Saturday, April 28, 2012

Episode 343/500: Tooth Extraction Demonstration - Isolated Mandibular Molar

Dr. Partridge is an amazing teacher, mentor, and human.  He is always available to give mentoring advice, even though he's long retired.  We've been through several extraction prototypes and he's been kind enough to play along with me each time. 






Root Canal, Extraction, Supraerupted Tooth, Hopeless Tooth, Furcation Involvement
This tooth has not had a restoration for an extended period of time,  as it appears that
it has suprerupted (look at the adjacent teeth)...I'd guess that the prognosis is near hopeless
(think furcation, need for ferrule, need for retreatment)


I remember when I was first out of dental school, not really knowing the fine line between complex restorative and herodontics. Here's an example:


Case: 40 year old male had undergone crown lengthening, endodontics and finally a crown on both first mandibular molars. 5 years later - there was clinically detectable and radiographic decay under both crowns.  I tried to remove the decay and save one of the teeth, but sure enough - it was non restorable.  I extracted both teeth...however - it wasn't pretty.
Had I known some of the tips that Dr. Partridge has provided us over the past few years, the extraction would have gone completely different.




Learning to extract teeth is like everything else.  It takes practice and mentoring - and both - I believe - are not provided to dental students/clincians frequently enough. These series of videos on tabletop extractions are an attempt to overcome the limitations of teaching extractions.








Cheers





Thursday, April 26, 2012

Episode 342/500: Forced Eruption/Extrusion

Orthodontic Extrusion/Forced Eruption


Indications: (from the linked PDF)

  1. Esthetic enhancement of the maxillary anterior periodontium
  2. Recontouring infrabony periodontal defects
  3. Esthetic restoration of subgingival and subosseous dental fractures, carious lesions, and resorbed areas
  4. Maintenance of osseous integrity in "early" trauma sites
  5. Slow extrusion of hopeless periodontally involved teeth in preparation for implant placement. 

This is a great technique - and - fairly simple as well.  There are a number of little details that need to be sorted out before initiating extrusion (endodontics, periodontics and restorative...not to mention ortho).  It's just another tool to place in your tickle trunk for use when the cards are on the table and you have no where to run.....just extrude it.


Similar to the walk before running analogy, I figured I'd start simple in the demonstrations and work a little more difficult.  This demo uses little more than composite, a paperclip, and some elastomeric material (read: mini rubber bands).  As a restorative dentist, I know that I won't always have ortho materials available, hence, I want to show things that replicate reality - not fiction.


Less talk, more action.


Here is a basic lecture (PDF) discussing Extrusion:


Forced Eruption/Extrusion Lecture



Monday, April 23, 2012

Episode 341/500: Audible Books

This is a little different post. I love to read books.  I'm a how to "x" kind of reader - including anything  about aviation, sociology, marriage, behavioural economics, buddhism, happinests, parenting, etc etc.  But, I have very little time to read, especially these past 2 years while in a residency.  But, I still need to fuel my learning for other things than dentistry. 


The advent of easily accessible audio books has opened a new world of hope for me!  A friend of ours gave me his 3G iphone 2 years ago (before we left Belgium) b/c his 2yr old daughter Hanna dropped the screen......and.....he needed a reason to purchase the 3GS at the time.  Well, thanks Mark, this has served as my audio book player ever since.


Here is a list of what I've read to and from work (25 mins one way) almost everyday (I think I took a break from books for a month or so...)


Audible.com, Audiobooks, Dentistry, itunes, wheatbelly, vaynerchuk
Screen shot of iTunes (books) at the moment..


I don't get paid for anything here, so, I've linked the books to the author's own site - not a purchase site.



