Often, I receive comments from frustrated practitioners stating that there has been a significant movement away from conservative intracoronal tooth restorations in recent years toward large, deep, aggressive preparations and full crowns.1,2
Are dentists accomplishing too many full-coverage restorations when less radical restorations could have been placed?3 In my opinion, the trend toward more aggressive tooth structure removal is evident. As an example, I recently heard in a continuing education course taught by a popular speaker that a tooth with any restoration to be replaced, regardless of the restoration size, should be replaced with a full crown.
It seems that the opposite practice of conservative restorations should be encouraged, since placement of conservative restorations has never been easier. What are the factors that have influenced this movement to aggressive tooth cutting, and should the trend be reversed?
This article discusses some of the reasons full crowns are being accomplished more commonly than in the past, the rationale for returning to more conservative restorations, the financial implications of crowns versus conservative treatment, concepts making conservative dentistry easier and more attractive to dentists and a discussion of the potential longevity differences between small and large restorations.
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REASONS FOR DOMINANCE OF FULL-CROWN RESTORATIONS
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Third-party payment implications.
Third-party payers have a significant role in the movement toward more aggressive restorations. If a tooth has a moderate-to-large defective restoration in it and the practitioner requests payment for a full-crown replacement, most dental benefit plans will pay for the crown. On the other hand, if payment is requested for a smaller, less aggressive restoration, such as an onlay or an inlay, payment is likely to be denied, or payment for the much less costly amalgam restoration is substituted by the company instead of a crown fee.
Pressed ceramic restorative materials—such as IPS Empress (Ivoclar Vivadent, Amherst, N.Y.), Finesse (Dentsply Ceramco, Burlington, N.J.) and Cerinate (Den-Mat, Santa Maria, Calif.)—have been available for many years, and clinicians and their patients have enjoyed significant success with restorations created with these materials.4 Such pressed ceramic inlay or onlay restorations allow preservation of tooth structure far beyond that of full crowns. These restorations are simple to place, and their use should be encouraged. Organized dentistry should educate benefit plan administrators about the advantages of properly placed, less aggressive restorations.
Perceived simplicity of the full-crown procedure.
All mature restorative dentists have placed many full crowns, and it generally is agreed that experienced dentists do not find the full-crown procedure to be difficult. In general, patients accept full crowns well and find them to be as similar to natural teeth as any dental restoration. It could be concluded that preparing a tooth for a full crown and seating the crown a few days later is an easy and predictable procedure, and that the success of this procedure is highly predictable and acceptable to patients. However, placement of an inlay or onlay made of ceramic or polymer seems to be a more formidable procedure to dentists.5 After placing thousands of conservative and crown restorations myself, I suggest that the tooth-colored inlay/onlay procedure can be as predictable and acceptable to dentists and patients as the full-crown procedure. I encourage dentists to recognize the success of indirect ceramic or polymer tooth-colored inlays and onlays, obtain education about the procedures that produce these restorations, influence third-party payment companies to provide payment for them and, most importantly, implement these conservative restorations in practice.
Laboratory emphasis on the full-crown procedure.
Laboratory owners tend to emphasize full-coverage restorations in their ads and promotions. Most laboratories fabricate far more crowns than the more conservative indirect tooth restorations. As a result, many technicians feel more comfortable making full-crown restorations. When laboratory owners and technicians working with them begin to fabricate more conservative indirect tooth-colored restorations, they find that these restorations also are simple and predictable.
Higher fees for crowns than for directly placed restorations.
Unfortunately for both patients and dentists, fees for directly placed restorations always have been proportionately lower than those for indirectly placed restorations, such as crowns or inlays and onlays. I have never been able to understand this discrepancy. Often, directly placed restorations require more time than do indirect ones, and yet the cost to the patient for indirect restorations may be up to six times more than the fee for direct restorations. Consciously or unconsciously, this fee inequality appears to influence dentists to opt for crowns instead of directly placed restorations.
Why not restore teeth conservatively for a replacement or two before a full crown is required?
I suggest that dentists should analyze their fees and change their fee structures to more adequately represent the well-known criteria for fee determination: time involvement and procedure difficulty. After doing this analysis, dentists likely will raise fees for direct restorations, and the fees for indirect restorations will be at least stabilized but, preferably, reduced.
