March

‘No plan survives first contact with the enemy’ ? Helmuth von Moltke

This quote may have lost a little in translation and has been adapted many times since, perhaps most eloquently by ‘Iron’ Mike Tyson;

‘Everyone has plans right up until they get hit for the first time’.

I am not making the case that we consider patients either enemies nor boxing opponents lol! I am making the case that adaptability from set plans is an inevitable and essential part of our path to success.

To date, this year, we have worked on easy to visualise Class IV sites and labial veneers. These can be challenging enough but at least they are right in front of you. At least you can see directly what you are doing. Your loupes bringing the tooth into crystal and perfectly illuminated clarity.

March is about preparing anterior teeth for crowns. Everything changes when we go to the palatal on upper anterior teeth. Everything is backwards, in the dark and possibly one handed. The tooth maybe seen through a fraction of a misted-up mirror and the words we hear delegates utter the most in March are ‘I’m finding the palatal really hard’.

There are two considerations for this:

• Firstly, when humans undertake tasks they find hard they tend to subconsciously try and get them over and done with as quickly as possible risking not doing their jobs properly.
• Secondly, if we get it wrong on the palatal when preparing a tooth for an anterior crown, it may be found out during the mechanical testing of our work that is the patient’s occlusion.

So anterior crowns are the subject in March and we learn material choices, how to make them look good, how to adhere to underlying tooth. We create smooth, curved even preparations and adhere them as well as can be done. All the essentials. We point out that doing these on someone with an anterior open bite is very different to doing them on someone who has a deep overbite along with a well-established and threateningly severe parafunctional habit. Crowns need to look good (labial aesthetics) and also to withstand the forces of their idiosyncratic occlusion.

So palatal reduction needs to be enough yet ‘under prepared’ is the phrase we tend to have to use most commonly in March. People tend to under prepare. Check with your technician today. Ask them what is the most common technical error they encounter: Under preparation, over preparation, taper, corners, lipped margins, rough preps, undercuts…

I bet, I truly bet they say ‘under-preparation’.

And whilst there are several places this can get you into trouble, the palatal of upper anteriors if they are involved in static and dynamic occlusion is certainly one. Coupled with us trying to not prep too much (we certainly don’t endorse glib over preparation) and the innate psychological desire to get hard things done as quickly as possible we see the cingulum area, at first, often reduced by the tiniest amount.

Not enough tooth tissue removed and problems for the patient, the technician and you thereafter.

Just to reiterate, we do not advocate thoughtless over prep but we do endorse the following:

If you are going to do a job then do it properly. Commit to the materials thickness needs and plan to either increase the OVD with intent (creating material space akin to Dahl) or remove enough tooth tissue with a bur. 

Adhesive dentistry has changed dentistry and will continue to do so. Preparations are far more tooth friendly. The old fashioned (meant as an insult) PFM with 1.5mm of full circumferential reduction really does deserve any ridicule coming its way. It’s an abomination.

If the average lower central is 5.5mm wide and you remove 1.5mm mesially and the same distally then the 2.5mm spicule of tooth remaining is surely as laughable as it sounds, yet someone somewhere will have this done to them today.

Time has moved on and we enjoy showing the latest technique and building the required skills set to deploy them. Equally…once again…don’t underprepare.  Don’t do it.

So back to Moltke and Mike Tyson.

We all have good intentions when we start treating patients, our ‘battle plans’ so to speak.  We must accept that our idealised processes will be disrupted. We must accept some parts of the process will be hard and our pure simple plans get mucked up by misted mirrors, poor light, patients who won’t sit still, sit back, tolerate any moisture, tolerate any dryness.

However, our job and the task we have chosen remain and that is to attempt this task as well as we can. We must have boundaries upon which we won’t compromise.

The good news is that practice (particularly practice under supervision) makes our skills improve. Diligent precision and deliberate practice at any task will make you good at it. So, to get good we have to choose a task. We then have to admit we are NOT currently good enough at it, then practice. Ergo, to get good you have to choose what to be bad at, lean into that area and practice.

You get to choose what to be bad at lol, just as well as the palatal is hard but spring is here and whatever task you choose to be bad at, by summer you can be unrecognisably better than you are right now.

‘Spring is the time for plans and projects’ wrote Leo Tolstoy so make a plan to get good at something and if we can help you achieve it, we will.