreditation. The accreditation process has evolved though the years to become an extremely fined-tuned program that has 3 parts: first, the written exam, which now can be taken at testing centers located in all areas of the country; second, a series of clinical cases are presented to the Accreditation Board anonymously; and, finally, the process is completed with an oral examination. There are 404 accredited and 66 Fellowed members presently, and, at this time, more than 630 general members are in the process of going through the accreditation process. We are so excited about that!

Figures 4a to 4d. Minimal preparations left some enamel on every surface to maximize adhesive bond strengths and to save valuable tooth structure.

Damon, since the majority of AACD members are not accredited, I would really like to share some of the benefits of general membership with your Dentistry Today readers.

Absolutely, Mike. Go for it!
Dr. Malone: To me the most important part of the AACD’s mission statement is “advancing excellence in the art and science of cosmetic dentistry and encouraging the highest standards of ethical conduct and patient care though responsible aesthetics.” The AACD’s main focus is excellence in continuing education. Recent changes have made it easier than ever to increase one’s knowledge in many different ways. The best option for many members is to attend the annual meeting of the AACD. The annual AACD meeting is by far one of the very best venues for keeping up to date and it always has an exciting line-up of some of the best educators and clinicians in the world on restorative and aesthetic dentistry.

This year, the annual meeting will be held from May 6 to May 9 in San Francisco. New education initiatives this year include blended education (online and live training for maximum CEs), the next generation of cosmetic dentistry, live dentistry, lab day, and more. The AACD meetings feature all-inclusive pricing; there are never extra fees for hands-on workshops, and this also includes breakfasts, lunches, and social events. Furthermore, as an AACD member, if you can’t make it to the big annual meeting, or if you missed some of the courses, you can bring most of the speakers to your own computer with the AACD’s virtual campus. With simply a few clicks of your mouse, you can watch world-class education in your own home or office at a very reasonable cost.

Figures 5a to 5d. Layered temporaries (Radica [DENTSPLY USA]) made indirectly on a model that was poured up in fast-setting dental stone (Snap-Stone [Whip Mix]).

Another great benefit of AACD membership is the quarterly Journal of Cosmetic Dentistry. In the span of just a few years, this journal has become one of the best in dental publications. In addition to updating readers with the latest information on all types of restorative and aesthetic dentistry, there is now an article every month that offers 3 CEUs for members, at no cost. That’s 12 hours of CE credit annually, and that alone is worth the annual dues.

Just operational this year, the all new Find-a-Dentist Locator and Member Profile site will help patients more easily find an AACD member dentist, display patient-based reviews, offer multiple images (like before and after photos), videos, and comprehensive information about the dentist, the practice, insurance and payment options, hours, etc.

Figures 6a to 6d. (a and b) Final lithium disilicate (IPS e.max [Ivoclar Vivadent]) veneers being placed; and (b and c) before and after view of anterior veneers.
Figure 7. All 3 dentists in the office use the in-office CEREC CAD/CAM system (Sirona Dental Systems).

Dr. Adams: Your genuine and heartfelt enthusiasm for the AACD, based on your own personal and professional experiences, really comes through, Mike! As a supporter of the AACD’s mission and general member for many years, I would strongly agree that membership in this fine organization definitely has its benefits. Plus, I have found that in joining such an active and dedicated organization, one gets to meet many colleagues and leaders who are dedicated to excellence, and the chance to make and develop life-long friendships with like-minded professionals is one of the best benefits in belonging to the AACD.

I want to mention here that we truly appreciate the time you have taken from your busy practice schedule and, yes, even from your gator wrestling activities down in the great State of Louisiana, to do this interview for us. You are, and will always remain, a good friend of the Dentistry Today team.

I would like to come back now to close this discussion with a couple of questions that bring us back to your thoughts related to indirect dental materials. As you know, there are quite a few new and different all-ceramic materials available today.

Would you please share with our readers what systems you use in your practice and, briefly, what do you see for the future as it relates to these materials?
Dr. Malone: When I first started bonding ceramics to tooth structure, the only option we had was feldspathic porcelain. The next generation to come along was pressed leucite-reinforced glass-ceramic (IPS Empress [Ivoclar Vivadent], Authentic [Pentron], Finesse [DENTSPLY Prosthetics], Optimal Pressable Ceramics [OPC] [Jensen], and so on). This material, used to fabricate restorations using a fairly simple “lost wax technique” and pressing process, made it much easier to predictably fabricate stronger all-ceramic restorations. Unfortunately, the pressing technique required more reduction of the tooth to allow a thicker restoration to be pressed from the wax pattern. The end result was, in many cases, teeth that were over-prepared and often, had most or all of the enamel removed. More recently, lithium disilicate, one example of which is IPS e.max (Ivoclar Vivadent), has become the most widely used aesthetic high-strength polycrystalline ceramic in the world for bonded all-ceramic restorations, including full-coverage restorations, veneers, inlays, and onlays. This material can be pressed very thin so the tooth preparation can be very conservative, leaving enamel for more predictable substrate-to-tooth bond strengths. The vast majority of my all-ceramic cases are completed with lithium disilicate, typically using monolithic onlays on the posterior teeth and layered veneers on the anterior teeth. When I need maximal strength, and aesthetics is not of primary importance—say on a second, or sometimes a first molar—monolithic zirconia, such as BruxZir (Glidewell Laboratories), is my material of choice. For bridges, I like to use zirconia frameworks/substructures, such as IPS e.max ZirCAD (Ivoclar Vivadent). When optimal posterior aesthetics are desired, fluorapatite glass-ceramic ingots (IPS e.max ZirPress [Ivoclar Vivadent]) can be used to press over the ZirCAD framework material as well as other zirconia frameworks that have a CTE of 10.5 to 11.0.

In my opinion, the future for tooth-colored restorative dentistry is bright and wide open for further development. Ceramic materials will continue to improve in both strength and aesthetics as new systems are being developed and released. These improvements will continue to allow dentists to remove less healthy tooth structure when preparing for all-ceramic restorations. Our dentin/enamel bonding resins are also improving and becoming more and more user friendly. The combination of stronger, more aesthetic ceramics and easier to use, higher bond-strength cements will allow dentists to predictably accomplish beautiful results with minimally invasive dentistry.


Acknowledgement
The lithium disilicate restorations shown in the case presented were made by Mike Bellerino, CDT, of Trinident Laboratory in Metarie, La. Dr. Malone has been working Mr. Bellerino for more than 30 years.


Dr. Malone is a member of the ADA, American Equilibration Society, the Pierre Fauchard Academy, and the Pankey Alumni Association, and is an AGD Fellow. He is an accredited member and past president of the American Academy of Cosmetic Dentistry. He serves as a product evaluator for CLINICIAN’S REPORT and is a member of the Catapult Elite group. He has been writing for professional journals, teaching hands-on courses, and speaking for more than 20 years. He is also on the staff of Louisiana State University as an assistant clinical professor in prosthodontics. He maintains a full-time dental practice with 2 associates in Lafayette, La. He can be reached at via email at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Disclosure: Dr. Malone has no financial interest in any of the companies mentioned in this interview, but he does occasionally receive speaking honoraria from DENTSPLY and Ivoclar Vivadent.



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