Private practice, Houston, Texas. The evolution of composite resins has enabled
clinicians to rethink the way they prac- tice dentistry. In comparison to amalgam ...
20
MINIMALLY INVASIVE DENTISTRY WITH COMPOSITE RESIN: A Success Story in Two Parts Douglas A. Terry, DDS Private practice, Houston, Texas.
he evolution of composite resins has enabled clinicians to rethink the way they practice dentistry. In comparison to amalgam, composites require less extensive preparation designs, reinforce tooth structure, demonstrate comparable longevity, and provide improved aesthetics. In this interview, Douglas A. Terry, DDS, begins a two-part conversation on success with composite resins to build practice profitability.
T
COLLAB: Please tell us how you have used composite resin technology to build your practice. TERRY: Many clinicians are familiar with the clinical applications of composite resins. These welldefined applications include: Anterior and posterior composite restorations (Figures 1 and 2); Sealants for caries prevention or wear resistance (Figure 3); Cementation of crowns, bridges, and posts utilizing resin cements (Figure 4); Placement of orthodontic brackets; Periodontal splinting; and Composite core preparations for crowns. However, the potential of adhesive dentistry does not stop here. Once we, as clinicians, begin to look at composites not merely as a restorative material for specific restorative procedures, but as a vehicle for practice growth, then the profitability will follow because of the additional benefits that accrue. The following examples illustrate this point: Diastema Treatment I once saw a patient who was 78 years old and who came to my office as a new patient from another city.
While examining her, I noted a diastema and asked, “How do you like the space between your teeth?” She said, “I’ve never liked it, but I thought I was too old for braces.” In five minutes, I was able to make a composite insert and show her how she would look if we restored the diastema. At the end of the appointment, she was able to take her composite insert home to show her husband. Well, when I drove up to the office the next morning, she was already sitting in my waiting room! After all those years of being dissatisfied with her appearance, she’d been able to see the difference that restorative treatment would make. Although we ultimately made the restoration from porcelain, the composite served us
well as a teaching tool because it allowed us to illustrate dramatically to the patient and her family what could be achieved. Sometimes you have to make patients want what they need, and the mockup accomplished that. Composite Mockups Composite mockups are useful on several levels. These models can function as internal marketing devices to promote treatment acceptance by visually predicting aesthetics. Not only the diastemata closure but modification of profile, shape, contour, and length of teeth lend themselves well to such evaluation. Diagnostically, the composite mockup also helps the patient and the restorative team to consider
and establish aesthetic parameters by simulating the final result in a visual form (eg, lip profile, incisal length, vertical dimension, gingival orientation). The composite model can be fabricated intraorally without anesthesia or on a diagnostic model. From the model, a matrix can be made to serve as an index for the clinician, be used over the teeth and soft tissues as a guide for the correction of abnormal occlusal planes, as a preparation guide to tooth reduction, as a surgical guide for tissue orientation, and as a transfer vehicle for resin material in the fabrication of the provisional restorations. Also, an incisal index matrix can be fabricated from the mockup
FIGURE 1. Preoperative occlusal view of preexisting amalgam restorations that required removal.
FIGURE 2. Postoperative appearance following restoration using a hybrid composite resin (Point 4, Kerr/Sybron, Orange, CA).
FIGURE 3. Sealants applied to the tooth surface can function as preventative resin restorations.
FIGURE 4. Excess resin cement is removed from around an all-ceramic crown using the “wet brush” technique.
