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OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.

Has tooth structure been replaced?


n the past 20 years, the
profession has eagerly hastened toward total acceptance of esthetic dentistry.
This has been an excellent
concept, both for the profession
and for the patients it serves.
Early in the esthetic revolution there was an emphasis on
conservative dentistry. When
ceramic veneers were introduced, it was suggested that
preparation of the tooth was not
necessary. On an even more conservative note, bleaching teeth
was suggested instead of cutting
off tooth enamel and placing
restorations. When resin-based
composite restorations were
introduced in the late 1960s,
small cavity preparations were
suggested instead of the typical
large G.V. Blackstyle tooth
preparations of the past.
Something has changed in
recent years; we now are seeing
deep tooth preparations suggested for even slight tooth discolorations. This article discusses the current trend to cut

teeth in less conservative ways


than were practiced in the past.
It includes the major areas of
esthetic restorative dentistry
and the current beliefs about
tooth preparation and restoration.
PORCELAIN VENEERS

When direct resin veneers were


introduced 25 years ago, one of
their major apparent advantages was the slight reduction of
tooth structure that they required. The resin could be
placed directly on acid-etched
enamel. Esthetic results were
excellent, even by todays standards. Shortly thereafter, the
fired porcelain veneer was introduced. Again, conservative
tooth preparation, or no preparation at all, was suggested.
The esthetic results were variable; some of these restorations
appeared to be bulky and overcontoured, while others were
relatively acceptable from an
esthetic standpoint.
Slowly, tooth preparation con-

cepts for veneers evolved into


removal of about two-thirds to
three-quarters of the enamel,
and the replacement of the
missing enamel with fired or
pressed porcelain. The esthetic
result produced by this type of
veneer was exceptional, and I
have stayed with this tooth
preparation concept. The resin
cement bonds well to etched
enamel and to the roughened
ceramic.1 The long-term clinical
success of this type of veneer is
well-known. The thin layer of
remaining enamel protects the
dentin from the sensitivity produced by resin cement. Almost
no postoperative tooth sensitivity occurs, and the esthetic
result can be outstanding.
More recently, veneer tooth
preparations cut deeply into
dentin have been suggested.
Legal representatives for a dentist recently contacted me to
make suggestions as to why 13
of 16 veneers placed by the dentist had come off after they had
served for only a few months.

JADA, Vol. 133, January 2002


Copyright 2002 American Dental Association. All rights reserved.

103

C H R I S T E N S E N

The veneer preparations had


been cut deeply into dentin, and
after my examination I decided
that separation of the veneers
from the teeth was taking place
at the dentin-resin interface. In
other words, the dentin bond
had failed. In addition to having
sensitive teeth, the patient was
very upset with the dentist. The
dentist was threatening to sue
the company that manufactured
the dentin-bonding agent he
used on the patient. I advised
him not to do so. In my opinion,
his problem was caused by deep
tooth preparations into dentin
and the resulting absence of any
mechanical retention in the
tooth structure. It appears that
dentin bonds that are impressive when analyzed in a laboratory by in vitro research are
transient when subjected to
temperature changes in the
mouth. In my opinion, the dentist could have prevented the
entire problem by making the
tooth preparations in enamel
instead of dentin. I also feel that
the esthetic result could have
been equal to the result provided by the deeper cuts.
ALL-CERAMIC OR POLYMER
CROWNS

It has been estimated that about


18 to 22 percent of crowns now
placed are all-ceramic or polymer crowns (oral communication, J. Shuck, Glidewell Laboratories, Nov. 7, 2001). These
types of crowns certainly have
their indications,2,3 especially if
patients have potential allergies
to metals used in porcelainfused-to-metal crowns. However,
in my opinion, there is a tendency in the profession to use
these crowns when other, less
aggressive restorations could be
used.
All-ceramic or polymer
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crowns require tooth preparations that involve significant


tooth reduction. Specifically, the
tooth preparations require about
2 millimeters of reduction on
occlusal surfaces, 1.5 mm of
tooth reduction on facial and
proximal surfaces, and at least
1 mm of reduction on marginal
areas. If these tooth preparations are accomplished on a
young person with large dental
pulps, or a person with sensitive

Dentin bonds that are


impressive when analyzed
in a laboratory by in vitro
research are transient when
subjected to temperature
changes in the mouth.

aspects of the teeth are not


affected. In these cases, many
dentists cut a standard crown
preparation, removing the unaffected facial and lingual tooth
surfaces, and they leave only a
small amount of tooth structure
to hold the subsequent crown in
place. The resulting tooth
restoration often has postoperative sensitivity and less-thanoptimum retention. More conservative, and potentially longerlasting, restorations could be
accomplished by preparing the
teeth for onlays, thereby preserving the facial and lingual
tooth surfaces.4 Either toothcolored onlays made from
ceramic or polymer or cast gold
alloy restorations would restore
the onlay preparations.
LARGE BURS FOR
OPERATIVE DENTISTRY
PROCEDURES

teeth, the result is predictable.