  1. Scream Free Marriage (Hal Runkel) - Fantastic!
  2. Scream Free Parenting (Hal Runkel) - Just as great as the marriage book
  3. The Upside of Irrationality (Dan Ariely) - My peers and wife are sick of me talking about the things I've learned from this man. I used one of his clips for a post on literature based decisions.
  4. WheatBelly - Lose the wheat, lose the weight (Wil Davis) - This was a life changer - honestly.
  5. 7 Habits of Highly Effective Marriage (Steven Covey) - Great marriage book
  6. The Tipping Point (Malcolm Gladwell)
  7. The Thank You Economy (Gary Vanyerchuk)
  8. Predictably Irrational (Dan Ariely) - I'm speechless about this book.
  9. Switch (Dan/Chip Heath) - Great book - I think I listened to it twice
  10. I'm Feeling Lucky (Google Employee) Doug Edwards - It was a good listen - perhaps just a few hours too long
  11. Linchpin - (Seth Godin) - He has some great books and is inspirational
  12. Made to Stick (Dan/Chip Heath) - Absolutely Fantastic
  13. Crush It! (Gary V) - My blogging inspiration, really.
  14. Brain Rules (John Medina) - Great stuff - stopped 3/4 way through.
  15. Getting Unstuck - Pema Chodron - Great Buddhist Teacher
  16. Unconditional Confidence - Pema Chodron 
  17. Natural Perfection: (Lama Surya Das): Next to the Dalai Lama, he is my Buddhist inspiration. (Sons, if you ever read this, now you know the answer to several questions you've been asking)
  18. Presentation Zen - Garr Reynolds - My presentation inspiration for all the presentations that I've been pimped during.
I've started and stopped several other books - but - there's no point in reviewing something that I didn't enjoy - as others may enjoy it.


Keep your mind open.

Ashley

Saturday, April 21, 2012

Episode 340/500: Root Coverage or Restoration

Root Recession:

To restore or root coverage?

Dr. Bisch, a periodontic mentor, discussed the idea about using root coverage techniques to cover those class V caries (after the decay is remove), root recession, and/or root sensitivity areas instead of restoring them.

Wow.  I never thought about that.  Ever.

He made a great argument.  In the age of esthetics, why would you place something like this?

Root Coverage, Class V restoration, Class 5, filling, restoration, composite

....when you could easily cover that recessive defect w/ a connective tissue graft.  Of course, there are a few limitations to the extent of coverage that you will obtain with different cases, however, for most patients with less than 20% bone loss, up to 100% coverage can be, dare I say, expected?

Even if you have no idea about how to even go about covering roots, the message is this: keep this idea in your toolbox as another treatment option that you can discuss w/ your patient - rather than placing that awful Class 5 restoration that will pop off in 2 years, stain, and/or develop recurrent caries - refer them for a periodontal eval and/or complete a short course in mucogingival surgery techniques.

That brings up an important point.  If you are thinking about attending a short course in periodontics, I'd have to say, from my own basic knowledge, start really basic.  The tunneling techniques are great - but - they are definitely for skilled, accomplished folks who have the basics down.  The instructor will show you how easy a tunnel (or whatever sexy technique) is to do - but - let me tell you, if you have never completed a Langer/Langer root coverage technique (or don't know what that is), find some CE that starts basic with some of the following as a guide:

  1. A simple full mucoperiosteal flap with possible papilla sparing incisions (those are fairly simple - see below) one tooth mesial and one tooth distal to the region you are covering
    1. Elevate the flap
    2. Debride the roots (scaling), remove any sharp enamel ledges
    3. Biomodify the roots
    4. Harvest autogenous connective tissue - this gives you even more practice with cutting and suturing
    5. Graft thinning (remove fat from the graft)
    6. Graft placement and lock it into place with either a sling suture or suturing into the existing papillas
    7. Periosteal release
    8. Coronally position the flap
    9. Suture

    I will be shooting some "reminder for myself" videos on this topic - so, when I move to my next duty station, I'll remember those basic techniques that Dr. Latte Ice taught me.

    Papilla Sparing Flap, Connective Tissue Graft
    Although this example is for an apicectomy,
    the incisions are exactly the same for a papilla sparing technique

    For now, here is the discussion regarding restoring or covering roots.


    Cheers

    Ashley



    Episode 338/500: Locator Pickup


    Overdenture attachments.  The world has many different shapes, brands, kinds, colors.
    Mandibular Denture:  
    Problem: Everything from fit, retention, speech and eating.
    Solution: Implant support and/or retention.
    Instead of relying on saliva to retain a mandibular denture, there are many inventions man has come up with to aid a mandibular denture user (partial and complete).  Those inventions can be attached to roots (endodontically treated teeth and crown removed) or implants.  They either support or retain the denture that is fabricated "over" the root/implant attachment device.  




    Hence - overdenture (or my theory on the root of the word).
    Locator, Locator Abutment, Denture, overdenture, dental implant, complete denture
    Locator Abutments

      Dr. Dray wanted to capture his technique of “picking up” locator attachments in a mandibular complete overdenture.  Honestly, this man’s 40 years of experience as a prosthodontist is evident - especially - this technique.  He’s played with enough little gadgets (intracoronal, extracoronal attachments for example) to know most are tiny little things that are difficult to manage, difficult to manipulate - and - often result in resorting to conventional treatments.

