The importance of occlusion in the failure of tooth-colored restorations is clear, with most tooth-colored nonmetallic restorations showing a sevenfold to 10-fold increase in failure rates when used on molars as opposed to anterior teeth.1–3 This corresponds closely to the ninefold increase in bite force measured on molars relative to that on incisors.4 It is not surprising, then, that an interest in occlusion has been rekindled as more and more dentists provide tooth-colored restorations.
A byproduct of increased interest in occlusion has been a renewed debate about which occlusal philosophy is correct. The purpose of this column is not to enter that debate. It is clear that whenever dental practitioners are successfully using multiple approaches to solve the same problem, there is more than one right answer.
The challenge, however, is that some occlusal philosophies that may be successful often can be achieved only by performing extensive dentistry on teeth that do not need restoration. It is one thing if a patient needs extensive restoration owing to the condition of his or her dentition, and one specific occlusal approach is used in reconstruction. It is altogether different when the justification for treating the patient is that his or her current vertical dimension or occlusal relationship does not match a particular belief or philosophy about how the occlusion should appear. In such circumstances, the practitioner may convince the patient that treatment is warranted to correct or prevent problems that do not exist.
The Hippocratic oath states "do no harm," and in dentistry for the past 100 years, that has meant only restoring teeth that need treatment. The last two decades of cosmetic focus have caused all of us in the profession to deal with the paradigm and ethical shift of restoring teeth purely to change their appearance. And while I love placing porcelain veneers as much as anyone, it still bothers me to prepare an untouched natural tooth unless I truly believe the esthetic enhancement is in the best interest of the patient and that he or she is fully informed about all of the potential consequences of restoring a perfectly good tooth. Even in the hands of an excellent clinician, the long-term failure rates of porcelain veneers average 7 percent at 15 years owing to the porcelain’s fracturing, cracking or debonding.5 In addition, microleakage with subsequent staining, sensitivity or even caries is a concern when the preparations have very little remaining enamel.6 These problems are magnified when the patient grinds his or her teeth; in such cases, the failure rates jump as high as 25 percent at five years of service.6 It is the obligation of the clinician to inform the patient that these risks exist any time a tooth is restored. But in placing a restoration on an unrestored tooth for occlusal or cosmetic reasons, the dentist is creating risks that would not exist if the tooth had been left alone—and it is critical that the patient have that information to make an informed decision before proceeding.
I see patients coming into the office for second opinions, bringing treatment plans in which the rationale for treating unrestored teeth is occlusal in nature. For example, the plan may aim to "correct" a perception of how far apart the cementoenamel junctions between the maxillary and mandibular incisors should be, or to correct "excessive freeway space" between the patient’s existing "overclosed" occlusion and some perceived correct rest position. Using these concepts on a patient needing a reconstruction is one thing; using them to justify the reconstruction simply is not supported scientifically.
As I stated earlier, there are several philosophies of occlusion that have been used successfully for decades. These include conservative ones involving procedures that are capable of restoring some teeth without needing to change them all. The challenge, of course, is to do what is in the best interest of the patient rather than perform treatment for the sole purpose of increasing production.
Unfortunately, when we focus on patients as a production resource first and on their health second, we degrade ourselves as professionals. Ultimately, we become used car salespeople attempting to get a person to buy the used car as well as an extended warranty, undercoating and paint protection.
The answer concerning occlusion is simple. It is incumbent on all practitioners to learn to examine and diagnose patients and plan treatments for conditions concerning patients’ temporomandibular joints, muscles and teeth—and to know when an occlusal change is warranted. The practitioner then should treat these conditions using the most conservative and appropriate means that will satisfy the esthetic, functional, structural and biological needs of the patient.
The practitioner who takes a comprehensive approach that includes esthetics and occlusion, and who does what is in the best interest of the patient, will grow a practice of loyal and appreciative patients who will provide all the production potential a practice will ever need.
It may take a little longer to cultivate a patient population that wants larger quantities of restorative dentistry as opposed to some of your peers who are pushing such dentistry on their patients, but your own self-esteem and reputation in your community and within your profession are worth the wait.
Providing occlusal therapy is a health care service first, a business and financial resource second.
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