HANDBOOKS

HANDBOOKS:

There are three technique Handbooks under construction, summarizing the procedures developed from 49 years of practice which includes 21 years of teaching. Once the handbooks are complete, access will be granted to purchase these handbooks online.

WHY I WRITE

 problems in composite dentistry. Most DDSs are placing composites without continuity; following methods that suffer from conceptual loopholes ; based on sketchy scientific justification; having incomplete awareness of relevant parameters in product selection. This is not their fault, because it is almost impossible to do otherwise in the vast landscape of products and the sea of professional discord.

My Personal story: In 2003 I did not set out to be a study club mentor nor an online vendor of expertise. I wanted to join an existing study group and improve my capability.

I had taken the RV Tucker Cast Gold Restorative  program at UBC to offset  limitations seen with composite molar MSOs, whereas amalgam MSOs , which I had studied in an Amalgam Study Club in the 70s, were effective. Patients couldn’t afford gold, and found amalgam unattractive. The incentives to be white and mercury free  was a big driver once we achieved dentin bonding with Generation IV  adhesives. I was motivated to join a similar program in composite method, and inspired by working personally with Dr Tucker.

British Columbia had 75 study clubs but  none focused exclusively  on composite resin technique and adhesive reconstruction. To my knowledge this still is the case, other than those I have led.

In fact nowhere in Canada was there a vigorous composite study club;  usually the teaching was an adjunct to cosmetic anterior procedures.  I looked through the USA in Washington, Idaho, Oregon and California, but all inquiries terminated in dead ends.

So, in the face of this frustration in 2004 I initiated a study club under the approval of the College of Dental  Surgeons of British Columbia. The format was similar to the Tucker Cast Gold Program; a group of dentists performing restorations on live patients, under mentorship.  We opened discussions and explored current practices in resin restoration with the 6 members. I began to supplement direct experience by penetrating the world of impartial reviews, subscribing to the most prominent  independent review organizations, viz.,  Reality Publishing, Clinicians Report, and The Dental Advisor,  and realized that a great deal of  didactic material needed to be brought forward to support best methods.

Soon after, as the internet gained power, I created a Wiki-based website, which eventually grew to 400 pages, supporting my teaching and research. This now obsolete platform was replaced by WordPress for this website, transferring most of the concepts across into the now common cross-linked layout.

I published spreadsheets and warehoused scientific references. When I felt I had a base of expertise worth sharing, I took my procedural conclusions to the local dental school, University of British Columbia, and entered the Canadian dental lecture circuit. It was disappointing that UBC did not want to include my new material on Enamel Axioms, Incisal Attrition restorations, the ever-so-powerful Bandbender Matrix System, and my leading edge Posterior multisurface designs. They were similarly uninterested in upgrades to the problematic Maryland Bridge.They probed at my “credentials” and discussed my methods with the frequent use of the words.”may” could” and might” prefacing their statements, my first exposure to the academic mind divorced from clinical reality.

I came away with two missions- to keep innovating, and improving my presentation base. I could not see that gathering more credentials was relevant, and it also was not viable to become a Trojan Horse as a weekly floor instructor while still practicing, as I lived 6 ferries away requiring an overnight stay. They had no other way to interface with outside practitioners.  It is sad to see a previously good institution drift towards irrelevancy from its surrounding dental community over the last decades.

IN 2008 I was invited to join the Canadian Academy of Restorative Dentistry and Prosthodontics www.cardp.ca . Subsequently I became a Fellow, and an online mentor for the BC Dental Association, while lecturing nationally at dental society meetings. I published articles in Oral Health-See Published Articles. The Pacific Dental Conference invited me to lecture, and ultimately opened a door to me four times to demonstrate my procedures on the PDC Live Stage

As the adage goes, if you want to learn, read a book. If you want to excel, write a book. If you want to become a master, teach. Thus, through this process, my expertise grew. Putting myself on the podium forced me to invent new procedures and new problem-solvers, clarify concepts, codifiy approaches to treatment,research hundreds of products, and improve my presentation skills.

I slowly became the mentor that  I  earlier wanted to meet.

It has taken an extraordinary amount of time and effort-at least 6,000 hours-  to find effectiveness in the complex and mystery-ridden field of composite realm, over these 20 years, presenting to over 4000 dentists in this period. It has been an active and rewarding pastime; live clinics, demonstrations, inventing devices, techniques, and assembling a large website and putting in the hours necessary for mastery. I have met some wonderful people and influenced many practitioners, according to their own testimony, for the better.

Now I  am retired from clinical practice and intend to hand off this learning to those willing to work at improving their skills through this website and these handbooks.

In this near quarter-century, the potential of direct composites has grown. Today’s resins are better; curing lights are stronger; curing times have reduced; adhesives are better; postoperative comfort has frequently improved ; matrixes and other adjuncts have improved. When all steps are optimum, we have tremendous restorative power. But the foundations of the field remain muddy. Direct resin restoration would be dentistry’s principle modality if they were not so inherently demanding and so time-consuming. Time saving methods like bulk fill have emerged but research disproves the manufacturer’s claims of freedom from leakage and contraction damage.