Collaborative Techniques Fall 2003 as a guide to fabricate the definitive restoration. In other words, with a minimal investment of time and materials, the composite mockup serves multiple purposes. Porcelain Repair Composite resins can also be employed to foster practice growth in the repair of fractured porcelain crowns to increase the longevity of failed restorations and to offer the patient and the dentist a cost-effective alternative to their replacement. Even if bonding is only transitional, it can enable the patient to continue functioning in comfort and with a pleasing smile during the provisional period. A proper surface preparation is essential for successful fracture repair with composites. Mechanical roughening of the surface of the restoration with diamond burs and microetching creates a micromechanical retention bond at a microscopic level. The fractured porcelain should be isolated by masking the uninvolved area with block-out resin, sandblasting, and rinsing. Hydrofluoric acid gel is placed on the porcelain for two minutes and rinsed. Metal primer and opaque color modifier are applied to the metal, and silane is applied to the porcelain. Then an artificial dentin layer—an opacious A-3 shaded hybrid composite resin—is applied and smoothed with a sable brush and light cured. An artificial enamel layer is applied with an IPC and smoothed to proper anatomical contour. Finishing and polishing can be completed with multifluted burs, composite silicone points and cups, and polishing paste (Figures 5 through 7). This procedure can provide the patient and clinician with a transitional restoration and the time to decide on a more definitive treatment procedure. Composite Post-and-Cores Fabrication of fiber-reinforced postand-core systems is a third way of using resin technology to build the practice. A fiber-reinforced post-andcore offers an alternative to rehabilitation of the intraradicular anatomy of the post-endodontic channel with a direct composite resin. A bondable reinforcement fiber (eg, Ribbond, Seattle, WA; Construct
and Connect, Kerr/Sybron, Orange, CA) is utilized as the post material, and a fourth-generation bonding agent or a dual-cure hybrid composite (eg, Nexus II, Kerr/Sybron, Orange, CA; Variolink II, Ivoclar Vivadent, Amherst, NY) as the luting agent. A dual-cure hybrid composite (eg, Corestore, Kerr/Sybron, Orange, CA; Marathon, Den-Mat, Santa Maria, CA) is selected for core buildup. The resulting postand-core can be completed in one appointment without laboratory fees or negative effect on aesthetics (Figures 8 and 9).1,2 The system is subject to no corrosion, no designated orifice size, and negligible root fracture.3 Retention resulting from surface irregularities is increased, and tooth structure is conserved.3 There are some disadvantages of the technique, including technique sensitivity, the need to follow careful adhesive protocol, and the requirement to maintain inventory of the reinforcement materials, but one study has indicated that fiber-reinforced posts may have a greater potential for longterm success than base metal alloy because of their greater flexibility.4 The list of ways that resin technology can be utilized to increase practice revenue is a long one, but the last one I will mention involves making it the subject of the clinician’s own in-office continuing education program, wherein the dentist and auxiliaries learn how to develop direct/indirect restorations in the laboratory. When the clinician and/or auxiliaries fabricate restorations within the office, patients benefit by receiving their restorations more quickly (in one appointment) and by receiving restorations with improved physical and mechanical characteristics. Patient satisfaction from prompt, predictable restorations benefits the practice by generating satisfied word of mouth. Working with resins also expands the clinician’s and auxiliaries’ understanding of color, of the importance of marginal integrity, and of supremely important function. The entire team comes to a better understanding of the magical optical properties of the natural tooth, the importance of proper selection of restorative materials and
21
A
B
FIGURE 5A. Preoperative appearance of a fractured metal-ceramic FPD. 5B. A block-out resin was applied to allow the clinician to sandblast the metal and porcelain surrounding the edge of the fracture.
A
B
FIGURE 6A. The metal primer and an opaque resin color modifier were subsequently applied to the metal substructure to conceal the underlying framework. 6B. Silane was then applied to the fractured porcelain.
A
B
FIGURE 7A. An opacious A3-shaded hybrid composite resin was applied and smoothed with a sable brush to create an artificial dentin layer. 7B. Postoperative appearance of the restoration following incremental composite buildup.
proceed to page 23
Collaborative Techniques Fall 2003
23
MINIMALLY INVASIVE DENTISTRY continued from page 21
the restorative dimension, the role of proper tooth preparation techniques, and the dimensions of color and how color can influence the final aesthetic result. Patients are provided with more naturallooking restorations, which increases their satisfaction, and their satisfaction translates into more patients for the practice. As the clinician and the auxiliaries better understand and appreciate the ceramist and the information that the ceramist needs, this relationship and improved communication allow for a much faster turnaround time and, therefore, lessen the chance for error. These benefits increase profitability and liberate more time for the restorative team to see more patients.
