Friday, December 30, 2011

Episode 237/500: Complete Maxillary Denture and Mandibular Anteriors

Here is a neat hint that I was taught a few months ago from a lecturing prosthodontist.

As dentists, we are taught from day one to conserve teeth.  Therefore, when prepping a patient to receive a complete maxillary denture (opposing mandibular natural dentition), we rarely think of leveling the "playing field", ie, the mandibular dentition, to aid in developing a successful prosthetic outcome.

Here is a great tip to think about removing a small amount of enamel from those pesky mandibular anterior teeth when planning for a Complete Maxillary Denture opposing the mandibular natural dentition.

Cheers

Ashley



Monday, December 26, 2011

Episode 236/500: Suturing

 In the Army, we are lucky to have a number of clinical short courses - 2 weeks of hands on dentistry by the respective specialist.  I have attended our endodontic and oral surgery short courses a number of years ago.

Here is a simple trick that an oral surgeon friend of mine taught me years ago whilst I was on the oral surgery course.  It makes suturing just a little easier.

Another method is to learn how to tie a surgeon's knot by hand and eliminate your needle holders all together for completing the throws/knot.

Cheers

Ashley


Friday, December 23, 2011

Episode 235/500: Bridge Cementation and Dental Floss

A resident colleague mentioned this great, simple, hint at lunch time the other day.  He had a friend that showed him to use floss during cementation of an FDP.  I was probably shown to do this during dental school....

Ashley


Monday, December 19, 2011

Episode 234/500: Periosteal Release and Bone Graft - on Pork Ribs?


I thought that a resident colleague mentioned that when he was on a periodontal clinical course, they practiced periosteal releases on porcine ribs.  It so happens that when I was talking w/ Dave this evg (he and his adolescent children came over), he only practiced crown lengthening on porcine jaws and stabident on porcine ribs......where did I get this releasing incision idea from?  I have no idea....but..it's done.

Anyways....

I was watching another method of periosteal release (in the OR) and figured I'd revisit the release - with a porcine rib.  I also tried using a bovine (cow) rib, however, the periosteum is about 1.5 mm thick - similar to a leather belt. The porcine rib better mimics human periosteum which is several cells to 0.375mm thick (see article below).
The periosteal release technique appears to be a well protected secret. I have no idea why it is a secret, but, it is rarely described by any author (other than the article referenced below), and yet, it is one of the many critical steps to successful ridge augmentation. Tension free flaps during augmentation procedures allow primary closure of the wound and prevention of flap dehiscence. Additionally, it is usually is performed before wound closure - meaning - that the clinician is tired by this point, and often, visual access is impaired (especially inferior to the anterior nasal spine).
The amount of release required dictates the type of release/periosteal scoring that you need. However, in my humble experience, you can never have enough easily moveable mucosa, ready to be sutured over your augmentation (or cashew in this case).
This was a one shot video, and there are a few errors that I'd like to point out - the largest being that I mean coronally positioned flap vs apically (around the 1-2min mark). A great article to review regarding tension free flaps is:

Flap advancement: practical techniques to attain tension-free primary closure (http://www.ncbi.nlm.nih.gov/pubmed/19228084)

I hope this helps,

Ashley


Sunday, December 18, 2011

Episode 233/500: Surgical Blade Handles and Adson Forceps

Here is a simple instrumentation post regarding scalpel blade handles and Adson forceps.  I have been fortunate to use variations of different instruments.  Different scalpel blade handles, for some reason, seem to make a little difference in placing precise incisions.  The classic #3 handle works well - universal.  For something that permits a little more precision (and uses the same blades), try the #7 handle - you can get it on Amazon of all places!

Adson Forceps - for manipulating tissues without crushing them.  From my cookbook days in dental school, there wasn't a significant amount of time dedicated to surgical armamentarium.  I can understand why...more on that later.  Adson forceps are critical if you're manipulating oral tissues during surgical procedures.  Often, there isn't an Adson forcep placed in the surgical kit, and it's too easy to reach/ask for a hemostat or regular pickups.  Use the proper pickups - it prevents crushing the tissue and decreasing the healing potential of the wound.

Cheers

Ashley


Episode 232/500: Holland & the Simple Rubber Dam

Folks,

I recently received a request for a close up video on the Simple Rubber Dam technique from a dental hygiene student from Holland.  Here is a photo of his technique w/ the hands free suctioning.

Pretty cool.

