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Use of Gold Foil in General Practice
691
F e r r ie r — U s e o f G o l d F o il B l a i r , V . P.; B r o w n , J. B ., and M o o r e , S h e r w o o d : Osteomyelitis of Jaw. M issouri
M . J.,
27:173, April 1930.
B l a i r , V . P .; P a d g e t t , E. C ., and B r o w n , J. B . : Diseases of Face, Mouth and Jaws; in G r a h a m , E. A .: Surgical Diagnosis. Philadel phia: W . B . Saunders Co., 1930. B o n n e r , H . : Osteomyelitis of Jaws in In
fants. Beitr. z. K lin . C h it., 133:163-183, 1925. H a d e n , R. L . : Dental Infections and Sys temic Disease. Philadelphia: Lea and Febiger, 1928. L e ib o l d , H . H .: Journal-Lancet, 4 5 : 113, M arch 1, 1925. O ’K e l l , C. C ., and E l l i o t t , S. D .: Bac teremia and O ral Sepsis. La ncet, 2:869-872,
P a d g e t t , E. C .: Surgical Diseases of Mouth and Jaws. Philadelphia: W . B. Saunders Co.,
1938 .
W il e n s k y ,
A. O .: Osteomyelitis of Jaw.
A rch . Surg., 25:183, July 1932. Osteomyelitis of Jaws in Nurslings and Infants. A n n. Surg.,
95:33, January 1932. Association of Osteo myelitis of Skull and Nasal Accessory Sinus Diseases. A rch . Otolaryng., 15 ¡805, June 1932. Z a r fl,
M .:
Ztschr. f. K in d erh., 2 5 : 266 ,
June 1920. R o s e n o w , E. C .; G i l m e r , T. L., and M o o d y : Quoted by B l a ir , V . P.; P a d g e t t , E. C ., and B r o w n , J. B .: Diseases of Face, Mouth, and Jaws, in G r a h a m , E. A .: Surgical Diagnosis. Philadelphia: W . B. Saunders Co.,
i 93 °-
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1935-
USE OF GOLD FOIL IN GENERAL PRACTICE By W. L .
F errier,
D .M .D ., Seattle, Wash.
H E R E have been, in the past, m any discussions as to the relative merits of gold foil and gold inlay opera tions. Differences of opinion have formed the basis for debate before dental associations by enthusiastic advocates of each method of restoring lost tooth struc ture. T he participants in these debates were usually those who advocated and used gold inlays, without knowledge or training in gold-foil technic, on the one side, and those who were trained in the technic o f gold-foil operating and also gold-inlay technic on the opposing side. These discussions were one-sided affairs, as it is obvious that one skilled in the use of gold foil as well as gold inlays was better qualified to judge their relative merits. M any operators use no foil what soever, while most operators who use foil use inlays wherever indicated; for each
T
R ead before the Section on Operative Den tistry, M ateria M edica and Therapeutics at the Eighty-Second Annual Meeting of the American Dental Association, Cleveland, Ohio, September 11, 1940.
Jour. A.D.A., Vol. 28, May 1941
has separate and distinct indications, and there need be no conflict in choice be tween gold foil and gold inlays, generally speaking, and there is none in the prac tices of those who are sufficiently ver satile to make creditable operations by either method. I am convinced from long experience with all methods and materials that gold foil fulfils more nearly the requirements for an ideal filling material than any substance known. W hile this opinion may be taken as entirely personal, it is sub stantiated by the writings of foremost educators and practitioners o f the past and those of the present who are pro ficient in the use o f all the filling m ate rials common to present-day practice. T o disregard the qualities o f any of our fill ing materials that m ay make them most suitable for a given case is a short-sighted policy indeed. A ll filling materials have properties that recommend them for cer tain operations and, in the absence of an ideal filling material, we should employ them for these operations without
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prejudice and should develop the opera tive technical features that are peculiar to some and common to all of them. O perative dentistry has been sadly neg lected b y the profession at large during the past two decades. T h e tendency has been to center attention upon restoring lost teeth rather than lost tooth struc ture. It would seem that the highest at tainment of dentistry was the construc tion of large fixed and removable pieces to restore lost teeth that could have been saved by intelligent and skilled operative procedure at the inception of dental de cay or periodontal lesions. T h e use o f silicate cements has multi plied the indications for porcelain jacket crowns and fixed bridges in the anterior
Dentistry has more to offer humanity than the seemingly inevitable conditions just recited. W e have had at our com mand, to preserve the human teeth, for a period greater than our professional lifetime, materials and a technic for their employment, but in our almost uni versal desire to find an easy method to restore lost tooth structure, we have not made proper use o f these older materials,
Fig. 2.— Narrow occlusal step. Sufficient dentin remains to protect the horns of the pulp.
Fig. 1.— Buccal and lingual walls of proxi mal portion converging toward occlusal sur face.
part o f the mouth, and faulty technic and carelessness in the insertion of gold inlays have had much to do with the loss o f pulps in the posterior teeth, resulting in extractions and replacement with fixed and removable pieces in endless variety. In short, unwise or faulty operative pro cedures have forged all too often an un broken chain o f destruction, finally and prematurely resulting in the loss o f the teeth through pulp complications, perio dontoclasia and systemic disturbances. Dentures are constructed and the very thing that we had hoped to obviate has come to pass.
