Pursuing Innovation and Conservation

Translating what we've learned during our educations into actual solutions for our patients is not always a cookie-cutter process. From patient to patient, subtle differences in anatomy and the subjectivities of presenting conditions often require us to adapt our treatment plans and techniques accordingly.

In this issue, Daniel Domingue presents an article in which surgically assisted orthodontics are given a digitally driven spin in the form of a 3D-printed surgical guide to reduce the complexity, and Gregg Helvey highlights a case in which the classic Maryland bridge is flipped to be facially retained by veneers. Domingue's method is flapless, requires no bone grafting material, and uses dentist fabricated clear aligners-an approach that resulted in faster treatment, less potential complications, and great savings for the patient. Clearly, CBCT provides us with one of the best methods to improve accuracy. In Helvey's case, all of the patient's issues are resolved with one novel, money-saving restorative approach. Stronger esthetic materials such as IPS e.max have really enabled dentists to do more in the anterior. The 3D printed corticotomy guide and facially retained Maryland bridge described in these articles provide excellent examples of how dental techniques evolve as materials and technology evolve. In the pursuit of lifelike esthetics with ideal occlusion, dentists need to be innovative.

When treating any given condition, the semantic differences or unique characteristics of an individual patient's particular situation may benefit from, or even necessitate, a modification to a traditional technique or a never previously used combination of techniques. Will this adaptation respect what is known about the needs of hard- and soft-tissue relationships, the effect of occlusal forces, and the known limits of the techniques and materials used? Is it conservative in its approach and focused on meeting the patient's treatment goals without sacrificing the long-term stability of the result? If the answer to these questions is yes, then you are not only providing a better outcome for your patient, you are also helping to advance the practice of dentistry.

The topic of conservation deserves some additional attention. Dentists must always be guided by the principles of conservation, but when working in the anterior, the more conservative-the better. It's easy to get excellent esthetics when you overprepare a tooth, but if you are as conservative as possible in your treatments, you'll have more tooth structure available to work with later on if re-treatment becomes necessary or when better esthetic options become available. I had been doing feldspathic veneers for 15 years when pressable ceramic veneers came on the scene, requiring us to do more preparation to accommodate the restoration. Once these materials are properly bonded to enamel, there is little difference in strength. So which is better? I like whatever it is that my lab can do with the best esthetics while requiring the least preparation. "Prepless veneers" receive a lot of attention, but I advise dentists to approach ALL veneers from the standpoint of "prep less." Enamel is sacred, and we should always be working to preserve it, even though this often requires more work for less reimbursement. Winston Chee and Terry Donovan once suggested that dentists charge an "enamel preservation fee" for prolonging the life of the dentition. Maybe they were on to something…

Robert C. Margeas, DDS
Editor-in-Chief, Inside Dentistry
Private Practice, Des Moines, Iowa
Adjunct Professor
Department of Operative Dentistry
University of Iowa, Iowa City, Iowa
rmargeas_eic@aegiscomm.com