Minimally Invasive Dentistry(MID)

What is Mininally Invasive Dentistry?

The phrase Minimally Invasive Dentistry is gaining momentum in the dental world. Raymond Bertolotti may have been the first to use it as a lecture header a few years ago.

Many practitioners practice with a MID bias without explicit use of the term.My drift towards MID began with the needs of lower-income patients,for whom conventional high end procedures will probably never be affordable. From attempting the impossible for these patients, I learned how to push the envelope of adhesive dentistry. The successes were at first limited but over time improved, and at this point in time are phenomenal compared to traditional non-adhesive dentistry. The restorative advantage of adhesive MID becomes very obvious at the impossible edge of the restorative continuum.The desire to extend into this range goes against the grain of the last decades of North American Dentistry.

In North America in the last decade, the distinction between elective and necessary procedures has apparently blurred. Concurrently, we have seen a willingness of practitioners to extensively cut young teeth for cosmetic reasons. This has the consequence of dooming young patients to a lifetime of expensive maintenance. The purpose of this website, among other goals, is to oppose that trend and instead offer a functional base for conservative treatment. MID meets similar clinical ends with lowered morbidity and cost.

In this new climate of economic downturn, it may be a practice lifesaver to know how to effectively perform these procedures.

You will find MID an underlying assumption throughout this website. Why?

Maximum Lifespan: It seems fatuous to state that longevity should be an axiom for restorative dentistry, but our mainstream culture of disposability, which seems to exclude accountability for the commons and the environment, also seems to disdain the value of tooth structure, spouses,children, neighborhoods, and so on. As a culture we seem to have lost the guiding principle of durability, substituting instead, the pursuit of short-term gain.

Lower Cost As a term, this may suggest a dwindling of income to dentists and may be therefore seem inherently unattractive. However, if lower fees are matched by high inherent efficiency and effectively lower costs for the practitioner, then normal and necessary revenue to the dental practice is always maintained.

Dr. Gordon Christensen weighed in on MID recently in the October 2009 issue of Clinician's report.See http://www.cliniciansreport.org/node/4490external link
The article title was "Minimally Invasive Dentistry Can Be Win-win!"

Specifically, he analyzed the advantages to the patient, and the revenue consequences to the practitioner of the following:

  • Inlays/Onlays vs full coverage
  • Small (mini) Implants vs conventional diameter fixtures
  • Bleaching vs veneers
  • Conservative periodontal therapy vs surgery
  • Repairing Crowns vs replacement
  • Direct Resin Veneers vs ceramic veneers
  • Preventive procedures vs restorative
  • Small, bonded resin restorations vs conventional GV Black preps

Christensen concluded that revenue to the practitioner was not significantly less when following the above restorative strategies.Importantly, he noted that the gains to the patient in retained tooth structure, lessened morbidity, reduced invasiveness and diminished negative sequelae were impressive.

What MID procedures are on this site?

New MID Procedures on this site

Incisal Attrition treatment seeIncisal Attrition

Incisal Attrition treatment, when carefully executed, is effective; six teeth can be easily treated in less than an hour, delivering improved esthetics, protecting tooth structure, maintaining occlusal stability, ensuring patient comfort during the procedure and providing sound service life. (One to two decades) That is a lot of benefit for a small amount of chair time. As well, it probably returns the best revenue per hour of any direct restorative procedure. There is no subsequent maintenance, post-operative sensitivity, or pulpal consequence.

The Inlay-Maryland? Bridge

This is a new simple yet powerful technique for splinting teeth and tooth replacement, seeAdhesion Bridgesand Inlay Adhesive Bridges. The Inlay Maryland splint may be an alternative to full coverage in some situations. However, it is far less invasive: only 5% of the tooth is cut, superficially, rather than 100%, deeply, as in full coverage. This is an enormous benefit for the patient, and, it is, coincidentally, an easier procedure for the dentist. A classic Win-win situation.

For multiple-tooth splinting,a trained practitioner can prepare six teeth in an hour, and the prosthesis can be seated, often without anesthetic, in 40 minutes. No facial show of metal occurs, no greying of abutments is entailed, yet retention has exceeded 95% in 10 years in our practice. To match this record, practitioners must pay full attention to all the necessary details of adhesive design and cementation. Problems such as laboratory matching of porcelain shades is eliminated, no wear is imposed on the opposing dentition, ceramic fractures are eliminated because there is no porcelain, only the untouched facial surfaces of the prepared teeth. When six teeth are treatable in the time normally allotted to a single crown, it obviously will be less costly to the patient.

The MODB and MODBXYZ restorations

On this website MODB MODXYZ we offer a functional alternative to full coverage crowns or bonded ceramic onlays. When properly executed, there is no post-operative sensitivity, premature recurrent decay, broken or open contact. This restorative capacity can be within every practitioner's capability. The website material is intended to raise the bar in these maximal composite restorations.

The Preventive Resin Restoration
See Preventive Resin Restoration for the technique currently used in the study club.

