Wednesday, August 31, 2011

Apicoectomy #10

Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)
Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)Apicoectomy #10 (FDI #22)

Apicoectomy #10, a set on Flickr.

Episode 118/500: Apicoectomy - On the Cast Incision Outline

Today, I finally developed an appreciation for endodontic microsurgery.  Not so much an appreciation for the apicoectomy procedure itself - I was appreciative of that already.

It was regarding flap design and the types of incisions when I finally had that, "ah-hah" moment.  Finally.

Key points wrt apicoectomy flap design:

  1. Endodontic surgery is dealing with "typically" healthy gingival tissue - therefore the use of papilla sparing flap design is, perhaps, encouraged.
  2. The papilla sparing incision consists of 2 incisions:
    1. The first 45 degree angled incision barely makes the mucosa hemorrhage.  It develops a split thickness design. 
    2. Return through the initial split thickness incision and angle the blade approximating an intrasulcular incision - contact bone.
    3. This style permits an easy re-approximation and suturing of the flap.
  3. Microsurgery using the microscope, 15c blades and tiny sutures enable the clinician to develop a super clean flap design, precise.  Suturing with 6-0, or 8-0 sutures speeds healing.
This is an introductory video showing the incisions on the cast prior to surgery. 

More to follow including a discussion regarding the decision to opt for an apicoectomy....must...finish....diabetes lecture.....for tomorrow....haven't started....arg.



Tuesday, August 30, 2011

Episode 117/500: Comprehensive Case #2 - Treatment Update #1 - Endo #5 Completed

Since the approval of my "Treatment planning board patient" a few fridays ago, I've started treatment on this patient -

I completed the endodontic therapy on tooth #5 (FDI #14) and wanted to quickly show a restorative option using a dual cured composite core.  I've elected to use a radicular composite core with Luxatemp.  and will have sufficient ferrule to retain the crown.  If you were asking with your inside voice regarding a post - a post would not be indicated b/c of the number of walls remaining - however opinions vary based on the fact this will be an RDP abutment.

The core will also cover the cusps (I reduced the cusps during endodontic access) to act as a cuspal coverage before the final restoration is fabricated.

The final restoration will be an e.max lithium disilicate crown (contours based on my waxup) which will serve as an RDP abutment.

Here is my waxup for this case.  The canines and tooth #4 (#15) will be replaced with an RDP.  The remaining teeth will be lithium disilicate crowns.

The canines will be denture teeth - therefore - don't get worked up about the waxup.  I was choked when I posted this as well - the facial contours of the canines can definitely be improved:

  1. Gingival 3rd is the most facially prominent portion of the canine,
  2. Both canines show too much distal aspect - either rotate or carve wax


Episode 116/500: Lingual Arch Band has debonded!

We achieved 3 months with this lingual arch - and it didn't break.  The mandibular left 1st molar band came off a few days ago, and this lingual arch has been floating around in this young girl's mouth.  I"m amazed it wasn't bent!  We successfully lute it down with dual cured glass ionomer cement.  I have the final video, but need to edit it - she's squirming!

We're using a lingual arch to preserve space and prevent mesial shifting of her posterior dentition.



Monday, August 29, 2011

Episode 115/500: After all, knowledge does no good, unless it’s shared.

I almost cried - internally..........not quite though.  Our new resident Oral Surgery Mentor, let's call him Dr. NCP (no cut and paste), wrote this at the end of his welcome objectives letter.....

"At this point in our lives, as professional adult men and women, we have to hold ourselves accountable for our own actions.  We have to hold ourselves to the highest standards, especially since we took an oath in the healthcare field to “DO NO HARM”.  We, therefore, have to make every effort and continuously strive to do what is best and safest for our patients.  We owe it to our (patients)."

"One of my mentors during my residency taught me something invaluable.  Because of her, before treating any patient, I always ask myself, Is this the best and safest thing for my patient?  In other words, would I do the same thing, if my spouse, mother, father, sister, or brother was in the chair?  And if I am the patient, wouldn’t I want my doctor to know everything there is about me and the procedure he is about to perform on me?"

"Just as I have learned invaluable and unforgettable lessons from my mentors, I hope that one day you will look back and say that you learned something invaluable from me.  After all, knowledge does no good, unless it’s shared."

"Simply said, I want you to have the best oral surgery rotation ever.  Together, we can learn from one another and make this an unforgettable experience."

I'm..speechless.  I will look back and remember the pimpage beating you dished out to Dr. In.s.ain.i.  (BTW, he told me the story today.)

Thanks Dr. NCP.  We're all excited to have you aboard.  These are words of wisdom to remember.



Episode 114/500: What would you do?

What would you do?  Post ideas/treatment to comments.

Tooth #12 (FDI: #24).  This was picked up today during an annual exam on the open tray implant impression technique patient episode 113.

39 YO female presents with no chief complaint, and is asymptomatic regarding this tooth.
Current/Past medical history clear.  No medications.  No past surgeries.
The ideal patient.
  1. Tooth slooth- no response
  2. Percussion - no response
  3. Cold - normal response
  4. Probing depths - <3mm
  5. Occlusion:  Left excursive = group function
  6. Radiographs (Bitewings/PA) = normal
  7. Maximum Intercuspation - Occludes on the palatal cusp #12.