If you folks have other tricks/hints that have helped you clinically, please send them, or post them online and start a community.

Thanks Milad.

Ashley.








Thursday, December 15, 2011

Episode 231/500: Dental Iliac Bone Graft

Patient CW successfully underwent maxillary and mandibular ridge augmentations today - with the autogenous bone being harvested from her Right hip (Anterior Iliac Crest).  I shot video and photos, and then participated in the surgery by fixating the third onlay block to her left mandible.
She is currently resting overnight and will be discharged tomorrow.  The surgeries went very well with no complications.  The next stage is healing for approximately 4 months, followed by implant placement, and then, restoration.  Total time is approximately 2 years.


Here is the patient preoperatively w/ Paradigm MZ100 CAD/CAM crowns placed on teeth #2,5,12,15 (FDI: #17,14,24,27)....{I'm really starting to forget the FDI system of numbering after using the Universal system for 1.5 years}




The photos and video stopped around the completion of the augmentation to her right maxillary ridge, as I was invited to complete the mandibular left augmentation procedure.  No one else appeared interested in capturing pictures/video. :(

I will be posting video of the surgery soon.

For now:

Cheers

Ashley

Donor Site Preparation (Right Anterior Hip)

Donor Site Osteotomies

Harvesting Cancellous Bone

Cortical Bone Graft

Suturing

Final Closure

Right Sinus Entry.  This is the best photo I have :(

Elevation of Sinus Membrane

Packing Cancellous Bone into the Sinus (Sinus Augmentation) 
Measuring Block Graft Requirements for Maxillary Right
(The patient had 3 locations grafted)

Preparing the Onlay

Onlay is trimmed and fixated w/ cancellous bone grafted around
PRP placed 
First Sutures Placed

Wednesday, December 14, 2011

Episode 230/500: Endodontics or Implants?

Here is an abstract for an endodontic seminar that we are having tomorrow - minus me.  I've been given the green light to go to the Operating Room and assist w/ an anterior iliac crest bone graft to this patient's maxillary and mandibular arches. Here is my article abstract that my resident colleague has promised he won't discuss on my behalf.....I have a few choice words, but I"ll keep them to myself!

Often the question arises:  Why not just extract the offending tooth that requires endodontic therapy and just place an implant - easy cheesy right? (Dr. H's favorite saying).  There are many articles discussing the success rates of both endodontic therapy and implant therapy - however - it is fairly difficult to quantitatively compare the two treatment modalities.  Enter this recent article:  Quality of Life of Endodontically Treated versus Implant Treated Patients: A University-based Qualitative Research Study.

This article describes a study that involves a number of patient's who underwent either endodontic therapy or implant therapy, and subsequently talked about a number of issues (in groups) concerning their treatment.  I have summarized a few of the key discussion points that I was intending to discuss w/ friends around a fire (projector) tomorrow morning.  Saved by the OR.

Having placed and restored a number of implants - and completed many orthograde and several surgical endodontic treatments - I'll opt for the root canal over implant...anyday.

Please enjoy. Let me know your thoughts.

Ashley



Radica/Ribbond Provisional FDP - Removed today for OR surgery tomorrow. 
BisAcryl Provisional FDP - removed as well for the Ridge Augmentation Surgery tomorrow.

Note the Allen Class C (vertical and horizontal) ridge defect requiring
significant augmentation prior to implant therapy. 

Both Maxillary 4 unit FDPs were sectioned and replaced w/ provisional FDPs.
The provisional FDPs have been replaced w/ single crowns on the abutments.

"Provisional" MZ100 CAD/CAM crowns luted on abutments. 

If the patient is satisfied w/ esthetics and function, these crowns will act
as provisionals for up to 12 months:
4 months healing post ridge augmentation
4 months post implant placement
2 months restorative procedures


Episode 229/500: Blackhawk UH-60 Simulator

Not a lot of dental tricks happening in this post - however - thanks to Dr. WPG, he arranged for the residents to take a ride in the full motion Blackhawk UH-60 simulator.  It was a great experience!  We all had a turn flying VFR for approximately 15 mins with full motion - which makes it fairly realistic.  #No rep, Dr. W and I were together for the first flight of the afternoon, after our oral board examinations.  We all received red screens of death during our flights - and walked away.

Here are a couple of a videos online showing the full motion simulator.
The first one is about the sim. It is much more exciting than my video of low and fast and a couple of poor attempts at landing.

