- Email: [email protected]
CROWN LENGTHENING
L E T T E R S
these are based on error, illusion and delusion. The error is that many of our present citizens from all demographic groups will not visit a general dentist or physician for noncatastrophic basic consultation, examination, treatment or testing unless they have “insurance.” The definitions of need, want, luxury, necessity, responsibility, obligation and entitlement have been skewed—so much so that one could fill JADA with a list of goods, services and commodities that would precede basic medical or dental care as a priority for many of our citizens. This is based on an illusion that insurance is an entitlement to free access and care. However, insurance for most people involves large copayments and deductibles, especially on initial services. There are also many limits to our freedom. Many corporate and government plans may limit access. Plans also may refuse basic treatment, consultations and testing that both patient and doctor agree to. The irony at present is that many citizens with “better” insurance plans may be penalized by the government for having “Cadillac” plans. All of this is based on the 20th century delusion hawked by political utopianism and demagoguery that everything and anything should or can be had for free, and without a loss of freedom. The 21st century is teaching us that we can only pick our neighbors’ pockets, and the government can only pick our pockets, for so long. It might be ancient history, but there was a time when people paid for basic medical and dental care the way they paid for a haircut, roof repair, 1182
JADA 141(10)
http://jada.ada.org
plumbing service and a thousand other goods, commodities and services. The authors suggest “the need for comprehensive efforts to increase access to dental insurance” for future citizens. My suggestion is to go back to the future with a comprehensive effort for present and future citizens to learn the value of payment for a doctor visit themselves. Andrew Tanchyk, DMD East Brunswick, N.J.
One could fill JADA with a list of goods, services and commodities that would precede basic medical or dental care as a priority for many of our citizens. Author’s response: We appreciate Dr. Tanchyk’s interest in our study and his concern about access to oral health care for all populations in the United States. Having dental or medical insurance and a regular source of care are the most important predictors of utilization of medical and dental care services in the United States.1-5 The goal of our study was to examine the determinants of utilization of oral health care services, especially insurance and a regular source of care, across a diverse group of immigrants. To gather our data we utilized a validated self-administered survey instrument. The survey was not designed to measure or rank the values that individuals place on seeking oral health care relative to other wants and needs. Although we respect Dr. Tanchyk’s right to express his personal opinion on this matter, our discussion and conclusions are based on our study results
and consistent with all previous reports on this area. Gustavo D. Cruz, DMD, MPH Adjunct Associate Professor Department of Epidemiology and Health Promotion College of Dentistry New York University New York City 1. Gilbert GH, Branch LG, Longmate J. Dental care use by U.S. veterans eligible for VA care. J Soc Sci Med 1993 Feb;36(3): 361-370. 2. Janes GR, Blackman DK, Bolen JC, et al. Surveillance for use of preventive health-care services by older adults, 1995-1997. MMWR CDC Surveill Summ 1999;48(8): 51-88. “www.cdc.gov/mmwr/preview/mmwrhtml/ ss4808a4.htm”. Accessed Aug. 31, 2010. 3. Davidson PL, Cunningham WE, Nakazono TT, Andersen RM. Evaluating the effect of usual source of dental care on access to dental services: comparisons among diverse populations. Med Care Res Rev 1999;56(1): 74-93. 4. Dolan TA, Atchison K, Huynh TN. Access to dental care among older adults in the United States. J Dent Educ 2005;69(9): 961-974. “www.jdentaled.org/cgi/content/ full/69/9/961”. Accessed Aug. 31, 2010. 5. Flores G, Tomany-Korman SC.Pediatrics. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics 2008;121(2): e286-298. Epub 2008 Jan 14. “http://pediatrics. aappublications.org/cgi/content/full/121/2/ e286”. Accessed Aug. 31, 2010.
