One of the aspects of good dentistry involves the conservation of tooth structure; that is, we always want to restore the tooth in question by removing only the decay, existing defective restorations, and undermined tooth structure, while maintaining the integrity of the rest of the tooth.  When it comes to restoring teeth with cuspal involvement (Figure 1), onlays and crowns are the usual treatment options because the cuspal areas require extra strength since they are the predominant contributors to masticatory function (chewing).  An onlay is an indirect restoration fabricated usually from either porcelain or gold, and is cemented onto a tooth that requires cuspal replacement.  A crown can be seen as an onlay that covers all the cusps.

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As you can see, both of these treatment options help to restore broken cusps, but the crown option requires the removal of more tooth structure to allow the crown to fit circumferentially around the tooth.  Conservation of tooth structure is important because every restoration will eventually break down over many years due to the exertion of high chewing forces, and when the restoration fails, new decay/cavities will form around and under that defective restoration.  In order to replace this defective restoration, more tooth structure will need to be removed due to new tooth decay.  If we aggressively and unnecessarily remove tooth structure during the time of the first restoration, there may not be sufficient tooth structure to support a second restoration and when this occurs, the tooth is deemed non-restorable and will require extraction.  Onlays help patients avoid the eventual need for more extensive treatment with dental bridges or dental implantsby conserving healthy tooth structure so when the initial onlay does break down, there is still plenty of tooth structure to perhaps render a crown.

Over the years, insurance companies have arisen to prevalence and have, in many ways, begun to dominate dental treatment.  Many patients may elect only to undergo procedures that are covered by their insurance plan and forgo all procedures that are not.  In reality, what insurance companies pay or don’t pay for has no correlation with what treatment is necessary or best for the patient’s dental health.  In the case of onlays vs. crowns, most insurance companies fail to include onlays as a benefit, and consequently, many dental providers may opt to render the crown as the treatment option, as crowns are almost always a covered benefit.  Here at Paragon Dentistry, we like to encourage a long-term perspective and advocate doing the best treatment for your teeth as recommended by your dental professional, as the consequence of undergoing a less desirable option now could lead to a more expensive and involved treatment in the future!