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by Michael DiTolla, DDS, FAGD
After last month’s Part 1, here is Part 2 of my interview with Dr. Bill Strupp about crown and bridge.
Dr. DiTolla: You suggested I start using Durelon as a temp cement years ago. It has helped, especially after I obtained a sonic scaler to clean the cement off the teeth. Please discuss this technique.
Dr. Strupp: Durelon is just another part of the antimicrobial protocol. It kills microbes, is relatively insoluble during the short provisionalization phase, minimizes lost provisionals, soothes the pulp, and is easily cleaned off with sonic scaling and air abrasion. One of the most pulp positive events in my practice was when I talked my periodontist into using Durelon to recement provisionals after surgery. Postsurgical sensitivity decreased tremendously when he quit using soluble temporary cements that promoted microbial growth and switched to Durelon.
Dr. DiTolla: Do you still use cast gold as your restoration of choice for second molars?
Dr. Strupp: Cast gold is the restoration of choice when cosmetics is not an issue, especially in the second molar areas that absorb 55 percent of the biting forces. Many patients refuse gold. I explain that the fee for all-ceramic and gold is the same but that gold will never fracture and the shade will always be spot on. When a tooth only needs a partial coverage restoration, I am hesitant to mutilate the tooth to place a crown on it just because the patient does not want gold. In such cases, I still use a partial coverage restoration but make it in all-ceramic. This cements the idea in a patient’s mind that fracture is more likely with the all-ceramic restoration, and that a fee to replace it will be required.
Dr. DiTolla: Do you place many porcelain veneers?
Dr. Strupp: I place approximately 600 all-ceramic restorations each year. More than two-thirds are veneers, or stated differently, partial coverage restorations. Full crowns mutilate teeth, pulps, and soft tissue. Partial coverage restorations are indicated on every tooth that requires restoration except the ones for which a crown already has been done. In this instance, another crown is required.
One of the most important points I stress in lectures is about preservation of biology. When all of the tooth structure is gone, it is not easily replaced. It is better to keep the tooth structure and modify the restoration rather than vice versa.
Dr. DiTolla: What are your cements of choice for routine crown and bridge and bonded restorations?
Dr. Strupp: I only use Panavia F 2.0 Light. I bond in every restoration I do, and have not used conventional cements except for provisionals since 2000.
Dr. DiTolla: I am a big fan of epinephrine impregnated retraction cord. But some dentists tell me I am playing with fire. What has been your experience with epi cord in the last 30 years?
Dr. Strupp: I have used the epi cord for almost every unit that I have ever done. Early in my career, I didn’t soak the cord in Hemodent. I did use larger cords that had much more epinephrine in them. Early in my career, I had a couple of systemic responses with patients after I packed 14 units of bleeding, red gums because we were using hydrocolloid impressions and subgingival margins at the time.
You had to beat the tissue to death to get it out of the way, and to cut the preps subgingivally. We used rotary gingival curettage with reversible hydrocolloid. Ultimately, with fresh and bleeding gum tissue, you could get a systemic response.
But in the late 1970s or early 1980s when my periodontist, Danny Melker, and I began to talk and challenge one another about what we thought, I realized you should not be in the tissue. I worshipped occlusion so I believed everything that was said about it by certain camps, and I made no bones about it. I was involved in doing reconstruction based on occlusal need.
Danny challenged me on everything and said, “You know, this is all about infection. If you get rid of the infection and the occlusion is within the envelope of where that patient functions on a normal basis, you’re not going to lose any teeth!” I didn’t believe him at first. But over time, I have come to believe him.
Still, I would say that I have not had a systemic reaction to epinephrine in the last 30,000 units of crown and bridge that I have placed since about 1978 or 1979.
Dr. Michael DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, Calif. He lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has several free clinical programs available online or on DVD at www.glidewell-lab.com. For more information on this article or his seminars, please contact him at www.drditolla.com.