CROWN LENGTHENING
I am writing regarding Dr. Timothy Hempton and Dr. John Dominici’s June JADA article, “Contemporary Crownlengthening Therapy: A Review” (JADA 2010;141[6]: 647-655). I congratulate Dr. Hempton and Dr. Dominici for writing such a comprehensive review. In my opinion, the only important issue they have missed to elaborate is the “orthodontic forced eruption (OFE) or orthodontic extrusion” as a crown-lengthening procedure. I think Dr. Hempton and Dr. Dominici have overlooked the OFE. They mentioned briefly that “orthodontic extrusion may be another option to expose tooth structure in some clinical situations. Any method used to
October 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
increase the ferrule length will reduce the root length invested in bone and possibly make the crown to root ratio unfavorable.” In my opinion, this is not always true when the OFE, with or without the surgery, is carried out. The OFE followed by surgical crown lengthening produces a more stable and favorable crown-root ratio.1 Surgical crown-lengthening alone would produce an unstable and unesthetic crown-root ratio. This is well explained through a schematic diagram by Shillinburg and colleagues.1 Associated with periodontal surgery, it also exposes subgingival lesions and preserves a harmonious gingivo-osseous morphology. The rationale behind the OFE is that, by stretching the gingival and periodontal ligament fibers during OFE, tension is imparted to the entire alveolar socket, stimulating osseous apposition at the alveolar crest.2,3 This increases the width of the attached gingiva, and the mucogingival junction remains stable when the gingival margin migrates coronally.2-4 Forced eruption has advantages over surgical crown lengthening, which causes negative change in the length of the clinical crowns of both the tooth and the neighboring teeth, produces poor esthetics, widens embrasures and is less conservative, considering the sacrifice of supporting bone of adjacent teeth.5 The authors also mentioned regarding the OFE that “[o]rthodontic procedures add to the cost of restoring the tooth and prolong treatment.” Generally, two anterior teeth and two posterior teeth can be bonded with orthodontic brackets for this
purpose. Removable appliances or anchorage wires bonded to adjacent teeth can also be used to achieve forced eruption.5 Whatever appliance is used, OFE can be as rapid as 1 millimeter per week without damage to the periodontal ligaments; hence, three to six weeks are sufficient for almost any patient.5,6 Looking at the cost-to-benefit ratio, I think the treatment involving OFE is advantageous, Forced eruption has advantages over surgical crown lengthening, which causes negative change in the length of the clinical crowns of both the tooth and the neighboring teeth.
and one should not overlook considering this option as one of the principal entities in treatment planning. Pravinkumar G. Patil, MDS Assistant Professor Department of Prosthodontics Government Dental College and Hospital Nagpur (Maharashtra) India 1. Shillinberg HT, Hobo S, Whitsett LD, Jakobi R, Brackett SE. Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago: Quintessence; 1997:191-193. 2. Schincaglia GP, Nowzari H. Surgical treatment planning for the single unit implant in aesthetic areas. Periodontol 2000 2001;27:162-182. 3. Chambrone L, Chambrone LA. Forced orthodontic eruption of fractured teeth before implant placement: case report. J Can Dent Assoc 2005;71(4):257-261. 4. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 1993;13(4): 312-333. 5. Jafarzadeh H, Talati A, Basafa M, Noorollahian S. Forced eruption of adjoining maxillary premolars using a removable orthodontic appliance: a case report. J Oral Sci 2007;49:75-78.
JADA 141(10)
6. Proffit WR, Fields HW Jr, Ackerman JL, Bailey LJ, Camilla Tulloch JF. Contemporary Orthodontics. 3rd ed. St. Louis: Mosby; 2000: 627-632.
