We all read many restorative articles that will describe a technique in detail intended to help show us the road to clinical success. In my opinion, this approach alone can leave out some really important information as it relates to our work. Many times you read a clinical article, or go to a clinical lecture, and there is no talk at all about the practice management ramifications of what is being taught. Most of the time, the opposite is true as well; we read practice management articles that may have little or no clinical relevance.
In most of my lectures, I like to teach attending dentists this concept—that the clinical and practice management aspects of your practice are completely intertwined. Everything you do on the clinical side of your practice has direct practice management ramifications. It certainly relates to overhead control, patient satisfaction, patient referrals, post-op sensitivity, and a myriad of other factors. The exact same thing is true with the practice management side of your practice. If you have happy patients, they will like you and the outcome of their restorative or aesthetic case.
CONTROLLING OVERHEAD COSTS
One of the most popular topics that I regularly address in my lectures is overhead control. Most dentists think that the key to overhead control is going to be to severely cut costs, dismiss team members, and live a frugal life. While I have no issue with living a frugal life, the key to overhead control is really to work smarter. One of the biggest keys to overhead control that is missed in most practice management seminars is efficiency; you need to learn how to work more efficiently in order to be more productive financially. Dentists are surprised to learn that, if they can just do more of the routine dentistry faster, easier, and better, their day goes smoothly with less stress and increased profits. In addition, their patients will benefit and also enjoy their visits more. That being said, in our practice, we will invest in anything—big or small—that changes what we do to make it faster, easier and better.
With that premise now installed firmly into your brain, let’s look at a routine procedure and see how choosing the right products, techniques, and materials can directly affect your clinical success, while making the process more efficient, much more profitable, and give the patient something to smile about.
CLINICAL TECHNIQUE-PRACTICE MANAGEMENT INTEGRATION: A CHALLENGING CASE Local Anesthesia or Not?
This case illustrates a failing composite resin (Figure 1). The first thing we need to do is to anesthetize the patient. You have a couple of faster choices here: standard techniques would work, or you could certainly consider using the single tooth anesthesia (STA [Milestone Scientific]) system of local anesthesia delivery. A single tooth anesthesia device, like STA, is a wonderful adjunct to any dental practice. The results are nearly instantaneous and there is no uncomfortable numb lip or tongue lingering after the procedure. If you do not have the STA system, using septocaine as a fast-reacting anesthetic might be your best choice.
Also, for those who do not have the STA system, there is also a brand new and affordable device called the DentalVibe (Bing Innovations). This device provides vibrations (Vibrapulse technology) during local anesthesia injections. The science behind this unique device is very interesting; it was developed using evidence-based brain science studies that show how the brain processes vibratory stimulation. While this instrument is vibrating, the brain cannot process pain signals, making injections virtually painless to the patient. We use DentalVibe in our office, and we are amazed by the patients’ positive responses to this new technology.
Traditional Preparation or Not?
Next we need to prepare the tooth for the restoration. If you have a laser (such as my personal favorite and most affordable LightWalker [Lares Research]) or Waterlase MD [Biolase]), it turns out you will not need any anesthetic, allowing you to proceed directly to preparation of the tooth. The common misconception is that it takes longer to complete a cavity preparation with a laser than with a bur. That is simply not correct if you have had proper training and learned the right technique. When you look at total treatment time between waiting for anesthesia to occur and preparing the tooth, a laser is actually much, much faster and much more comfortable for the patient.
Take a look at the preparation as shown in Figure 2. I show this case because in many clinical articles presented, the restorative procedures are shown with a simple “softball” case that is easy to accomplish no matter what products were used. This is definitely a more challenging case for the simple reason that there is a long lingual area that needs to be properly banded. For the past 25 years, the 2 most common complaints that I have always heard related to placing posterior composite resin restorations are significant post-op sensitivity and difficulty in creating decent interproximal contacts.
Regular Matrix Bands or Not?
