Thursday, May 31, 2012

Episode 354/500: E.max (lithium disilicate) FDP

Before I joined the residency, I knew only one type of esthetic restoration - the good old PFM (porcelain fused to metal).  Quite frankly, I really didn't know much about it until completing this residency.

We were taught all ceramic restorations, however, it was implied that we should stay away from them....too much reduction,  flexural and compressive strength are poor.  I still remember Nick and I cutting away on our typodonts for an all ceramic maxillary canine preparation.  Painful.

Now, I know better.  It's not really that I know what material is better, it's that I have been given a basic foundation in reviewing pertinent literature about materials and how different properties affect their clinical success.  Currently, the sex is with lithium disilicate.  There are 2 recent articles (approximately 8-10 year prospective clinical studies) discussing the in vivo (intraoral) success of lithiutm disilicate crowns and bridges.  Things are looking good!

Gerht - Clinical results of lithium-disilicate crowns after up to 9 years of service

Kern - Ten-year outcome of three-unit fixed dental prostheses made from monolithic lithium disilicate ceramic

So, I"ve just about completed patient SA's case.  After a number of rounds of endoodontics, crown lengthenings, extrusion, and multiple other single CAD/CAM (CEREC) anterior/posterior restorations - the time is here to finally lute the 3 unit e.max FDP (Maxillary left canine to second bicuspid).  I'm excited, she's excited.  This is 1 of 2 board cases to be presented next year for board certification.

Here's a poem.

Things were going great.

Until I checked the restoration after I luted it with a resin cement.

Open margins on both abutments.

You must be kidding.

Occlusion is high, outlook is nigh.

I'm leaving in 1 month......

I think we figured out what the problem was, other than operator error.


This video is right before I tried in and luted the FDP....if only I could have predicted the future.

Wednesday, May 30, 2012

Episode 353/500: Crown /Veneer Organization

Dr. K showed Dr. In.Saini this technique for cementing multiple restorations at the same appointment.  Often, even when fooling around with 2-3 crowns, it's easy to get them mixed up.  They're here, they're there, they are everywhere on the top of the alabama cart or tray.  This simple technique just makes life - easier.

Thanks Dr. K.

Friday, May 25, 2012

Episode 352/500: Flap Elevation Assistance

I was performing crown lengthening surgery on a maxillary molar and was remembering a conversation that I recently had with our perio mentor, Dr. Ice Latte.  He was discussing mandibular posterior implant placement and said that after he elevates the lingual periosteum to allow him direct visualization of the submandibular fossa, he places gauze to maintain the space.  
Fast forward 20 minutes and I'm trying to crown lengthen the interproximal osseous tissue between the first and second maxillary molars.  Nice. 

 Then, I thought to myself - "Self, whynot pack gauze between the palatal tissue and the bone to make life a little easier?"

Bam - that's for #norep.

Crown Lengthening, Flap, Muco Periosteal Flap, Dental Surgery

Crown lengthening is really one of those procedures that is either go big or go home (anterior maxillary excluded).  It is frustrating to know that you've crown lengthened - but not enough.....especially when trying to take (or make - I'll never figure the make/take an impression thing) a final impression for an indirect restoration and there's no more room to place cord.  Been there...done that....myself.

Just as I was cutting this video, I had an interesting discussion with Dr. In.Saini and a technique that he uses - a suture to retract the flap to the opposing quadrant.  He likens this to creating a clothesline...he says it works.



Thursday, May 24, 2012

Episode 351/500: Endodontic Cold Test - Endo Ice

This is a great tip that I was introduced to at the residency - how to "properly" use the endo ice.  Vincent Jones has 2 studies in particular in which he (and colleagues), discuss their research with Endo Ice.


