By Jeffrey C. Hoos, DMD
As appeared in Dental Economics Everyone knows that dentistry has gone through incredible changes since the G. V. Black days of modern dentistry. When I graduated from dental school in 1978, my knowledge of cosmetic dentistry was severely limited by a lack of experience and the available materials and methods. Success in my practice meant finding the balance. Part of the process of providing beautiful dentistry was producing art. Armed with a "universal shade" composite, I was trying to do fillings that were invisible, and I learned the day they looked the best was the day I put them in my patient's mouth. I had many patients who were thrilled when I took out anterior Class 5 amalgams and placed Adaptic composite restorations. I had heard about direct bonding and a "crazy" guy named Ray Betolotti who talked about composites on dentin. I also had seen a caries detector that a professor had brought back from Japan. But because direct bonding and "decay detectors" had been laughed about in dental school, who was I to try this "outof-the-box" thinking? My disappointment came when these Adaptic fillings came back stained, discolored - and frequently with recurrent decay - on the patient's recare appointment. "Doc, you told me you could make me look great, but what good is it if it doesn't last? On top of that, my insurance didn't pay for it !" These nonbonded composite fillings were not helping me find the "balance" at all. I could carve a pretty nice Adaptic universal shade composite, but if the shade was not "universal," I was stuck. In my dental education, I was told never try to do a single central incisor requiring a tooth to be restored with a crown. All porcelain restorations were frowned upon because they just were not very strong. Metal-supported porcelain crowns were the new thing, and if done very well - and certainly only two at a time - the results, so I was told, were not bad. I did not have any experience with all-porcelain restorations, until one day a patient came to see me with a broken all-porcelain crown. She was a wonderful patient who had broken the corner of Tooth No. 9 and exposed the stump of the tooth. What was I going to do with this? When I suggested two new metal crowns, she said, "What? Are you kidding? Call my dentist in Philadelphia and find out who made these six front crowns." I had to admit they were beautiful, and so I began my quest to provide my patient with the "art" she needed and that I wanted to provide. I could not let her leave the office with a broken front tooth. Besides, I had all morning to do my work. The first thing I did was to cut off her porcelain crown and make a universal Adaptic temporary composite. Removing the crown was a lesson in itself, and I marveled over how beautiful the margins were. I had not seen a butt joint before, because I had only been taught shoulder and bevel preparations. I had read about butt joints, but that went beyond my training. To make a beautiful temporary, I thought I was being pretty innovative by using a crown-former, filling it up with the composite, letting it self-cure, and then cutting it back. Was I lucky that the universal shade looked great! I explained to the patient that she had to be careful with the temporary and I would speak to her dentist in Philadelphia. The dentist in Philadelphia could not have been nicer, and put me in touch with the gentleman who made the patient's original porcelain jackets. I finally reached Guntas Berzins, the lab technician who had made the jackets so beautifully, and my glass education began. A new world of indirect cosmetic dentistry opened up. "Send me a beautifully poured impression and I will send you back a jacket. Be sure to cement it in with standard color zinc oxyphosphate and do not fill the crown up like a bucket or you will break the crown." The end of the story was perfect. The crown came back and fit like it had grown there. After three tries to correctly mix the cement, the restoration was cemented - and I was so happy that the occlusion did not need an adjustment! I no longer looked at broken front teeth with the direct-bonding methods which were previously my only option. Sure, I took away a lot of tooth structure, but I was giving someone a beautiful smile. Fast forward to 2004 and what have we learned about finding the balance? Bonding has become easier and lasts longer, but using an outside technician who makes beautiful indirect restorations is a wonderful option. How about a combination and how about smaller "tooth-conservative" glass restorations? Think about finding that balance between the two modalities of composite versus glass. Jeffrey C. Hoos, DMD, FAGD, is president of the Giraffe Society: "Professionals willing to stick their necks out." His seminars focus on "Balancing: The Art, Science, & Business of Dentistry." Contact him by email at jchdmd@msn.com [1] or visit his Web site at www.dentalexplorations.com [2].