November 1, 2003
by Bruce Glazer
What separates a “margin of error” from a “margin of perfection”? Prosthodontics is the replacement and/or restoration of missing anatomic structures in the oral cavity. It also broadens to include maxillofacial concerns and temporomandibular disorders and is far more complicated than advanced restorative dentistry. The discipline of prosthodontics is a veritable amalgam. The referrals range from dentistry tried-and-failed, to difficult patient management problems or sometimes just the restoration of a single endodontically treated tooth. Whatever the reason, the essence of treatment must be a focus on the pursuit of a real margin of perfection — a focus on quality care.
There are a select few who have a genetic pre disposition to achieve this high goal. The rest of us must toil like Sisyphus, many times working the same case over and over in order to achieve a qualitative result.
The architect, Mies de Rohe could have been referring to the complexity of a prosthodontic rehabilitation when he remarked, “God lies in the details.” Attention to detail is a prerequisite in a labour intensive specialty like prosthodontics. We must be very focused when we work, being diligent not to allow outside distractions to interfere with our concentration.
Attention to detail demands extra time: except, for those gifted individuals able to do restorative dentistry at “Concorde speed.” They are able to complete a single crown, including temporization and final impression, in under fifteen minutes.
In most quotidian prosthodontic cases, wax-ups are needed to complete the treatment planning stage. The completed wax-ups are then used to create silicone matrices for temporaries and tooth or tissue preparation guides. If we skip these steps and jump right into the treatment phase, we have no clear vision of our goals. Many times the vertical dimension of occlusion (VDO) due to this lack of planning is altered in order to create space for metal and/or porcelain. Altering the VDO in a dentate prosthodontic rehabilitation is not to be taken lightly. This is missing by a long shot that margin of perfection; it is merely convenience and laziness. But to be pragmatic, there is not much point in tackling complicated prosthodontic cases when you are still struggling to capture crown margins. We should be realistic about what we aim for and the margins of their realization.
Once you have mastered capturing crown margins accurately it is time to move on; perhaps to discover a quality lab technician. Such a technician is one who is willing to stand behind his or her work for more than the “magical year.” Many times the pursuit of a real margin of excellence demands that a case be remade. Whatever the reasons, this is one of the times that lab support is essential; none of this re-doing the case at half price. We are all too familiar with the high cost of laboratory remakes. Many times the thought of a lab bill of several hundred dollars is a deterrent to our pursuit of a real margin of perfection, in this case our moral imperative to heal.
Achieving a margin of prosthodontic perfection is a life long pursuit. Navigating the abyss between the margin of error and the margin of perfection comes not only with the wisdom of experience but also with the desire to care.