Thanks WPG.

Ashley






Sunday, December 11, 2011

Episode 228/500: Milled Titanium Bar - Implant Supported Denture

I just received a 3i milled titanium overdenture maxillary bar.  Here are the preliminary photos.  Similar to the "All on 4" methodology of restoring the edentulous patient - we'll call this situation an "all on 3".


Brief patient overview:

  1. 50 YOF
  2. Born w/ cleft palate - Le Fort 1 and mandibular set back ~15 years ago
  3. Received 6 x Branemark implants in the late '90s - Maxillary arch
  4. Heavy smoker
  5. Out of 6 original maxillary implants, she has 3 useable (4 remaining).  
  6. Unable to tolerate a conventional denture
  7. Currently has locator abutments on maxillary and mandibular implants.  
I was pretty excited when the bar fit.  Complex cases (as I'm learning) are, at times, a struggle between patience, patients, and attention to detail......damned that 3rd point.

Points up to here:
  1. Should have used a verification jig to verify impression/cast to reality prior to having the bar milled.  The bar fit when it returned from the lab - however - I wasn't 100% sure that it would.
  2. Currently trying to determine the maximum "cantilever" length possible distal to #6
Next Stage:
  1. Waxup w/ denture teeth (maxillary and mandibular) and wax tryin
  2. CR record confirmation (confirm intraoral to articulator)
  3. Purchase correct clinical screws
  4. Flask
I'm excited!

Thanks Dr. K

Ashley
Occlusal View - 6 original implants

Frontal





Saturday, December 10, 2011

Episode 227/500: SOAP Notes

I never really understood how to use SOAP notes practically.  Yes - it's fairly straightforward, but how does one use this in a dental chart?  What am I looking for during the exam?

Well, one day, as I was getting my chops busted as a junior resident, I was guided by one of our OMS mentors (Dr. Kris Hart) as to one of many methodologies of how to collect, analyse and present patient data.

I uploaded the example (PDF), and a blank word and pages document for your review - at - your leisure of course.  I trust that you will be able to download them from slideshare - if not - comment and I'll change the file sharing site.

Cheers

Ashley




http://www-personal.umich.edu/~szwetch/SOAP.html

http://forums.studentdoctor.net/showthread.php?t=422481





Here are some formats that I placed on slideshare.net.

Episode 227/500: AEGD-2 Residency - Board Exams

What a great time of the year for all students.  Exams.  Including us as residents.  As I"m sure with all residencies, the point of board exams (oral and written) is ensure that the residents are learning a some sort of rate - and - now, mentors can sit back and pass on the pain of sitting in the hot seat - to someone else.

I subscribe to #dentalschoolproblems on twitter and always amused by the really artful and creative tweets from some dental students.  Of course,  we all remember well the days of too many exams over too little period of time.

Some recent tweets:


3 exams down 6 more to go.... Done on Wednesday. I ask is 9 exams legal in less than a week?? #dentalschoolproblems#livinginthelibrary
~50% of our class failed our last final. Not joking. Worst test ever written#dentalschoolproblems
nothing like starting the week out exhausted. from studying. not partying. obvi.#dentalschoolproblems

In this residency, we have oral boards and 2 written boards.  During the oral boards, we all wander around the building, spending 20 minutes in each mentor's office, getting grilled on material covered in the past 6 months..perhaps.

There is also the classic written board which is 200 questions - either hand fabricated or old board exams from other speciality residencies.

Finally - there is the write for life.  A 4 hour treatment planning session where you have to essentially take a case and develop a comprehensive treatment plan and rationales in 4 hours.....I'm still questioning the utility of this exercise in treatment planning.  It is, however, a long exercise that consists of continual writing for the 4 hours.

If you've tracked to this point- here is where I say, "I am sorry for the few posts, I"ve been studying and preparing lectures that have since been delivered as of yesterday"

Ashley

Episode 226/500: Denture Custom Tray Fabrication

This was a great hint from Dr. Lundell (He is the the say ahh guy - impressive ability to resist gagging) and Dr. K.  They had a patient present with a broken maxillary denture and were planning on fabricating a new set of complete dentures for the patients. The patient was a gagger and barely could tolerate alginate impressions - although - he did have set of dentures.  Perhaps the fracturing of the denture was due to thinning of the palate to make the denture more palatable?

Terminology:
Intaglio:  Inside surface of crown/denture, etc
Cameo: Surface of prosthesis facing the oral cavity.