    Locator, Locator Abutment, Denture, overdenture, dental implant, complete denture
    Locator Attachment freshly picked up into the denture base.
    Just before trimming excess acrylic.

    Locators are one implant/tooth overdenture attachment "gadgets" that have passed the Dray test.

    Dr. Dray delivered a complete set of maxillary and mandibular dentures the week previous and had the patient return for followup and incorporation of the locator attachments into the mandibular denture.

    This is his technique - and - it’s straightforward.
    We don’t work for companies, nor, do we receive cold/electronic cash, cheque, or, well, anything from dental companies - so - this is straight from the hip.

    Cheers

    Ashley



    Thursday, April 19, 2012

    Episode 337/500: Complete Denture Workshop

    Complete Denture Workshop.


    Dr. Dray and his colleagues from years past put together some amazing content regarding complete dentures.  I've added my 2 cent videos in there as well.  I've placed the entire workshop + pdf lectures from Dr. Dray here:


    Complete Denture Workshop Forum

    Complete Denture Workshop PDF

    http://www.dentistrylearningnetwork.com/








    Monday, April 16, 2012

    Episode 336/500: RPD Cast Stop

    Here is a tip that has been "drilled" into us by Dr. Dray.  'Tis not a tissue stop, it is a Cast Stop.


    "A what?"


    "Cast Stop"


    It's a little nub at the end of a distal extension framework used during the acrylic processing stage of a partial denture.  It prevents the framework from moving towards the cast during wax and acrylic processing - ensuring that there is a minimal space available for acrylic to seep under the framework.


    I was taught that it was a tissue stop, but that made absolutely no sense.  There were too many other things to be concerned with to worry about why it was called a tissue stop, so, I thought it was that for only 10 years. 


    Wow.


    Ashley






    Thursday, April 12, 2012

    Episode 334/500: Endodontic Obturators

    Thermafil, Soft Core, Microseal, JS Quickfill - all variations on a theme typically employing alpha phase gutta percha loaded onto a metal/plastic carrier.



    Food for thought:  Standard gutta percha is fabricated using Beta phase gutta percha.  So, what's the difference?  Well, these folks published a study trying to observe any differences in vitro: 


    A comparison of two gutta-percha master points consisting of different phases in filling of artificial lateral canals and depressions in the apical region of root canals when using a warm vertical compaction technique




    The obturator idea was most likely developed to facilitate a faster and easier method of obturation.  Are they bad - probably not.  Are they misused - probably.  What am I talking about?  


    1hr molar endodontics, start to finish - on a middle aged individual - nonvital.  Just think, if you can jam a plastic needle into a poorly shaped canal and have a dense obturation  - and - complete the procedure in under 1 hour - bam - that's sweet.  What's even sweeter, is, scanning the tooth and milling out a crown - endo and crown in 1.5 hours.  Dang.  That's splenda sweet.


    But, check out this article about the time Sodium Hypochlorite needs to be in contact with the canal system:


    Biofilm dissolution and cleaning ability of different irrigant solutions on intraorally infected dentin


    This is not a post regarding speedy endodontics, rather, it is about looking at radiographs of endodontically treated teeth and using a few tips to predict if a carrier type of obturator was employed.  This may aid during the retreatment procedure if required.




    1. If the apical extension of the obturation looks incredibly dense, yet extremely fine (ie, poorly cleaned and shaped apical extent) - it's probably an obturator.  
    2. If you can see the handle in the radiograph - well - that's obvious.





    Apical Leakage of Different Gutta-Percha Techniques: Thermafil, Js Quick-Fill, Soft Core, Microseal, System B and Lateral Condensation with a Computerized Fluid Filtration Meter

    Comparison of different gutta-percha root filling techniques: Thermafil, Quick-fill, System B, and lateral condensation




    Here's what the American Assoc of Endodontists say about Gutta Percha:



    Gutta-Percha: This material was first used in dentistry in the late 1800s as a temporary restorative material and then to obturate root canal systems. During the Civil War, a material called Hill’s stopping (which contained gutta-percha, quick lime, quartz and feldspar) and gutta-percha were advocated by Taft and Harris as temporary filling materials. Its use as a temporary filling material continued until 1950. 22
     Used without sealer, gutta-percha does not provide a seal. It is derived from the Taban tree (Isonandra perchas). The natural chemical form of gutta-percha is 1, 4-polyisoprene.23 It is an isomer of natural rubber and has been used for various purposes such as coating the first trans-Atlantic cable and for the cores of golf balls. Gutta-percha undergoes phase transitions when heated from beta to alpha phase at around 115° F (46° C). At a range between 130° to 140° F (54° to 60° C) an amorphous phase is reached. When cooled at an extremely slow rate the material will recrystalize to the alpha phase. However, this is difficult to achieve and under normal conditions the material returns to the beta phase. The softening point of gutta-percha was found to be 147° F (64° C).24 
    The phase transformation is important in thermoplastic obturation techniques.





