When a dentist begins to practice, he/she has a finite number of known methods in their mind’s eye for use in performing, as we used to say, “operative dentistry,” or what we now seem to call “restorative dentistry.” All they know is what they have absorbed to date.
As time passes, they pick up a new idea here, a new idea there - a technique, a new cement or resin, a better body posture or better vision through magnification, to name a few. What can really accelerate the accumulation of these tips, tricks and ideas is when you somehow immerse yourself into an atmosphere where very passionate, like-minded dentists are more than willing to share these tips, tricks and ideas.
In our local Study Club that has existed since 1931 (that’s right, 1931!), we call them pearls. At the beginning of our monthly meetings, we often have a brief presentation where someone wants to share something that somehow helps them practice better. The segment is called, “Enamel Pearls.” Thought you would appreciate the pun.
Back in the 1990’s, I was just like what was described above. I knew little. I picked up tips, tricks and techniques, went to seminars, etc. The local Study Club was beneficial in many respects, but the acceleration came when I started serious advanced continuing education. I was going away for days at a time spending time in “think tanks,” hanging out for days and days with passionate, like-minded dentists in the pursuit of excellence and proficiency by gaining instruction from the best of the best - think tanks like The Pankey Institute and, of course, our very own Spear Education.
Whether you are at the Spear Education campus or you are participating somehow with Spear Education’s “virtual campus,” (as Frank Spear coined it, “a Virtual Lodge,” paying respect to his wonderful experiences visiting and lecturing at The Pankey Institute and staying in “the Pankey Lodges,” a set of condos we lived in to share the good, the bad, and the indifferent), you come across droves of dentists who talk with fervor about their tips, tricks and techniques.
They/we almost always use the phrase, “tools in your toolbox.” As a moderator for Frank Spear’s virtual lodge, Spear Talk, I spend an inordinate amount of time helping and learning from other colleagues, gaining insight and compiling an inordinate number of tools for my own toolbox. So, what is your favorite tool in your toolbox?
And what is my favorite tool?
Thank you for asking. There are too many wonderful tips, tricks, and techniques to truly choose one. But there is ONE I cannot live without.
For those of you who have not had an opportunity or taken the opportunity to participate in the Restorative Design Workshop at Spear Education in Scottsdale, AZ, you may be missing a chance to significantly change the way you practice in a very warm, inviting, low-key atmosphere. You prepare teeth every day, right? Here are the details for this workshop:
Tooth preparation is the foundation of what we do as restorative dentists. Material requirements provide the guide for creating space, and will be discussed in detail. A step-by-step system of tooth reduction using specially-designed diamonds created by Dr. Robert Winter will increase your competence, your confidence, and your efficiency for all the materials you choose to work with.
It is a workshop that can immediately impact your life as a clinician. Yes, I opine and extoll the virtues of Dr. Winter and what he has created, and have even written a fun article about Bob and this workshop last year. But with today’s materials, lithium disilicate and zirconia, tooth preparation is critical to their success and is different than the classic PFM styles. It allows for conservatism in tooth reduction, as well as a bit of artistic freedom in the design of the preparation.
Preparing teeth in a workshop in-vitro is challenging enough, as you are learning newer methods that are likely different than what you are accustomed to feeling. I will tell you this: the time you spend at Spear truly prepares you to go back to the office and start the first day back. Then it becomes an in vivo experience, doesn’t it? Things are a bit different in the mouth than the lab bench, aren’t they?
Herein lies the purpose of the article: using something we learn and applying it in a completely different way than how we were taught, e.g. using a bur in a way it has no business being used, but doing so to get you out of an impossible operative situation.
Sometimes what we learn and practice, then take to the mouth, cannot be applied or implemented as clean as it could be in a lab bench or a slide in a keynote presentation. Sometimes there are circumstances that make us use our heads, needing to abort “the standards.”
My best example of a hurdle is room to work. Having enough room is often THE biggest hurdle in achieving a well-prepared tooth. You can only get what the patient gives you, and you can only prop them open wide for a finite time.
The bur block above is the newest collection of burs used for the Restorative Design Workshop. You take them home and continue the journey towards a more structured method of tooth preparation … until you run into someone like Susan.
The short version is that she was specifically referred to me by a patient who appreciated the comprehensive approach. Susan had an occluso-muscle disorder with significant wear on her posteriors. She was engaged in appliance therapy to make her comfortable.
However, when it came to restoring a fair amount of her dentition, she hedged. She said no to full ortho, no to segmental ortho with TAD therapy for intrusion/extrusion of molars and refused crown lengthening. The wear on her mandibular molars warranted these considerations. She took responsibility and accepted the consequences. This is the very short version.
The teeth in question were 18 and 19 specifically. Notice the retrusive and lateral excursive wear.
Prep day for the compromised tooth
Legendary boxer Mike Tyson once said, “every boxer has a plan when they enter the ring until they get punched in the mouth.” Appliance therapy improved her muscle tone and fatigue, but it was her posterior angle and shallow articular eminences that got me. When there is no room to hold your handpiece vertically (upright or perpendicular to the mandibular plane) and prepare a compromised tooth, your plan has changed.
