Volume 11, Number 5

May 2000

EDITOR
Arun K. Garg, DMD Associate Professor of Surgery Director, Center for Dental Implants Division of Oral/Maxillofacial Surgery University of Miami School of Medicine

Allied Success: Making the Most of the Relationship between the Doctor and the Lab Technician
Overwhelmingly, dentists nationwide seem pleased with the service they are receiving from laboratories. According to a survey conducted by the editorial and research departments of Dental Products Report and Dental Lab Products, sister publications of Dental Implantology Update, more than nine out of 10 of the responding doctors say they are satisfied with their laboratories in terms of overall quality. Of those, more than half (52%) said they were extremely satisfied with the overall quality of lab services; the remainder indicated being somewhat satisfied with quality. While inarguably pleased with all aspects of their laboratories services, fees and turnaround time are two areas that may be causing concern among practitioners. Of the 18 areas addressed in the questionnaire, the lowest percentages of respondents said they were satisfied with their laboratories ability to clearly explain fees (72%) and with the actual fees charged (79%). In addition, when questioned about custom fees, almost onefourth (23%) of the responding dentists said they were not sure if such extra charges were assessed on an hourly basis or per procedure. Regardless, a relatively small percentage remains either indifferent or unsatisfied. Other survey results include the following: Of methods for choosing a laboratory, dentists appear to be relying more on the recommendations of their colleagues than on any other method, including a personal visit to the practice by a representative of the laboratory. Slightly more than one-third (37%) of the responding doctors said their labs charge custom fees for above and beyond services, the most common of which are custom staining and rush service on crown and bridge cases. Respondents were almost equally divided when asked about who in the practice carries out communication with the laboratory:

EDITORIAL ADVISORS
Editor Emeritus: Morton L. Perel, DDS, MScD Charles A. Babbush, DDS, MScD Head, Section of Dental Implant Reconstructive Surgery Mt. Sinai Medical Center Cleveland Thomas J. Balshi, DDS, FACP Private Practice, Implant Prosthodontics Prosthodontics Intermedica Institute for Facial Esthetics Fort Washington, PA Anita Daniels, RDH Clinical Instructor Center for Dental Implants University of Miami School of Medicine Miami Charles E. English, DDS Staff Prosthodontist Veterans Affairs Medical Center Augusta, GA Jack A. Hahn, DDS Private Practice Cincinnati Kenneth W.M. Judy, DDS Clinical Professor Department of Prosthodontics University of Pittsburgh School of Dental Medicine Jack T. Krauser, DMD Private Practice, Periodontics and Implantology Boca Raton, FL Department of Periodontics Nova Southeastern College of Dental Medicine Davie, FL Richard J. Lazzarra, DMD, MScD Associate Clinical Professor Periodontal and Implant Regenerative Center University of Maryland Private Practice West Palm Beach, FL Robert E. Marx, DDS Professor and Chief Division of Oral/Maxillofacial Surgery University of Miami School of Medicine Carl E. Misch, DDS, MDS Co-Director, Oral Implantology University of Pittsburgh School of Dental Medicine Daniel Y. Sullivan, DDS Private Practice, Implant Prosthodontics McLean, VA; Washington, DC

This Month Inside

Clinically significant abstract ......40

NOW AVAILABLE ON-LINE! Go to www.ahcpub.com/online.html for access.

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49% of the responding dentists are the only members of the practice team to communicate with the lab, while 47% said communication with the lab is the job of both the doctor and the chairside assistant. Loyalty runs high. Fewer than one-third (29%) of the respondents have changed labs in the past two years, and only 18% said they foresee changing labs within the next year. One in five of the respondents said they maintain an in-house laboratory. Of these, only small percentages fabricate complex cases such as crown and bridge, inlays/outlays, and veneers. More often, these inhouse labs handle athletic mouthguards, nightguards, orthodontic appliances, and denture repair and relining. In terms of communication, the survey results attest to the skills of both the doctor and the technician. Only 8% of the responding practitioners said their laboratories employ the services of a dentist to facilitate communication; only 18% said laboratory personnel come to the practice to consult on cases; fewer than four in 10 (38%) receive specific product recommendations from their laboratories; and just about half (51%) said their laboratories take shades. However, nearly nine in 10 (89%) of the respondents said they are satisfied with the communication process between themselves and their laboratories. So they must be doing something right! Matt Roberts, owner of CMR Dental Lab in Idaho Falls, ID, has worked with David S. Hornbrook, DDS, for more than five years. They are in the process of writing a book focusing on how to strengthen communications between dental technicians and clinicians. Additionally, they have collaborated to devise a prescription form intended to enhance communication about all aspects of case design. The form was developed by Pacific Aesthetic Continuum-live (PAClive), Hornbrooks continuing education program. What follows are excerpts from Roberts and Hornbrooks discussions with the editors of Dental Products Report and Dental Lab Products.