Fig. 3.— Black parallel lines indicating amount of tooth structure saved when gold foil filling is placed instead of inlay.
and operative dentistry has suffered thereby. Let me say, especially to those younger in the profession, that there is no easy method o f restoring lost tooth structure to the condition of permanency that we have a right to expect. The most cele
F er r ie r — U se brated operators of the past and present work with a diligence second to none in any vocation of life, eternally seeking improvement in their technic, with con cern about each and every operation. It is true that they do work with an ease that seems simplicity itself, gained by years o f experience in close application to d eta il; but make no m istake: there has been no royal road to the attainment of their technic and there has been no effort spared in attaining it. Gold inlays have suffered more from inefficiency than has gold foil. The inlay lends itself to a slovenly technic if the operator is so disposed. Some sort of a filling m ay be easily made from a wax pattern and, for a time, the cement will
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of the wax pattern and the final seating and finish of the inlay. T h ey are usually made of hard gold, which does not give the fine margins obtainable with alloys. If I have had any success with inlays, and I have used them since the inception of the casting process, it is largely due to the use of the rubber dam throughout the operation wherever possible, and the use of a casting gold not less than 23-K. fine for all inlays not subjected to great stress. Gold foil and gold inlays, having such distinct and separate indications, should not conflict. I realize that what m ay be an indication for the experienced op erator m ay not be an indication for one of less practice and skill. T o draw a
Fig. 4.— Cross-section of Class 2 cavity in bicuspid. The buccal and lingual walls are placed at an obtuse angle, not undercut to the axial wall. Figure 2 shows the retentive form.
fill in the discrepancies, and the unin formed patient has no reason to suspect that other than an excellent operation has been performed. But if the ultimate is sought in an inlay operation, as much time and effort must be expended as for the insertion o f gold foil. The results ob tained with a carefully made inlay where indicated fu lly justify any necessary amount of time and effort. Gold inlays have not had a fair chance with the m ajority o f the profession. They are more often than not made without the use of the rubber dam, which is es sential to cavity preparation, the forming
hard and fast line of distinction and to cover all closely overlapping indications is, of course, impossible. I prefer to use gold foil in all cavities of decay and erosion where the size and position of the cavity in the mouth and the age and temperament of the patient will permit. A n actual count of all filling operations made in my practice for a ten-year period showed that 44.9 per cent were made with gold foil. I desire to present here a type of den tal service that I practice in my own office, something suitable for most m e n ; a type not reserved for the few who are
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naturally talented, but applicable by all those who are willing to put forth the effort essential to do things worthily. It has no place in the hands o f indifferent practitioners. I shall consider the types o f cavities that are particularly suitable for goldfoil operations, with such variations from type as most often occur. class
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Class 2 cavities (Fig. i ) , especially in their incipiency, offer ideal situations for gold foil. T h e areas most susceptible to the recurrence o f decay are the linguo-
lingual cusps to form the embrasure, opening occlusally as well as lingually, call for a linguogingival angle that is sharply acute. This principle m ay be ap plied in a limited degree to the bucco gingival angle. (Fig. 2.) As the lingual and buccal walls approach the occlusal surface, they converge toward each other, forming a proximal cavity that is much narrower at the occlusal third than at the gingival third. This shape permits a narrow step across the occlusal surface that blends in fine proportion with the proximal portion o f the cavity. A cavity so outlined meets all the requirements of extension for prevention, and, when the interior is formed, fulfils all the essentials to convenience, retention and resistance.
Fig. 6.— Mesial surface lower first bicuspid Class 2 cavity; showing angulation of buccal and lingual walls. Fig. 5.— Sagittal section of upper bicuspid and Class 2 cavity. The unbroken lines at the gingival third indicate non-cohesive gold. The broken lines of the remaining two-thirds indi cate cohesive gold foil and the direction in which the layers are placed.
gingival and buccogingival angles of a Class 2 cavity and these angles m ay be extended well out into areas of im munity without a corresponding ex tension of the buccal and lingual walls as they approach the occlusal portion of the step. T he bicuspids and molars, hav ing a greater diameter buccolingually at the middle third than at the occlusal third, together with a rounding off at the
M uch tooth structure is saved by such a preparation; the horns of the pulp have greater protection, and the strength of the tooth is but slightly impaired. Thus, we suit our technic to the con ditions met with instead o f m aking the preparation suit our technic, as is neces sary in preparing a cavity for the with drawal of a w ax pattern. L et us assume that the operator is skilled in both tech nics, that he can, in a given case, make a good gold-foil filling or a good inlay. Is it not apparent that, in the interests of tooth conservation alone, he should use gold foil as his filling medium rather than
F er r ie r — U se a gold casting? Let us disregard for the moment the advantages of each as a m a terial for restoring lost tooth structure and consider only the tooth and as an organ not capable of regenerative proc esses, as are bone, muscle and the mucous membrane. L et us acknowledge that once any part o f it is lost, it can never be restored in kind, and that any restora tion in any material falls far short of the
Fig. 7.— Cross-section through lower first bicuspid. Retention is obtained by undercut ting the buccal and the lingual walls.
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The lingual wall converging toward the occlusal surface permits a narrow step, a strong lingual cusp and an immune linguogingival angle. Com pare this with the outline form o f an inlay preparation whose gingival wall has an equal buccolingual dimension, and note the tooth structure saved by the former. (Fig. 3.) The cavity shown in Figure 1 is sub ject to m any variations to suit the con ditions present, particularly the mesial surface of the lower first bicuspid. This
Fig. 9.— Ferrier separator adjusted to obtain necessary space; modeling compound used to stabilize instrument.