The idea is to fabricate an edentulous custom tray directly on an impression of the intaglio (inside) surface of the dentures.  Rather than make preliminary alginate impressions and preliminary casts (upon which custom trays are fabricated), the custom trays fabricated directly on the impression.

Steps:
1.  Impression of the intaglio (inside) surfaces of the denture w/ alginate
2.  Place a few bent paperclips into the alginate to hold it in place
3.  Pour a "cow patty" base in stone and set the alginate impression onto the stone.
4.  Salt/pepper custom tray resin over the alginate to fabricate a custom tray.

You could substitute alginate w/ any other impression material.

Thanks to Dr. Lundell and Dr. K.

Cheers

Ashley


Tuesday, December 6, 2011

Episode 226/500: Excruciating Tooth Ache - Friday at 4pm

The conundrum - to help a fellow human with Symptomatic Irreversible Pulpitis - to relieve their pain and throw on the superhero cape.  However - let's add to this scenario.  It's 4pm on a Friday and you have to be with your family by 5:30 to leave for a vacation.  Yikes.  Now what?

You know deep down that this can of worms may develop into a wrestling match that may end at 7pm and neither party is happy following the exchange.  No - this isn't tag team dentistry.

Well - here is one of many tips that I've learned from Dr. Kenneth Hargreaves.  A kind, funny, humble man who has a deep passion for pain........


Success of an alternative for interim management of irreversible pulpitis
Mcdougal et al. JADA, December 1, 2004 vol. 135 no. 12 1707-1712

Emergency pulpotomy: pain relieving effect with and without the use of sedative dressings
Hasselgren G, Reit C; J Endod 1989;15:254-6; 


It turns out that a few studies have shown that rather then completing a pulpectomy for a tooth diagnosed with "vital" Symptomatic Irreversible Pulpitis, there is another option - a pulpotomy.  Remove the pulp - stay out of the orifices, place a restoration and reappoint to continue the endodontic therapy.  I had no idea.

Thank you Dr. Hargreaves,





Cheers

Ashley

Monday, December 5, 2011

Episode 225/500: Local Anesthetic Reversal - Oraverse

Ever liked going to the dentist - me neither.  What's worse, is that numb feeling that seems to go on for hours.  Well - maybe not so much anymore.  I learned of this product called Oraverse, which is touted to decrease the length of action on soft tissue by local anesthetics.

Soft tissue?  What are you talking about?

Lips, cheeks - things that matter when you have to eat lunch w/ others, or present at a meeting after a dental appointment.

So.....since our clinic box of Oraverse is about to expire, I figured I'd give it a shot and have a resident colleague provide a local infiltration (tooth #6 - FDI #13) w/ 1/2 carpule of 2% lidocaine 1:100k epi and then infiltrate w/ 1/2 carp of Oraverse 15 mins later.....and time it.

Truly, I should have had the left side anesthetized as well - for control.

Here are my results from my little case study.

PS.  It doesn't have an intoxicating effect - even though the video thumbnail makes me look like I'm buzzed.

Cheers


Ashley


Sunday, December 4, 2011

Episode 224/500: CEREC - LAVA Ulitmate

I've been working with E4D and CEREC (3 and AC) for approximately 1 year.  We have an incredible opportunity to push the envelope and use CAD/CAM for whatever situation we see fit.  Here are a few things that I've learned when designing an onlay for tooth #12 - (FDI #24).  The material I'm going to be using is a composite block from 3M called Lava Ultimate.  It's based on Filtek Supreme (silica/zirconia fillers).  I will have some intraoral video soon of this crown and onlay.

Here is a question that we've been throwing around:

1.  Why does this material have to be silanated before cementation?  It's composite, non?  Don't we silanate porcelain crowns?

2.  Because these Lava Ultimate blocks have to be silanated (resin) - shouldn't regular composite be silanated when repairing them?  Note - repairing - not initial placement.

Cheers

Ashley




Thursday, December 1, 2011

Episode 223/500: Reverse Crown Preparation

I was attending some local continuing education and picked up quite a few hints that I will share over the next few weeks.  The presenter was a staff prosthodontist who works at a VA laboratory.  He shared a few things that aren't game changers, however, are significant enough that will make a difference in a few of the things that I do.

Here is a video that he showed which was coined the reverse crown preparation. Most of us had never heard of this technique.  I"m not sure how applicable it is to your practice, however, I figured I'd share it.