The reason for the interproximal contact deficiency in many cases is that dentists want to use what they have used in the past, thinking that it will be successful. Tofflemire matrices were a great invention, but this matrix system design was developed for amalgam restorations where one firmly packs and condenses the amalgam into place, thus creating a long and broad contact area. Well, we are not using amalgam for this restoration—we are using composite resin. The tofflemire matrix band design may work with some composite resin procedures but, in most cases, a little pinpoint interproximal contact is formed which becomes a food trap resulting in an unhealthy gingival/periodontal response and an unhappy patient. Then, the unhappy clinician has to do the restoration again, at no charge. What’s the ultimate solution? Use a composite matrix system specifically made for these restorative materials. There are a number out there (such as Composi-Tight [Garrison Dental Solutions] and the one that we like to use, the V3 Ring [Triodent]) that will assist you in placing direct composite restorations with well-designed and functional interproximal contacts. The 2 systems are very similar but, in the author’s opinion, there are some advantages to the V3 Ring and the way the rubber bumpers adapt to the tooth, as you will soon see.
With many other matrix systems, even if they were developed for composite resin, in this kind of clinical situation, you would fill the preparation with composite resin and when you remove the matrix system, the tooth would have a little annoying bump on the lingual because of the poor adaptation. With the tofflemire matrix in this case, you would have an even larger and more annoying bump there. In Figure 3, take a close look at how well the V3 Ring adapts to the tooth, especially with that long lingual area. This is the primary reason why I really choose the V3 Ring for my practice. The way it is designed, it has an incredible ability to adapt to a wide variety of clinical situations that are easy and that are challenging, like this case.
Choosing a Composite Resin Restorative Material
We are blessed to have so many wonderful restorative composite resin systems available today. You can’t go wrong with Filtek LS (3M ESPE), Tetric EvoCeram (Ivoclar Vivadent), Synergy D6 (Coltène/Whaledent), Herculite Ultra (Kerr), and others. In our office we have chosen to use a new nanofilled composite resin called KALORE (GC America) which is used with its companion self-etching bonding agent, G-Bond (Figure 4). This is a new monomer resin technology that GC America has developed with DuPont that results in some nice clinical advantages. Kalore has a chameleon-like optical duplication property allowing it to blend beautifully with surrounding tooth structure, very little shrinkage, is very strong, and it maintains its high polish well because it is a nanofilled composite. In addition, it has an extremely low reaction to ambient light so that the clinician will not begin to feel like it is a little “crunchy” as it is packed into place. Be aware that some of the composite resins available on the market are very sensitive to the operatory light, so one can only imagine what the long-term effects on the margins are if one of these materials are utilized.
In Figures 5 and 6, you can see the primary benefits of using this entire combination of restorative materials and products. Because of our choice in matrix systems, there was only a slight bit of composite resin flash on the lingual that needed to be finished. When there is gross excess of composite resin due to a poorly fitting matrix system, I have the challenge of trying to finish a tooth-colored restoration against a tooth-colored tooth. Most dentists have experienced this dilemma on more than one occasion. Because it is hard to distinguish between the resin and the tooth, one can unintentionally ditch the margin of the restoration, with the need for subsequent repair. That is definitely not the faster, easier, or better way to do restorative work—it takes significant time for finishing with a problem that could have been prevented.
Figure 7 shows the completed restoration. Notice the high shine that was achieved with the Jazz (SS White Burs) polishing system (Jazz can be used on any nanofilled composite resin system). You will also notice the long and broad interproximal contact from using the V3 Ring Matrix System. There will be no worries with the patient packing food in this contact area and calling a week or 2 later with complaints. The bite-wing radiograph in Figure 8 clearly demonstrates the marginal adaptation as well as the successful interproximal contact.
A successful dental practice needs a synthesis of clinical techniques and practice management delivered within a philosophy of excellence. The clinical and practice management aspects of your practice are inseparable, no matter how small or complex the dental procedure is. When choosing dental materials and products for one’s practice, one must do it with the goal of providing the best dentistry possible with simpler, better, and more efficient techniques, in order to ensure long-term restorative success and optimal patient satisfaction.
Dr. Malcmacher is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, he is the president of the American Academy of Facial Esthetics. He is on the faculty of the American Academy of Facial Esthetics, which provides training in BOTOX and dermal filler procedures. He can be reached at (440) 892-1810, firstname.lastname@example.org, or his Web site commonsensedentistry.com.
Disclosure: Dr. Malcmacher is a consultant to Triodent, GC America, and Lares Dental.