The Tools of Communication

Which of the following communications media do you and your laboratory use? (Check all that apply.) I I I I I I I I I Telephone Shade guides Study models Preprinted prescription forms Direct technician contact with patient Shade tabs Photographs E-mail images Cosmetic imaging simulations 85% 82% 76% 68% 43% 42% 40% 2% 2%

The Nature of Doctor/Lab Communication

I think it initially should be a directive relationship, followed by consultation. As a clinician, I should gather so much information from the patient that all Im doing is directing the ceramist about what the patient wants, says Hornbrook. If I provide enough information about what the patient desires, then the technician just follows directions. The labs role is to make sure fit is accurate, that the occlusion or function is correct, that my instructions are followed, and that it looks like a live, vital tooth.

Communication between your office and the laboratory is carried out by: I Dentist only 49% I Dentist and chairside assistant 47% I Chairside assistant only 3%
Source: Dental Products Report/Dental Lab Products survey, August 1999.

The relationship becomes consultative once the directive role breaks down that is, if theres incomplete information or if theres conflicting information, says Roberts. If the case comes to the laboratory, we read

Dental Implantology Update (ISSN 1062-0346) is published monthly by American Health Consultants, a unit of Medical Economics, 3525 Piedmont Road NE, Building Six, Suite 400, Atlanta, GA 30305. Telephone: (404) 262-7436. Periodical postage paid at Atlanta, GA 30374. POSTMASTER: Send address changes to Dental Implantology Update, P.O. Box 740059, Atlanta, GA 30374. American Health Consultants, in affiliation with Boston University Goldman School of Graduate Dentistry, offers continuing dental education to subscribers. Each issue of Dental Implantology Update qualifies for 1.5 continuing education units. Customer Service: (800) 688-2421. Fax: (800) 284-3291. Hours of operation: 8:30 a.m. - 6:00 p.m. Monday - Thursday; 8:30 a.m. - 4:30 p.m. Friday EST. E-mail: customerservice@ahcpub.com. World Wide Web: www.ahcpub.com. Subscription rates: U.S.A., $449 per year. Students, $200 per year. To receive student/resident rate, order must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the regular rate until proof of student status is received. Outside U.S., add $30 per year, total prepaid in U.S. funds. One to nine additional copies, $269 per year; 10 to 20 additional copies, $180. Missing issues will be fulfilled by customer service free of charge when contacted within 1 month of the missing issue date. Back issues, when available, are $75 each. For 18 continuing education units, add $96 per year. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. Clinical, legal, tax and other comments are offered for general guidance only; professional counsel should be sought for specific situations. Copyright 2000 by American Health Consultants. Dental Implantology Update is a trademark of American Health Consultants. The trademark Dental Implantology Update is used herein under license. All rights reserved. Reproduction, distribution, or translation of this newsletter in any form or incorporation into any information retrieval system is strictly prohibited without express written permission. For reprint permission, please contact American Health Consultants. Address: P.O. Box 740056, Atlanta, GA 30374. Telephone: (800) 688-2421. Group Publisher: Brenda Mooney, (404) 262-5403, (brenda.mooney@medec.com). Editorial Group Head: Leslie Coplin, (404) 262-5534, (leslie.coplin@ medec.com). Managing Editor: Kevin New, (404) 262-5467, (kevin.new@medec.com). Senior Production Editor: Brent Winter, (404) 262-5401.

Dental Implantology Update

May 2000

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Clinicians Rate Lab Services

Rate your outside dental lab(s) in terms of the following:*+

Satisfied
Achieving doctor/patient satisfaction Overall quality Ability to deliver successful remakes Overall communication Overall value (price vs. quality of work) Willingness to respond in a timely fashion to members of your clinical team Overall response to rush orders Overall quality for PFM restorations Turnaround time Skill in following your specifications for restoration shade matching Overall quality for crowns and bridges The prescription form in terms of thoroughness of communication Willingness to provide valuable insight to achieve successful case outcomes Fees charged for services Overall quality of ceramic restorations Remaining up-to-date on how to achieve optimal results with latest dental materials Overall quality for dentures Clearly explaining fees charged * No response percentages not shown. + Totals may not equal 100% due to rounding.
Source: Dental Lab Products survey, September 1999.