MORE ABOUT CROWN LENGTHENING
I am writing regarding Dr. Timothy Hempton and Dr. John Dominici’s June JADA article, “Contemporary CrownLengthening Therapy: A Review” (JADA 2010;141[6]:647-655). Regardless of the need for crown lengthening, the type of restoration proposed is not as advantageous as short chamfer long bevel. A chamfer bevel preparation removes less axial tooth structure than long shoulders, resulting in stronger tooth integrity. The advantages of a long bevel versus shoulder are less chance of creating a ledge from short/long gingival restoration margins, resulting in easier patient hygiene; allows high noble metal to be burnished, resulting in a better restoration profile and sealing against bacteria, therefore leading to less inflammation. In addition, long bevels (diagonal cut of the cylinder) allow for longer margins on harder tooth structure enamel/ cementum exposed to oral cavities than dentin in case of any gaps or uncovered margins of restored teeth. The article suggests that for a Class V restoration, “the dentist can perform the needed osseous removal solely on the facial or lingual aspect.” According to Lindhe and colleagues,1 the soft tissue cannot follow abrupt and steep changes in the osseous profile: “The process of osseous resection requires that bone be removed from the adjacent teeth to create a gradual rise and fall in the profile of the osseous crest.” The restoration would invade the zone of superhttp://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
October 2010
1183
these are based on error, illusion and delusion. The error is that many of our present citizens from all demographic groups will not visit a general dentist or physician for noncatastrophic basic consultation, examination, treatment or testing unless they have “insurance.” The definitions of need, want, luxury, necessity, responsibility, obligation and entitlement have been skewed—so much so that one could fill JADA with a list of goods, services and commodities that would precede basic medical or dental care as a priority for many of our citizens. This is based on an illusion that insurance is an entitlement to free access and care. However, insurance for most people involves large copayments and deductibles, especially on initial services. There are also many limits to our freedom. Many corporate and government plans may limit access. Plans also may refuse basic treatment, consultations and testing that both patient and doctor agree to. The irony at present is that many citizens with “better” insurance plans may be penalized by the government for having “Cadillac” plans. All of this is based on the 20th century delusion hawked by political utopianism and demagoguery that everything and anything should or can be had for free, and without a loss of freedom. The 21st century is teaching us that we can only pick our neighbors’ pockets, and the government can only pick our pockets, for so long. It might be ancient history, but there was a time when people paid for basic medical and dental care the way they paid for a haircut, roof repair, 1182
JADA 141(10)
http://jada.ada.org
plumbing service and a thousand other goods, commodities and services. The authors suggest “the need for comprehensive efforts to increase access to dental insurance” for future citizens. My suggestion is to go back to the future with a comprehensive effort for present and future citizens to learn the value of payment for a doctor visit themselves. Andrew Tanchyk, DMD East Brunswick, N.J.
One could fill JADA with a list of goods, services and commodities that would precede basic medical or dental care as a priority for many of our citizens. Author’s response: We appreciate Dr. Tanchyk’s interest in our study and his concern about access to oral health care for all populations in the United States. Having dental or medical insurance and a regular source of care are the most important predictors of utilization of medical and dental care services in the United States.1-5 The goal of our study was to examine the determinants of utilization of oral health care services, especially insurance and a regular source of care, across a diverse group of immigrants. To gather our data we utilized a validated self-administered survey instrument. The survey was not designed to measure or rank the values that individuals place on seeking oral health care relative to other wants and needs. Although we respect Dr. Tanchyk’s right to express his personal opinion on this matter, our discussion and conclusions are based on our study results
and consistent with all previous reports on this area. Gustavo D. Cruz, DMD, MPH Adjunct Associate Professor Department of Epidemiology and Health Promotion College of Dentistry New York University New York City 1. Gilbert GH, Branch LG, Longmate J. Dental care use by U.S. veterans eligible for VA care. J Soc Sci Med 1993 Feb;36(3): 361-370. 2. Janes GR, Blackman DK, Bolen JC, et al. Surveillance for use of preventive health-care services by older adults, 1995-1997. MMWR CDC Surveill Summ 1999;48(8): 51-88. “www.cdc.gov/mmwr/preview/mmwrhtml/ ss4808a4.htm”. Accessed Aug. 31, 2010. 3. Davidson PL, Cunningham WE, Nakazono TT, Andersen RM. Evaluating the effect of usual source of dental care on access to dental services: comparisons among diverse populations. Med Care Res Rev 1999;56(1): 74-93. 4. Dolan TA, Atchison K, Huynh TN. Access to dental care among older adults in the United States. J Dent Educ 2005;69(9): 961-974. “www.jdentaled.org/cgi/content/ full/69/9/961”. Accessed Aug. 31, 2010. 5. Flores G, Tomany-Korman SC.Pediatrics. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics 2008;121(2): e286-298. Epub 2008 Jan 14. “http://pediatrics. aappublications.org/cgi/content/full/121/2/ e286”. Accessed Aug. 31, 2010.