Cheers

Ashley

Episode 222/500: Add Wax to Denture Base w/ Saran Wrap?

Problem: I need to add wax to maxillary wax rim before try in.  I"m not setting maxillary teeth before the esthetic tryin......b/c I know I"ll end up moving them!

Solution:  Saran Wrap.

This technique can be used to add vertical wax height even if you don't have teeth set.  This way, you won't wax-glue your rims together.

Cheers

Ashley











...and......just a reminder video about wax rims.


Tuesday, November 29, 2011

Episode 221/500: Sectioning a Crown - with a 330 bur?

I was sectioning an FDP (bridge) on this patient yesterday and Dr. K waltzed up to my operatory (dental cubicle) and suggested I use 330 bur to section the crown.

??

It worked like a charm.

Cheers

Ashley


PS:



Note the Rubber dam technique for this 4 unit FDP; explained here:











Monday, November 28, 2011

Episode 220/500: Promotion to Major

Today was a special day - a little out of the ordinary - I was promoted to Major.  It was supposed to be a "secret", but Dr. K likes to verbalize his emails as he reads them.  I was sitting in his office, waiting to discuss a case, as he started reading an email - "Don't tell Captain Mark, his promotion is a surprise".....and then...he continued to finish the 400 word email.  Upon finishing this email, he turned and looked at me and said, "Uh oh......you didn't hear that from me!".

Thanks to my beautiful wife for preparing the surprise luncheon that I helped cook the potato salad for...all day Sunday.

...and of course, Iris, Dave, Katie, and Jess for all your help and coordination.

Ashley


Until several years ago, the insignia for Dental was CFDS
Canadian Forces Dental Services - or - to a lesser extent:
Canadian Forces Dance Squad

Sunday, November 27, 2011

Episode 218/500: Adhesive Posts - the future or past?


I started this post as a reply to a comment on Episode 217 - custom dowel post.  But...it turned out to be longer than I initially thought it would be, so - as in the words of Latte Ice - "here we go"


Anonymous said...

What do you mean by adhesive technology? You use fiber posts/cores (ie. with luxacore?) Could you elaborate a little? Thanks!



You raise a great point.  After reading your question, I  actually started second guessing what I meant as well.  I am referring to using fiber reinforced composite posts and a dual cure adhesive.  I reviewed the literature this morning and afternoon on the current status of post systems.  This article summarizes almost everything, except Cast Post and Cores.



Ok, so - here is where I was about 1.5 years ago.  I was trained to use 1 of 3 techniques to retain a core.

1.  Good ol' metal serrated post.  I believe that the idea is to passively fit the post into the canal system, lute it with some cement and build up the coronal portion with amalgam....and maybe composite?  I think the composite was old school (I just saw an article from 1987) - but - that was newer school than I was before the residency.  The worse part of using these is drilling the post space.  I can't stand it.  Even today, after 10 years of practice.






2.  The golden beast.  I've fabricated a number of these and although the idea before starting the procedure is entertaining - fitting one always seems to be a challenge.  Also, once the tooth is broken from one of these - it's really broken.


3. Amalgam Radicular Core - something like this radiograph below.  I still use these on occasion.  We have access to 3 CAD/CAM machines, therefore, the use of amalgam is fairly low at the moment.




Fiber Reinforced Composite Post and/or Ribbond


I'm not an expert by any stretch of the imagination, and, I've asked a number of really smart folks here and they don't know the answers either when it comes to using adhesives and posts.

Metal Posts

 Fairly straightforward - Fence post in ground to a decent depth so the wind won't blow fence over,  concrete the base -let set, finish fence.  Got it.

Adhesive Posts


Here is a great place for some material reviews D.T. Light-Post Review by the Airforce

What are we really trying to achieve with a fibre reinforced post?  Is it:
  1. Monoblock structure of composite in the canal? 
  2. Post adhered to the dentin walls with shrinkage gaps between the post and cement?
  3. Long parallel sided post for "mechanical" retention?
  4. How long does the post now need to be if I"m adhering it?
  5. Do we need a post at all?  What about Fibers - ie - Ribbond?
As far as I can see, there are a number of factors affecting adhesive posts.  I've now come to question what we're trying to achieve with a post anyways.  I mean, if we're trying to adhere to the inner canal system - why use a post? Why not just place some luxacore down the canal system and build up the core on that?  I"m sure that's not a great idea secondary due to composite shrinkage, C-factor and many other little details.

