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Lasting Dentistry

November 09, 2018

K.I.S.S.

No, Not the Eighties Glam Rockers, the Acronym representing Keep It Simple Stupid!

Below are pictures of a patient’s front teeth. I am incredibly proud of this work which was carried out about 20 years ago when the patient was still a student and attended with severe dental problems.

Both central incisors and the left lateral incisor were treated endodontically (root filled) and then restored with composite fillings bonded onto the teeth.

At the time I was treating this patient they were heavily decayed with large abscesses under these teeth as well as a couple of the back teeth. I was unsure if the teeth could have even be saved.

Over the years the composites have been polished and touched up but are essentially the same fillings. The back teeth that were root filled, were then restored with crowns. The crowns are still in place, still functional, but at this stage, they look awful. The porcelain has chipped off in places, the gum has receded revealing the metal margins.

In comparison these front teeth look amazing, the gum is really healthy. When I compare them to the crowns at the back I am so glad I did not crown these teeth. If I had, I would have needed to place metal posts along the root to support the crowns. By now I would have been forced to replace the crowns at least once due to recession.

Statistically, at least one of the posts would have failed, fracturing the root, requiring the extraction of the tooth. The solution, we would either have to bridge the area or place an implant. Both these options are expensive and have at best a lifespan of 15-20 years.

Since we carried out all the treatment to rehabilitate this mouth I have replaced a couple of fillings and carried out only routine scaling. The patient has been exemplary in their oral hygiene and diet control.

We are about to carry out further work on these front teeth, I have started to bleach all the upper teeth to lighten the colour of the teeth in general. This is a completely harmless process that does not damage or remove any natural tooth.

Once this is completed I will build up these teeth with very fine composite veneers, bonded onto the tooth surface, shaped and shaded in the surgery by hand.

Throughout life, the tooth surface is lost from teeth. As a young person, the surface of the tooth has an amazing 3D quality. When the tooth ages, the surface tends to become a lot flatter, this effects how the tooth reflects light and how it appears.

As I restore these teeth I will reproduce this “young” 3D surface, bonding composite onto the existing surface. I will not need to remove any natural tooth this is purely additive.

The composites we now use are amazing in their performance, so much better than the composite available to me 20 years ago when I initially placed these fillings. The tooth is still the same old tooth that was present 20 years ago, and it is still the best material we have for a tooth by a mile. The artificial materials we currently have available cannot touch the ability of natural tooth.

In dentistry the gold standard is a natural tooth, it is the best thing to have in your mouth. These root filled heavily restored teeth are compromised but there is still enough natural tooth to have allowed them, function and survive within the mouth.

Compromised as they are, these teeth, have and will outperform any crown or implant, it is not due to my dentistry or materials it is down to the preservation of the natural tooth.

When this treatment was first carried out, I was unsure if the abscess under the teeth would heal and so the fillings were placed as a temporary restoration. The patient had dental fatigue and I wanted to assess how the patient would manage their hygiene programme.

Year after year passed, with the restorations surviving and so in consultation with the patient, we decided to keep and maintain the restorations.

During this period I was also seeing the shortcomings of cases I had carried out placing crowns. Best Evidence Dentistry was also on the rise and the statistics of the survival of root-filled teeth restored with posts and crowns made for sober reading.

Best Evidence Dentistry looks at stats for a wide range of treatments, the work of a wide range of dentists and will predict with accuracy the survival rates of treatments. Initially, dentists would think these rules didn’t apply to them, their work was better with improved survival rates.

This was slightly arrogant and incorrect, based on personal professional bias, (the scourge of professionals), the stats bear out to be accurate, every dentist will have cases that are better, cases that are worse (hard to admit to) but we all average out, any dentist who ignores best evidence advice is foolish.

The overriding lesson we are learning from the best evidence is minimally invasive dentistry is best, the survival of a tooth increase with how much natural tooth remains. Nothing we can do or make come close to the natural tooth.

I will have completed the above work in the next month or so and will post the results, hopefully, it will last another 20 years with touch-ups only, but by then it will be the responsibility of another dentist. I don’t think anyone will ever persuade this patient that a crown is necessary.

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