A "Permanent" Esthetic Procedure for Maxillary Anteriors
Bruce B. Smith D.M.D.
Mentor of the George Ellsperman Gold Foil Seminar
Presented at the AAGFO Meeting 1:15 PM Hawaii November 3, 2000
Throw away your chemistry sets, your bonding agents and adhesives, and put your lamp bulb in the bottom drawer and try some fine dentistry, completely esthetic that will serve for forty, fifty, sixty years. Proven by service in the mouth; not just short small surveys of a year or a few years. Avoid concerns about leaching methacrylic acid. Use gold foil.
Before you start to operate be sure to use a topical anesthetic, ex: "Hurricaine". Let it stay over the injection site long enough to allow pain free needle insertion and avoid "fear of the needle".
Select your case carefully, especially at first to ensure that caries will not cause the labial margin to extend where it can be seen. If it will, use a trustworthy type material such as a fired, well-fitting porcelain inlay, with good retention and without fragile fins.
For foil, the area should be fairly small and hopefully a little toward the lingual without incisal involvement.
A brief history of the development of this type of operation may be of interest. In the early 1930's, Baird and Rule in the San Francisco area advocated this type of operation and recommended using a small cylinder of non-cohesive foil placed against the labial wall. Ferrier disagreed and felt that this would lead to caries. Ernie Jones,
however, wrote (A.D.A. Journal in April, 1939.) advocating the technique and presenting a cavity with a separate axio-lingual wall as well as a proximal axial wall. In the 1940's, Bud Fisher of Portland, Oregon gave chair clinics demonstrating a slot-type of preparation with strong retentive incisal, gingival and labial walls.
Harry True, when at the University of Physicians and Surgeons in San Francisco, published a related type of operation that was not hidden but was called “The Inconspicuous Class III Foil”. (J.A.D.A. Sept. 1943). The labial outline, though slightly in view, paralleled the proximal contour of the labial plate of the enamel in a harmonious curve. Access was secured through the lingual incisal. True's notable offset angle formers were included later by Jeffery in his instrument set.
In 1950, the author published an operation designed for the mesial of the maxillary cuspid (J.A.D.A. and Yearbook of Dentistry). This was with the thought that due to small lateral incisors and the relatively conspicuous mesial of the cuspid, a hidden foil done from the lingual would be an asset. Further, the technique was relatively easy for the average practitioner. With the patient's head tipped back at 45degrees and the chair at 45degrees, the work could be done by direct vision.
In 1957, Alex Jeffrey designed a set of instruments to facilitate work on the incisors. (Suter Instrument Company, Chico, California). He included the True offset angle formers and the U of W set B #11-S, designed for foil condensation on the mesial of the cuspid. This design has a unique feature whereby the face of the condenser is at
a right angle to the shaft of the instrument and the metal is slightly thicker to prevent springing action. This is in contrast to the U of W set B # 10. This right angle design allows the condensing force to be utilized by the entire face of the condenser, and in a lingual approach, facilitates cavo-surface coverage of the labial wall.
The Jeffrey’s set is very complete with cutting instruments and condensers. The cutting instruments have very sharp sides and rotated enamel hatchets, some with angle former type cutting blades.
Jeffrey's contribution to cavity preparations was the addition of gingivo-axial pits on the labial and lingual of the gingival. These are made with a 33 1/2 Inverted cone bur. The side flutes of the bur can be ground off to make it end cutting only and to make it smaller.
In 1960, William Kramer, (A.A.G.F.O. Journal, Oct. 1960) wrote about hidden, not invisible, Class III Foils for adolescents. The tooth root should be fully formed, but with their thicker periodontal membrane more separation and smaller preparations are possible. This approach, like True's, was inciso-lingually.
In this respect, sometimes a very tiny contact point type of foil can be placed using modified #7 and #8 Spoons by Suter. The sides are ground flat and the cutting end is modified to sharp straight angle. A pair of these, for forward and reverse cutting, look like tiny gingival margin trimmers. This type of operation requires a highly skilled operator.
Another pair of gingival margin trimmers, designed by Clint Fleetwood, #280 and #290, are of normal length and curvature but are much narrower than the customary #28 and #29. They are great help in lingual approach, especially in securing retention areas and a retentive gingival wall. The normal #19, 3-2-28 hatchet helps retention in the incisal area.
The cavity frequently can be opened with a narrow chisel. A small 700 or 500 series bur can enlarge the preparation and set the location of the labial and lingual walls and also rough out the interior. A triple 0 round bur can set up the inciscal retention and gingival pits for instrumentation. Well-planed walls are very helpful for distinct margins and allowing the gold to flow smoothly into place.
In foil placement the labio-gingival retention and cavo-surface margin are covered first and a normal bar of gold built across the gingival to the lingual retention. Occasionally the size of the preparation will allow the gold to be placed up the retentive labial wall from the gingival retention. Great care must be taken to cover and condense the labial cavo-surface angle and to ensure a slight excess. There will no chance to add foil later from the labial.
Separation may be used with care during condensation, as a greater amount must be secured later in finishing. Some prefer to condense the foil and wedge separation as they build the foil using the separator after condensation. This technique allows more freedom and access in operating.
Separators are varied. The Ferrier separators distribute the stress to several teeth and give a more gentle but more positive action. The Jack- screws can be slightly modified using a little XXX carborundum and a glycerin paste. This gives a little looseness so the operator can feel the pressure exerted on the teeth and not be confused by the binding of the screws. It will also allow one jaw to be lower or higher to protect the gingiva. The jaws can thinned carefully to gain closer tooth adaptation and give greater access.
We have found the True separator even with its single arch to be very inconvenient. However, the so-called wedge separator with points that are rounded (and if well stabilized) does not injure the gingiva. It can give great access and rapid simple operation. Care should be taken as it works rapidly. The Ferrier separators seem to have a little more springing affect as their separating movement seems to slowly continue.
In finishing, one must realize the proximal shape of the condensed foil has assumed the contour of the adjacent tooth. After a slight separation a matrix strip is slipped through the contact and at first, wrapped around the adjacent tooth to compact the protruding foil. This is followed by the normal progression of abrasive strips used in a manner to preserve the contact area. It is not necessary to highly polish the restoration. A well-worn extra-fine cuttle strip can leave a creditable finish and an esthetic restoration that will serve the patient for very many years.
Photography: Robert J. Murray, Alex Jeffery, & the Author
NOTE: For the uninitiated, courses are available through A.A.G.F.O.
President Richard D. Tucker
Secretary Ronald K. Harris
17922 Tallgrass Court
Noblesville, IN 46060
Author and Presentor : Bruce B. Smith, D.M.D., B.Sc. 1564 77th Place N.E. Medina, WA. 98039
Scanned & Edited by Dr. John R. Sechena