Fig. 10.— Occlusal view of Figure 8. O nly a small amount of gold is visible. Fig. 8.— Occlusal view of cavity with nar row gingival wall mesiodistally.
original. Is it not then apparent that the logical thing to do is to restore the lost part with as little sacrifice of the re maining structure as possible? The cavity shown in Figure 1 is a good ex ample o f conservative preparation. The buccal wall will scarcely be visible from any point of view, yet the buccogingival angle will be immune to further decay.
tooth resembles a cuspid whose cingulum has been overdeveloped. (Fig. 6.) Stress is exerted on the buccal cusp from the distal angle o f the upper cuspid when the jaw is moved in a lateral excursion. A gold-foil filling placed in the mesial sur face o f this tooth is subjected to no stress, and the preparation m ay be exceedingly conservative. In fact, we m ay here vio late a principle of cavity preparation that applies to all other Class 2 cav
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ities ; namely, that retention must be in the step or occlusal portion. Here, re tention m ay be entirely in the proximal portion of the cavity, as it has no step for retention and none is required. (Fig. 7.) T h e buccal and lingual walls con verge decidedly toward the occlusal sur face, because the tip o f the buccal cusp occupies a position at or near the center of the tooth and the cusp itself com prises four-fifths of the occlusal surface. T o cross the triangular ridge o f the buc cal cusp to form a step weakens the tooth and is not essential to the retention of the filling. Therefore, we undercut the buccal and lingual dentinal walls,
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ginning of cavity preparation, as we de sire only enough buccal extension to per mit a self-cleansing margin, and this minimum cannot be obtained without separation. By the time that the cavity is prepared, the spring of the separator has gained sufficient space in which to manipulate the foil with the assurance that a proper contact can be made with the distal surface of the cuspid. Three small cylinders of non-cohesive foil (usually about one-sixteenth o f a sheet o f gold each) are placed on the gingival wall in the manner that has been so often described in connection with typ ical Glass 2 cavities, and malleted securely to place. I f too much soft foil is used, the retention for the cohesive foil
Fig. 12.— Cavity form and filling of distal surface of upper cuspids. Fig. 11.— Cavity preparation for distal sur face of lower cuspid. The lingual wall is not extended on the lingual surface. Access to the cavity is obtained at the expense of the labial wall.
but not the enamel at the occlusal open ing of the cavity. This procedure, to gether with the convergence o f the buc cal and lingual walls toward the occlusal surface, affords ample retention. Figure 8 illustrates a small cavity, the gingival wall o f which is very narrow mesiodistally and which requires a care ful technic for insertion of foil. A separator is usually placed at the be
is reduced to an unsafe degree and care must be taken that the cylinders are not too large. Insertion of the cohesive foil is started with small pellets in the point angle formed by the buccal or lingual wall with the axial wall and the soft gold on the gingival wall, a holding instru ment being employed for stabilization until the cohesive foil is anchored. Suc cessive pieces o f gold are placed and con densed until the cavity is full and the filling contoured. Gold foil is capable of great wedging force, and more care must be used here than ordinarily to prevent fracture or undue strain on the under cut buccal and lingual walls. T h e fill
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ing is finished in the usual manner, the soft foil facilitating the finish o f the gin gival margin. (Figs. 7, 8, 9.) Cavities like the one shown in Figure 10 are of frequent occurrence in the bi cuspids o f young people. T h e technic that I describe is adaptable to nearly all of them. For meeting all the require ments of a filling operation, this is the most conservative method o f all that are employed on the proximal surfaces of teeth. T o those who make inlays for these cavities and who are most con cerned regarding the appearance of the teeth, let me recommend this small, in conspicuous example of the foil operator’s art.
harmony o f color— the principal objec tion to gold foil in Class 3 cavities, in so m any o f which gold foil m ay be used without being conspicuous that a good working knowledge o f the technic is de sirable if the best interests o f the patient are to be served. T h e preparations vary somewhat from the typical. T h e distal surfaces of lower cuspids are frequently involved by the decay adja cent to them in the mesial surface of lower first bicuspids just described. When these areas occur in pairs, the operation is much simplified as the cuspid m ay be restored after the cavity in the bicuspid is partially prepared and, with the aid of separation, free access to the diseased
Fig. 13.— C avity prepared in proximal sur face of lower incisor. Gold need not be visible.
Fig. 14.— T ypical Class 5 cavity. This form is subject to many variations to suit operative requirements.
Class 2 gold-foil fillings should not be placed where the size or position in the mouth puts an unreasonable strain on the patient or the operator. Where indi cated, they m ay be made with less loss o f tooth structure and are less conspicu ous and more in harmony with the form of the tooth. G LASS
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As this presentation is intended to com prise only those operations that are most applicable to general practice, none will be included that m ight be considered impractical in many cases because of in
area is attained. These cavities follow the typical Class 3 preparation and are made surprisingly small. Extension re quirements m ay be met without any appreciable showing o f gold and this showing only at an angle o f vision never revealing it in ordinary conversation. O f all the sins committed in the name of operative dentistry, the practice o f re m oving the m iddle third of the lingual wall o f the distal surface of a lower cuspid with a round bur and jamming therein a mass o f silicate cement that dogs not even extend to the labial surface,
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where a semblance of a m arginal finish m ay be made, is indeed the worst. Is there any wonder that there is a growing concern among m any operators as to the failure of operative dentistry to live up to its responsibilities? Cavities in the distal surfaces o f lower cuspids m ay occur where the mesial sur face o f the first bicuspid is not involved or where there has formerly been placed a good filling that should not be removed. In this situation, it frequently is advis able to make a preparation that varies from type. T h e approach is gained at the expense o f the labial wall, which is cut well out to give access to the linguogingival angle and the incisal angle. (Fig. i i . ) T he lingual wall is left standing
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time, and, in such a situation, a Class 4 inlay is indicated. Foil will serve us well, and better than anything else, if we con fine it to its indications, but we must not expect too much, and continual wear and stress on a thin angle will soon prove its undoing. Class 3 cavities in the distal surfaces of upper cuspids have long been consid ered most difficult to restore and many types o f preparation have been devised. I f the cavity has not been treated with cement in the ridiculous manner just de scribed for lower cuspids, a cavity form m ay be made that offers no unusual diffi culties. T h e distal angle is removed suffi ciently to allow an accessible and ade quate incisal anchorage so that gold m ay
Fig. 15.— Ferrier cervical clamp, adjusted with modeling compound for support.