Neutral Dissatisfied
2% 2% 4% 5% 9% 11% 10% 3% 8% 8% 4% 12% 15% 12% 6% 12% 7% 20% 1% 1% 2% 2% 2% 2% 4% 3% 7% 5% 2% 4% 4% 7% 3% 4% 5% 5%

95% 94% 92% 89% 87% 85% 83% 82% 82% 82% 82% 81% 79% 79% 78% 75% 74% 72%

through the directions provided, and if something doesnt quite make sense, then it becomes a consultative process. If the material selection isnt appropriate for the preparation design, or if the material selection is inappropriate for the color of the underlying dentin or something of that nature, then a telephone call is made, he adds. When attempting to match natural teeth with a small group of restorations maybe a single tooth or three or four teeth the best means of May 2000

communicating shade information is to provide good-quality 35 mm photography with a shade tab in place, advises Roberts. A photograph is about the only tool that conveys all the subtleties that exist within a tooth, Roberts says. Writing down on the laboratory slip tooth 9, A-2 has little chance of producing a natural-looking tooth, regardless of which ceramist you use, he adds. On the other hand, when doing a full esthetic reconstruction, listening

to the patients expectations is crucial, Roberts notes. For example, he adds, does the patient want white teeth, very natural-looking teeth, or colors that are appropriate for his or her age? Those types of issues become the guiding factor in color choice, he notes. With all-ceramic restorations, the underlying dentin is an integral part of the final shade, and photographs of the prepped teeth are necessary for communication. Any photograph of the preparation with some known value of a type of the shade tab in there is necessary to predict the final shade, adds Roberts. Usually, the bigger the case, the less the problem with shade, says Hornbrook. So, If Im doing a case where we are designing the eight or 10 anterior units, and I have total control of shade, then communication with the laboratory will be pretty clear-cut, he says. I will have the patient look at the prefabricated shade tabs and choose one he or she likes. Its very easy for the ceramist to match that. Its more difficult matching single teeth or matching existing dentition. Photography is really the key to communication. Its important to be specific any time theres a chance for variability. For example, says Hornbrook, so much variability is possible in terms of incisal edge translucency it could be as little as zero to as much as 2 mm. The laboratory slip should allow the clinician to look at a case and ask where variability could exist and where communication could break down. If I say I want a medium occlusal stain, is that an area of variability? If so, do I need to photograph an opposing tooth, a contralateral tooth, or an adjacent tooth so the ceramist can see exactly what I mean? he explains. Another important factor is to communicate to the laboratory the patients facial features and how the smile relates to the rest of the face, adds Roberts. Dental Implantology Update

36

Prescription Forms
Does your laboratory provide you with a fill-in-the-blank preprinted prescription sheet for ordering restorations, orthodontic appliances, etc.?

2%1% 6% 20% 71%

No response No, have own No, already provided by statute in my state No Yes

When we have a patients models mounted on an articulator, we need to have some idea where the incisal edge should go, what the length of the teeth should be, how to tell whether a midline is vertical, and whether the incisal edge is following a lipline and is parallel to the interpapillary line, says Roberts.

Use Profile Photos

When the finished case is placed in the mouth, you want to make sure that the reflective surface of the centrals is reflecting forward or slightly down, notes Roberts. The ceramist needs to be able to know this information without the benefit of the patient sitting there. You need to have profile photos of the patient with lips parted at rest or with a slight smile, he notes. These photos can be taken preoperatively or with temporaries in place. A study model of the preoperative teeth or the temporaries (whichever was photographed) is then sent with the case. This allows the technician to visualize the facial/lingual inclination of the teeth in the laboratory, Roberts explains. The same goes for midline canting. A photograph of temporaries in place or a mock-up with a flowable resin on the centrals shows the laboratory what that length looks like in the patients smile, adds Roberts. It also shows where vertical is in relation to a stone model that we have in the laboratory. This way, we can picture how the final case should fit and can make it appropriate. Face bows and stick bites are mandatory communication tools, he adds. Sometimes photos are submitted in which some aspect of the composition is not good enough to give the laboratory sufficient information, says Roberts. If you are matching a natural tooth, it is important to put something like a shade tab into the photograph to calibrate it. In other words, take the shade tab that most closely matches the natural tooth, hold it next to the tooth, and May 2000

If your lab provides a prescription sheet, is it easy to fill out and understand?

