The bottom line for sustainability: core buildups
The single greatest leap in producing better dentistry that ever happened in my practice was the development of dentin bonding products.
William Strupp, DDS
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The single greatest leap in producing better dentistry that ever happened in my practice was the development of dentin bonding products. They were reliable, thus allowing me to rebuild missing tooth structure with resin composite to create an ideal preparation. Before that time, no dentin bonding agents or suitable core materials existed to make a foundation that would support weak tooth structure or all-ceramic restorations.
I often found teeth to be virtually nonrestorable when the old restorations, bases, decay, and fractured tooth structure were removed. Also, it was not unusual to have difficulty establishing a suitable line of draw for complex bridges, unless the existing tooth structure on the gutted-out abutments was ground relentlessly until no retention was left for the prosthesis and no volume of structure was left to impress or support the restorative dentistry. Nonretentive crowns and bridges fail quickly and miserably with conventional cements, and frequently with resin cements.
Core buildups changed all of that. Now I can remove all the old restorations, bases, decay, and fractured tooth structure and completely rebuild the abutment with resin composite to or beyond its original form. The restructuring of the abutment has allowed me to cut preps that look like textbook images. It has also allowed me to alter a line of draw for complex bridges.
The immediate decrease in postoperative sensitivity due to millions of tubules being occluded with resin has made my patients more comfortable. It also has significantly decreased the need for root canals after cases are placed.
Furthermore, because I use an enamel shade core material (Den-Mat), there are no cosmetic compromises with core buildup material being visible through all-ceramic restorations that previously existed with amalgam or gold. Impressions are more predictable because I impress an abutment with full volume, instead of an undercut sliver of tooth that frequently breaks off upon cast retrieval. I do not have to cut off provisionals with the fear of breaking fragile abutments.
Retention can be cut to perfection in full- and partial-coverage restorations. I can use partial coverage instead of full coverage in many instances, thus preserving biology while it is easier to make impressions and cement the final case. The lab has a much easier job with my dies as well, because there are no undercuts and their wax-ups are homogenously thick so their castings fit better. Porcelain fractures caused by thick zones of metal no longer exist, not only making the lab’s job easier, but clinically making the porcelain stay on the metal much better and longer. In essence, I became a much better dentist with the arrival of predictable dentin bonding.
At the end of the first year of doing core buildups, I sat down with my accountant and reviewed my yearly numbers. He started out by saying that he was shocked. I asked why. He said that I had a 30% increase in income and wanted to know how I had done it. As I compared my numbers from the previous year, it was obvious that the only thing that had changed was core buildups. I had done the same thousand-plus crown and bridge units that I had done the previous year, and the same number of prophies, fillings, partials, new patient exams, radiographs, etc.
Yet, the money was in the bank because I chose to do core buildups on every unit. He told me that he did returns for most of the dentists in town, and that the best practices he serviced produced barely $500,000 per year, and that my numbers simply stunned him. My numbers showed $300,000 from core buildups. Mind you, this was when a $500,000 a year gross was considered an extremely successful practice.
In the end, after 25,000 core buildups under that many units of crown and bridge, I don’t look back at the huge volume of dollars they created as the source of pride in my decision. What I look back on — and I proudly see it every day in my recall system — is the number of cases that have not lost cement seals or needed root canals, not fractured porcelain or abutments, not suffered from iatrogenic periodontal disease created by placing margins subgingivally to gain retention, and a host of other positive clinical factors.
In addition, it is with even greater pride that I see those patients with long-term successful cases insist that their friends see me for dentistry. They know it is better!
Dr. Bill Strupp is a practicing clinician and inspirational speaker, acclaimed for his practical and predictable presentation, “Simplifying Complex Cosmetic and Restorative Dentistry.” He is an accredited fellow and founding speaker of the AACD. He is a member of the AAFP, AOD, APS, AES, AAIP, IASD, AAOSH, FACD (president and founding speaker) and other organizations. Contact him by phone at (800) 235-2515, by email at Bill@strupp.com, or visit his website at www.strupp.com.