wherever possible, as its removal in creases the difficulties o f placing the gold and weakens the incisal angle, which is subjected to m uch stress and wear. By mechanical separation, access is gained so that a lingual margin barely visible through the lingual embrasure is ob tained. Such fillings are visible only when observed at right angles to the tooth and this line o f vision is rarely taken. All too often, we find decay upon the distal surface o f lower cuspids where the distal angle o f the tooth has been worn down to a point level with the marginal ridge o f the first bicuspid. Gold foil can not be well retained for any length of
be placed with the proper line of force. T he cavity is boxlike in its entirety, with a slight incline o f the strong gingival wall toward the axial wall to obtain all the retention possible. T h e linguogingival shoulder that I have described in former papers here frequently becomes a definite angle into which foil m ay be condensed with a direct line of force. T h e tooth has a strong root and will tolerate a wellcondensed filling. In finishing the opera tion, the incisal angle is well sloped to prevent any direct stress in mastication. (Fig. 12.) There is but one choice of material in this situation and that is gold foil. I have used it in this cavity prep aration for nearly twenty-five years and
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I have had just that m any years o f satis faction in treating a troublesome area of decay, in a common sense manner, re duced to simplicity by virtue of the cav ity form. There is an area o f decay that calls for a Class 3 preparation varying from type, one that occurs with less frequency than in any other proximal surface of the teeth— the cavity in the proximal surface of the lower incisor. (Fig. 13.) These areas are usually immune to de cay, and cavity forms should be made with this in mind. The teeth are small and require areas o f preparation in keeping with their size. T h e incisal angles must be safeguarded at the ex-
believe that much liberty can be taken with the outline form o f cavity in these teeth because o f the general immunity that they enjoy. T h ey are easily sepa rated and readily accessible in placing foil in any part of the cavity. Cements of any kind have no place in the lower anterior teeth, with the possible excep tion o f the case of very young people. Something enduring is essential. T h e teeth are so small that not m any renew als can be m ade without loss o f the angle or the pulp or both. I f they could not be made inconspicuous when op erated on at the beginning of decay, I would not include them here, as I am striving to show the wide use to which
Fig. 16.— Non-cohesive gold used to line the peripheral walls. T he flattened cylinder, placed diagonally, is forced gingivally to lock the mesial and distal cylinders. The incisal wall is covered in like manner. The remainder of the filling is made with cohesive gold.
Fig. 17.— Finished gingival third gold foil filling. T he gum tissue covers the gingival and most of the mesial and distal margins, the outline of the filling then being in harmony with its surroundings.
pense of all else, as, once the angle is lost, it is impossible to restore it esthetically. Fortunately, we m ay consider the point where it is safe to lay the incisal angle of the cavity within an immune area. T h e lingual wall is left standing to further strengthen the incisal angle and the linguocavosurface angle is also in areas of immunity. T h e cavity form here shown m ay be reduced in size to a point where it can scarcely be seen. I
gold foil can be placed, eliminating en tirely its principal objectional feature, lack o f color harmony. In teeth that have decayed to the point where gold is objectionable to the patient because of its color, porcelain inlays are indi cated. T h e septal tissue is full and much o f the filling is covered interproximally, and a healthy gum tissue cannot be maintained under these conditions with cement fillings o f any kind.
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small percentage of those that occur. Foil The cavity form for Class 5 cavities m ay be placed at one appointment and shown in Figure 14, with slight modifi the clamp adjusted but o n ce; and ad cations to suit individual tastes and with just it you must, or the gingival margin such variations as conditions warrant, will never be finished as it should be, seems to be meeting with widespread regardless of what filling material may approval. I have had the satisfaction be used. The gum tissue takes more o f seeing the technic that has been pre kindly to a gold foil margin than any sented on a number of occasions adopted other, largely because it is capable of b y men high in the profession. T h e suc such a high finish. Long clinical ob cess o f the operation does not lie in the servation on all types of filling materials use o f the specially designed clamp, as substantiates this view, and, for the fore I designed the clamp only six years ago. going reasons alone, I cannot see how there can be any question as to the It is a helpful instrument and the best filling material most desirable. that I have to date, but is not essential In presenting this paper an attempt to a good Class 5 gold foil operation. has been made to show that gold foil O ther clamps serve well, and some kind o f clamp is indispensable. As the proper m ay have a wide use in the general prac use o f clamps became known, the prac tice of dentistry. A ll fillings m ay be tice o f cutting away the gum tissue for made with less sacrifice of tooth struc ture than in preparations for inlays in such a simple procedure as the placing similar positions and, in some cases in and finishing o f gold foil in gingival cavities was abandoned. I have never lays should not be placed at all. A n found it necessary to cut away gum tis attempt has been made to place gold sue in this type o f cavity, not in one foil and the gold inlay each in its proper single instance. T h e technic, which is place, uninfluenced by enthusiasm for fairly well known, is fully portrayed in one or prejudice against the other. W e are fortunate in having both methods Figures 15 to 17. M y purpose is to show that there need of tooth restoration. A combination of circumstances and be no conflict in the use o f gold foil and gold inlays in these cavities o f decay and events has during the past decade done erosion. Gold foil is always indicated much to revive interest in the gold foil filling among large groups in various unless the cavity is so large that the sections of the country. This is highly vitality of the tooth will be endangered from the trauma o f excessive malleting. gratifying to one who has spent the major efforts of a professional lifetime in There are inaccessible places in the trying to perfect a technic that would be mouth where gold foil cannot be used applicable to the practices of most men. and something else must be substituted. These cases, however, constitute but a 1329 M edical & Dental Building. c l a ss
c a v it ie s
F e r r ie r — U s e o f G o l d F o il B l a i r , V . P.; B r o w n , J. B ., and M o o r e , S h e r w o o d : Osteomyelitis of Jaw. M issouri
M . J.,
27:173, April 1930.
