Finding the Right Balance
Oftentimes, dentists overprepare teeth. This can occur for a variety of reasons, most of which have nothing to do with pushing aggressive treatment. Sometimes, it's related to experience and skill-placing an onlay is much more technique-sensitive than spinning down a tooth and placing a crown. Other times, such as when a patient's insurance will only provide reimbursement for a crown to restore a given indication, skill has nothing to do with it. The need for overpreparation must be weighed against leaving the patient untreated. In the past, I've been guilty in this situation.
In this month's cover story, Inside Dentistry examines tooth preparation, discussing the principles that guide preparation design as well as material and restorative considerations.
We are taught that one of the tenets of excellent dentistry is to remain as conservative as possible when preparing a tooth for restoration. Minimally invasive preparation that is respectful of our patients' natural tooth structure not only improves retention form and the strength and longevity of restorations but also results in increased patient comfort and leaves more options available should the need for re-treatment arise in the future.
We all aspire to this, but what happens when the pursuit of this ideal results in a preparation that is too conservative? In certain cases, dentists can be quick to blame their laboratories for poor esthetic results, when the truth is that they didn't leave sufficient room for the ceramist because the tooth wasn't properly prepared. I've never had a ceramist tell me, "you gave me too much room," but they will say otherwise. In this regard, underpreparing can be as bad as overpreparing. Results with ideal occlusion and esthetics require the combination of a great preparation and a great ceramist. You really need to work closely with your ceramist if you want to perfect your preparations. I've spent a lot of time at my laboratory.
Sometimes, using minimally invasive preparations that are too conservative can increase the strength and longevity of restorations but also make it difficult to achieve high-value esthetics in the process; therefore, an important aspect of preparation design involves finding a balance between being conservative and facilitating esthetics. Furthermore, the relationship between the patient's specific restorative situation, the preparation design chosen, and the materials selected is a dynamic one in which each component must meet the needs of the others to synergistically optimize occlusion and esthetics. Understanding this relationship and finding the right balance for each patient is the key to mastering preparation.
Robert C. Margeas, DDS
Editor-in-Chief, Inside Dentistry
Private Practice, Des Moines, Iowa
Department of Operative Dentistry
University of Iowa, Iowa City, Iowa