CROWN LENGTHENING
I am writing regarding Dr. Timothy Hempton and Dr. John Dominici’s June JADA article, “Contemporary Crownlengthening Therapy: A Review” (JADA 2010;141[6]: 647-655). I congratulate Dr. Hempton and Dr. Dominici for writing such a comprehensive review. In my opinion, the only important issue they have missed to elaborate is the “orthodontic forced eruption (OFE) or orthodontic extrusion” as a crown-lengthening procedure. I think Dr. Hempton and Dr. Dominici have overlooked the OFE. They mentioned briefly that “orthodontic extrusion may be another option to expose tooth structure in some clinical situations. Any method used to
October 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
increase the ferrule length will reduce the root length invested in bone and possibly make the crown to root ratio unfavorable.” In my opinion, this is not always true when the OFE, with or without the surgery, is carried out. The OFE followed by surgical crown lengthening produces a more stable and favorable crown-root ratio.1 Surgical crown-lengthening alone would produce an unstable and unesthetic crown-root ratio. This is well explained through a schematic diagram by Shillinburg and colleagues.1 Associated with periodontal surgery, it also exposes subgingival lesions and preserves a harmonious gingivo-osseous morphology. The rationale behind the OFE is that, by stretching the gingival and periodontal ligament fibers during OFE, tension is imparted to the entire alveolar socket, stimulating osseous apposition at the alveolar crest.2,3 This increases the width of the attached gingiva, and the mucogingival junction remains stable when the gingival margin migrates coronally.2-4 Forced eruption has advantages over surgical crown lengthening, which causes negative change in the length of the clinical crowns of both the tooth and the neighboring teeth, produces poor esthetics, widens embrasures and is less conservative, considering the sacrifice of supporting bone of adjacent teeth.5 The authors also mentioned regarding the OFE that “[o]rthodontic procedures add to the cost of restoring the tooth and prolong treatment.” Generally, two anterior teeth and two posterior teeth can be bonded with orthodontic brackets for this
purpose. Removable appliances or anchorage wires bonded to adjacent teeth can also be used to achieve forced eruption.5 Whatever appliance is used, OFE can be as rapid as 1 millimeter per week without damage to the periodontal ligaments; hence, three to six weeks are sufficient for almost any patient.5,6 Looking at the cost-to-benefit ratio, I think the treatment involving OFE is advantageous, Forced eruption has advantages over surgical crown lengthening, which causes negative change in the length of the clinical crowns of both the tooth and the neighboring teeth.
and one should not overlook considering this option as one of the principal entities in treatment planning. Pravinkumar G. Patil, MDS Assistant Professor Department of Prosthodontics Government Dental College and Hospital Nagpur (Maharashtra) India 1. Shillinberg HT, Hobo S, Whitsett LD, Jakobi R, Brackett SE. Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago: Quintessence; 1997:191-193. 2. Schincaglia GP, Nowzari H. Surgical treatment planning for the single unit implant in aesthetic areas. Periodontol 2000 2001;27:162-182. 3. Chambrone L, Chambrone LA. Forced orthodontic eruption of fractured teeth before implant placement: case report. J Can Dent Assoc 2005;71(4):257-261. 4. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 1993;13(4): 312-333. 5. Jafarzadeh H, Talati A, Basafa M, Noorollahian S. Forced eruption of adjoining maxillary premolars using a removable orthodontic appliance: a case report. J Oral Sci 2007;49:75-78.
JADA 141(10)
6. Proffit WR, Fields HW Jr, Ackerman JL, Bailey LJ, Camilla Tulloch JF. Contemporary Orthodontics. 3rd ed. St. Louis: Mosby; 2000: 627-632.
MORE ABOUT CROWN LENGTHENING
I am writing regarding Dr. Timothy Hempton and Dr. John Dominici’s June JADA article, “Contemporary CrownLengthening Therapy: A Review” (JADA 2010;141[6]:647-655). Regardless of the need for crown lengthening, the type of restoration proposed is not as advantageous as short chamfer long bevel. A chamfer bevel preparation removes less axial tooth structure than long shoulders, resulting in stronger tooth integrity. The advantages of a long bevel versus shoulder are less chance of creating a ledge from short/long gingival restoration margins, resulting in easier patient hygiene; allows high noble metal to be burnished, resulting in a better restoration profile and sealing against bacteria, therefore leading to less inflammation. In addition, long bevels (diagonal cut of the cylinder) allow for longer margins on harder tooth structure enamel/ cementum exposed to oral cavities than dentin in case of any gaps or uncovered margins of restored teeth. The article suggests that for a Class V restoration, “the dentist can perform the needed osseous removal solely on the facial or lingual aspect.” According to Lindhe and colleagues,1 the soft tissue cannot follow abrupt and steep changes in the osseous profile: “The process of osseous resection requires that bone be removed from the adjacent teeth to create a gradual rise and fall in the profile of the osseous crest.” The restoration would invade the zone of superhttp://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
October 2010
1183