B l a i r , V . P .; P a d g e t t , E. C ., and B r o w n , J. B . : Diseases of Face, Mouth and Jaws; in G r a h a m , E. A .: Surgical Diagnosis. Philadel phia: W . B . Saunders Co., 1930. B o n n e r , H . : Osteomyelitis of Jaws in In
fants. Beitr. z. K lin . C h it., 133:163-183, 1925. H a d e n , R. L . : Dental Infections and Sys temic Disease. Philadelphia: Lea and Febiger, 1928. L e ib o l d , H . H .: Journal-Lancet, 4 5 : 113, M arch 1, 1925. O ’K e l l , C. C ., and E l l i o t t , S. D .: Bac teremia and O ral Sepsis. La ncet, 2:869-872,
P a d g e t t , E. C .: Surgical Diseases of Mouth and Jaws. Philadelphia: W . B. Saunders Co.,
1938 .
W il e n s k y ,
A. O .: Osteomyelitis of Jaw.
A rch . Surg., 25:183, July 1932. Osteomyelitis of Jaws in Nurslings and Infants. A n n. Surg.,
95:33, January 1932. Association of Osteo myelitis of Skull and Nasal Accessory Sinus Diseases. A rch . Otolaryng., 15 ¡805, June 1932. Z a r fl,
M .:
Ztschr. f. K in d erh., 2 5 : 266 ,
June 1920. R o s e n o w , E. C .; G i l m e r , T. L., and M o o d y : Quoted by B l a ir , V . P.; P a d g e t t , E. C ., and B r o w n , J. B .: Diseases of Face, Mouth, and Jaws, in G r a h a m , E. A .: Surgical Diagnosis. Philadelphia: W . B. Saunders Co.,
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1316 Professional Bldg.
1935-
USE OF GOLD FOIL IN GENERAL PRACTICE By W. L .
F errier,
D .M .D ., Seattle, Wash.
H E R E have been, in the past, m any discussions as to the relative merits of gold foil and gold inlay opera tions. Differences of opinion have formed the basis for debate before dental associations by enthusiastic advocates of each method of restoring lost tooth struc ture. T he participants in these debates were usually those who advocated and used gold inlays, without knowledge or training in gold-foil technic, on the one side, and those who were trained in the technic o f gold-foil operating and also gold-inlay technic on the opposing side. These discussions were one-sided affairs, as it is obvious that one skilled in the use of gold foil as well as gold inlays was better qualified to judge their relative merits. M any operators use no foil what soever, while most operators who use foil use inlays wherever indicated; for each
T
R ead before the Section on Operative Den tistry, M ateria M edica and Therapeutics at the Eighty-Second Annual Meeting of the American Dental Association, Cleveland, Ohio, September 11, 1940.
Jour. A.D.A., Vol. 28, May 1941
has separate and distinct indications, and there need be no conflict in choice be tween gold foil and gold inlays, generally speaking, and there is none in the prac tices of those who are sufficiently ver satile to make creditable operations by either method. I am convinced from long experience with all methods and materials that gold foil fulfils more nearly the requirements for an ideal filling material than any substance known. W hile this opinion may be taken as entirely personal, it is sub stantiated by the writings of foremost educators and practitioners o f the past and those of the present who are pro ficient in the use o f all the filling m ate rials common to present-day practice. T o disregard the qualities o f any of our fill ing materials that m ay make them most suitable for a given case is a short-sighted policy indeed. A ll filling materials have properties that recommend them for cer tain operations and, in the absence of an ideal filling material, we should employ them for these operations without
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prejudice and should develop the opera tive technical features that are peculiar to some and common to all of them. O perative dentistry has been sadly neg lected b y the profession at large during the past two decades. T h e tendency has been to center attention upon restoring lost teeth rather than lost tooth struc ture. It would seem that the highest at tainment of dentistry was the construc tion of large fixed and removable pieces to restore lost teeth that could have been saved by intelligent and skilled operative procedure at the inception of dental de cay or periodontal lesions. T h e use o f silicate cements has multi plied the indications for porcelain jacket crowns and fixed bridges in the anterior
Dentistry has more to offer humanity than the seemingly inevitable conditions just recited. W e have had at our com mand, to preserve the human teeth, for a period greater than our professional lifetime, materials and a technic for their employment, but in our almost uni versal desire to find an easy method to restore lost tooth structure, we have not made proper use o f these older materials,
Fig. 2.— Narrow occlusal step. Sufficient dentin remains to protect the horns of the pulp.
Fig. 1.— Buccal and lingual walls of proxi mal portion converging toward occlusal sur face.
part o f the mouth, and faulty technic and carelessness in the insertion of gold inlays have had much to do with the loss o f pulps in the posterior teeth, resulting in extractions and replacement with fixed and removable pieces in endless variety. In short, unwise or faulty operative pro cedures have forged all too often an un broken chain o f destruction, finally and prematurely resulting in the loss o f the teeth through pulp complications, perio dontoclasia and systemic disturbances. Dentures are constructed and the very thing that we had hoped to obviate has come to pass.