The wax-up was performed by the Winter Lab (please excuse the condition of the models in the images, as they have been in storage for three years).
Enter the RW 2.0 occlusal reduction guide
The RW 2.0 is an occlusal reduction guide, period. It is part of the original set of Restorative Design burs Dr. Robert Winter developed for the workshop. I took the workshop many years ago and still use the originals every day of practice.
They are short in stature but as mighty as you need in a tight space. They were replaced a couple of years ago by the WDL (Winter Depth Limiting) 2.0 reduction burs, BUT the original Restorative Design bur block is still available from Brasseler Dental. Dr. Winter re-vamped the burs into newer block to enhance your experience in preparation design. It spawned a whole family of similar occlusal reduction burs:
Notice the contoured flange intended to meet the cavo-surface margin, hence limiting depth.
Back to the prep day. The plan had changed. It was already a daunting task attempting to prepare 18 and 19 “as is.” 14 and 15 were going to be altered:
- 14 was planned for full coverage
- 15 had an obnoxious palatal cusp which required warping (plasty); no restoration was planned (ortho intrusion was denied)
Further, there really was no room to work. We employed 800mg Ibuprofen and 0.5 mg Lorazepam with hopes of creating supple muscle tone. If it helped, I cannot imagine what the oral atmosphere would have been like.
This was the most challenging situation I ever experienced, and I could do nothing but occlusal depth preparation, thanks to the short and slight stature of the RW2.0. Ultimately, I prepared the axial walls with the RW2.0 as I was reaching for anything. It began to look like a preparation!
I continued and finished both 18 and 19 using ONLY the RW2.0. This was a prep and provisional visit. The patient had to live with these to evaluate performance, and the Winter Lab needed to provide feedback on the preps, of course. A preliminary impression was taken. Feedback basically surrounded the central fossae of both preparations.
Below are the master dies after Susan returned about six weeks cemented in only with Temp Bond.
As you can see, the preparations are rather reasonable (please remember all the lab work and stone is many years old and stored; the DL aspect of the #19 die was damaged) considering:
- The entire preps were with the RW2.0 only
- Where the teeth were, 18 and 19, for a right-handed dentist
- The short clinical coronal structures
- How smooth they were (there is no fine RW2.0; the Forza electric handpiece was slowed to add control and improved smoothness)
- The fact that they were approved by Dr. Winter’s lab
- It avoided crown lengthening and/or ortho
I would say it is about as proud as one can be. I only write this because the restorations have been in play since 2014. #18 was made of Zirconia. #19 was made from e.Max Press.
In preparation for this article, the final images below were taken on December 19, 2017, four years this February … on a patient who has nocturnal bruxing and daytime clenching!
It is not always possible to deliver optimal, comprehensive care to patients, as they must be an equal partner and engaged in the process. Susan is a wonderful individual and patient who allowed me to plan her comprehensively, but could not commit fully to treating her dentition.
She fully understood how these decisions may have compromised outcomes. It is possible to inform them that you will not treat them. But it will be done, and who will do it? Should it not be you with all those tools in your tool box? These are the challenges we face everyday as we attempt to phase out older models of dental therapy and practice.
Despite standards and a plan, when you get hit in the mouth, plans change. The ONLY reason this case has had any viability is because of that wonderful RW 2.0 bur, and of course, the newer materials in zirconia and lithium disilicate (full disclosure: the patient insisted on not using gold). This is why advanced dental education matters.
The birth of the Restorative Design and, ultimately, the RD bur block, first and current, was the residue of now defunct past workshops: Anterior Live and Posterior Live. There used to be live patient workshops where the participating dentist would fly out their patient and assistant (sometimes) to prepare teeth for anterior restorations or posterior restorations, then fly back about a month later to seat them.
Despite the success and proficiency of these dentists, it fell upon the Resident Faculty that there really were not any definitive standards for preparation design, especially with the advent of e.Max. Dr. Robert Winter was commissioned to do just that, and the Restorative Design workshop was born, and later, Anterior Restorative Dentistry.
A significant flaw for dentists is that we so often dwell on the procedures and outcomes that were challenging or inoperable. They become burdensome without balancing them with the abundant procedures and outcomes that go as smooth as a symphony.
For all of us, there so many more victories than defeats. Defeats are just as or more important than victories, as growth evolves from them. Let us not beat ourselves up and revel in all the good we provide our patients.
The RW 2.0 occlusal reduction bur is, indeed, a toolbox essential, with applications more than its intent. It can bail you out in a tight spot. You might consider putting a few in your toolbox, and maybe consider coming out to visit Spear Education and spend a few days with Drs. Winter and Bonk in the Restorative Design Workshop. I hope this article was compelling enough to encourage you to do so.
David St. Ledger, DDS is a Visiting Faculty member, Spear Moderator and Contributing Author