OPERATIVE DENTISTRY, 1979, 4, 20-23.
More and Better Foils: Forward by Fundamentals Rather than Back to Basics
GERALD D STIBBS
433 Medical Dental Building, Seattle, WA 98101, USA
GERALD D STIBBS, BS, DMD, conducts a private practice part time and is professor emeritus of the Department of Restorative Dentistry at the School of Dentistry of the University of Washington where formerly he was chairman of the Department of Operative Dentistry and chairman of the Department of Fixed Partial Dentures, director of the dental operatory and clinical coordinator. He is instructor of three gold foil study clubs-the George Ellsperman Gold Foil Seminar, the Vancouver Ferrier Study Club, and the Walter K Sproule Study Club. He is a charter member, past president, and past secretary of the American Academy of Gold Foil Operators, past president of the Associated Ferrier Study Clubs, past president of the British Columbia Dental Association, and past president of the Vancouver (BC) Dental Society. He is a member of the American Academy of Restorative Dentistry and the Academy of Operative Dentistry and is a fellow of the American College of Dentists.
Presented at the annual meeting of the American Academy of Gold Foil Operators, Honolulu, 20 October 1978.
In this era of multiple-restoration dental appointments and third-party dental contracts, is there still a place for direct gold restorations? If so, what is it? What forces influence the use of the direct golds? These questions will be addressed in the first part of this article.
Since there is need for exchange of knowledge of technical procedures, the second portion of the article will summarize the philosophy and technics followed by the Associated Ferrier Study Clubs.
The title above borrows an expression from the advocates of positive thinking. They believe it is more constructive to work on the premise of moving forward with fundamentals rather than wistfully harping back on the good old days and preaching back to basics.
In stressing forward rather than back, we in no way deprecate our great heritage in operative dentistry. We are privileged to have as a foundation for our highly important phase of dental health service the amazing efforts and contributions of countless unselfish, brilliant, clinical and didactic teachers. It is difficult, and perhaps unfair, to name any of them specifically, because, inadvertently, others will not be mentioned. However, I am thinking of such early members of our profession as G V Black, E K Wedelstaedt, A C Searl, Robert Arthur, and S C Barnum, who organized our procedures, discovered the property of cohesiveness of foil, brought us the rubber dam, and standardized instrumentation.
The dental generation succeeding them includes names familiar to those of us who have been in dentistry for some time, such as Ferrier, Prime, Hollenback, Woodbury, True, Rule, and Baird; also E M Jones, George Ellsperman, Lester Meyers, Alex Jeffery, and James Metcalf. Their protégés, along with the members of their study clubs throughout this country and Canada, and the efforts of the American Academy of Gold Foil Operators, have done much to provide an increase in technical competence and an exchange of ideas and technics. With such a background, we are justified in looking forward, holding to fundamentals, and applying them to the conditions of a rapidly changing world.DETERRENTS TO EXCELLENCE IN DENTAL SERVICE
Those who are interested in the finest in conservative restorative procedures have an uphill battle today. Perhaps they always have had. There are powerful, subtle forces diluting your efforts. There is not time to elaborate on these obstructive forces to any extent, but it may be worthwhile to turn the spotlight briefly on them.
Changes in Training
First, there has been substantial change in the approach to preprofessional and professional training, and in the attitudes of many of its recipients. For example:
There is more emphasis on "doing your own thing."
The concept of apprenticeship and continued training has been rejected.
There is relatively little concern for tradition or past achievement.
Less attention is being given to clinical competence.
Undergraduate education is being subjected to many whimsical changes and innovations. These undermine, to varying degrees, the foundations for most students.
In the present flurry to predicate renewal of licensing on compulsory postgraduate training, there is a vast increase in the number and scope of offerings of continuing dental education. While many of these have merit, many others are but token efforts. The latter dilute the long-term activities of study clubs that have been so helpful for so many years.
Pressures on Dentistry
Second, there are many pressures and forces on today's practice and the conditions surrounding it. These forces can be classified as external and internal.
The external considerations are:
The internal influences affecting our practices include:
The problems of equipping and maintaining practice facilities. Many new manufacturers of equipment flash across the dental sky, then fade away to be replaced by others. It is costly to discard equipment that can be serviced no longer. Quality supplies and instruments are increasingly difficult to obtain. The executive officers of the conglomerates that, more and more, control the manufacturers find it difficult to attune to a relatively limited market for their quality products. Consequently the trend is to discontinue specialty items such as well-made rubber dam retractors, separators, finishing strips, and discs.
Another internal factor is the trend to group practice and the concept of expanded duties for auxiliaries. Although these modifications in dental practice bring certain advantages, they also, unfortunately, dilute the personal relationship of doctor to patient. To this, there is a divided reaction by practitioners and by patients.
Well, what to do? The conditions are with us. We cannot wish them away. How do we work with and around them? There is some temptation for those who are established and secure to feel that they can ride out the storm with their present practice, their reserve supplies, durable equipment, and their relative independence. Perhaps so, but what of those who are coming along tomorrow? Theirs will be a difficult dental world.
