Sunday, June 24, 2012

Episode 370/500: Diastema Closure

Charles has been in ortho for a few years.  The past 4-6 months has been focused on retracting the maxillary incisors posteriorly approximately 1.5mm.  The goal was to reduce the horizontal overjet to approximately 0-.5mm.  Here you can see niti coil springs bilaterally, attached to hooks to retract the incisors.


Diastema Closure, orthodontics, braces, niti coil spring
This is approximately 4 months before debonding.
Retracting the incisors was a fairly slow process, utilizing sliding mechanics
with a rectangular wire.
Diastema Closure, orthodontics, braces, niti coil spring

Diastema Closure, orthodontics, braces, niti coil spring
Ortho treatment getting close to being complete



We planned to have 2 diastemas between the lateral incisors and canines (bilaterally).


Diastema Closure, orthodontics, braces, niti coil spring


Diastema Closure, orthodontics, braces, niti coil spring



I thought that I'd be able to scan the teeth into the CEREC AC and mill out 2 "no prep" veneers.  Well, after 1 hr of fooling around with finish lines, I decided to go direct - with composite.  I've completed a few of these cases previously and never took the time to complete a simple preclinical waxup on a set of models that I took during the debonding appointment.

Direct composite diastema closure often seems easier than it really is.  To achieve a truly esthetic result, time can be easily wasted chairside if you don't have a plan.  Some simple decisions  can be completed before even reclining the patient - saving you time and significant frustration - if you have a set of diagnostic models.
  • Which teeth to add composite
  • Enamelplasty (if any at all)
  • Need for crown lengthening/gingivectomy
  • Change the plan to veneers?

I remember one case of direct composite veneers I completed before the residency.  I had good intentions, but didn't have the tools - ie - the know how, and it was a long 2 appointments.  The result could have been better had I been better trained.

Diastema closure, composite, dental composite, braces, waxup, diagnostic waxup





After approximately 30 mins, I have a road map.  I"ll use the waxup to guide the enameloplasty on the mandibular left canine and addition of composite to the laterals and the canine (left side). Additionally, I'll use the stent that I made to mock up the waxup intraorally with bis-acryl...just to get a sense of how the esthetics will appear (or hope to appear) once I've completed the additions.

Is this difficult?  No. But take these few things into consideration.
  • Gingival tissues are significantly inflamed from orthodontic therapy.  If I were to complete the closures at the same appointment (even a week later), there will be significant gingival hemorrhage......leading to problems with bonding, shade selection and possibly a red hue to any composite that I may have to add on after the main bulk has been added to obtain ideal contours
  • Without a waxup, I'd have to try to figure out chairside how to divide up the space between the canine and the lateral - and - determine how much enameloplasty is required.
  • Do you need this much of a workup for every case - no - but - it helps to plan a road trip before getting in the car and running out of gas 2/3rds of the way


Diastema closure, composite, dental composite, braces, waxup, diagnostic waxup

Diastema closure, composite, dental composite, braces, waxup, diagnostic waxup

Diastema closure, composite, dental composite, braces, waxup, diagnostic waxup

Diastema closure, composite, dental composite, braces, waxup, diagnostic waxup



Saturday, June 23, 2012

Episode 369/500: Dental Crown Rinse

Even after 2 years, the tips just keep coming.


The scene.  I"m walking past my director's operatory and I notice this on the Alabama cart...????


Dental suction, Funnel, coghlans, rinse crown, hydrofluoric acid rinse, silane
A funnel - what is that for?


The reply, "ever dropped crowns into the garbage or into the sink while you're rinsing them before luting?"


Yes.


This little friend will prevent having to search for a lost crown during rinsing procedures.


Make sure that you have a screen!


Dental suction, Funnel, coghlans, rinse crown, hydrofluoric acid rinse, silane




Thanks Mike.  Even better it's fabricated in Winnipeg Manitoba - the home of the Jets (hockey)..and where I graduated dentistry.


Dental suction, Funnel, coghlans, rinse crown, hydrofluoric acid rinse, silane








Wednesday, June 20, 2012

Episode 368/500: Tooth Extraction Model



A few folks requested some information on the way that the teeth were mounted for Dr. Partridge's extraction demonstrations.


Here is a series of stillshots and the video regarding their simple fabrication.  I'm a believer in keeping it as cheap and simple as possible, as these will be ultimately be discarded after use.


Points:

  • Disenfecting the teeth tends to "dry out" the teeth and make them brittle and susceptible to fracture under light forces - take that into consideration during usage
  • If you are taking radiographs, try to capture before placing staples (chamis) - the staples show up and can block the tooth on the radiograph

If you come up with something better - let me know!



