Clinical Chat

Have you noticed any modification in the reduction of appointments and learning more about the patient and what would satisfy them?

Dr. Frank Vidjak: Have you noticed any modification in the reduction of appointments and learning more about the patient and what would satisfy them?

Dr. Stephen Wagner: Well a patient is not a patient I mean there is a lot of different levels – the ACP has their own classification of difficulty but you are also – I mean you are also talking from their standpoint. They are really involved in the psychology of the denture making and I think we also realize at some point that you are margin a denture for the patients head not for their jaws. What I tell people and I guess when I talk to general dentists here is that if you are not doing a lot of dentures then maybe you did not do enough in school to get started. What you want to do is select and easier patient and refer the other ones out, and so that is probably going to be the biggest decision you make when it comes to the success of a denture, is picking the patient right, in other words if you make beautiful denture and the patient is not a fan of it, the you are a failure or the denture is a failure you are a failure in the patient’s eyes. But so I think patient selection is important.

Have you ever recreated an entire denture for a patient?

Dr. Frank Vidjak: Have you ever recreated an entire denture for a patient that has lost one?

Dr. Stephen Wagner: I had a patient that was a lawyer here in Albuquerque and she was a lawyer by day and biker by night.

Dr. Frank Vidjak: (Laughs)

Dr. Stephen Wagner: And she had me make a denture that was a lawyer like denture, and then her evening wear were two gold canines in her denture. So I made her one that was her biker denture and one that was a lawyer denture. But I mean, you could I mean just think of it, you can now make an offer a second set which makes people a lot more secure, and you don’t have to redo the whole thing. Or let’s say they went on their cruise and they lost their teeth on their cruise, it is easy for you to make another one. You don’t have to go through the process of making it; you just have to go through the process of ordering it.

In the digital workflow, what if your philosophy in the discussion of the selection of teeth?

Dr. Frank Vidjak: In the digital work flow what is your philosophy and where do you fit t in, in the discussion of the selection of the teeth?

Dr. Stephen Wagner: What you can do now is have someone bring their picture to you and show you that picture. And they can match that tooth by manipulating let’s say from 22 they can turn it into the tooth to the tooth that the patient had when she was 22. So there are a lot of things t can be done that are very creative. So yes you can pick a tooth but maybe do a lot of thing that you did not even think you could do with that in the digital workforce.

What is it that makes Digital Denture Fabrication different from traditional?

Dr. Christopher Marchack: what is different about his digital work force, what is it that you are doing differently now.

Dr. Stephen Wagner: Al right instead of 6 we are down to 4, and we – in some cases and we will talk about this if we have time we are done with 3 or 2 and it is valid. But let’s say our classic appointment technique we would teach at dental school. I have got rid of that preliminary impression d have gone straight to final impression, with this impression tray I developed. The idea being is that in a private practice, it would cost you to run your prices about 7 to 10 dollars a minute and you really can’t afford burning 6 appointments. 5 appointments are stretching it and we are not even counting the adjustments. But if you can get it down to 4 30 minute appointments, that would be nice and so – first part is not, is not digital. You are taking a traditional impressions.

How do you create impressions? At which point then would you go digital?

Dr. Frank Vidjak: How do you create the impression, and at which point then would you go digital?

Dr. Stephen Wagner: Well there are really two processes, now that are becoming popular. If a patient comes in and I am making a new denture for them I make a traditional border mold impression actually using an impression creator that I developed back in the early 2000s. The big thing for denture making and I think one of the reasons why people didn’t make dentures is that they really were not cost effective. There was just too much time making the denture that you could not really afford to do it. So early on I realized that you could cut out the preliminary impression like Voucher taught us and really fall back to the compound impression that was previous to Voucher in the 40s, Kendall Pen and those people – and particular to the 21st century – so I developed a thermo plastic. I make a tray I shape it o the mouth and then I go through using a PVS impression technique that would be very comfortable for you. You know it is tradition impression making 101 but then it comes out within price and then I scan and that is how it enters the digital work flow.

Why digital dentures? What are your thoughts on doing denture fabrication for a patient in a digital means?

Dr. Christopher Marchack: Why would you do dentures you know what is it about doing denture fabrication for patients in a digital means?