To meet the challenge, we should consider it our professional and moral obligation to do everything possible to keep alive the concepts of (1) training for, and providing, the finest service of which we are capable, and (2) indoctrinating the willing learner in the methods and technics that have produced results that are long-lasting, conservative, functional, and esthetic. Academies such as ours and operating study clubs are highly important in meeting this obligation. Practicing dentists can exert considerable influence by assisting educators who are willing to accept their services. Young people in dentistry can profit greatly by listening to and emulating the teachings of those who have been so fortunate as to learn from the early "greats."
PROMOTION OF DIRECT GOLD RESTORATIONS
What technics and precepts should we have in mind as we contemplate an increase in the use of direct gold restorations? Can we hold to many of the old tenets? Is there anything new to be learned?
There is much room for renewed emphasis, undergraduate and postgraduate, on essentials such as:
In addition to these considerations of technic, one of the most pressing needs is to modify dental insurance programs so that they will include the best of conservative restorative therapy. It is distressing that most of the current plans accept the redoing of multiple, complete crowns in as little as two years, yet they exclude conservative restorations such as small gold foils, intracoronal cast restorations, and fired porcelain inlays, which would provide many years of preventive restorative service. The present situation encourages waste of manpower, the needless sacrifice of tooth structure, and increase in costs to carrier and public alike.
What technics are the members of the Ferrier Study Clubs following? Basically, Ferrier's concepts hold as true today as they have for the past fifty years. Some new doors have been opened, of course; considerable research has been done; countless hundreds of restorations have been placed and observed through the years. A few additions or changes evolve when operators with individual characteristics work with any procedure, Some of these changes have been essential to cope with changes in instruments and materials available today. Others have come about with the constant striving for improvement in longevity, esthetics, and quality of dental restorations. A few may have occurred as a result of the innate urge to change for the sake of change.
Each of the phases of our procedures could be discussed at length, if space permitted. One of the advantages of the study club method of continuing dental education is that time can be spent on the consideration of details in procedures. The participating members learn more, master more, and gain the reward of personal satisfaction by regularly operating before peers and teachers.
Condensing the salient features of the Ferrier technic, the essential rubber dam is supported with a headband type of holder rather than with a frame. Gingival retractors are modified and refined as necessary. The retractors are carefully blocked or stabilized with compound. Incidentally, one of the most difficult steps in the technic to learn is the proper, nontraumatizing placing and stabilizing of the 212 retractor; yet, as taught by Ferrier, it is an efficient, precise procedure, devoid of frills.
The study club operators are fortunate in having good, Ferrier-designed separators and in knowing how to use them. For awhile it appeared that these instruments were to be lost in the general shuffle to seek only the large volume market. Now we have found a new ally in the manufacturing field. Atmore International, Inc of Portland, Oregon, is now making these essential instruments.
As to cavity design, the preparations remain conservative for both the class 3 and class 5 restorations. There is some increase in the use of the lingual approach for class 3s, but since the basic Ferrier design, properly executed, is so inconspicuous and is so much easier to fill, it is given first consideration. High-speed rotary instruments have some use in foil preparations, but the slower speeds, plus refinement and finish with hand instruments, predominate.
The various types of gold other than foil are used to some extent. However, lengthy clinical experience supported by laboratory studies by outstanding research workers such as the honorary members of our own Academy-George Hollenback, Jean Hodson, Ralph Phillips, and others-lead us to concentrate on foil, with limited use being made of mat and powdered golds. For class 5s, Ferrier and the Seattle Dental Study Club routinely used a combination of noncohesive and cohesive foil. In recent years, some of the study club members have discontinued using the noncohesive lining of the peripheral walls of the preparation. However, it is a technic that has many advantages and should not be lost.
One phase of technic that is highly important is the control of the compaction of the gold. It is not emphasized quite as much as it should be. The amount and direction of the compacting force need continuing study and attention.
In our area of the country, the emphasis in compaction is on the use of the hand mallet by the assistant to supplement the hand pressure of the operator. Mechanical and electronic devices are used only minimally.
Attention to detail in finishing restorations to proper form and contour, without damage to surrounding, supporting tissues, is extremely important. We have to be continually aware of the potential danger of excessive separation of teeth, of undue compacting force, of uncontrolled discing, of over instrumentation, of ditching cementum, and of losing mesiodistal dimension.
We give high priority to the wishes of the patient in respect to esthetic, inconspicuous restorations, but we do not sacrifice the sound rules of cavity preparation, such as outline and convenience form, to the request to show no gold.
Those who are interested in providing the ultimate in conservative, long-lasting, restorative therapy can fulfill their desire by continuing to increase their expertise in the science and art of working with gold foil.
They have a great opportunity to work for the benefit of the public by fighting for the inclusion of conservative procedures in insured programs.
They can serve the profession and the public by contributing time and effort to undergraduate and postgraduate dental education,
We can look back to our predecessors with gratitude and appreciation; we can move forward with fundamentals into the new dental picture with confidence and enthusiasm, You who are dedicated to fine restorative dental service can and should assume leadership in that movement.
*Digitized and made Web available by Dr. Von Hanks & Dr. John R. Sechena
*Any additions or corrections send to Dr Von Hanks & Dr. John R. Sechena