Tuesday, February 26, 2013
As clinicians we have an obligation to do what is best for our patients, and as practice owners we must make sound business decisions in order to be profitable.
When making clinical decisions we’re often faced with figuring out what treatment option is best for our patients while working toward a goal of being as conservative as possible. But, if cost is not an issue for the patient being treated, does this impact your goal of practicing conservative dentistry?
Do factors such as your comfort and skill level with the procedure, the cost of the procedure, the time required to complete it, and the possibility of preserving tooth structure influence these clinical decisions?
We all must make decisions such as these every day, but too often we think the porcelain veneer will equal more production for the practice. Sometimes it does, but not always. For example, what if you had to choose between 2-4 veneers or direct composite bonding?
Before: Existing anterior teeth display moderate, irregular wear.
After: Direct composite added to lengthen the teeth and create symmetry.
In my practice to complete the case with veneers, I would have a records appointment, send the case off to the lab for a waxup, have a prep/final impression and provisionalization appointment, and then a final seat appointment. This means 3 visits for the patient to receive his or her veneers.
While my fee per unit is higher for completing one or two porcelain restorations in comparison to completing three or more porcelain restorations, I can tell you it is still more profitable for me to do direct bonding for these smaller cases. Direct bonding requires just one appointment and there are no lab costs or expensive impression materials used to complete the case.
Before: Tooth #10 peg lateral as shown after orthodontics was completed. Space remaining was wider than ideal.
After: Direct composite in 2 shades to close the space and create a more balanced smile.
In my practice, I always present the available treatment options to the patient first. I let them know the risks and the benefits of each option. While I always recommend the most conservative options, ultimately the patient has to decide what his or her motivations are for doing a procedure.
I think most doctors tend to shy away from direct bonding in the anterior and tell patients things such as, “It won’t last as long as porcelain,” “It is only temporary,” or “It is weaker than porcelain.” However, what dentists don’t understand about the choice between porcelain veneers and direct bonding is that the main difference between the materials is the mode of failure.
While composite may wear over time while porcelain does not, porcelain can chip or wear opposing teeth when friction is applied. Composite may pick up some staining, but the newer resin systems have incredible strength and polishability and are certainly capable of delivering excellent esthetics. If occlusion is maintained and parafunctional habits controlled, then either material will deliver predictable long term success.
Before: Patient had existing composite on tooth #7-10 with rough margins and discolorations. Midline had an unnatural curve to it.
After: Direct bonding in one shade to correct the uneven midline and discolorations.
The technique of handling composite is another issue for some dentists. However, with some basic understanding of color and materials, most clinicians can achieve beautiful results.
The advantage with composite is the ability to color match in one appointment, and the chameleon effect of composite color that blends with natural dentition. Delivering direct resin restorations will greatly improve a clinician’s understanding of tooth contour and form as well.
The more I place direct resin restorations, the more I understand natural tooth anatomy and how line angles affect contours and light reflection. It makes sense that the more I practice, the better I get at placing direct bonded restorations, and the more I enjoy doing it.