Dr. Stephen Wagner: Digital dentures fit better. And when they fit better the patients are happier. Either printed or with – milled. Both of them are so accurate all the, all the small little incremental problems that we are going from, in pricing making a cast, shrinkage of the stone, shrinkage of the PMMA when it was processed, all those things added up to a denture that we accepted. But turns out in hindsight, it fit okay but it was not the potential it could be with. With digital all those intermediary steps are cut out. And so they fit down to the micron probably – into the microns. When you have such good approximation form the metallic surface from the denture to the rich. The adhesion and cohesion that can be created causes a great actually fabulous protection, and you don’t – evidently I don’t know why but you don’t get as many sore spots. I adjust a denture here and there but honestly that is not the way it used to be. So it is a pleasure to put in a digital denture.

What restorative material do you choose?

Dr. Christopher Marchack: Many clinicians or maybe I am just talking is that they are – they are expecting what a laboratory is going to choose, what the restoration is now vice versa.

Dr. Markus B Blatz: Of course

Dr. Christopher Marchack: And the laboratory is only limited by how many different materials that they have because to get it into each one of these systems, it is thousands and thousands of dollars. And then what systems are this or this or which one is good for that –

Dr. Markus B Blatz: I mean now a day the great things is I mean, with the milling machines we have available now and chair side additional I mean it has become so versatile that you pretty much use those mills for almost every type of material – almost every type of material and that is the great things about it and that is a great thing about digital wells because now we can see that you know the mill does not care what mineral is this is that you are milling, we even have some gold onlays that are milled and you can mill any material and that is a great thing about it – it becomes really versatile and then you really can choose from the different materials that you have availed based on the patient’s needs.

What technique for fabrication do you choose?

Dr. Christopher Marchack: so when you also look at this you have different techniques in the millings and castings and all these differ things o be used, intra oral scanners or do we still make impression and scan the dyes and you know – what is your preference, what and why? What and why what is predictable?

Dr. Markus B Blatz: what I see as well is that habitual dentistry was for the longest time limited for fabrication restorations. This is changing tremendously now. We can now have a digitized patient, CBTs – face scans; intra oral scanners that can now read carriers, or can detect things because they can now scan through hard and soft tissues. Now the whole picture is changing. Because we can put all this information together and for some of this we can even use arterial intelligence that will tell you where the teeth should be, it can tell you based on the face and things like that. So making your life easier, of course it does not replace everything that we do analog and we still do thorough wax stuff and how to set teeth because you cannot be a good digital dentist unless you are a good analog dentist.

What is the most ware is it silica based or high strength ceramics?

Dr. Christopher Marchack: so Markus when you have these porcelain restorations one of the biggest fears especially with high strength porcelains is ware of the natural dentition opposing wear, what is your common – what do you think about wear and how about the different types of silica based to high strength ceramics? What has the most wear is it really that hard causing more ware? What is the deal with that?

Dr. Markus B Blatz: this is another big misconception – you have to ask yourself, what creates ware? You are calling it such a hard material – it is!

Dr. Christopher Marchack: Yeah

Dr. Markus B Blatz: But hard materials don’t create wear! Roughness creates ware.

How do the different types of Zirconia affect strength and roughness?

Dr. Christopher Marchack: what is the difference between these types of Zirconia’s because there are some zirconia that are opacious and some that are so translucent.

Dr. Markus B Blatz: Yeah

Dr. Christopher Marchack: Some of these newer ones that are high translucent so it a HT version and does that affect strength and does that effect roughness?

Dr. Markus B Blatz: roughness not so much, but strength absolutely yes. If they are higher in cubic octant the greater the translucency but the lower the intellectual strength.

Dr. Christopher Marchack: So the bottom line is if I get this right Markus. More aesthetics the weaker the porcelain. More the opacious the stronger the porcelain? Bottom line?

Dr. Markus B Blatz: Exactly

Dr. Christopher Marchack: Don’t have anything to take and nothing to take anything else from that.

What do the patients prefer? Digital or conventional dentures?

Dr. Christopher Marchack: What do the patients prefer? Do they prefer digital or conventional means of their dentures?

Dr. Mathew Kattadiyil: ok this technology has got something that I can never do with conventional prosthetics.

What would be the workflow of printed partial denture?

Dr. Christopher Marchack: so man I have not done printed partial denture, what would be the comparison or what would be the work flow doing it and how would I go about doing this?