A
B
FIGURE 8A. Preoperative appearance of a fracture on tooth #8(11) that required endodontic treatment. 8B. Removal of gutta-percha was facilitated using a Gates Glidden drill.
ple, she receives a bonus. This bonus not only provides her with additional income, it motivates her to sell dentistry because she, too, benefits directly from it. The advantages of this arrangement to the practice are manifold. As mentioned above, the quality of the work increases because the auxiliaries learn the technology hands-on by working with it. This opportunity to increase their skills and apply those skills in a meaningful way
“Once clinicians look at composites as a vehicle for practice growth… profitability will follow.” — Douglas A. Terry, DDS COLLAB: You often talk about the role of resin technology in promoting personal satisfaction and motivation among the clinical team members. How does this work in your own practice? TERRY: There are at least three ways that I’ve seen adhesive dentistry improve the work experience for the people involved and, as a result, increase personal satisfaction and motivation. Let’s start with the auxiliaries. In my office, we conduct continuing education in resin technology as I’ve suggested above. Staff members who go through this continuing education and gain these valuable skills are given additional salary and benefits. When one of my assistants fabricates a provisional in the office lab, for exam-
A
promotes excitement, job satisfaction, and job security. Practice morale is high. I have essentially no turnover, which means I have no retraining expenses, but I do have many people who would like to work in the practice. Patients are treated in a harmonious setting, which improves their total treatment experience and generates further positive feedback and reinforcement to the staff as well as good word-of-mouth promotion in the community. Outside the office, we send our patients to see the ceramist whenever possible. Afterward, the technician and patient always thank me for letting them be a part of this process. When ceramists are confined to working with stone models, their satisfaction can be limited.
B
FIGURE 9A. The fiber is inserted into the post hole and the folded ends are arranged into the desired shape of the core. 9B. The completed fiber-reinforced composite resin postand-core.
However, when we add the personality of a patient to the process, the whole world changes for them! Now there is substrate color, eye color, hair color—not simply what I call a “stone model without a face.” Even if it is not possible for the patient and the technician to meet, I tell all my restorative patients that if they really like their results, they should call the laboratory and tell the ceramist. Sharing postoperative results constitutes the final and most often-neglected avenue of communication available to the clinician and technician. Postoperative photographs allow all members of the restorative team to review, discuss, and reflect on the final outcomes of the restorative procedures and can benefit all members of the team. Since the laboratory technician rarely has the opportunity to observe the definitive restorations in the patient’s mouth, any postoperative comments, suggestions, or questions from the clinician can improve the relationship among the members of the team and contribute to the success of future endeavors. Many times it is through sharing not only our successes but our shortcomings that we can understand each other better and move to new levels. Finally, there is the clinician’s own personal satisfaction and motivation. The illustration I like to use when I talk about this is my first experience in dental school. I have never forgotten it: I performed an amalgam restoration on a mandibular left second bicuspid. At that time, this was the restorative medium of choice for the clinical situation. I performed it under a rubber dam, and my instructor
asked me to go deeper because I wasn’t in the dentin. He wanted me to extend the grooves to diminish the possibility of future caries. Today, of course, I know I could have stopped in the enamel. Nonetheless, I look back on that restoration with great satisfaction. What motivated me then and motivates me today is the pursuit of excellence. I’m quite confident that if G.V. Black—the dental forefather whose principles of systematic approach to cavity preparation I used in school to prepare myself for that first restoration—came back today, he would advocate treatment of that second premolar with an adhesive preparation design. He would do so because of his pursuit for excellence, which can be seen in adhesive dentistry today.
CONCLUSION Adhesive technologies give us the opportunity to pursue excellence with a modality that is highly aesthetic and often virtually immediate—two qualities that are valued by our patients. When we achieve that excellence, every member of the restorative team wins: the patient, the auxiliaries, the technician, and ourselves.
REFERENCES 1. Landerwerlen JR, Berry HH. The composite resin post and core. J Prosthet Dent 1972; 28:500-503. 2. Rada R. Placing esthetic bonded direct posts and cores. CDS Rev 1999; April:24-27. 3. Miller MB. Composite Reinforcement Fibers: The Rating. 14th ed. Houston, TX: Reality Publishing; 2000:121-124. 4. Eskitasioglu G, Belli S, Kalkan M. Comparison of two different post and core systems using a finite element stress analysis and a conventional fracture strength test. Paper presented at: 4th Joint Meeting of the Continental European and Scandinavian Association for Dental Research; August 24-27, 2000; Warsaw, Poland.