    Episode 333/500: Endodontic Shift Shot

    2 endo cases, 2 residents, 2 very different outcomes.


    How many times did I initiate endodontic therapy without a shift shot periapical radiograph?  Many times - before I started this residency.  Now, like marriage, I'm a changed man - ok - scrap the marriage part.  The straight on periapical radiograph is nothing without it's twin - SLOB


    We've all been harassed by Dr. Crossfit/paleo/glutenfree to take a straight on periapical radiograph and shift shot (either mesial or distal) at the following times:

    1. Initiation of an endodontic procedure.  This includes before each stage of a procedure (if you're completing a retreatment, or 2 stage endo - chronic apical abcess)  The reason: you never know what may have happened between the last visit and now. 
    2. Any radiographs during the procedure.
    3. Post procedural - including calcium hydroxide placement.  You need to track if the CaOH exited the apex and if, perhaps, it found its way into a sinus, or, even worse - the Inferior Alveolar Nerve Canal - it's happened.
    A shift only takes another second, and it can reveal some interesting things.

    Cheers

    Ashley
    Imagine this as the straight-on periapical radiograph.  The file appears to be inline with the axial
    inclination of the tooth

    A little shift (ok, 90 turn) of the tooth shows the perforation
    Watch the video - I forgot to email the radiographs home.


    Tuesday, April 10, 2012

    Episode 332/500: Immediate Denture 24 hours Post Op Discussion

    Aaron is back after 24 hours.  He has had minimal pain following extraction of several anterior maxillary and mandibular teeth.  Here is a basic dicussion of what the 24hr post operative appointment entails.


    I actually have 1hrs worth of occlusal adjustment to his partial dentures - but - I deem it REALLY boring, so, here's what I was instructed to do:




    1. Evaluate the fit of the partial dentures w/ pressure indicating paste (not always necessary) and relieve any pressure spots.  Remember that the tissues will shrink over time, so be judicious.

    1. Evaluate the occlusion.  


    In Aaron's case, we were using the above posterior stops on his right side as a guide.  The partial dentures were preventing those 2 teeth from contacting ...by about 3mm.  Yikes!


    So, after 45 mins of adjustment, these 2 teeth contacted each other.  However, it wasn't pretty.  I was guided to split the grinding 50/50 between the maxillary partial denture and the mandibular partial denture.  As with everything, you start slow - and after a while (with the end not in sight), selective grinding becomes liberal grinding.  And of course, I overshot acrylic/plastic tooth removal on the left side by about 1mm.  Yes.  There is a 1mm space on the left side.  Learning point:


    Check all places that could contact, including acrylic/denture base.  It was a small spot on the denture base that was truly preventing the right posterior teeth from contacting at the end.....and I removed waaay too much on the left side.


    Ok, enough.  Here's what Dr. Dray had to say:



    Episode 331/500: Immediate Partial Denture

    The big day came and went - and Aaron - our immediate partial denture patient - is/was pleased with his dentures.  "Wait Aaron, we're only 1/2 way home, the esthetics should get better after round 2 of extractions (posterior dentition).  


    Here are some of his pre operative photos.









    And....24 hours post op:








    24 hours post op - partial denture adjustment








    Here is an overview of the extraction and insertion of the immediate partial dentures.  Dr. Dray did a great job pre-fitting / relieving the immediate partial denture (it required minimal adjustment, other than the clasps - which were probably bent during polishing).


    Notes:  


    1. Dr. Dray typically does not use a soft liner/conditioner until the immediate denture starts to fit loosely (resorption of the alveolar processes fol extractions.
    2. The patient was followed up in 24 hrs and 72 hours.  At the 24 hour appt, I checked fit of the partial denture (pressure indicating paste), and adjusted any gross occlusal discrepancies.