Dr. Mathew Kattadiyil: so yeah there are multiple work forces present and one would be a completely you know you make the impression for them and then you an – what I like about that in a graduate process, when that cast is fabricated you can actually visualize it and see the rest if it is deep enough, if the guide points are well enough and so I get a chance to absorb all that and then we go ahead with the scanning of the cast and digitize the cast into the digital world in the software on which you can do the designing, and once you do the designing you issue it and that is what we do here and then we send them to an outside lab that will fabricate a framework based on the design that we send with the lab owner. What they do is- and kind of this little mystery but here is – I – there is a processing aspect to printing even a post processing aspect to printing.

Is there anything that I should have asked, but I didn’t?

Dr. Christopher Marchack: hey I can’t believe how fast this time has flown by. It is so educational to me, a greet understanding – is there anything I should have asked but I didn’t?

Dr. Mathew Kattadiyil: It takes some honest assessment of what your outcomes are and to be able to deal with it and to make it a bonus I think is a critical aspect of this whole situation with prosthodontics. Contemporary prosthodontics

Who is one or a few of your mentors?

Dr. Christopher Marchack: You are a mentor to many residents, Prosthodontic residents, students, dentist – who is one or a few of your mentors Mat?

Dr. Mathew Kattadiyil: Well thank you for that question Chris. I started my Prosthodontic training in India like you mentioned and since you specifically asked about prosthodontics today – one of my first mentors in prosthodontics was my programme director in India.

Dr. Christopher Marchack: Oh!

Dr. Mathew Kattadiyil: And you never heard of him, but you could have – but anyway Dr. Kashap Mubarak was a US trained Prosthodontist and guess how he trained under? He was a student of Ervin Hardy.

Dr. Christopher Marchack: Oh my Gosh! Really?

Dr. Mathew Kattadiyil: Yes back in 1958.

Dr. Christopher Marchack: (laughs)

Dr. Mathew Kattadiyil: So it is very funny because I have been lucky all my life, never having to chase mentors, they somehow appear where I am!

What is your philosophy to guide and mentor your residents?

Dr. Christopher Marchack: What is your philosophy to guide and mentor your residents?

Dr. Mathew Kattadiyil: My philosophy about teaching in a grad programme evolved when I was a graduate student. My philosophy is always to be someone who encourages the students to treat me like their colleague with a line drawn when needed, but that opens up communication.

Dentistry over the years?

Dr. Frank Vidjak: how do you see when you started, and how things are right now and then I bounce to the sons and kind of do a comparison and kind of see what your thoughts are in your practice life.

Dr. Ronald Goldstein: look I am 87 now but I am still practicing 2 half days a week. You know why? Because over the time I am like my father – I love seeing the patients and they love seeing me!

Dr. Cary Goldstein: We are always doing something you know dad got me doing that, as an entrepreneur we developed instruments together we developed techniques together it is just, I am always thinking – right I am always thinking and trying to come up with the next great, next greet concept.

Baldwin Marchack: oh Man those were the golden days of dentistry and those were the good old years – you know the golden days of dentistry is right now – it is just different. We you know, we enjoy dentistry today just as much as we did 50 years ago – we just do differ things.

Dr. Christopher Marchack: Through all these years because of the excellence that we try to do in our practice, it keeps making us better and better and keeps motivating us to get into the office the next day.

What is your advice to the new generation on Dentistry & what would you have done different if you would not have gone to dental school?

Dr. Christopher Marchack: I told my children not to go into dental school. What would you say to them? This whole different path?

Dr. Ronald Goldstein: What with the new technology and artificial intelligence coming into it now, it is the best time ever for someone to come into dentistry.

Dr. Christopher Marchack: Cary is there anything you would have done different, would you have not gone on to dental school?

Dr. Cary Goldstein: Dentistry has done everything for my life.

Dr. Ronald Goldstein: I was going to be a journalist

Dr. Baldwin Marchack: if I were to do something else now it would be restore old cars!

Is there anything we should’ve asked but we didn’t?

Dr. Christopher Marchack: is there anything, anybody here that I should have asked or frank should have asked but we didn’t?

Dr. Ronald Goldstein: And the message that I would tell dentists who have children in the practice is, look at the alternative and look at that child, and see if you can at that point who is a dentist is that the best place. Are you – stopping the progress of your child?

Dr. Baldwin Marchack: there is no one right way, there is not nay right way

Who are some of your Mentors?

