A Nod to Modern Dentistry Founder Dr. G.V. Black

Recently, I was preparing a tooth for an onlay and thinking about Dr. Greene Vardiman (G.V.) Black (1836–1915), one of the founders of modern dentistry. As my bur moved around the tooth, I thought of his “extension for prevention” concept about extending a prep outline to an area of the tooth the patient had easy access to clean. And that way, the risk of recurrent decay around that margin decreased — in theory. Nowadays, dentists have archived this theory thanks to our amazing composite materials that don’t need anything extended anywhere. We put our filling material only where we need to and can keep the preparation size small and, dare I say, conservative. That sounds like true modern dentistry in 2016 and a far cry from that ancient extension idea of the 1800s. 

However, after practicing for nine years, which I know is hardly extensive experience, I’ve noticed the occasional inverse relationship between how advanced our materials are and true “conservatism” of our preps. Allow me to be frank: I think many of us should admit that there are dentists who do the exact opposite of what Dr. Black was trying to promote. We then hope that our patients floss and our margins stay beautifully sealed for 20 years.

Really? I think Dr. Black would laugh at that.

On one hand, we may be trying to say extending a filling prep margin out is overkill, overaggressive and totally unnecessary, yet on the other, we’re perfectly fine with dropping our indirect margins all the way around a tooth and down to where we might hope that our margins don’t become a condominium complex for the friendliest of bacterial residents in our mouths.

And by “we,” I mean that I, too, was once guilty of that. In my mind, also covering the tooth (the whole tooth and nothing but the tooth) was swearing in the tooth to the protection it needed to not break. Lately, I’ve been mentored to do otherwise, and I’ve been enlightened by the wonderful world of onlays and inlays. I love not cutting away so much tooth anymore and putting margins in easy-to-reach and easy-to-clean places for the patient. I know this may not be news to anyone and biomimetic dentistry is not a new trend; rather, it has been a solid concept circulating in dental circles with many dentists who practice it every day.

But for me, not having cut an onlay or partial crown since dental school, I had to relearn this skill, and I’m loving it. The concept of preserving tooth structure has always been inherent to my philosophy, but now, I feel empowered by preserving most of the tooth by altering my prep design. If I don’t have to remove two-thirds of sound enamel, then why remove it? If I can place the margin of my onlay high above the gumline where my patient can easily keep it clean, that makes me a happy dentist. After all, we have amazing cements that will help keep that onlay bond to the tooth, so why not take advantage of them?

“I suppose I’m applying an under-extension for prevention,” I thought to myself as I made my way around the tooth. I think Dr. Black would be proud.

Zeynep Barakat, DMD, FAGD