What about the fact that the adhesives don't bond to the posts very well - and - what about the obturation junk left on the canal walls, including AH+, Roths, NaOCl, EDTA?  Yikes.  A poor dentin bonding MPa of RelyX Unicem of 7 mPa to fresh dentin isn't surely going to bond well to canals with mud on them - even after you clean them mechanically...But then, do you really need 3.5 mPa of shear strength to retain a post?  The data is in the document below.



So, maybe the idea is to create a monoblock structure, try to reduce adhesive shrinkage, reduce C-factor (or manage it) - what about something like Ribbond?  What I like about this idea is:
  1. No need for a drill like a parallel sided post (I haven't perforated during post placement - I've perfed other times during endodontic access, however....) 
  2. Perhaps the best attempt at creating a monoblock structure in the canal system.  
  3. The fibers are used to decrease the amount of cement shrinkage
  4. No post to shrink away from.
  5. The ends of the fiber are placed in the pulp chamber to bond to as well as to decrease C-factor  on the pulpal floor.
More to follow...the never ending post discussion.

Let me know what you think.

Ashley
    Adhesive shrinkage away from the fibre reinforced post

    It was there, now it's not!

Saturday, November 26, 2011

Episode 217/500: Custom Dowel Pattern

Cast Post and Core - This is what I believed in before I joined the residency in order to fix a severely broken down tooth.

Now - Adhesive technology.

However, for something to remember (like the days of cassette tapes), here is an excellent video describing one way of creating a custom dowel core.  Thanks to Allen Dray for providing this video.


Thursday, November 24, 2011

Episode 216/500: Dental Anticipation - The Good Kind....perhaps?

This is you.

You have:

  1. Been edentulous in the Anterior Maxilla for 25 years.  
  2. Severe Generalized Chronic Periodontitis and recently underwent maxillary osseous resection w/ apically placed flaps bilaterally (both procedures were successful in the eyes of the patient - he doesn't have blood on his toothbrush anymore).
  3. Generalized Miller mobility of 2
  4. A desire to have fixed teeth. Period.  The ol' valplast just isn't working.
  5. Inadequate ridge width for implant therapy and insufficient time for an implant based overhaul.
Ok.  This one is a shoe in.  An easy case to hammer out esthetically.  A classic fixed prosthesis is perhaps frowned upon w/ the miller mobility of the abutments - however - Ribbond is in.  BTW, he is a great patient.  Funny, quiet and very appreciative of what we've done so far.....

We selected the shade preoperatively, and the patient was happy - C4.  Unfortunately, in the process of adapting the teeth to the ridge and Ribbond, the dentin shading of the teeth was removed...and..the teeth became....B1 maybe?






Edentulous for 25 years

Edentulous for 25 years


No problem.  Here's what you started with (Valplast) and yes, what I ended up bonding to the Ribbond was much lighter - but - you've been edentulous for many years and I'm assuming this is better than what you had, right?


Valplast

Removed the dentin shade in the denture teeth.
 Hollywood white, right?

Well, we've decided to revisit the denture teeth shade issue and in January, I will replace the 2 denture teeth with either composite or Radica based teeth.  We'll do our best to match the shade.  Maybe I didn't discuss expectations well enough with the patient.

The point of the above case is:  
Anticipation.  

I don't really have time to read anything other than literature and/or dental stuff - and - with blogging....well...time is limited (Not to mention child #3).  But, I do have time to listen to audiobooks to and from work and this book:



has really made me think about patients and anticipation of the final result - be it - orthodontics, surgery, periodontics, and restorative....maybe endo?

Here is a great snippet from his book - perhaps the above patient's wife had been anticipating all his teeth matching?