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RATIONALE FOR CONSERVATIVE RESTORATIONS
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Preservation of tooth structure.
Assuming that a given tooth has a significant amount of tooth structure remaining and that the structure is not discolored or cracked, conservative restorations have some significant advantages. Among these advantages is long-term retention of esthetic acceptability for the tooth restored with a conservative tooth-colored restoration. When a tooth-colored full crown is placed in the esthetically observable zone of the mouth, the esthetic acceptability of the crown usually is good for only months to years. Eventually, the gingival tissues around the crown begin to shrink and recede, and the margin joining the tooth-colored crown and the remaining tooth structure is revealed. The overall esthetic result is unacceptable.
Most dentists agree that preservation of tooth structure is a desirable goal. Once enamel is removed, it cannot be replaced with anything as long-lasting. If tooth structure and restorative material can be bonded successfully, the result achieves the goal of preserving tooth structure. Bonding tooth structure, especially enamel, to restorative materials is a reality today.
It is well-known that restorations, including full crowns, have a finite life expectancy. People are living to older ages than ever before. At some point in the life of every restoration, replacement is practically inevitable. Why not restore teeth conservatively for a replacement or two before a full crown is required? Full crowns always can be placed in the future.
Conservative dentistry has become easier.
In recent years, numerous advancements have become available to make conservative dentistry easier and more attractive for dentists and patients.6–9 Caries-detection devices have been accepted relatively well, including the popular DIAGNOdent (KaVo, Lake Zurich, Ill.). This device indicates the likelihood of the presence of dental caries on occlusal or gingival areas of teeth, thus reducing questions about the location and extent of caries present. Air abrasion techniques, available with water incorporated to reduce airborne debris, allow easy, conservative cutting of teeth.10 Digital radiography11 has made caries detection easier and more predictable because of the various enhancing concepts available when using digital radiographic devices. Caries-detection solutions and gels provide the dentist with the ability to determine caries depth and an indication of when to remove suspicious tooth structure. Clinical microscopes allow clinicians to observe and analyze dental caries in a manner never possible in the past. Conservative dentistry has never been easier. Dentists just need to be convinced that such dentistry can serve patients and still be profitable for dental practices.
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FINANCIAL IMPLICATIONS OF CONSERVATIVE TOOTH RESTORATIONS
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If a full-crown restoration costs $X, a typical mesial-occlusal-distal direct tooth-colored restoration costs about one-fifth or one-sixth $X. If the conservative restoration can be placed with the confidence that it has a reasonable chance of achieving adequate longevity, such conservative placement allows several replacements before the patient’s financial outlay reaches the cost of a crown.
As mentioned previously, restorative fees for directly placed restorations always have been lower proportionately than those for indirect restorations. It is feasible that directly placed restorations should have somewhat higher fees than the current level, thus making the time involvement for direct restorations more acceptable.
When properly organized, dentists and their adequately educated staff personnel can place intracoronal restorations in quadrants, rather than one or two at a time. With the quadrant placement method, the time involvement for each individual restoration is significantly reduced and the income to the practice is greater. An attractive side advantage is that patients enjoy having fewer appointments and having the restorations completed sooner. By increasing fees for direct restorations somewhat and accomplishing the restorations in quadrants, the financial picture for conservative restorations becomes more desirable.
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LONGEVITY OF CONSERVATIVE AND FULL-CROWN RESTORATIONS
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Contrary to popular belief among dentists, conservative restorations can demonstrate good service longevity. Using models, pictures and intraoral cameras, patients need to be shown how much tooth structure can be preserved when conservative restorations are used instead of larger restorations. In my opinion, patients can be educated easily regarding the advantages of such restorations, since I have yet to find a single patient who wants more tooth structure removed.
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SUMMARY
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There is an obvious tendency in dental practice to place more full crowns than may be necessary. This article has discussed some of the reasons for this increased use of full crowns, and for a reduction in the use of full crowns. I have supported the desirability of placing more conservative restorations, and I have discussed the financial and longevity implications offered by more conservative restorative dentistry.
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