Page 46 - CEREC Q4|2012

42 | cerecdoctors.com | quarter 1 | 2013
‘We’ve Got
You Covered!’
Offering the Option of Partial-coverage Onlays
during cerec 27 and a half, i was
astonished when Dr. Gordon Christensen
told us the percentage of full-coverage
crowns versus partial-coverage onlays
done in the United States. According to his
numbers, the ratio of full coverage versus
any type of partial coverage was 98 percent
to 2 percent, respectively. Meaning the vast
majorityof teeth treatedwith indirect resto-
rations last year were full-coverage crowns.
What caused those treating these teeth to
choose full- versus partial-coverage? Was it
easier?Was it justmore convenient?
GiveasetofX-rays,afewsymptomsand
an intraoral picture of a tooth needing
restoring to 20 different dentists, and you
would likely get 30 different answers as
to how andwhy they would treat it. Don’t
believe me? Read the forum on cerec-
doctors.com sometime; you’ll see all the
differing opinions out there. Conversely,
I would guess that if those same 20
dentists had the exact clinical presenta-
tion and symptoms in their own mouth,
their aforementioned diagnosis would
oft times differ from what they placed or
wouldhave placed on that patient’s tooth.
Why do some dentists have differing
standards for what they want done with
their own teeth than they do for their
patients? Why do we place such blinders
on our own eyes and not routinely offer
the benefits of a well-prepped and -fabri-
cated onlay when it would be ample
treatment for the situation? If it’s some-
thing you’d want in your own mouth,
shouldn’t we be giving the patient the
same consideration?
So, let’s clarify a few
fundamentals. What is an
onlay? “An onlay has been
C A S E S T U D Y | | | b y b r a d l e y s u t to n , d . d . s .
defined by U.S.A. dental benefit compa-
nies as a restoration that covers at least
one cusp of a multi-cusp tooth.”1 To be a
little more specific, if more than one-third
of the occlusal table is compromised, the
cusps adjacent to the affected area need to
be covered. This is where our training and
ability to make evidence-based decisions
comes into play. If the mesial portion
of the tooth is intact or affected in less
than one-third of its intercuspal space,
and the distal has a broken cusp or the
decay extends beyond 1/one-third of the
occlusal surface, then the tooth by defini-
tion needs an onlay with cuspal coverage
on one or both distal cusps (Figs. 1-2).
Delta Dental issued a statement to me
over the phone that “with X-rays and the
surfaces specified, as longas the toothmeets
the criteria, we will reimburse it as a major
service, but without the proper criteria, we
will only reimburse it as a normal filling.”2
Having written a proper narrative and
provided the necessary documentation
(including a photo when needed), I have
never had an onlay rejected by an insur-
ance company. At times I’ve had to call and
speak with their consultants, but they have
allowedbenefitswhenthesituationdictated
coverage of one ormore cusps.
At the risk of sounding too harsh, we, as
a dental community, have the obligation to
seek out better solutions for our patients, no
matter the barrier that exists to prevent it. A
favorite prosthodontics professor ofmine at
Marquette University, Dr. William O’Brien,
D.D.S., M.S., made a point of saying to his
classes that “Dentists solve problems!” His
mantra (and because of him, the mantra
of our class) was “If you don’t know some-
thing now, FIGURE IT OUT!”3 We have
all the tools at our
disposal—between
our current educa-
tion and the ability
we all have of
continuing our
education— to find
theanswers toeach
set of issues we face. Our patients deserve
the very bestwe have to offer; which should
be an evolving set of solutions as we learn
and practice our profession.
Another thing we need to remember is
that we are at the helm. No one else will
dictate what type of prep we do besides
us.We canmake our preps as conservative
as they can be, but also we can alter the
prep according to the morphology of the
underlying tooth. Even our full-coverage
crowns can be prepped to preserve
important tooth structure on the facial
and lingual surfaces (Fig. 3). So-called
“crownlays” can be a go-betweenwhen all
of the cusps need coverage but the facial
and lingual surfaces are intact (Fig. 4).
Dr. Dennis Fasbinder, a renowned
research clinician and program director
of the Advanced Education in General
Dentistry program at the University of
Michigan School of Dentistry, has said,
“Onlays are a very conservative and excel-
lent restorative choice when addressing
a moderately damaged tooth.”4 Dr.
1 2
3
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