1. Endo Ice (1,1,1,2 tetrafluoroethane) has a faster pupal response than CO2 ice:

Jones - Comparison of Carbon Dioxide versus Refrigerant Spray to Determine Pulpal Responsiveness

2. Endo Ice and a #4 cotton pellet caused the greatest change in temperature:

Jones - Effect of the Type Carrier Used on the Results of Dichlorodifluoromethane Application to Teeth

A Youtube viewer mentioned that the #4 may be too large for mandibular incisor teeth - and I'd have to agree with that.  The large cotton pellet (CP) may elicit a false positive response from neighboring teeth.  Fix - use a small CP.   Interestingly, Jones used isolated mandibular incisors (in vitro) with a temperature probe in the pulp.



Wednesday, May 23, 2012

Episode 350/500: Crown Impression Tips Part 3

Here is the final instalment of the crown impression tips.  Part 3/3.

Tips from mentors and residents:

1. Step on the gas and keep your foot on the gas - don't stop and try to reorient the syringe tip - just keep going!
2. Rehearse, rehearse, rehearse.  Go around the tooth with the tip several times as a dry run.
3. Remove the top cord in a wet environment, then dry the mucosa and teeth afterwards.
4. No latex gloves and addition silicones - ie - Polyvinylsiloxane.  It may retard/inhibit the set.
5. Dry angles - on the buccal mucosa and the floor of the mouth.



Saturday, May 19, 2012

Episode 349/500: MaxiloMandibular Record

Just as I thought I started to get comfortable with removable prosthodontics, this maxillomandibular record throws a wrench into things - but - it's great learning.

Let's talk verbage.  There are a few different ways to describe the same thing:  This is taken from the glossary of prosthodontics 8th edition: (

interocclusal record: a registration of the positional relationship of the opposing teeth or arches; a record of the positional relationship of the teeth or jaws to each other
maxillomandibular relationship record : a registration of any positional relationship of the mandible relative to the maxillae. These records may be made at any vertical, horizontal, or lateral orientation
centric relation record: \se˘n#trı˘k rı˘-l a#shun rı˘-kord\ : a registration of the relationship of the maxilla to the mandible when the mandible is in centric relation. The registration may be obtained eitherintraorally or extraorally

In most cases, we are attempting to record centric relation.  You can argue about centric relation, centric occlusion and maximum intercuspation and what you're trying to capture with a dentate patient by having them "bite your teeth together" with a registration material.  Of course, when the patient doesn't have teeth, it's difficult to obtain a centric occlusal record and/or MI record in wax rims.
End state - it's confusing.

Here we are with the milled titanium bar for an implant supported overdenture.  The esthetic wax trying.  It's no different than conventional dentures - however - there is added time to the appointments to get the bar in and out.

1.  Checked esthetics, phonetics with only the waxed up maxillary denture (bar) intraorally.  The patient was happy and so was I.
2.  Checked the waxed up mandibular denture.  Good to go.
3.  Fabricated 3 x blue mousse CR records - 2 of the 3 were similar and the patient's "bite" was different since the wax rim appointment.  Remount the mandibular cast.
4.  Cast remounted - reconfirm mounting with 3 x CR records again......then...I look at the mounting and see that her "bite" is way off.  Damnit.  Why didn't I see that earlier?

Problem - the patient was posturing forward and I will have the patient return to recapture another CR record.



..and a true professional at work:

Thursday, May 17, 2012

Episode 348/500: American Board of General Dentistry

The American Board of General Dentistry (ABGD). I had no idea this even existed before I joined the residency program (AEGD-2).  Well, I found out quickly that in order to be "board certified", I had to pass the written exam, oral exams and present 2 completed cases.

Long story short, I passed the written exams 2 months ago.  Why am I sharing this information?
Here's why.

This residency has changed my professional abilities.  It is unbelieveable how much basic information is out there, but, is not taught at dental school.  Yes, dental school is total overload and perhaps a recipe book is the easist method to teach.

But, I believe, more folks should be aware of these residencies.  Any residency after graduation (Endo, Prostho, OMFS, Perio, AEGD, GPR) takes you back to square one and builds on your experience.  10 years out of school, I had a lot of catching up with respect to materials and techniques.