Fig. 3.— Black parallel lines indicating amount of tooth structure saved when gold foil filling is placed instead of inlay.
and operative dentistry has suffered thereby. Let me say, especially to those younger in the profession, that there is no easy method o f restoring lost tooth structure to the condition of permanency that we have a right to expect. The most cele
F er r ie r — U se brated operators of the past and present work with a diligence second to none in any vocation of life, eternally seeking improvement in their technic, with con cern about each and every operation. It is true that they do work with an ease that seems simplicity itself, gained by years o f experience in close application to d eta il; but make no m istake: there has been no royal road to the attainment of their technic and there has been no effort spared in attaining it. Gold inlays have suffered more from inefficiency than has gold foil. The inlay lends itself to a slovenly technic if the operator is so disposed. Some sort of a filling m ay be easily made from a wax pattern and, for a time, the cement will
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of the wax pattern and the final seating and finish of the inlay. T h ey are usually made of hard gold, which does not give the fine margins obtainable with alloys. If I have had any success with inlays, and I have used them since the inception of the casting process, it is largely due to the use of the rubber dam throughout the operation wherever possible, and the use of a casting gold not less than 23-K. fine for all inlays not subjected to great stress. Gold foil and gold inlays, having such distinct and separate indications, should not conflict. I realize that what m ay be an indication for the experienced op erator m ay not be an indication for one of less practice and skill. T o draw a
Fig. 4.— Cross-section of Class 2 cavity in bicuspid. The buccal and lingual walls are placed at an obtuse angle, not undercut to the axial wall. Figure 2 shows the retentive form.
fill in the discrepancies, and the unin formed patient has no reason to suspect that other than an excellent operation has been performed. But if the ultimate is sought in an inlay operation, as much time and effort must be expended as for the insertion o f gold foil. The results ob tained with a carefully made inlay where indicated fu lly justify any necessary amount of time and effort. Gold inlays have not had a fair chance with the m ajority o f the profession. They are more often than not made without the use of the rubber dam, which is es sential to cavity preparation, the forming
hard and fast line of distinction and to cover all closely overlapping indications is, of course, impossible. I prefer to use gold foil in all cavities of decay and erosion where the size and position of the cavity in the mouth and the age and temperament of the patient will permit. A n actual count of all filling operations made in my practice for a ten-year period showed that 44.9 per cent were made with gold foil. I desire to present here a type of den tal service that I practice in my own office, something suitable for most m e n ; a type not reserved for the few who are
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naturally talented, but applicable by all those who are willing to put forth the effort essential to do things worthily. It has no place in the hands o f indifferent practitioners. I shall consider the types o f cavities that are particularly suitable for goldfoil operations, with such variations from type as most often occur. class
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Class 2 cavities (Fig. i ) , especially in their incipiency, offer ideal situations for gold foil. T h e areas most susceptible to the recurrence o f decay are the linguo-
lingual cusps to form the embrasure, opening occlusally as well as lingually, call for a linguogingival angle that is sharply acute. This principle m ay be ap plied in a limited degree to the bucco gingival angle. (Fig. 2.) As the lingual and buccal walls approach the occlusal surface, they converge toward each other, forming a proximal cavity that is much narrower at the occlusal third than at the gingival third. This shape permits a narrow step across the occlusal surface that blends in fine proportion with the proximal portion o f the cavity. A cavity so outlined meets all the requirements of extension for prevention, and, when the interior is formed, fulfils all the essentials to convenience, retention and resistance.
Fig. 6.— Mesial surface lower first bicuspid Class 2 cavity; showing angulation of buccal and lingual walls. Fig. 5.— Sagittal section of upper bicuspid and Class 2 cavity. The unbroken lines at the gingival third indicate non-cohesive gold. The broken lines of the remaining two-thirds indi cate cohesive gold foil and the direction in which the layers are placed.
gingival and buccogingival angles of a Class 2 cavity and these angles m ay be extended well out into areas of im munity without a corresponding ex tension of the buccal and lingual walls as they approach the occlusal portion of the step. T he bicuspids and molars, hav ing a greater diameter buccolingually at the middle third than at the occlusal third, together with a rounding off at the
M uch tooth structure is saved by such a preparation; the horns of the pulp have greater protection, and the strength of the tooth is but slightly impaired. Thus, we suit our technic to the con ditions met with instead o f m aking the preparation suit our technic, as is neces sary in preparing a cavity for the with drawal of a w ax pattern. L et us assume that the operator is skilled in both tech nics, that he can, in a given case, make a good gold-foil filling or a good inlay. Is it not apparent that, in the interests of tooth conservation alone, he should use gold foil as his filling medium rather than
F er r ie r — U se a gold casting? Let us disregard for the moment the advantages of each as a m a terial for restoring lost tooth structure and consider only the tooth and as an organ not capable of regenerative proc esses, as are bone, muscle and the mucous membrane. L et us acknowledge that once any part o f it is lost, it can never be restored in kind, and that any restora tion in any material falls far short of the
Fig. 7.— Cross-section through lower first bicuspid. Retention is obtained by undercut ting the buccal and the lingual walls.
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The lingual wall converging toward the occlusal surface permits a narrow step, a strong lingual cusp and an immune linguogingival angle. Com pare this with the outline form o f an inlay preparation whose gingival wall has an equal buccolingual dimension, and note the tooth structure saved by the former. (Fig. 3.) The cavity shown in Figure 1 is sub ject to m any variations to suit the con ditions present, particularly the mesial surface of the lower first bicuspid. This
Fig. 9.— Ferrier separator adjusted to obtain necessary space; modeling compound used to stabilize instrument.