5%
No response

14%
No Yes

81%

Who fills out your prescription forms?

3% 4%

No response Chairside assistant

36% 57%

Both dentist and chairside assistant Dentist

Source: Dental Products Report/Dental Lab Products survey, August 1999.

Dental Implantology Update

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Extra Services
Does your laboratory employ the services of a dentist to facilitate communications?

8% 13%

1%
No response Not sure

78%

Yes No

Do laboratory personnel come to your office to consult on cases?

Often Never

18% 51% 31%

Seldom

Does your laboratory take shades?

6%

No Response No

43%

51%

Yes

Does your laboratory charge 'custom' fees?

6%

No Response Yes

38%

56%

No

Source: Dental Products Report/Dental Lab Products survey, August 1999.

photograph it. That way, if theres some shift in color during the development or exposure of the film, at least theres a known in the picture that forms a relative point, explains Roberts. The ceramist is able to assess whether the tooth is a little darker or lighter or more yellow than the shade tab, he notes. Specifically, I want a photograph showing the face, eyebrow to chin, with temporaries in place, says Roberts. Also, to verify that, Id request a photograph with a stick placed in the bite registration material that indexes off the lower anterior teeth thats parallel to interpapillary line. That way, I can clip that stick bite into the model when the case arrives in the laboratory. Ill know from the photograph how the stick bite relates to the patients facial features, adds Roberts. Clinicians have a tremendous advantage, Hornbrook points out. As we design the smile, we have the patient sitting in front of us. We can look at the face, the profile, and the skin tone. If we can provide the

ceramist with full-face photographs and profile photographs, it will help him or her get to know the patient more intimately than by looking at just a set of models, adds Hornbrook. Many dentists who call themselves esthetic or cosmetic dentists just dont have the proper equipment to take the correct photographs, says Hornbrook. A 35 mm singlelens reflex camera will provide the best information. Also, the new digital cameras are an excellent communication tool if used properly with shade tabs in place.

Shade Tabs
In terms of shade, the shade tabs currently available are good, says Hornbrook. In an ideal world, Id like to see them go a step further, to have various surface anatomies. As far as transfer of shade, I think theyre good enough. In the future, well see more development in the transfer of information via digital photography, predicts Roberts. Several people are working on shade-mapping programs that are based on digital photography. Well also see lab strips arriving via modem rather than with the case in the mail, he adds.

Still-Digital and Video Cameras

Todays digital cameras are very high-quality, notes Hornbrook. With a digital image, I can see immediately if Ive captured the information I need. I can print it right there and send it to a lab, explains Hornbrook.Im not crazy about the intraoral camera for color and shade representation. I think these cameras still have problems with distortion. I do like to use intraoral video, however, when communicating about posterior cases, he adds. If Im looking for a certain characteristic on the occlusal surface of a Dental Implantology Update

May 2000

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What, Where, and How Many

How many commercial labs do you use?

restoration, its easy for me to use my intraoral camera to take a picture of an adjacent or contralateral tooth and tell the lab, match this, Hornbrook says.

4% 3% 10% 32%

No response Five or more Four

Relating Information About Contour

The desired contour for a restoration is one of the more difficult things to communicate. If you are trying to match a single tooth or existing teeth in the arch, one of the most important things is to get an accurate impression of the teeth that are to be matched, advises Hornbrook. Too many times I will see impressions in the laboratory that reproduce excellent marginal detail, yet fail to reproduce the contours of the contralateral or adjacent tooth. Theres no way a ceramist can blend that single restoration into the surrounding dentition if he or she cannot see what the dentition looks like, he adds. As far as restoring multiple teeth, we have some options. We can show the patient photos, models, or even the smiles of our office team members, Hornbrook says. Another option is to use denture teeth to convey different contours, Hornbrook says. The patient can look through a denture mold guide and choose the desired shapes and characteristics. Then these teeth can be sent to the ceramist for duplication, he notes. Finally, the provisionals are among the most useful communication tools, Hornbrook adds. As we design the provisional restorations, they become a model for the final restorations. The patient gets very involved in determining shape and contour of the provisionals, he notes. We then take an impression of the provisionals and send it to the ceramist to match. As the patient wears the provisionals, I can get feedback from him or her regarding contour and shape, make necessary May 2000

21%
Three

30%

Two One

What type of laboratory do you use most frequently?