Crown Repairs Recementing of Lost Crowns outlines a way to refurbish crowns if crown margins,contacts and occlusion are still satisfactory, but abutment re-decay or core de-bond has led to un-cementation.

Other Subjects on this website: GV Black Revised

The definitive textbook of composite dentistry has yet to be written. Some sections of this website propose to reconfigure GV Black designs for Class Vs, Class IIs, Class Is, and adhesive pit and fissure treatment, ie.PRRs and Sealants. These segments are an attempt to contribute to the dialogue on preparation design, towards an eventual consensus in the dental profession on definitive preparations for composite resin.See Technique Library

Improved Efficacy in Routine Procedures

Adhesive principles applied to Posts Posts and Coresand to core buildup (Vital Core Buildups|)) improve strength, versatility and clinical performance relative to non-adhesive treatment.

Effectiveness is increased when adhesive design is integrated in crown, onlay and inlay procedures. See Temporary Crowns, impressions Predictable Crown Impresssions and instrumentation Diamonds and Burs.

The Composite Paradigm.

Necessary techniques and their conceptual underpinnings are covered under the following links:
Many of these chapters are password-protected, but are available through subscription or by attending a course presented by Dr. Walford. Contact Dr. Walford at pwalford@telus.net to purchase a subscription, available for one year at a cost of US$120 or for 3 months for US$65.

For the Practitioner: The Practice Management Challenge of MID

The practice management challenge for the MID operator is to become efficient enough at these procedures to earn high practice revenue. This is achievable through hard work and determinedly acquiring these techniques and knowledge. The secrets lie in clarity of purpose, skillful clinical steps, efficient 4-handed teamwork, optimized treatment coordination, positive patient relationships, ideal isolation, controlled visibility,and cost-efficient materials selection, purchasing, and inventory.

Leave anything out of the mix and beneficial outcomes decline. Some MID procedures actually net higher hourly revenue than anything else in the restorative spectrum. The majority of procedures equal conventional treatment. A few fees must be raised higher than fee guide, (and hence third party level), but this is justified by the extended lifespan attained and can be explained to the patient as needed.

Investment in New Materials and Products

Limited investment is necessary,but absolutely, one does not have to leap with both feet into the high tech world be be effective. No lasers, milling machines, optical scanners, computer terminals, or large capital outlays are required, and there is no rapid obsolescence. Small initial outlays are offset quickly by savings in consumables, increased income from new procedures, and the reduction in failures.There is no need whatsoever for high-end capitalization, i.e., in the tens of thousands; no inactive inventories used only for rare high end applications. These techniques are free of moral stress, the pressure to propose treatment to service one's capitalization choices.

This makes MID procedures ethically neutral: no temptation exists to recommend treatment on the basis of needing to recoup high-end capital outlays.

MID is therefore Everyman Dentistry; accessible, transparent, honest.

Where there is a need for serious investment, it is in energy: to transform oneself: train oneself and staff, revise the known and comfortable, evolve with one's experience, acquire new habits and master new treatments. Learning can require several years.

However, one day you wake up and you are there. When the journey is over, you can offer more treatment alternatives, many of them easier, all effective. Your treatment spectrum is populated with a quiver of new and effective options. And these all are equally remunerative, no bias towards the high end. This is practical dentistry: In our study club I offer no procedures too un-remunerative to implement into conventional practice.

MTA Pulp Treatment- a new MID Frontier

MTA pulp cap is an alternative to conventional RCT when pulpal pathology is limited. MTA has earned a recognized place as a root fill material in apicoectomy, and also for repair of root perforation.

The potential for pulp cap is currently untapped in North America. MTA has evolved from positive initial experience in pulp caps with the Kanca/Bertolotti technique of direct pulp cap using composite resin. This procedure is usually clinically asymptomatic, but cell culture studies reveal that apoptosis, i.e., gradual cell debilitation ensues, sometimes ending in pulp death. See References

Exposed pulps histologically respond to MTA much better than resin, as it is far more biocompatible. Unlike calcium hydroxide formulations, which impose transitory cell inflammation and inconsistent secondary dentin deposition, MTA has the ability to promote homogeneous secondary calcification with minimal inflammation.

A large international body of literature demonstrates high success rates in both primary and permanent pulpectomy and pulpotomy using MTA. Efficacy exceeding 90% is reported, unlike a range of 13 to 58% reported with other materials. That puts MTA treatment for vital pulps on a par with conventional RCT in lifetime outcomes. Try this: Google MTA,Dental and peruse the 20 pages of references that emerge.

Protocols for MTA pulpotomy and pulp cap are not yet common, due in part to a cost barrier,viz, the steep price demanded by North American patent holders, Tulsa Dental (Dentsply.)

MTA products are now available at 15% of Tulsa's price in Canada. As well ,a ten minute set time brings the material into clinical practicality. The twin deterrents of high price and 24-hour setting time will keep MTA out of the hands of practitioners no more.

Soon, as of mid-2015, a new powder/gel formulation will be to improve clinical ease of MTA placement.Currently it has not completed Health Canada approval, but is available in the USA.

An extensive body of MTA literature is on file on this website.