Prospection and Emotion


"We daydream about slamming the game-winning homer at the company picnic, posing with the lottery commissioner and the door-sized check, or making snappy patter with the attractive teller at the bank—not because we expect or even want these things to happen, but because merely imagining these possibilities is itself a source of joy. Studies confirm what you probably suspect: When people daydream about the future, they tend to imagine themselves achieving and succeeding rather than fumbling or failing. Indeed, thinking about the future can be so pleasurable that sometimes we’d rather think about it than get there. In one study, volunteers were told that they had won a free dinner at a fabulous French restaurant and were then asked when they would like to eat it. Now? Tonight? Tomorrow? Although the delights of the meal were obvious and tempting, most of the volunteers chose to put their restaurant visit off a bit, generally until the following week. Why the self-imposed delay? Because by waiting a week, these people not only got to spend several hours slurping oysters and sipping Ch√Ęteau Cheval Blanc ’47, but they also got to look forward to all that slurping and sipping for a full seven days beforehand. Forestalling pleasure is an inventive technique for getting double the juice from half the fruit. Indeed, some events are more pleasurable to imagine than to experience (most of us can recall an instance in which we made love with a desirable partner or ate a wickedly rich dessert, only to find that the act was better contemplated than consummated), and in these cases people may decide to delay the event forever. For instance, volunteers in one study were asked to imagine themselves requesting a date with a person on whom they had a major crush, and those who had had the most elaborate and delicious fantasies about approaching their heartthrob were least likely to do so over the next few months."

Gilbert, Daniel (2009-02-24). Stumbling on Happiness (Kindle Locations 386-395). Random House, Inc.. Kindle Edition.

It all comes back to ensuring that we discuss expectations before treatment, b/c, as in the wise OLD words of Dr. Allen Dray:

"Explanations after the fact are just excuses"

Cheers

Ashley

Tuesday, November 22, 2011

Episode 215/500: Articaine Infiltration 3rd Molar Extractions

Oral Surgery Clinic

wisdom tooth, third molar, extraction mesioangular, impaction, surgery


3rd molar extractions - full/partial bony impactions under local anesthesia.  Lots of fun on the receiving end of this stick.  I compare the central sensitization theory on pain to tickling my sons.  Once you start the tickle train, all you have to do is look at them, and the boys will start laughing.

It appears that this may be similar to molar extractions.

Assume local anesthesia is completed (2% lido, 0.5% marcaine) and I ensure that I have adequate anesthesia (numb lip test does not indicate pulpal anesthesia)....more on that topic later....I let the patients "marinate" for approximately 15 mins to ensure "solid" local anesthesia.  I have another lit article on the times required for anesthesia - more on that later as well!

Let's pretend we're now just completing the ostectomy on the mandibular left 3rd molar, and just about to section the tooth and.........the patient winces.  Oh no.  It has been my experience that once the patient experiences pain during a procedure - all bets are off.  It's like heroin (always chasing the first high?) - I just can't get back to that complete level of solid anesthesia.  The patient is seemingly always experiencing something.  Perhaps, they are experiencing allodynia.  The definition of allodynia is "is a pain due to a stimulus which does not normally provoke pain".  Of course, on a normal daily basis, poking around 1cm into someone's mandible would elicit a painful response.  Therefore, I need to clarify that I think I'm referring to sensations such as pressure - that are now being perceived as pain.  Or - the patients are so wound up by this point (I would be also), that, any little movement (remember tickle train) is in anticipation of a painful response.  

Anyways, like the tickle train, I've extracted enough 3rd molars to know that once on the tickle train, it's a really bumpy road to the finish.  Enter ARTICAINE!  I believe this made a SIGNIFICANT, although empiric, difference in my ability to achieve complete mandibular anesthesia.  No tickle train like usual today.

Thanks to Dr. Elyassi for chop crushing not only on paperwork and administrative responsibilities, but also for reminding me about these 2 articles that we recently reviewed in our current literature seminar:
Quick point
  1. Use 1.7 mL Articaine to infiltrate the buccal mucosa for mandibular molar extraction, in addition to the standard IAN block using Lido 2% and Marcaine 0.5%.
  2. Use Articaine to infiltrate Maxillary molars (don't forget the greater palatine block)
CONCLUSION:

The IANB injection supplemented with articaine buccal infiltration was more successful than IANB alone for pulpal anaesthesia in mandibular teeth.

CONCLUSION:

The efficacy of 4% articaine was superior to 2% lidocaine for maxillary buccal infiltration in posterior teeth.

Monday, November 21, 2011

Episode 215/500: Blue Mouse to Check Crown Prep Interocclusal Clearance

Well - it's hard to imagine that everyday I learn something new.  The basics just keep reinventing themselves.  I also wish that I could openly verbalize the issues that really frustrate the heck out of me - but -  of course, that is an entire waste of time and energy.  Thank goodness for lunchtime workouts.

BTW, this Movember gig is just about over!

Ok, back on track.  So - there are many methods to checking crown interocclusal clearance - usually using some sort of caliper device.