1%
No response

23% 38%

Both equally Specialty Full-service

38%

In miles, how far is (are) your lab(s) from your practice location? 30% 25% 20% 15% 10% 5% 0% 1-2 3-4 5-10 11-25 More No than 25 response

25% 15% 16% 14%

28%

2%

Source: Dental Products Report/Dental Lab Products survey, August 1999.

Dental Implantology Update

39
changes, and then send a new impression to the lab, Hornbrook says. Most returns, adjustments, and remakes result from a lack of communication at some point, notes Roberts. When the case arrives in the laboratory, if the impression is inadequate and the ceramist does not communicate that to the clinician, a remake most certainly will be required. Multifaceted communication is vital to the success of cosmetic cases, adds Roberts. If, for example, I just guessed where the midline was or the horizontal plane was, the teeth would look inappropriate in the patients mouth. Thats probably the No. 1 reason for remakes. The secondmost-common reason probably would be a lack of shade communication regarding single teeth, Roberts says. M prescription medications also are using herbal medications, megavitamins, or both. The article notes that in 1997, consumers spent more than $10 billion on these products, and some 15 million people who do so may be at risk for adverse interactions. One of the problems with overthe-counter herbal medications is that they are not required to go through the costly U.S. Food and Drug Administration (FDA) approval process. The FDA can only suggest, but not require, manufacturers of herbal products to provide reproducible, evidencebased scientific data to consumers, the article reports. The most devastating side effects and interactions that anesthesiologists need to be aware of are cardiovascular instability, prolongation of anesthesia, and bleeding, particularly in conjunction with other anticoagulants such as warfarin. Ephedra sinica (ma-huang), an ingredient in many over-the-counter diet aids, may cause deadly sympathomimetic effects, particularly in conjunction with heart glycosides, guanethedine, or other prescription medications. Panax ginseng (ginseng) may cause tachycardia or hypertension, particularly in conjunction with other cardiac stimulant drugs. Tanacetum parthenium (feverfew), commonly used as a migraine prophylactic, may enhance bleeding by possible inhibition of platelet activity. Warfarin also may be potentiated by concomitant use of Allium sativum (garlic), Ginkgo biloba (ginkgo), or Zingiber officinale (ginger). Valeriana officinalis (valerian), Piper methysticum (kava-kava), and Huypericum perforatum (St. Johns wort) all may prolong the sedative effect of anesthesia. Two brochures What You Should Know About Your Patients Use of Herbal Medicines and a patient information brochure titled What You Should Know About Herbal Use and Anesthesia are available through the publications department of the American Society of Anesthesiologists executive office in Alexandria, VA. Telephone: (847) 825-5586. M

Congress Investigates Federal TB Control Measures

Congressional auditors will launch a priority investigation of the public-health capacity to control drug-resistant tuberculosis, a General Accounting Office (GAO) spokeswoman said on March 24, 2000. Reps. Tom Biley (R-VA) and Fred Upton (R-MI) called on the GAO in a March 17 letter to undertake a study of the U.S. efforts to control and eliminate TB and to focus specifically on efforts to control multi-drug resistant TB. They asked congressional auditors to examine: the use of federal resources to strengthen TB surveillance and improve laboratory capacity for identifying mycobacterial species and conducting real-time drug susceptibility testing; the effectiveness of state and federal efforts in targeting TB prevention and treatment services to hard-to-reach populations and groups at high risk for multidrugresistant TB; the history of White House budget requests and congressional appropriateness studies since 1989 for TB prevention and control at the federal level. The two lawmakers cited published news reports on the international spread of what they said are lethal strains of drug-resistant TB. Source: ADA News Daily, March 27, 2000. M Dental Implantology Update