    Monday, April 9, 2012

    Episode 330/500: Top Ten Tips April 2012

    Here we are again,  the top ten tips (IMHO) since the last time I posted one of these lists.  A huge thank you to the following folks on twitter and Youtube who continue to give me morale boosts:


    Twitter
    @endoexcel (Dan, you are a friend for life)
    @DrGstoothpix (Radiology made fun)
    @dentinaltubules (thanks for your support)
    @Gabeproulx
    @thenextDDS


    Youtube
    smoothbanana
    gautejohnson
    avalony2011
    Thunderofbabylon
    trellisk
    rubikbg


    Many, many of these tips are from folks I work with (residents....ok, maybe not many tips from them....), mentors, and consultants.  We are extremely fortunate to have listened to credible speakers who are well versed in the human attribute we all strive to perfect:  Storytelling. Credit has been given where credit is due - which is essentially 99.97% of this material.


    Without further adieu: (and in no order of anything)....


    I googled top ten and this is what I found -
    Mike Myers is Canadian, I just "had to"

    I think Betty Rubble is at least top 5.


    The Top Ten (April 2012)
    1. Custom Incisal Guide Table
    2. Alginate Impression Tips
    3. Dental Papilla Return?
    4. Light Curing Fibre Composite Posts
    5. Greater Palatine Anesthesia
    6. Calcium Hydroxide Placement
    7. Endodontic Radiographs - Which canal is which?
    8. Oral Surgery/Exodontia Instrumentation
    9. Smile Design Opinions and Provisionals
    10. Anterior Guidance

    A really short list of the past consultants includes:

    Dr. Ken Hargreaves (Endo)
    Dr. Brian Mealy (Perio)
    Dr. Neville (Oral Path)
    Dr. Karl Kaiser (Endo)
    Dr. Van Ramos (Prosth)
    Dr. Fred Bisch (Perio)
    Dr. Charles Wakefield (AEGD Baylor)

    Sunday, April 8, 2012

    Episode 329/500: Antibiotics

    We were tasked to complete the following antibiotic table:


    This is a basic overview of antibiotics in use for dentistry as of 2012 - everything always changes!


    If you see mistakes, please email me: 
    ashley@allthingsdentistry.com


    ..this is a continual work in progress


    View more presentations from Ashley Mark.

    References:

    1. Lexicomp Drug Reference Manual: 16th Edition
    2. Position Paper (2004) American Academy of Periodontics
    3. Swift and Gulden: Antibiotic therapy—managing odontogenic infections, Dent Clin N Am 46 (2002)
    4. Peterson's Principles of Oral Surgery, 2nd edition, 2004

    Thursday, April 5, 2012

    Episode 328/500: Endodontic File Separation

    File Separation.


    Procedural Error.


    File Fracture.


    Call it what you want, but on a radiograph of your own, it's a cringing moment.  "Damnit".  On someone else's radiograph - it's that feeling of, "thank gosh it wasn't me."
    endodontics, file separation, root canal, radiograph
    This was me alright.  But, I learned a heck of alot from this and a recent literature article
    (Cone Check Radiograph)


    Truly, the literature indicates that there really isn't a significant change in the outcome (success/survivability) of a tooth containing a separated file.  I will be posting more on this topic soon.


    See the systematic review from 2010:




    But, most of us don't have access to publications - and - the only resource out there amongst the quagmire are colleagues and folks on the lecturing scene....and do they really know what they're talking about?  You can spin literature anyway you want.  It's the subjective, storytelling part of being human, including the "I've read this article, here's my synopsis - and unless - you've read it and have anything to say about it, I'm pretty sure that my opinion is GTG (good to go)".


    Or - how about this great, easy, cheesy, frequently updated, endodontic resource rather than slowly antiquated textbooks?  www.aae.org




    American Association of Endodontics, AAE, Endodontics, root canals


    The above treatment options pdf is a new addition to their guidelines/protocols: http://www.aae.org/guidelines/





    Monday, April 2, 2012

    Episode 327/500: Custom Incisal Guide Table

    Custom Incisal Guide Table - think - custom pipes for a chopper motorcycle


    I remember learning what this thing was - but - never really came to grips/understanding of its purpose in life.  I think I have it now (watch a mentor pull the carpet out from under me after they see this post...) and it's best used in cases where there are multiple anterior restorations and you want to ensure that develop the guidance that you want.  It could be as simple as using the patient's existing guidance scheme, or mixing it up and giving them a fresh, new experience for the teeth and owner.


    You can also use the machine incisal guide table to develop the guidance pattern as well.


    Or - don't use either.  Just go with the flow of whatever happens, happens...


    It's ugly, I know.  