Fig. 10.— Occlusal view of Figure 8. O nly a small amount of gold is visible. Fig. 8.— Occlusal view of cavity with nar row gingival wall mesiodistally.
original. Is it not then apparent that the logical thing to do is to restore the lost part with as little sacrifice of the re maining structure as possible? The cavity shown in Figure 1 is a good ex ample o f conservative preparation. The buccal wall will scarcely be visible from any point of view, yet the buccogingival angle will be immune to further decay.
tooth resembles a cuspid whose cingulum has been overdeveloped. (Fig. 6.) Stress is exerted on the buccal cusp from the distal angle o f the upper cuspid when the jaw is moved in a lateral excursion. A gold-foil filling placed in the mesial sur face o f this tooth is subjected to no stress, and the preparation m ay be exceedingly conservative. In fact, we m ay here vio late a principle of cavity preparation that applies to all other Class 2 cav
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ities ; namely, that retention must be in the step or occlusal portion. Here, re tention m ay be entirely in the proximal portion of the cavity, as it has no step for retention and none is required. (Fig. 7.) T h e buccal and lingual walls con verge decidedly toward the occlusal sur face, because the tip o f the buccal cusp occupies a position at or near the center of the tooth and the cusp itself com prises four-fifths of the occlusal surface. T o cross the triangular ridge o f the buc cal cusp to form a step weakens the tooth and is not essential to the retention of the filling. Therefore, we undercut the buccal and lingual dentinal walls,
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ginning of cavity preparation, as we de sire only enough buccal extension to per mit a self-cleansing margin, and this minimum cannot be obtained without separation. By the time that the cavity is prepared, the spring of the separator has gained sufficient space in which to manipulate the foil with the assurance that a proper contact can be made with the distal surface of the cuspid. Three small cylinders of non-cohesive foil (usually about one-sixteenth o f a sheet o f gold each) are placed on the gingival wall in the manner that has been so often described in connection with typ ical Glass 2 cavities, and malleted securely to place. I f too much soft foil is used, the retention for the cohesive foil
Fig. 12.— Cavity form and filling of distal surface of upper cuspids. Fig. 11.— Cavity preparation for distal sur face of lower cuspid. The lingual wall is not extended on the lingual surface. Access to the cavity is obtained at the expense of the labial wall.
but not the enamel at the occlusal open ing of the cavity. This procedure, to gether with the convergence o f the buc cal and lingual walls toward the occlusal surface, affords ample retention. Figure 8 illustrates a small cavity, the gingival wall o f which is very narrow mesiodistally and which requires a care ful technic for insertion of foil. A separator is usually placed at the be
is reduced to an unsafe degree and care must be taken that the cylinders are not too large. Insertion of the cohesive foil is started with small pellets in the point angle formed by the buccal or lingual wall with the axial wall and the soft gold on the gingival wall, a holding instru ment being employed for stabilization until the cohesive foil is anchored. Suc cessive pieces o f gold are placed and con densed until the cavity is full and the filling contoured. Gold foil is capable of great wedging force, and more care must be used here than ordinarily to prevent fracture or undue strain on the under cut buccal and lingual walls. T h e fill
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ing is finished in the usual manner, the soft foil facilitating the finish o f the gin gival margin. (Figs. 7, 8, 9.) Cavities like the one shown in Figure 10 are of frequent occurrence in the bi cuspids o f young people. T h e technic that I describe is adaptable to nearly all of them. For meeting all the require ments of a filling operation, this is the most conservative method o f all that are employed on the proximal surfaces of teeth. T o those who make inlays for these cavities and who are most con cerned regarding the appearance of the teeth, let me recommend this small, in conspicuous example of the foil operator’s art.
harmony o f color— the principal objec tion to gold foil in Class 3 cavities, in so m any o f which gold foil m ay be used without being conspicuous that a good working knowledge o f the technic is de sirable if the best interests o f the patient are to be served. T h e preparations vary somewhat from the typical. T h e distal surfaces of lower cuspids are frequently involved by the decay adja cent to them in the mesial surface of lower first bicuspids just described. When these areas occur in pairs, the operation is much simplified as the cuspid m ay be restored after the cavity in the bicuspid is partially prepared and, with the aid of separation, free access to the diseased
Fig. 13.— C avity prepared in proximal sur face of lower incisor. Gold need not be visible.
Fig. 14.— T ypical Class 5 cavity. This form is subject to many variations to suit operative requirements.
Class 2 gold-foil fillings should not be placed where the size or position in the mouth puts an unreasonable strain on the patient or the operator. Where indi cated, they m ay be made with less loss o f tooth structure and are less conspicu ous and more in harmony with the form of the tooth. G LASS
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As this presentation is intended to com prise only those operations that are most applicable to general practice, none will be included that m ight be considered impractical in many cases because of in
area is attained. These cavities follow the typical Class 3 preparation and are made surprisingly small. Extension re quirements m ay be met without any appreciable showing o f gold and this showing only at an angle o f vision never revealing it in ordinary conversation. O f all the sins committed in the name of operative dentistry, the practice o f re m oving the m iddle third of the lingual wall o f the distal surface of a lower cuspid with a round bur and jamming therein a mass o f silicate cement that dogs not even extend to the labial surface,
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where a semblance of a m arginal finish m ay be made, is indeed the worst. Is there any wonder that there is a growing concern among m any operators as to the failure of operative dentistry to live up to its responsibilities? Cavities in the distal surfaces o f lower cuspids m ay occur where the mesial sur face o f the first bicuspid is not involved or where there has formerly been placed a good filling that should not be removed. In this situation, it frequently is advis able to make a preparation that varies from type. T h e approach is gained at the expense o f the labial wall, which is cut well out to give access to the linguogingival angle and the incisal angle. (Fig. i i . ) T he lingual wall is left standing
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time, and, in such a situation, a Class 4 inlay is indicated. Foil will serve us well, and better than anything else, if we con fine it to its indications, but we must not expect too much, and continual wear and stress on a thin angle will soon prove its undoing. Class 3 cavities in the distal surfaces of upper cuspids have long been consid ered most difficult to restore and many types o f preparation have been devised. I f the cavity has not been treated with cement in the ridiculous manner just de scribed for lower cuspids, a cavity form m ay be made that offers no unusual diffi culties. T h e distal angle is removed suffi ciently to allow an accessible and ade quate incisal anchorage so that gold m ay
Fig. 15.— Ferrier cervical clamp, adjusted with modeling compound for support.