If you have any questions regarding this residency, please feel free to contact me.

ABGD, American Board of General Dentistry, AEGD, Dr. Ashley Mark
Add caption

Wednesday, May 16, 2012

Episode 347/500: Photography - Basic Overview

I"ve been taking pictures of teeth and gums for almost 2 years straight.  Everyday, almost every procedure, almost everystep - all day long.  I think the only disciplines in which I don't take pictures are endo and oral surgery.  Endo - it's tough for this G11 to get light into the pulp chamber and Oral surgery - everything always seems to be so rushed that I feel like I'm wasting time by taking's probably my perception.

Dental photography, dentistry, root coverage, recession, canine
The G11 functions at a level I know how to use - and - can capture
decent photos.

An oral surgeon mentor 2 years ago told me a trick to photography.

Take lots of photos.

I heed his advice and it's true.  Snap more than you need b/c it may be out of focus, the light may be bad, the mirror is fogged...

Other points:
  1. Flip images captured in mirrors.  One huge issue that we get nailed on when presenting cases is the proper rotation/flipping of the photos.  This is especially true when using mirrors.  In almost every dental journal, you will see photos that are lazily placed in the article that are not flipped or reversed to show the proper location of the tooth in question.  This simple change will positively affect your presentation.
  2. Photos take time - don't get discouraged at the beginning.  Go slow and add extra time to each procedure.
  3. Camera - I'm a generalist in life - ie - I don't specialize in one thing (stamp collecting).  I aim for 80% at everything, including crossfit, music, tests, raising children (can you aim for something like that?).  So, if you're not taking your photos on the road to show others, I beg to ask why you need to spend 3-4k on a camera.  Purchase something that gives you simple great photos - and - if you're not using the camera everyday, you don't have to reread the manual (which is often useless for dentistry).  This is the biggest failure of other residents and their super expensive cameras - they don't know how to use them - and if they actually do learn, they forget b/c it's extremely complicated.  In other words - go Honda, not Space Shuttle.

Monday, May 14, 2012

Episode 346/500: Crown Impression Tips - Part 1

A Youtube viewer requested some tips regarding final impressions for indirect restorations.  Over the past few years, I've been privy to some tips from great folks.  I reviewed a couple of textbooks (Schillingburg and Summit), some literature, and talked to mentors and residents.

This is another procedure that is full of opinion and limited literature - however - let's hope in July 2056, all impressions will be optical - ie - CEREC type device - and we'll have long finished using analog methods (impression materials).  I feel like popular mechanics with that statement!

Here's part 1 of 3



Monday, May 7, 2012

Episode 345/500: Orthodontic Wire Headgear Tube


I have been placing the fixed orthodontic wire into the headgear tube.  Yes, my workout amigo is the orthodontic mentor. Yes, he doesn't let me live it down.
However, I put my foot on the scale at the gym when he was on it and it read 10-20lbs over - and - he fell for that one 3 times.  I couldn't stop laughing.  We're even.

Orthodontics Headgear tube, Orthodontics, Braces
I didn't place the wire in the correct tube.
But, now I know how to fix this minor dilemma.
So, the problem here is fairly obvious when you review the photo.  The mandibular right 1st molar is somewhat out of place relative to the remaining mandibular dentition.  I have been placing the 0.20" Stainless Steel round wire into the wrong tube for the past few months.  
At this point, there is absolutely no way I could get that wire to fit into the molar tube that it's supposed to go in.  But, Niti wire to the rescue.  I changed to an 0.18 Niti wire (saved the SS wire) and we should see movement back into the expected archform location within the next 1-2 months.

Yes, this is what it's all about - learning.  Thankfully I'm not perfect.

Thursday, May 3, 2012

Episode 344/500: Check Denture Flange Extension

Here is a great tip from Dr. K regarding checking the extension of the denture flange during delivery.  He has a couple of gems in this video - one using a permanent marker and the other using disclosing wax.