Traditional Pain Management Methods Gain Popularity

With nearly everything going retro, it should come as little surprise that people would look into the past for methods of healing and pain management, writes Jessie A. Leak, MD, associate professor at the M.D. Anderson Cancer Center in Houston. Writing in the February 2000 issue of the American Society of Anesthesiologists Newsletter, Leak notes that people began using plants and plant parts for medicinal purposes more than 60,000 years ago. Today, the publics fascination with all things natural continues to grow, in spite of possible dangers associated with herbal remedies. According to Leak, estimates are that one in five U.S. adults taking May 2000

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Clinically Significant A B S T R A C T
Li D-H, Liu B-L, Zou J-C, Xu KW. Improvement of osseointegration of titanium dental implants by a modified sandblasting surface treatment: An in vivo interfacial biomechanics study. Implant Dent 1999; 8:289-292. Most of the conventional rough surfaces on implants are produced by coating techniques. Although this type of surface can improve osseointegration of dental implants, the additional interface between the coating and the substrate of titanium can cause problems. Because of these potential problems, a noncoating technique was developed, which consisted of a sandblasting surface treatment and an acid attack. In this study, the authors took 48 commercially pure cylindrical titanium implants and divided them into two groups. Implants in the modified sandblasted surface group were sandblasted with 18- to 24-grit corundum and modified with oxalic acid attack. Implants in the second group (the smooth surface group) were polished with a series of silicon carbide papers to 800 grit. All implants were degreased, rinsed, and sterilized before use. The implants were inserted in six healthy male dogs that were randomly divided into three groups for three different time intervals (two, four, and 12 weeks). The insertion sites were the same in each dog. To obtain initial implant stability, the implantation holes were made smaller than the diameter of the implants. At two, four, and 12 weeks following implantation, the implants and surrounding bone and tissue were harvested. Using an Instron pullout tester, the shear strength of the implant-bone interface was measured. Implants that were pulled out Dental Implantology Update

after 12 weeks were processed for routine observation by scanning electron microscopy and then observed under a microscope. Results showed that the shear strength of the modified sandblasted surface group was significantly higher than the smooth surface group. At the initial stages of bone healing, the shear strength of the modified sandblasted surface group exceeded the highest value achieved by the smooth surface group at 12 weeks. In addition, the initial strength observed with the modified sandblasted surface group increased with progression of bone healing. According to the authors, these findings show that the modified sandblasting surface treatment can improve the bone interfacial biomechanics of dental implants. There are three reasons why the modified sandblasting treatment increases the shear strength of the implant-bone interface: 1. The interlocking of the rough surface with surrounding bone. This surface is characterized by many secondary micropores. According to the authors, these micropores play a much greater role in bonding between the bone and the implant than sandblasted surfaces alone. In this respect, the authors concluded that the acid attack method is essential in processing. 2. Enlargement of the implantbone attachment area. The surface area of the dental implant is dramatically enlarged with the use of modified sandblasting surface treatment, especially with the exposure of many secondary micropores in the macrotexture. 3. Bone attachment pattern at the osseointegrated interface of the dental implant. This may be a real bone fiber, perpendicularly integrating attachment instead of conventional capsule-like attachment, the authors stated. If this is the case, the interfacial biomechanics of dental implants would be greatly improved. M

New Product News

Composite System for Restorations
The Cristobal+ indirect composite system is indicated for three-unit metal-free/fiber-free bridges, from second premolar, single-unit crowns to first molars, inlays, onlays, veneers, implants bonded to metal, and all types of fused-to-metal restorations. The Cristobal+ system features a post-curing polymerization process that cures quickly and creates superior strength, hardness, and wear. The nonporous, biocompatible surface provides superior chairside polishability that is virtually impermeable to microorganisms. Because it is mechanically polished as opposed to glazed, the finish does not wear off. For more information, call Dentsply Ceramco. Telephone: (800) 487-0100. World Wide Web: www.ceramco.com.

Metal Ceramic System

IPS d.SIGN is a metal/ceramic indirect restorative system featuring a leucite-fluorapatite ceramic and six complementary alloys. The ceramic is indicated as a veneering material over metal frameworks for singleand multiple-unit restorations. It also can be used to fabricate metalfree veneers using refractory-die or platinum-foil techniques. The ceramics proprietary formula (crystalline phases of leucite and fluorapatite produced through controlled crystallization) is said to replicate the shape of the needle-like hydroxyapatite crystals found in natural tooth structure for natural light reflection and high wear compatibility. For more information, contact Ivoclar North America. Telephone: (800) 533-6825. World Wide Web: www.ivoclarma.com. M May 2000