wherever possible, as its removal in creases the difficulties o f placing the gold and weakens the incisal angle, which is subjected to m uch stress and wear. By mechanical separation, access is gained so that a lingual margin barely visible through the lingual embrasure is ob tained. Such fillings are visible only when observed at right angles to the tooth and this line o f vision is rarely taken. All too often, we find decay upon the distal surface o f lower cuspids where the distal angle o f the tooth has been worn down to a point level with the marginal ridge o f the first bicuspid. Gold foil can not be well retained for any length of
be placed with the proper line of force. T he cavity is boxlike in its entirety, with a slight incline o f the strong gingival wall toward the axial wall to obtain all the retention possible. T h e linguogingival shoulder that I have described in former papers here frequently becomes a definite angle into which foil m ay be condensed with a direct line of force. T h e tooth has a strong root and will tolerate a wellcondensed filling. In finishing the opera tion, the incisal angle is well sloped to prevent any direct stress in mastication. (Fig. 12.) There is but one choice of material in this situation and that is gold foil. I have used it in this cavity prep aration for nearly twenty-five years and
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I have had just that m any years o f satis faction in treating a troublesome area of decay, in a common sense manner, re duced to simplicity by virtue of the cav ity form. There is an area o f decay that calls for a Class 3 preparation varying from type, one that occurs with less frequency than in any other proximal surface of the teeth— the cavity in the proximal surface of the lower incisor. (Fig. 13.) These areas are usually immune to de cay, and cavity forms should be made with this in mind. The teeth are small and require areas o f preparation in keeping with their size. T h e incisal angles must be safeguarded at the ex-
believe that much liberty can be taken with the outline form o f cavity in these teeth because o f the general immunity that they enjoy. T h ey are easily sepa rated and readily accessible in placing foil in any part of the cavity. Cements of any kind have no place in the lower anterior teeth, with the possible excep tion o f the case of very young people. Something enduring is essential. T h e teeth are so small that not m any renew als can be m ade without loss o f the angle or the pulp or both. I f they could not be made inconspicuous when op erated on at the beginning of decay, I would not include them here, as I am striving to show the wide use to which
Fig. 16.— Non-cohesive gold used to line the peripheral walls. T he flattened cylinder, placed diagonally, is forced gingivally to lock the mesial and distal cylinders. The incisal wall is covered in like manner. The remainder of the filling is made with cohesive gold.
Fig. 17.— Finished gingival third gold foil filling. T he gum tissue covers the gingival and most of the mesial and distal margins, the outline of the filling then being in harmony with its surroundings.
pense of all else, as, once the angle is lost, it is impossible to restore it esthetically. Fortunately, we m ay consider the point where it is safe to lay the incisal angle of the cavity within an immune area. T h e lingual wall is left standing to further strengthen the incisal angle and the linguocavosurface angle is also in areas of immunity. T h e cavity form here shown m ay be reduced in size to a point where it can scarcely be seen. I
gold foil can be placed, eliminating en tirely its principal objectional feature, lack o f color harmony. In teeth that have decayed to the point where gold is objectionable to the patient because of its color, porcelain inlays are indi cated. T h e septal tissue is full and much o f the filling is covered interproximally, and a healthy gum tissue cannot be maintained under these conditions with cement fillings o f any kind.
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small percentage of those that occur. Foil The cavity form for Class 5 cavities m ay be placed at one appointment and shown in Figure 14, with slight modifi the clamp adjusted but o n ce; and ad cations to suit individual tastes and with just it you must, or the gingival margin such variations as conditions warrant, will never be finished as it should be, seems to be meeting with widespread regardless of what filling material may approval. I have had the satisfaction be used. The gum tissue takes more o f seeing the technic that has been pre kindly to a gold foil margin than any sented on a number of occasions adopted other, largely because it is capable of b y men high in the profession. T h e suc such a high finish. Long clinical ob cess o f the operation does not lie in the servation on all types of filling materials use o f the specially designed clamp, as substantiates this view, and, for the fore I designed the clamp only six years ago. going reasons alone, I cannot see how there can be any question as to the It is a helpful instrument and the best filling material most desirable. that I have to date, but is not essential In presenting this paper an attempt to a good Class 5 gold foil operation. has been made to show that gold foil O ther clamps serve well, and some kind o f clamp is indispensable. As the proper m ay have a wide use in the general prac use o f clamps became known, the prac tice of dentistry. A ll fillings m ay be tice o f cutting away the gum tissue for made with less sacrifice of tooth struc ture than in preparations for inlays in such a simple procedure as the placing similar positions and, in some cases in and finishing o f gold foil in gingival cavities was abandoned. I have never lays should not be placed at all. A n found it necessary to cut away gum tis attempt has been made to place gold sue in this type o f cavity, not in one foil and the gold inlay each in its proper single instance. T h e technic, which is place, uninfluenced by enthusiasm for fairly well known, is fully portrayed in one or prejudice against the other. W e are fortunate in having both methods Figures 15 to 17. M y purpose is to show that there need of tooth restoration. A combination of circumstances and be no conflict in the use o f gold foil and gold inlays in these cavities o f decay and events has during the past decade done erosion. Gold foil is always indicated much to revive interest in the gold foil filling among large groups in various unless the cavity is so large that the sections of the country. This is highly vitality of the tooth will be endangered from the trauma o f excessive malleting. gratifying to one who has spent the major efforts of a professional lifetime in There are inaccessible places in the trying to perfect a technic that would be mouth where gold foil cannot be used applicable to the practices of most men. and something else must be substituted. These cases, however, constitute but a 1329 M edical & Dental Building. c l a ss
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