Stephen Malone, DMD 

Our Knoxville, Tennessee, dental practice has grown to where we now have four dentists, as well as four hygienists, six dental assistants, two patient coordinators, a practice manager with two front-office patient care specialists, and one more primary partner in our dental practice—Bob Cutshaw. Bob is a master lab technician with over 40 years of experience and owner of Cutshaw Labs. He has been a partner in care with me for nearly 25 years and collaborates with our doctors on all dental restorations requiring lab work. 

Recently, I was thinking again about how grateful I am for my association with Bob and for the many benefits of having his lab located downstairs within our practice facility. Perhaps, having a lab in-house is something other dentists might aspire to eventually have in their own private practice. 

Bob is involved in care planning just as much as I and the other dentists. We can sit side by side to collaborate on treatment using a combination of digital 3D modeling and analog articulated models and wax-ups. 

For patients with complex needs, he routinely comes into the operatory or the consultation room to meet with patients. As he explains his involvement in their care and how the highest quality materials and latest techniques will be used, they become fascinated in the laboratory methods and technologies. Some request a tour of the lab and want to watch some of the process. 

We use digital designs for all prosthetics. Bob’s professional-grade 3D printers work all day long for predictable, efficient fabrication of custom restorations. Then he hand-paints and glazes the crowns and prosthetics for optimal natural aesthetics. Because he is involved in planning our most complex cases that involve implant supported hybrid denture, he is deeply invested in the details that allow the finished product to be delivered with ease. 

Having his lab in-house allows us to rapidly fix issues that arise, for example, alterations to a restoration when it doesn’t quite fit right or has a slightly incorrect shade. Instead of waiting for days or weeks to deliver back and forth a restoration to an outside lab, we make the changes here on the same day. 

For Patients undergoing clear aligner treatment, we manufacture our clear aligners in-house. If a patient loses or damages a tray, it is immediately replaced so the patient doesn’t lose precious time in treatment. The same goes for our occlusal splints, night guards, sports mouth guards, and Essix retainers. 

One of the branding traits of our practice that has earned us our high reputation is the in-house laboratory. Without a doubt, having this lab just downstairs is a major way in which we enhance the quality of care we provide to our patients. 

Trying to match the color of the cement between the abutment and the dental implant crown in the anterior can be very frustrating. Here’s a trick that works well for me. 

A while back I was struggling to match the color of the cement between the abutment and an anterior implant crown. I always try-in the abutment and the crown and try to confirm the shade before they are put together. We do this because the laboratory can’t redo the shade once they’ve bonded the crown and the abutment for screw retention without trying to separate the cement, which is difficult. 

Over the years, it was a challenge to replicate the opacity of the cement used to connect the titanium abutment and ceramic crown. I’ve tried using some of the opaquest try-in paste on the market. 

In the case I referred to above, we thought we had it. My lab cemented it together and I put it in. I could see the opacity of the cement through the restoration. So, we had to take it apart and try again. My laboratory technician shared with me a trick that he had learned from one of his other dentist clients. And that was to simply go to CVS, Costco, or Target and buy good old fashioned liquid white out.  

Now, I put a very tiny amount of whiteout on a micro brush and paint it on the inside of the labial surface of the crown on the intaglio surface. Then, I use a bit of translucent try-in paste to seat the crown. 

The whiteout works well because it is basically titanium dioxide and water with preservatives—the same white compound that is in super white sunscreens. In my opinion, it is relatively safe to use, and I can see what the implant will look like when the pieces are cemented together. 

We use the words “multilayer” and “multilayered” to describe lots of different materials from different manufacturers. If your lab tells you they use multilayered zirconia on a restoration or abutment, do you know what you are getting?

One of the ways we use the word multilayered is to describe a puck of zirconia that has two different types of zirconia.

Some of the pucks are a layer of 3y (the strongest but least aesthetic zirconia) with a layer of 5y (the weakest but most aesthetic zirconia). The laboratory technician puts the restoration design in the puck so that the 5y is on the facial of the restoration where you can see it and the 3y is on the incisal edge and lingual.

There are also pucks that are 4y zirconia layered with 5y zirconia. The 4y zirconia is a middle grade of both strength and aesthetics. In this case, the 5y is on the facial and the 4y is on the incisal edge and lingual.

Thus, there are two different ways to mix strength and aesthetics in one puck of zirconia and both variations are called “multi-layered.”

Complicating this even more, we use “multi-layered” to describe layers of chroma gradient or translucency. The laboratory technician can put the design pattern in the puck to achieve different gradient effects, but the restoration is all of one strength (one type of zirconia).

One of the challenges today with zirconia is that there is no place on a laboratory prescription to specify one of these varieties, and it needs to be clarified when communicating with your lab technician. Ask what your lab technician means by “multilayered zirconia,” and communicate clearly the multilayering you want used.

I had a patient in a provisional on tooth #7, and he called to tell me he ate the crown. When he came in, I checked his occlusal marks in MIP, and there was a nice coupling with the opposing tooth. He was not hitting the tooth at all in protrusive, in right and left, and in crossover. He had not used floss and had not chewed on something sticky that would pull the provisional off. So, I put articulating paper between his teeth and used my iPhone to video him as he chewed like he was chewing food. What I discovered in the video is that he had a functional interference. He had broad strokes on the provisional whenever he was in his chew stroke.

I sent the video to the lab with the hope that the new information could be used to make a crown that would protect the tooth from breaking or becoming loose. This patient was adamant about not wanting orthodontics. I was able to show him why equilibrating his opposing tooth would be beneficial and he accepted equilibration.

Having run into this problem once, I am now checking for functional interferences with more patients by having them do “the chew test.”