OPERATIVE DENTISTRY, 1976, 1, 1, 7-11.
GOLD FOIL IN TODAY'S PRACTICE
Gerald D. Stibbs, B.S., D.M.D
of Restorative Dentistry SM-56,
Dr. Stibbs is professor of restorative dentistry at the University of Washington, where formerly he has been chairman of the Department of Operative Dentistry and chairman of the Department of Fixed Partial Dentures, director of the dental operatory and clinical coordinator. He is a charter member, past president, and past secretary of the American Academy of Gold Foil Operators, past president of the British Columbia Dental Association and of the Vancouver (B.C.) Dental Society and instructor of three gold foil study clubs—the George Ellsperman Gold Foil Seminar, the Vancouver Ferrier Study Club, and the Walter K. Sproule Study Club. He also has a part-time private practice.
Renewed interest in prevention and conservative therapy emphasizes the need for gold foil.
What is the status of the direct golds in restorative dentistry today? For many years gold foil has been placed on either the highest or the lowest rung of the ladder in our list of restorative materials, depending on one's indoctrination, training, or experience with it, and on whether one is a student, a candidate for a state board examination, or a member of a foil study club.
Operative dentists may be grouped into three categories in respect to the use of direct golds. Some, because their practices are limited to other phases of dental service or because they harbor a deep-seated aversion to foil, do not use it at all. Others, while acknowledging the merits of these restorations, use them only occasionally, due to habit, because of pressures of practice, or because their training in foil was deficient and they have an anxiety regarding the material. Finally, there are those who use the direct golds enthusiastically where indicated.
With space and time limited, it is unlikely that the unbelievers can be changed, and the active users are as knowledgeable on the subject as is the author. The most fertile ground is with those who earnestly want more information and are wondering just how satisfactory the direct golds are today as a restorative medium and how to acquire a comfortable, effective technique in their use.
Why Gold Foil Is Important
One reason foil is avoided by many is that it lends itself admirably to being a testing medium in schools and on State Board examinations, since in just one operative appointment an examiner can observe a broad spectrum of an examinee's appreciation of and consideration for tissues, technical knowledge, and clinical competence. With other so-called permanent restorative procedures, at least two clinical appointments are required for the one taking the test to cover the same ground. Consequently, most of our State Boards require a direct gold restoration as part of the clinical examination. This makes life difficult for candidates if their alma mater did not teach the procedure with enthusiasm or competence. It would be so much better if students were taught the use of foil as a prime restorative procedure, which it is, rather than as an unpalatable discipline. Then it would be just one of the familiar facets of their operative repertoire instead of a strange and frightening testing device.
Dentistry and the public are presently riding an encouraging wave of enthusiasm for "preventive dentistry." A preponderance of the attention is being given to preventing the incidence of dental caries and, of course, prevention is of vital importance. However, we must
not forget that prevention must include even more. Since carious lesions still do develop, it is important that (1) we halt their progress with the best possible restorative therapy as early as possible (see Fig. 1); (2) we should be conservative in respect to cavity preparation, pulp protection, producing esthetic restorations, and meeting biomechanical requirements; (3) we should have an increasing concern regarding the trend to accept short-lived service just because it is easier or faster or because the insurance carrier will pay for the replacements.
A few enthusiasts for preventive dentistry seem to be under the impression that the reduction in the incidence of caries will make gold foil unnecessary or obsolete as a restorative medium. Yet the opposite is actually the case. It is not expected that caries will be eliminated completely in the foreseeable future. Earlier care of dental needs will control the large, complex lesions—which were never indications for direct gold therapy. But as "only one or two cavities at this check-up" are detected, being minimal in extent, increasingly they will be prime indications for control by the most conservative and most permanent means available, and that is still gold foil. Thus it would seem that progressive schools should ensure competency in the manipulative techniques for its use by their graduates.
Interestingly enough, when gold foil is used to control defective grooves or pits in primary teeth, young patients are unusually enthusiastic. They display the new acquisition to their friends and schoolmates with delight and pride, and are great boosters for continued preventive dental service.
Specific Indications for Gold Foil
Gold foil, or one of the other direct golds, is without peer in meeting the requirements of permanent, conservative, esthetic restorations in a number of areas exhibiting incipient lesions (Figs. 2, 3, 4). Principal indications for use include defective pits and fissures, erosion, abrasion, or caries in the gingival third of clinical crowns, small proximal lesions in anterior teeth—maxillary and mandibular—and in first bicuspids (Fig. 5). One of the most rewarding uses for foil is to restore the distal surface of cuspids and thus preserve the mesiodistal dimension of the arch (Fig. 6). A highly useful indication and an easy operation is the
restoration of cusp tips exhibiting wear through the enamel and cupping of the dentin (Fig. 7). Another excellent use for direct golds is in extending the margin of an existing cast restoration. For example, a complete cast crown may be quite satisfactory, but recession of the gingiva has exposed a portion of the gingival margin and caries is beginning there. Gold foil will extend the service of the cast crown conservatively and esthetically (Fig. 8). If wear by an opposing tooth creates a hole in a cast crown or inlay, the entire restoration need not be replaced—the area of failure may be restored with a small repair of direct gold.