Ashley




Toot Extraction, Demonstration, Teeth, Extraction, Model
The teeth were stored in both 6% NaOCl and 0.12% CHX.
The roots are stained green from the CHX (chlorhexidine)


Toot Extraction, Demonstration, Teeth, Extraction, Model
This illustrates that an average of 1cm was used to drill the holes into wood

Toot Extraction, Demonstration, Teeth, Extraction, Model
I used a 3/8" wood cutting bit to create the holes for individual teeth
The tooth is covered with wax (PDL space) and vaseline
The hole is filled with some 5min fast set epoxy


Toot Extraction, Demonstration, Teeth, Extraction, Model
This is for the impacted 3rd molar teeth


Toot Extraction, Demonstration, Teeth, Extraction, Model
Into melted rope wax - this acts as a spacer or PDL between
the tooth and the epoxy
Toot Extraction, Demonstration, Teeth, Extraction, Model
Coated with vaseline to make removal just a little simpler.
Toot Extraction, Demonstration, Teeth, Extraction, Model
Seated comfortably in its new home.
Toot Extraction, Demonstration, Teeth, Extraction, Model
Chamis cloth to aid in practicing incisions (if required)


Tuesday, June 19, 2012

Episode 367/500: Roast Night

Roast Night
Every organization has its own habits (Power of Habits by Charles Duhigg).  Most of those habits were created unintentionally to try to keep the machine oiled.  Roast Night - this is one habit that was definitely created to have some fun and make fun of others in the residency.  The mentors, seniors and juniors develop videos and play them for the attending audience.

We had a similar night in Dental School - our class size were only 25 students, so it was easy to get the entire faculty into large room to enjoy the videos and skits.

Essentially, our task as Seniors was to develop some skits showing the lighter side of our mentors, video tape them, and play them to the entire staff.   
Attached is the video roasting me.  My wife and I laugh each time I watch this video - great job Troy.  
These points may aid in deciphering what he's talking about.
  1. I'm a huge believer in fitness - Crossfit has changed my approach to fitness.  
  1. I tend to eat small meals throughout the day...no, I don't own a fanny pack.
  1. I recently enjoyed reading the book Wheatbelly - It's paleo-esque.
  1. The sun is our friend.  We spend up to 16 hours a week in a little dark room trying to fend off sleep during lectures.  I try to catch as much sun as possible - why to people always close the blinds?

Please enjoy,

Ashley


Thursday, June 14, 2012

Episode 366/500: Seniors Office Tip Board

Today, the 3 musketeers graduated from the residency.  We started with 7 and finished with a truly diverse group of 3 folks.  What a great day it was, particularly b/c I was able to spend most of it with my family.  I"m not terribly excited about leaving - I learn so much everyday, that I will truly miss this experience.


For the last year, this whiteboard has been sitting in front of me (atop my lab bench).  The graduating class from last year put these little reminders up and left the board with us.  We haven't touched the board, as it had some nice little reminders on it.  There may be some incorrect information (Ketac cement can be used with ceramic restorations) or a point that could use more information (Panavia and veneer cementation - you can use many more resin cements than Panavia).  But overall, it's a nice, quick overview.


Here are some great tips from that board.




  1.  A sharp explorer can detect an open margin up to 36 microns.  
  2. Reliability of tactile perception using sharp and dull explorers in marginal opening identification
  3. After CaOH placement in endodontics, ensure that you take a radiograph to ensure that you know if you have/have not extruded CaOH into the periradicular tissues.
  4. If you see a tooth fracture, it extends 25% more than you can see.
  5. Active and Passive eruption definitions




Cheers


Ashley

White Board, Dental Tips, Implant, Oragraft


Thursday, June 7, 2012

Episode 356/500: Temporary Anchorage Devices and Cementum

TADs - Temporary Anchorage Devices.  I've used them in a few situations and blogged about their use during Molar intrusion


Study:  Root damage and repair in patients with temporary skeletal anchorage devices

Am J Orthod Dentofacial Orthop 2012;141:547-55


There is a possibility of contacting cementum when placing these helpful friends intra-orally and this study was a unique study that essentially used ortho extraction patients (ie the premolars were planned for extraction) and zinged each root with a TAD.  The TADs weren't left in situ, and were removed after radiographic confirmation that the TAD contacted cementum.


Long story short: Despite varying depths of the injuries, including involvement of dentin, reparative cementum formation was observed in all sections. Healing cementum was almost exclusively of the cellular type; 70% of all the teeth exhibited good repair by the end of week 12.


Here is my abstract for this month's current literature review: Root damage and repair in patients with temporary skeletal anchorage devices

Interestingly, I'm sure that the results from this study can be compared to cementum injury during the use of intraosseous injection systems (ie stabident, x-tip).  I'm guilty of zinging a molar root (or so it appeared on the radiograph) and always wondered if there would be any long term effect on the cementum.  Now I know...


Cheers


Ashley



Sunday, June 3, 2012

Episode 355/500: Sling Suture

Often during root coverage techniques, a sling suture can be utilized to aid in ensuring that the coronally positioned flap will remain coronally positioned.  The key, which I didn't catch on early, is to ensure that you use a non resorbable suture.  


Yes, it makes sense - however - when you're up to your elbows and it's just one more "thing" to ask for (and it wasn't set up initially), you tend to use what is passed to you.  Don't.


Proline is the best for this procedure (monofilament, non resorbable, no wicking effect, little inflammatory reaction).  However, it is difficult to use - practice beforehand!


Cheers


Ashley