In my practice,  the emotional stress of uncertainty and the financial stress of low profitability disappeared   years ago. Seeing what has stood the test of time over 37 years of practice in the same location has been rewarding. Most patients avoiding crown work, retaining  more tooth structure and more pup vitality, keeping their mouth healthy at much lower cost than the upward divergence of conventional dentistry, while providing me with a comfortable living once I became efficient and proficient.  Not that I did not place crowns; only fewer- about 50% less than the norms according to provincial tabulations.  My income per hour was as high as conventional practices due to inherent cost efficiencies .The completion of this journey you now see on this site.

Despite progress in the composite resin field, we continue to face the same  shortcomings and difficulties as existed in 2003.

  • Standard of care remains inconsistent
  • Scientific underpinnings lack continuity
  • Products are over-marketed
  • Manufacturers make unsubstantiated claims
  • Academia remains hesitant and cautious, without consistency from school to school
  • Dentistry  is practiced as if it were a cottage industry with little consistency from practice to practice.
  • Increasing technique capture by manufacturers rather than a research base

I hope that these Handbooks contribute to better dentistry and provide a clear background against which  to evolve. The present consensus of mediocrity inhibits progress to better treatment and flaws the prestige of our wonderful profession.

If you want to play good music you must first tune the instrument.

THE HANDBOOK OF COMPOSITE TECHNIQUE:

The Handbook of Composite Technique  revises GV Black procedures explicitly for direct composite resin.

  • Class I including Sealants and Fissurotomy or Preventive Resin Restorations (PRR)
  • Class II including multi-surface designs and solutions to premature proximal re-decay and damage to the adjacent tooth
  • Class V including abfraction lesions and geriatric caries, addressing elements of esthetics and resistance to re-decay
  • Incisal Attrition A new category of treatment, which might be called Class VII. It addresses composite treatment for incisors. Also, cusp tip restorations, Class VI in GV Black nomenclature  -for cuspid and molar cusp tips –  are covered.

Enamel Axioms are applicable to  Class III and Class IV restorations but do not have their separate chapter. Applying these axioms to the facial and lingual margins is the only substantive change .

Taken together,The posterior and anterior new  treatments open the door to Full Mouth Composite Rehabilitation which has seen recent popularization by big-name dental teachers in the private sphere. With the involvement of TMJ, Vertical Dimension, and the need to use articulator and Laboratory stents, it becomes its own science, see Handbook of Composite Prosthodontics:

This handbook  leads to excellent restorations that are a source of pride. They meet the expectations of the public ,professional oversight and government . They deliver lifespan comparable to amalgam; they  restore the strength of the tooth to a higher level than amalgam;  they require less coronal destruction destruction than indirect treatment; they are esthetically  sophisticated.

Direct restorations always had this edge over laboratory procedures: they are less destructive and inherently less invasive because there is no tooth structure sacrificed for taper and path of insertion.

However, widespread technique dysfunction and intolerance of adhesive methods to poor design still  propel dentistry backwards into laboratory procedures. based on old-school low-adhesion and extensive reduction rather than new -school high adhesive and minimal reduction of remaining tooth. It also is still inherently easier to let the laboratory do the reconstruction rather than deliver it with your own hands. But the direct restoration does not waste time making a temporary crown that is discarded at insertion.

Adhesion has not penetrated deeply into dental minds and hearts. Often the principles remain bogged down in the clash between dentistry’s foundations in the late 1800s,  horse-and-buggy-era. Adhesive luting and design remain an afterthought or a light bonus.

This essay addresses the question: “Does composite dentistry meet the TRADITIONAL GOALS OF DENTISTRY.

Dental texts commonly state the following traditional goals:

  1. To conserve tooth structure
  2. To maintain the occlusion
  3. To prevent further breakdown of the clinical crown
  4. To protect the periodontal tissue
  5. To preserve the comfort and vitality of the pulp

To these traditional goals, adhesive composite has added a new series of attainable outcomes, meshing with the development of new tooth colored laboratory procedures, both anterior and posterior, and in some cases, outperforming them:

  1. To preserve and promote the appearance of the patient (Beyond dark metal)
  2. To reduce systemic ill-health (Beyond mercury leachate)
  3. To reduce emotional and physical trauma (Retaining  natural facial tooth structure is almost always the patient’s first choice!)
  4. To foster the economic well-being of the patient ( less costly treatment alternatives)

Like all  revolutions in thought, change moves through the dental profession slowly.  First, inventors bring new ideas to life.Then they are picked up by early adopters,  middle adopters, late adopters, and finally there remain practitioners who refuse change and remain non-adopters.

I’ve practiced long enough to see many such waves pass through our field- Porcelain Laminate Veneers, Invisalign Orthodontics, Implants, Rotary Endodontics, Digital  data management, now Digital everything, and on we proceed to ever-soaring heights.All beautiful. All expensive.

Unfortunately, these methods have left about 50% of the patients in the Western World behind, due to cost, and almost 100% of the other 7 billion.

Within these Handbooks of Composite Technique lies potential for a broad baseline that reaches downwards into  lower economic strata of society and out to the so-called Third World, rather than upwards to a narrow elite of the privileged classes of the western world. It aims to service dentistry’s mandate to society  rather than the profession’s upwardly ambitions, which currently has the grip on the wheel.

It speaks to prioritize our humanitarian purpose; my goal is to show this can be done without having to sacrifice our business needs.

This may seem a tall order, but they attainable. I’ve done it, as have  others when following the  methods of these  Handbooks. So let’s get going.