It seems that every time I have a blog post due, I have an "aha" moment. Well, today it was an "uh-oh" moment. After 15 years in practice and thousands of crowns seated, I was doing my usual protocol for an eMax CEREC crown. Everything was going smoothly, the crown fit like a champ, and it looked beautiful after staining and glazing
We prepared the tooth, put our resin cement in the crown, and cemented it. As I was cleaning up the cement, I noticed something funny and my heart sank. My beautiful crown was not seated all the way to the margin. As a matter of fact, it was open probably 1 to 1.5 mm on the lingual. I stared in disbelief and kept thinking to myself "What the heck happened?"
I have never hoped so much that my assistant handed me something backwards than tonight. Lo and behold, it didn't seem as if the crown was turned. I just didn't push it all the way.
It’s 6 o'clock and everybody's ready to pack up. What to do? Well, really, there was only one thing to do: cut it off and do it over. Fortunately, with a CEREC, that's not the hardest thing in the world to do. It can still be completed in one visit, albeit a much longer visit than planned. I think I will be thanking my assistant for staying with me another week.
This humbling little incident got me to thinking. It certainly was not a crisis and not the worst thing I've had happen in an operatory (we'll save that for another post). But it did get me to thinking.
While this was a pretty major open margin and the patient certainly could have perceived it, I'd like to think that I would have done the same thing even if the margin was imperceptible to the patient. One of the things that I constantly remind my residents to do is to take post-delivery bitewings. We want to make sure that our margins are nicely closed and, particularly with resin cements, that all of the cement is cleaned up.
When we do see that cement fleck, it is easy enough to take care of. There's nothing worse than having a patient coming in on recall and finding cement at that point. The slightly open margin is probably a trickier decision. I'd like to think we would all cut off that less-than-perfect crown but, having seen thousands of x-rays in my day, I know that's not the case.
My point is this: for those young dentists, please make sure you take bite wings after crown delivery, and particularly after cementing implant crowns. It is so much easier to clean something when the patient is numb and right there. They appreciate that extra step when it needs to be taken.
If that crown is slightly open, use your best judgment. As the old saying goes, "Let your conscience be your guide." The most important commodities we have are our reputation and integrity. How do we handle that situation when nobody else really knows there is a problem? Under time and economic pressures, I'm sure I haven't always made the perfect decision, whether it be an imperfect contour on the filling, open contact on the crown or Class II filling.
The really powerful, amazing, and humbling thing about being a general dentist, however, is the fact that we get to see our work repeatedly over a number of years. As much as I always want to do the best for the patient, what motivates me even more to fix those small (and, in today's case, large) issues immediately is the fact that I know I will have to see it on an X-ray at their check up appointment. Honestly, that will bother me more than anything. How many other professions do you know where the professional has to see their work annually or semiannually and has the ability to constantly reevaluate and critique themselves?
As I say in my lectures all the time, we general dentists are a special breed and the superstars of our profession.
I mentioned there were a couple of things that came to mind this evening. The other big one was how lucky I am to have an amazing assistant that would stay with me while I corrected my boo-boo. Delia has been by my side for 13 years. I don't know what I've done to be so lucky to have such a consistent chairside partner and, for that matter, such a stable and consistent team. My three primary employees have been with me since the beginning. I am so lucky that they will walk through fire for me. Again, I don't really know what I've done to deserve that, but boy am I thankful for it.
So, after you read this, go give your team a high-five and thank them for everything they do for you. Tell them how lucky they are that they don't have a bonehead dentist who cements crowns incorrectly and keeps them late at night.
And Delia, I'm sorry I ruined your dinner out with your friends. I'll try to make it up for you. Just add it to the list of things I owe you.
Christopher Perry, DMD, MAGD