On the other hand, direct gold restorations can be disastrous if there is poor case selection, or if the operating technique in cavity preparation, material manipulation, or finishing procedure is improper or inadequate. Examples of improper case selection would be lesions that are too large, too conspicuous, or too inaccessible, or where the patient's attitude, general or oral health are contraindications. It must be recognized that these materials do require more knowledge and expertise from the operator than can be gained from a "once over lightly" exposure to the technique. It is not enough to read about it in a book, watch one film or one clinical demonstration. As with any worthwhile skill, practice and a real desire and effort to do well are essential. Just because a restoration is direct gold, the tooth has not necessarily received a superior service. A poor or mediocre gold foil is perhaps one of the worst restorations our patients can receive.
If we are going to offer this refined, preventive restorative service to our patients, there are some definite requisites. The first essential is a proper field, one that is clean and dry (Fig. 9). A simple dam application, one that is effective and comfortable, that improves rather than impairs visibility and accessibility, provides the best means available. At present, many more practitioners use the rubber dam than was the case a few years ago. While a dry field is obtainable with some of the current holding devices, operators who work with direct gold freely tend to favor a holding device
which will keep the edges of the dam out of the way and which will retract and support the lips and cheeks. Such a holder also permits use of a comfortable absorbent face mask between the face and the dam and keeps the patient more comfortable.
In Class V’s, the field attained with the rubber dam needs to be supplemented by a suitable retractor, and in many Class III’s by a suitable separator (Fig. 10). The technic of applying and stabilizing these instruments needs to be performed carefully and well, with
the welfare of the teeth and the supporting tissues in mind.
Another requirement is a set of good cutting instruments, hand and rotary, in top condition. As you are aware, we are faced with a problem of quality control of instruments and supplies due to the current increase of manufacturers that are not dentally oriented. To perform restorative procedures expeditiously and well, instruments must have sound specifications; then we must insist on them being made to those specifications. A vigilant eye is essential or we will find it more and more difficult to perform our work properly.
Next, there must be a good cavity preparation that satisfies the requirements laid down so long ago by G. V. Black. There is justifiable interest at present in minimal display of metal in restorations, so preparations are increasingly conservative in outline. Care must be taken, however, not to carry esthetics to such an extreme as to sacrifice extension for prevention of recurrence of caries, or adequate convenience for insertion of gold.
As to the gold used, several forms are now available: foil in pellet, rope, sheet, or laminated form; mat; powdered gold; alloyed filling gold; or combinations of these. Each requires a specific technic if optimum results are to be achieved. In recent years fine research has been done with the material in its various forms. The reports of Hollenback, Hodson, Baum, Welk, G. Smith, Zhonga, Cantwell, and their co-workers, and others are well worth your attention.
Next, suitable means of preparing and compacting or condensing the gold are essential. Aside from a means of annealing or purifying the gold and conveying it to the preparation, these range from hand condensers, usually supplemented by a mallet, to one of the mechanical devices—spring, pneumatic, or electronic. Each has its advocates. One must be aware, too, of the governing principles of compacting gold, the part of the procedure which is perhaps the most demanding. The operator must understand proper control of the amount and direction of the compacting force. Even nib size and serration are important factors.
Proper finishing is particularly important. Improper procedures will damage the dental and supporting tissues. Careless trimming with files or knives, excessive use of abrasives, or inadequate coolant can spell doom for a gold restoration or its host tooth. Extreme care and meticulous technique are essential to avoid marring tooth surfaces, or bruising and lacerating surrounding soft tissues. Abuse of tissue is inexcusable. Correct procedures leave the tooth and supporting tissues in excellent condition, and the patient and operator should be able to anticipate with confidence a lifetime of service from such a restoration.
If an individual wishes to increase his competency with these materials, a few suggestions are offered. One should read some of the fine papers and monographs on the subject. The forerunner of this new journal, the Journal of the American Academy of Gold Foil Operators, has published many excellent articles in the various phases of foil technique. Some of the most outstanding papers can be found in earlier periodicals in the better dental libraries. The particular technique and material of greatest interest will dictate the direction of the individual's search into the literature.
How To Gain Competence
After reading, the next step is to practice the procedure on the laboratory bench. The chairside assistant should work with the operator on the technique project so the essentials of team effort are acquired before going to the patient. Next, one should enroll in a continuing education course in the use of direct golds. Finally, if geographic conditions permit, the finest possible avenue to confidence in the new skill is to affiliate with an active, operating study club. The regular practice, under supervision, will improve operative competency in all phases of clinical dentistry as well as in the ability to utilize the direct golds effectively.
In conclusion, I urge you to retain this means of therapy in your active repertoire, for there is a definite place for foil in restorative dental practice today. Our techniques must be current, conservative, and executed to the best of our ability. Then we may use the direct golds more often, more confidently, and more competently, wherever indicated.
This Article was scanned and edited By Dr. John R. Sechena