Thursday, January 24, 2008

Its just a filling

Have I ever told you how much I love doing fillings.
If I see fillings on the schedule I start licking my chops.
Now I know what you are thinking. Come on now, they are boring. Well you must not being doing them in a way that is exciting.
Ever since I got out of school, I have loved doing fillings. I want every one of them to look just like teeth. It has become my personal life goal to make a filled tooth look like a natural tooth.
I was the only kid in school that would ask to do posterior composites. I took the elective course and then went into the clinic and they wouldn't let me do it.
None of the instructors knew how to do it. It is funny as I talk to some of the younger dentists in town they still are not doing many posterior composites in school. Now, I do 100% composites (not that I have any problem with amalgam). In my practice and I have been doing composites exclusively for about 10 years and the schools still aren't sold on them.
Again I digress.
Fillings are a way I can put my signature in people mouth. I believe they are so powerful to people when you are replacing an amalgam with composite. I find this is a way to WOW a patient without doing $6000 worth of veneers on them.
I take a intraoral photo of the filling before. I am not talking making a big deal out of it. I am not printing it up (unless they want it). I am just taking it. I may take a shot at the midway point to show them how much destruction the decay did. This makes me look better because they say, "How are you going to do this." I just sit back and say "just watch". I have a mirror on my overhead light and some of the patients want to watch. But next thing you know I have resurrected this tooth.
I take a picture of this and then at the end I have a before,during and after photo on the screen. I tell them what I did and how I did it.
They usually ask questions but mostly just say "WOW". It is so powerful. I call most of my patients at home at night to see how they are feeling and most of them will comment on the fillings and how there spouse couldn't see where the fillings where? I always get a kick out the vision I get when I think of two non dental people looking in one of their mouths looking for a filling.
Now some people don't like doing them because they don't make as much money.
You have to put your fees such that if it takes you an hour to do a crown, and it takes you an hour to do 3 filling. So if you like doing fillings you should get paid the same as if you are doing a crown (think of the net not the gross).
I do 3 fillings in an hour and I make about 75% of a crown fee. But gross money is the same.
But I don't have to bring them back for cementation, I don't have a lab fee. I don't have room time.
This also makes me not change my treatment because of money. If they need a filling they get a filling. I am not thinking to myself, If I can only do more crowns.
I probably do more fillings than the next guy because I think of the "cycle of restoration". I think if I can just do one more filling on this tooth before crown then I have save the tooth from being cut down for another 10-20 years.
So I may do a big filling. But I find if I make this thing look like a tooth the patient is more pleased because I have explained to them the benefit to one more filling. I explain that because it is big it may not last as long. Still they are cool with that.
I have found I am doing more all porcelain inlay/onlays and loving it.
I am taking a root canal tooth and just covering the top of the crown. I put the margin anywhere and the onlay looks just like a tooth. This might be the subject for another blog.
But fillings... I do all kids teeth with composite. Parents LOVE IT. I do pulpotomies just like before. I take out the coronal part of the tissue. Formo for 5 minutes and then IRM. Then I put a sectional matrix on it and do a big filling with a Compromer.
Tooth looks great, no stainless steel. Now I wouldn't do it if my stuff wasn't lasting. I have extracted for baby teeth because of failure in my 12 years. So the stuff is lasting. I check my own work, so if I did it and the kid was 7 and I took the tooth out when he is 12, (because the permanent tooth was coming in causing problems), I check the margins of my filling. Like money in the bank.

Speaking of checking my work...I have been paying close attention to my fillings since I graduated from school. At every recall I look at all my old fillings and see how long ago I did them. I have to say some of my patients have beaten them to death, but other fillings look really good.
I don't think I can count on one hand how many fillings, I have done, that I have replaced. And I have done a lot of fillings. I am thinking I do 20 a week (I have a 23 filling day once) that is 1000 a year, that is 13,000 in my lifetime. This is a pretty good clinical trial.
Now my filling technique has evolved over the years. I started doing my anatomy with a white stone. Then I went to a small dove tail diamond. Now I still use a small dove tail but after that I take the pointiest diamond they make and I do terciary grooves with. I have talked to my lab technician about how he makes certain type of anatomy.
Speaking of lab technicians. My lab dude is now my patient. This to me is quite an honor because people see and appreciate the type of work you do. He and his whole family come to me, even his mother.
Now if you are doing stuff and you don't think people see your are mistaken.
I am going to make a list for you and you think about this (we will be talking about this again) because I am a real stickler for excellence leaving my office. But more importantly things that are NOT excellent leaving the office.
People that see your work.... (what are they saying about you?)
You, the patient, the patient's family, maybe your patient's neighbor, your assistant, the assistant you fired, your lab technician, your orthodontist, your orthodontist's assistant, your periodontist, your endodontist (he or she has to see your work when they have to dril through it), the patient's next dentist.

Think about it, we will talk later.

About the photos
One has a filling a did awhile back, an occlusal on #18 and a MOF and #19, this was a a recall appointment. I don't know how old they are. You can tell my anatomy is kind of straight lines.
The next photo is a DO on #29 (this filling came out real nice) but I put this photo in because tooth #30 has a DOFL porcelain onlay on it.
Double click on the image and you can get a full screen of it.


YOUTH said...

I am a new young dentist and trying to figure out the best way to finish my composites. You talked about a dovetail bur- what is that? I will gloss over some bonding agent on top of my last increment before I cure, and found that it makes it look smoother. Any comments? Also how do you create a nicely contoured marginal ridge in a class II compostie that looks rounded? ALso any tips on filling adjacent teeth with class II comps? Thanks.

gatordmd said...

As far as a marginal ridge I use sectional matrix and binetine rings for my contacts. Lately I have been trying the TriDent stuff (the V-shape ring) and have been liking it.
Polishing...I a soflex disc, just one. I use the second to last one. If I use anything coarser it takes too much away. I usually get what you see with burs. I don't do any sealing or glossing over stuff because I find it either messes with my occlusion or just washes away by the next time I see it. There is obviously some benefit to it but I am not having problems with stained open margins on the occlusal.
About the specific burs..I am not at work today. I know the "dove tail" is from the company called Two Striper. I will get you all the information tomorrow. I will post some pix of them.


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