Professor Richard Ibbetson opened proceedings in the historic Edinburgh Faculty on September 20, by admitting that he had the luxury of hand-picking his speakers for the day, adding that the sub-text – or proper title - might have been ‘What’s (most effectively) done, why and how?’
He then began the day with an overview of ‘Restorative skills for the 21st century’, commenting that he had lived through two eras: that of the ‘maximally invasive’ (1974–85) and the ‘minimally interventive’ (1986–2012), with the advent of new materials and treatment options, which themselves now demanded a far wider skill-set of the clinician. In short the preservation of tooth structure and the management of functional loading are the keys to long-term success: and no restoration can be regarded as ‘permanent’.
Minimising the restorative burden leads to maximising successful outcomes, although it must be accepted that such techniques as adhesive direct restorations are enormously time-consuming to do well.
Veneers, in particular were highlighted as the most demanding of operative procedures, while the use of porcelain onlays or inlays replacing worn restorations had been shown to have a better longevity - of 92 per cent at eight years and 86 per cent at 12 years.
Richard was followed by Martin Kelleher, whose views on the condition he names ‘hyper-enamelosis’ are by now well appreciated. Talking on ‘Ethics, success and profit’ we knew where this session was going.
Discussing current work on the failure rate of dental implants, Martin re-emphasised the dangers of considering any treatment as lifelong, and offered the epithet that for dentists, ‘self-improvement plus self-preservation’ equals success.
His well-known advice: ‘never treat a stranger’ was expanded to the suggestion that no definitive treatment plan should ever be offered at an initial appointment with a new patient. Martin concluded with a review of the evidence base on the importance of maintaining vertical dimension and use of Dahl appliances, which he viewed as largely mythical – a challenging end to a challenging talk.
Professor Bill Saunders next gave the William Guy Memorial lecture, and occasional and prestigious event which commemorates the remarkable life of a man who was Dean of the Edinburgh Faculty from 1899 until 1933. Ninety-one years seems today a less than remarkable age to attain, but a life which spans the time of Florence Nightingale to the hydrogen bomb must surely have been quite incredible.
The ‘Root to success’ offered a masterly review of contemporary endodontic theory and practice. Work by Ng and others was quoted as suggesting that in the past 60 years, long-term survival rates had not significantly altered following non-surgical endodontic intervention.
The advent of cone-beam (CBCT) technology offered new insight into canal morphology revealing for instance that more than 80 per cent of upper first molars exhibited a second mesio-buccal canal.
Access, Magnification and Isolation remain the three most significant pillars for endodontic success.
The intra-canal biofilm has been shown to contain upwards of 600 species of micro-organism, with viruses such as Herpes, CMV and HPV implicated. Thorough irrigation, at least three times, with Tesco bleach is still recommended, using a 30G needle with side delivery tip. Betadine (povidone-iodine) also had value, as did ultrasonic activation, while 20 per cent citric acid removes the smear layer effectively.
The literature gives no clear indication as to whether a single or two-visit procedure is superior, we heard, and a variety of current techniques for canal preparation and patency were each discussed, including the use of modern reciprocating files and apex locators.
Current views are that post-trauma, calcium hydroxide should not be left for long periods, and its replacement after two weeks (or indeed initial treatment) with an MTA plug was indicated. Biodentine was a useful material for perforation repairs, with evidence of fibroblast infill and reliable success rates.
After lunch, Nick Lewis, consultant in restorative dentistry at the Eastman reviewed complex restorative cases and no less complex treatment in ‘Cosmetic conundrums’. He predicted a ‘senior tsunami’ to be imminent as the heavy metal generation get ever more demanding with the added problems of polypharmacy in the elderly population.
Tooth replacement generates a hierarchy of possible approaches, with adhesive bridgework, implants and orthodontics high on the list, conventional bridgework and removable prosthodontics towards the bottom. As with Martin Kelleher’s comments, Nick referred to the challenge of peri-implantitis as being a ‘shadow on the horizon’.
Defending his lowly placement of removable prostheses, Nick pointed to evidence showing the average survival time of abutment teeth as 40 per cent over five years and just 20 per cent over 10.
Nick expounded on the provision and design of adhesive bridgework and noted an average retention period of eight years, extending to 10 years for cantilever designs. This was illustrated with a rapid succession of complex, daunting even, restorative cases demonstrating the need for whole-patient and whole mouth treatment planning, and the need for “when it fails” planning.
The day drew to a close with a presentation from Derrick Setchell, now retired as professor and legendary restorative consultant at the Eastman. Since all the lecturers, bar one, had at some time come under his searching gaze in training, there had been a fair amount of repartée during the day.
Derrick reminded the audience that in days long past, preparing teeth had been long, hard work and over-preparation was, in consequence, a rarity. The use of Bandlish’s Restorative index was advanced as a good guide as to whether extensive operative dentistry was likely to lead to success, failure – or possibly erasure.
By way of conclusion, he treated the audience to a ‘professional tour of Barnet’, a photographic essay on commercialism, leaving us wondering whether the bold future of dentistry lay with glossy promotion or discreet professionalism. One to ponder!
An enthralled audience left feeling that they had learned a lot from a series of masterclasses, delivered by diagnostic, as well as technical, experts in their field. And yes, restorative dentistry does work!