Dr. Christopher Marchack: who are – maybe some of your mentors?

Dr. Ronald Goldstein: I will tell you a few – probably the first one was Charlie Tinkers.

Dr. Baldwin Marchack: so many people that influenced the way I practice dentistry, but really truly mentored I have to name a few and one would be – Carl Reader.

Dr. Christopher Marchack: what did your dad mentor you in, in dentistry?

Dr. Cary Goldstein: we would be watching TV and dad would always turn on to the beauty pageants, and he would have us analyze the aesthetics of the women in those beauty pageants.

Dr. Christopher Marchack: Ha!

Dr. Cary Goldstein: While watching TV and he would say now look at that guys smile what would you do and-

What is the Ah-ha moment that made you realize dentistry is your career?

Dr. Frank Vidjak: for the 4 of you, when was it – the Ah-ha moments that you realized that dentistry was going to be your professional life?

Dr. Ronald Goldstein: the contact you make with people. Because the physician spends 5 minutes with you for an exam, dentists spend hours working with patients and you become friends with so many people.

Dr. Cary Goldstein: it was really Jack Creston in USC prosthodontics that turned my head.

Dr. Christopher Marchack: the quality of my father’s dentistry was so high and his knowledge was so much that I did not know what I was doing and I needed more education.

Do you routinely bond restorations or use a resin smith when doing full EMax Crowns for posterior teeth?

Dr. Christopher Marchack: so when you are doing full EMax crowns in the posterior teeth single units, are you routinely bonding these restorations or using a resin smith?

Dr. Ken Malament: I use a little gluma to seal the tooth to create a fire that clogs up the tooth. That by the way minimizes the amount of water that is going to be exposed, then I dent in bond with I dent in – any denting bonding agent and I hit it with a light and polymerize it and then I cement with an H ceraut but a full resin material but I would not care if you used resin reinforced glass iron in the same situation because it is all resin it is not going to have any effect I believe in the long term survival of the material.

Would you choose different materials to do in-lays vs. out-lays?

Dr. Christopher Marchack: would you chose different material to do an In-lay vs. and On-lay such as would you always use lithium dislocates or would you use empress, which is a lucid tact material or just because they have different quantities of gloss in there.

Dr. Ken Malament: I don’t use empress at all, when I- years ago an Thomson Diane asked me to come down to New York to watch a study which is in my lecture here, to just show you the – show me what happens with lithium dislocate and how you have to come up with little 11 hundred newton’s and that is a sliding contact. In water – and they just don’t break! Empress wood break – so no I don’t use empress at all, it is not even in my lab now and it has not been since I first started using – since I first started using EMax that was just the end of empress, completely and I would never do it in Zirconia ever because you cannot etch it and then the net material is gold – and I would do gold!

What do you think is round enough not to create a potential internal fracture?

Dr. Frank Vidjak: when it comes to rounding, having that rounded junction that transition from palpable to axio.

Dr. Ken Malament: Ok

Dr. Frank Vidjak: What do you think is round enough not to create a point of potential internal fracture or does it matter?

Dr. Ken Malament: if you rounded the surface we get more bulk of ceramics at the clusion area and that meant the stress from a clusion down to the margin to create that semi line fracture would be significantly less, so I take a slow speed with an amalgam round polishing point from the shelf room and I round all those points out.

What are the critical steps for successful restoration?

Dr. Christopher Marchack: What are the critical steps that you could see – if we can just summarize materials and steps for successful restorations, how would you what would you say – what are those critical steps?

Dr. Ken Malament: well first question – first statement is to recognize that anterior teeth never break on the view of – almost ever, they really truly almost never break and I have that on every material – I have that on lecture – so once you accept that then you realize it is all a question of how much layer by unit material that you do, with EMax you literally just scratch the surface, it could be deep scratches and then add your veneering material which is not pathetic but the glass ceramic as well, those will always those to a minimal and then you can make a great aesthetic restoration. If you are not in posterior teeth that should almost always be full monolithic, and onlays inlays they are all monolithic and then bond them appropriately so that is the first step. The second statement is that the cementation process is really important and the fact that you can etch a cemai because really important in the choice of material. Look I am in private practice I do not want to lose money I don’t want to do restorations over, and when I look at my results – and it is not that I mean God gave me great training but he didn’t give me great abilities over anyone else in dentistry I am saying we deal with bet up teeth that is why we crown them, or do onlays on them so now the only statement would be – I am doing a classic, I am using an extra surface that can then bond into place.