    In this situation, I"m using my trusty Hanau articulator vs a sexy new(er) whipmix or Artex.  We just have more pieces that fit w/ the Hanau articulator.


    Things to consider:
    1. Need a facebow of the provisionals or preparations.  If you're deep into the literature on facebows and don't use them - just fakebow it.
    2. Impression of your provisional restorations.  A waxup will also work...uhm.....but, it's best to determine your excursive patterns intraorally in plastic (provisional restorations) rather than guesstimate them in wax and go straight to definitive restorations.  The latter plan may create a can of worms you don't want to open and won't be easily closed.
    3. Interocclusal record (bite registration) between the opposing arch and provisional/preparations.
    4. Protrusive and/or excursive records to set the condylar guidance.  Average values are 30-35 degrees (see PubMed)
    5. Time
    6. Patience
    7. Resin for the custom table.
    Right Mandibular Excursion - We're trackin in stereo (plastic and stone)
    Protrusion

    Left mandibular excursion.




    Sunday, April 1, 2012

    Episode 326/500: Alginate Impression Tips

    Man, there are LOTS of alginate videos online.  With that amount of coverage, I didn't want to make another boring alginate video and figured that I'd just add the few things I've learned over the past 2 years to the mix (short and sweet).


    Dr. Dray's most poignant question and answer:


    "Dr. Mark, what is the most important step (in whatever you are doing)?"


    "Uh...When I mount the casts?"


    "Wrong - what you are doing at the moment is the most important step"


    "Oh"  


    He's talking about shortcuts, sloppy work, etc.  I"m guilty - I'm an 80%ist.  I look at something and if it is around the 80% mark of being correct, I'm good to go.  That may not be the answer for everyone.  Dr. Dray (a 110% ist) is talking about taking your time and doing it right the first time.  The most critical step is the one that you're at right now.  That is, if you KNOW what you're actually supposed to be doing.


    Alginate impressions are one of those things that falls into the, "they're only alginates, whatever."  However, there are a few points that I must have forgotten since dental school:


    1.  Pour alginate impressions within 12 minutes of fabrication - or - they will distort.
    2.  Don't leave the alginate impression set on the new model for more than 45mins.  The alginate will start to degrade the cast surface (obvious if left overnight)
    3.  Many more rules that I don't want to bore you with.




    Honestly, I never paid attention to even the basic rules (see 1 and 2).  Perhaps that's why my models always looked terrible......


    Try these tips and let me know what you think.


    Episode 325/500: Crown Lengthening

    Crown Lengthening.  This procedure is perhaps, the meat and potatoes of periodontics (other than open debridement, coronally/apically positioned flap, GBR, GTR...)  I remember fondly another dentist I was serving with who said it best 9 years ago, "if you think it needs crown lengthening, do it.  Don't mess around." Thanks Jodi - that advice has served me well over the past few years.  However, the problem that I ran into, was how to manage the esthetic zone and crown lengthening.  I remember being scared into "refer this to perio" for esthetic cases....hmm.....I'll have to discuss a few cases that I've completed that deal w/ anterior crown lengthening - it's really "easy cheesy" (that saying is compliments of our pedodontic mentor, Dr. Muscle Milk).


    Healthy gingival tissues - a pleasure to meet you.


    This lingual tori case, I thought, was interesting b/c most conversations regarding "how to do" crown lengthening consist of instrumentation, amount of ostectomy, osteoplasty (festooning), amount of gingivectomy - and - if dealing w/ a mandibular molar - are you going to distal wedge it or not?  Here, we're throwing in some lingual tori - to return the mandible to standard anatomy or not, is the question.
    Flap Elevation - remember - 3mm osseous crest apical to the PLANNED
    finish line - which shouldn't be at the existing level in this case


    The best way to think of ostectomy as bone contacting tooth/root structure.  Ostectomy is defined as removal of tooth supporting bone (isn't all bone supporting teeth in the maxilla and mandible?), but that never made any sense.  Osteoplasty is removal of non supporting bone - ie - it's not directly contacting bone.  Therefore, it is recommended  that during a crown lengthening procedure, - plasty before ectomy.


    Medium sized mandibular tori waiting to be freed.


    Upon removal of the mandibular tori, I was able to re-establish physiologic architecture on the lingual side which will "probably" aid in healing.....I say that, b/c, well - this is a food for thought case presentation.  Will the patient heal fine with the tori still there - probably yes.  Will there be a large osseous crater if I didn't remove the tori - yes.  Is the sky blue on most days w/out clouds and smog - yes.


    Freed at last