The teeth will be sensitive
because of the deep tooth preparations and use of pulpally irritating resin-based composite
cement. Often, the patient experiences lingering postoperative
tooth sensitivity and the potential need for endodontic therapy.
Could the teeth described
above be restored using less
aggressive crown tooth preparations? Could the teeth be restored adequately with simple
intracoronal restorations? Even
more thought-provoking, could
the teeth have been made
esthetically acceptable by
bleaching?
INLAYS OR ONLAYS
INSTEAD OF CROWNS

Often, the intracoronal areas of


teeth to be restored are
destroyed with previous tooth
preparations made for amalgam
or resin-based composite restorations, and the facial and lingual

Years ago, when ultrahighspeed handpieces were not yet


available, cutting instruments
such as the still-popular 557 bur
were popular. When placed in
an air rotor handpiece that has
undergone a few hundred sterilizations and has lost its concentricity, this bur becomes a mutilating instrument. Such large
burs are not required for operative dentistry when only small
carious lesions are present. Frequently, I see overcutting that
apparently has resulted from
the use of large burs and nonconcentric handpieces. Today,
smaller burssuch as the 56,
330, 256 or other small-diameter
noncross-cutting bursare recommended for routine use in
operative dentistry.
Nonconcentric handpieces
should be repaired as soon as
the lack of concentricity is identified.5 The ultrasonic vibrations
that are produced by such hand-

JADA, Vol. 133, January 2002


Copyright 2002 American Dental Association. All rights reserved.

C H R I S T E N S E N

pieces are highly destructive to


teeth, causing cracks and tooth
breakage easily observed clinically by dentists.
OVERCUTTING
CONVENTIONAL TOOTH
PREPARATIONS

It is extremely easy to overcut


teeth when using air rotor handpieces or high-speed electric
handpieces. I suggest the following strategies to avoid overcutting:
dCarefully cut conventional
tooth preparations for fixed
prosthodontics or operative dentistry, using magnification of at
least 2.5 on a routine basis.
dEvaluate handpieces for concentricity regularly and have
them repaired as soon as lack of
concentricity is observed.
dUse new burs or inexpensive
one-use diamonds for one patient only or until dull if multiple teeth in the same patient
are being prepared.
dUse small burs.
dRestore carious lesions as
soon as they are evident clinically, by radiograph, using caries
diagnostic instruments such as
the DIAGNOdent (KaVo, Lake
Zurich, Ill.) or transillumination. Waiting longer to restore
teeth requires the cutting away

of more tooth structure, weakens remaining tooth structure


and requires more clinical time.
dUse optimum water spray
for bur lubrication and to reduce
pulpal damage caused by heat.
dExercise care to conserve
as much tooth structure as
possible.
SUMMARY

In my opinion, there is an
obvious trend in the dental literature and in continuing education courses to promote overcutting teeth when preparing them
for restorations. There are many
reasons for overcutting. Some
feel that there is a more
optimum esthetic potential
when the teeth are prepared
more deeply, which is a debatable view. Others are using allceramic crowns or polymer
crowns when other types of less
radical crowns could be used.
There also is a significant tendency to prepare teeth for crowns
instead of for onlays or inlays,
thereby removing more tooth
structure than is necessary.
High-speed dental air rotor or
electric handpieces can cause
inadvertent removal of more
tooth structure than is necessary. Using large burs can
overcut tooth structure, and

nonconcentric
handpieces
tend to overcut
and crack tooth
structure. The
result of these
Dr. Christensen is codescribed
condifounder and senior
consultant of Clinical
tions can result
Research Associates,
in postoperative
3707 N. Canyon Road,
Suite No. 3D, Provo,
tooth sensiUtah 84604, and is a
tivity, low
member of JADAs editorial board. He has a
retention of
masters degree in
restorations
restorative dentistry
and a doctorate in eduand weak
cation and psychology.
overall restoraHe is board-certified in
prosthodontics. Adtions. In my
dress reprint requests
opinion, the
to Dr. Christensen.
trend to overcut
teeth should be reversed.
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental Association.
Educational information on topics discussed
by Dr. Christensen in this article is available
through Practical Clinical Courses and can be
obtained by calling 1-800-223-6569.
1. Christensen GJ. Ceramic veneers: state of
the art, 1999. JADA 1999;130:1121-3.
2. Christensen GJ. Why all-ceramic crowns?
JADA 1997;128:1453-5.
3. Christensen GJ. Porcelain-fused-to-metal
vs. non-metal crowns. JADA 1999;130:409-11.
4. Christensen GJ. Intracoronal and extracoronal tooth restorations, 1999. JADA
1999;130:557-60.
5. Christensen GJ. The high-speed handpiece dilemma. JADA 1999;130:1494-6.

JADA, Vol. 133, January 2002


Copyright 2002 American Dental Association. All rights reserved.

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