Do you have a preference over pressed EMax vs. Milled EMax?

Dr. Frank Vidjak: Do you have a preference over capsid, EMax vs. milled EMax? Do you have a preference one way or the other?

Dr. Ken Malament: No preference whatsoever but it is, I could get 3 or 4 castings into a ring, so it is so cheap for me to do crowns as opposed to mill now EMax within the year is going to have a hockey puck and you are going to be bal to mill out 25 crowns. That is going to be a complete game changer because then labs are going to be able to make many units and the cost of everything is going to come down profoundly. So right now I don’t do any office milling I have nothing against it but you have to make sure you clean the machines and calibrate it almost everyday day. I don’t have any problems but I think there is a lot of misuse and what we do know clearly is these machines have a shelf life – have a time or service life 2 or 3 years, and until – f you have to spend that kind of money and then have to buy a new one every 2 or 3 years I think the industry is now starting to realize maybe they can lease it to us and then you get new equipment al the time. So Frank I don’t think there is a difference.

What is your opinion on zirconia crowns? Why aren’t you doing that?

Dr. Christopher Marchack: What is your opinion on zirconia crowns? Why aren’t you doing that?

Dr. Ken Malament: I think there is a lot of misuse with zirconia, it is a good material it will improve I think what Avodart has done with the fusing of the 3Y and 4Y into a different unit layering it, has changed it. I think al the companies will do it, but I think in clinical practice for m unless I am splinting it or if I am doing a whole reconstruction where I am splitting everything or if I am doing a – that is an important point too. I used the zirconstant technique. So if I am doing a ful l implant reconstruction I mil a full titanium bar through the whole arch and then I make a zirconia that is literally on top of that, it is cemented but then all the screw go through that. I have never seen a failure with that.

Tell us about Dicor crowns and what you have learned about it.

Dr. Christopher Marchack: can you just tell us a little bit about Dicor crowns and you have such long term studies – what did you learn about this?

Dr. Ken Malament: I have realized too that the reason Dicor didn’t work is directly related to me because I chose the crystals, I wanted the crystals to have the same light absorption reflection that a natural tooth had.

Dr. Christopher Marchack: So Dicor is basically a glass right?

Dr. Ken Malament: A glass ceramic. The crystals are touching each other

Dr. Christopher Marchack: Yes

Dr. Ken Malament: So close to each other so that when you study the fracture mechanics you have to go around a lot of crystals to get it to break.

Dr. Ken Malament: So it is actually not a very strong material compared to what we are using today?

Dr. Christopher Marchack: Yes but it could have been.

How do you explain your way of crown preparation?

Dr. Christopher Marchack: so you said some really important things, such as pawning the restorations, you said about your tooth preparations, in regards to partial denture preparations, or partial coverage preparations you are doing it very similar to gold

Dr. Ken Malament: yep just like Herb Shilingburg’s book almost exactly the same.

Dr. Christopher Marchack: You are not seeing anything of any difference using hogwash or fountain – minimally invasive but how about your crown preparations?

Dr. Ken Malament: Crown preparations are modified to shoulder the way Frank Spear and John Clovis advocates where they take a rounded shoulder. One of the thing that Jack always obsessed on was if you had a shoulder and you turn a corner you can get a lift, so jack always said to take a shoulder or a Shafer barrel, I use a polishing one, it is part of the spear series and I just go through and I just flatten out the margin so I don’t have any lips, so the perpetration is a Shaffer.

What is your treatment plan on complete coverage restoration?

Dr. Frank Vidjak: what is on your mind when you are treatment planning you know a complete coverage restoration?

Dr. Ken Malament: there is no question that all materials suffer in the post era because of the molars. Bicuspid almost never break and anterior teeth almost never break if you are working with lithium disilicate. The thing I care about is do these crowns come out? Do these onlays come out? Lord knows we started with gold, we started with metal ceramics we see it like crazy with Zirconia. I know that they are working like crazy trying to figure out some way to make Zirconia more attentive, it is a very smooth internal surface, so my choice literally is either going to be gold or gold in the back tooth if the patient has gold and does care – I can do gold just as easily as I can do lithium disilicate or I do EMax – it is one of the 2.