  1. Wax
  2. Interocclusal tabs (1.0, 1.5, 2.0mm)
  3. BlueMousse
  4.  ?
  5.  ?
  6.  ?
  7.  ?
Dr. Dray mentioned this small hint today, as he watched from a far, closely, at what I was fumbling with in my hands.

Prosthodontists!

Cheers

Ashley





Friday, November 18, 2011

Episode 213/500: Simple Orthodontics to Move Single Teeth

Yesterday - 17 Nov 11.

0730hrs.  Ready to cement a CAD/CAM crown - I wasn't extremely happy about the contours of the crown. However, I had milled three different variations to try to achieve a functional result, and, the intertooth distance btn #14&15 (FDI #26,27) was limited.

"I"m sorry Dr. Mark, but, the palatal contour of this crown just isn't perfect.  Let's move the 2nd molar and redo."

??????????

Dr. K wanted me to distalize the left 2nd maxillary molar to gain approximately 1.5mm restorative space for a crown on #14 (FDI #26). I had the crown milled, fired and ready to go for insert.  I was like..come on?  After 2 rounds of kickboxing...or well...gentlemanly discussion, he proposed that I prosthodontically distalize the 2nd molar.  You know - the ol' move teeth by adding provisional material to your provisional crown each week after you place separators - for like - 8 weeks.

I figured I could meet him halfway - with - simple orthodontics.

"Sir, I"ll meet you halfway.  I really don't foresee the 'place separators and followup once a week, then add interproximal bisacryl to the #14 provisional - and do that for 8 weeks - taking 8 weeks.  With our schedule, it will take months."  "However, using simple orthodontics to distalize that tooth and see the patient once in 4 weeks"  He conceded. I won.  Not really.  We both gained by learning each other's techniques.  I am his grasshopper.

End learning tip.  If you need to distalize a tooth, you have several options:


  1. Prosthdontically (Provisional restoration, ortho separators, addition of provisional material at each followup period)
    1. Pros:  Cheap (don't need brackets, wires), easy to do
    2. Cons: Slow, clinician painful, need patient followup weekly
  2. Orthodontically (either TADs, removable ortho, or fixed)
    1. Fixed
      1. Pros:  Easy, fast, stable, only 1-2 visits
      2. Cons:  Need basic ortho supplies




Wednesday, November 16, 2011

Episode 212/500: Orthodontic Debonding

Patient MS has now had 4 hours of relief from fixed orthodontic appliances.  As of today, he is 3 grams lighter (I really have no idea) since we removed both maxillary and mandibular braces.  It's a fairly straightforward process.  This is an interesting case b/c it was my junior comprehensive treatment planning board patient.

Here is the treatment plan:

  1. Fixed orthodontic Appliances (~12 months) 
    1. Goals: 10% overbite, 2 mm overjet, intrusion #14
  2. Implant Supported Mandibular RDP
    1. Placed Implant #18
    2. Changed to Kennedy Class 3 RDP w/ Implant #18 to be crowned
  3. Crown lengthening #14 (and possibly a few other areas)
  4. Maxillary Crowns and FDP #11-14 (yes, I realize this is a 4 unit, however, it will oppose plastic teeth)
  5. Mandibular RDP (tooth/implant borne)
We're now approaching Phase 3

Cheers

Ashley


Tuesday, November 15, 2011

Episode 212/500: University of Oklahoma - Crown - Waxing Start and Gold Finishing

A resident colleague sent me a link to an RPD test from the University of Oklahoma College of Dentistry website.  We're in the midst of studying for December board exams as well as our ABGD March Board exams.

http://dentistry.ouhsc.edu/rpdreviewquestions/

Then, I started peaking into some of the other resources available on their site and I found this one.  Start to finish, waxing and finishing a full gold crown.  Here are a few videos and the link to the entire page.

http://dentistry.ouhsc.edu/fpd/Clinical%20Aids/visualLabguide_fgc/Pam%20waxing%20Session/index.html#Margins






Episode 211/500: Dental Dad Diary


I'm not sure how this guy has time to blog, but he does.  "Dental Dad" is a second year dental school student who blogs on his endeavors in preclinical labs.  His latest posting on "#11 ProTemp Provisional" really caught my eye.  This guy has either talent or sheer determination to make plastic look that good.

Please take a look at his blog.  I enjoy reading it because it reminds me dearly of what I escaped....barely.