Episode 113/500: Open Tray Impression Technique

Here are a series of videos on how to take an open tray impression for a dental implant.  It turns out that we didn't have the correct impression coping (size) for the implant - so - we had to improvise.  Nor did we have closed tray copings either!  I grew up on a farm in the middle of Canada - you have to improvise all the time.  It worked.

The restoration will be a screw retained implant crown, followed by a perio surgical technique to increase the width of attached gingiva.  There is no attached gingiva at the moment.  We're using a screw retained implant due to a minimal amount of interarch space.  The attached gingiva issue.....I'll white board it later....I have a diabetes lecture in 2 days and have to get cracking on it.

Thanks again to Dr. K({orea}) for his guidance, mentoring, and patience.  I'm always in his office searching for implant pieces - he's always on the phone with his stockbroker.  Just kidding - parole officer.



Episode 112/500: GSW & Extraoral Dressing

This past weekend, I was tasked to change the dressing on a GSW patient - gun shot wound.  This kid was lucky.  The exit wound was fairly small.

Here is the key for suturing extraoral wounds.   With any wound - suture the margins first, then suture towards the centre.



Sunday, August 28, 2011

Diagnostic Waxup for an Implant Stent

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Facial Contour imageFacial Contour photoFacial Contour photoOcclusal ViewDenture Tooth WaxupDenture Tooth Waxup
Denture Tooth WaxupDenture Tooth WaxupDenture Tooth WaxupDenture Tooth WaxupDenture Tooth WaxupDenture Tooth Waxup
Waxup, a set on Flickr.
This is the photo set of a video compilation for waxing up a single tooth for an implant surgery stent.

Episode 111/500: Anterior Tooth Waxup - Start to finish

I had a request to video a waxup start to finish - I apologize for the poor lighting in advance.  This waxup is 14 clips - so - I hope you find it helpful.  I have also included photos to compare it to a denture tooth waxed into place.  Compare contours - facial, mesial, distal and palatal.

Value Added Points:


Review the images of the waxup.  Compare the contour of adjacent teeth to the waxup itself.  This will guide you not only for waxups, but also for anterior composites.  This case is for an implant stent, hence, none of the other teeth are adjusted.  I need the stent to fit to his existing dentition the way that it is.

  I have put videos 1-14 on a page by themself.  Please click the link below to access them.  The direct link is below the header.



Saturday, August 27, 2011

Episode 110/500: Mounting Casts on Articulator with a Fakebow

What are the indications for a facebow when mounting casts on an articulator?  Honestly, until I met Dr. Alyn Dray and Dr. K{(orea)}, I really had no idea.  This is what I've learned:

Facebow indications:

  1. Changing the Vertical Dimension of Occlusion
    1. Fixed or removable
  2. Multiple complex restorations
  3. Anterior Maxillary Esthetic work?
Based on those guidelines, I'm mounting this implant case (to replace #9 [two-one]) with a fakebow.  

The term fakebow is loosely referenced in the 2011 GDT manual (Glossary of Dray Terminology)

I figured I'd try fixating the max/mand cast together with zip ties - it worked!  I made notches in each cast to ensure that the ties didn't slip upon tightening and voila.  I used base plate wax to place the casts arbitrarily in the articulator.  "A little this way, a little that way" - just ensuring that the midline is coincident with the pin and the occlusal plane is flat.

Thanks to my oldest son for mixing.  I love you.


Friday, August 26, 2011

Episode 109/500: Rapid Palatal Expansion

Dad had crowding, his older brother had crowding - guess what?  You guessed it.

There is limited space for the eruption of #7 and 10 (12/22), therefore, we elected to place an RPE (Really Practical Eurolympics - that's all I could come up with @ 2320hrs).  The bands are luted with a light cured Glass Ionomer Cement.


  1. Fit bands to maxillary molars (in this case)
  2. Take alginate impression with bands on teeth
  3. Remove bands from teeth and place into alginate impression.  You can crazy glue them into place and/or use ortho wire to make a "cage" - I'll post something about this
  4. Pour up in stone
  5. Fabricate.
The RPE is luted down and cranked open about 3 full turns - or - until there are tears in the patient's eyes.  Then, it's one turn at night and one in the morning.  Followup in 1 month.

**Note**  Warn the patient that their central incisors are going to have a large diastema between them - We'll talk about stability of the expansion in a later post.

Easy Cheesy.


Episode 108/500: Lab Steamer - where have you been my entire life?

 I remember first being introduced to the lab steamer in Belgium.  Claude (lab tech) was doing something and then used the steamer to clean up a crown (or a die).  I was like - wow.  Where was that thing like - in dental school?

With a steamer, you can clean almost anything - almost - I've tried to get permanent marker off of something (even after trying with alcohol) - but it didn't quite pull it off.  Nevertheless, I am a believer.  Especially when you mess up dies, drawings on casts (RDPs) - you just steam and go - and never look back!

Here, I'm steam cleaning a CAD/CAM e.max crown before glazing - recommended by Ivoclar.



Episode 107/500: Separate Provisionals and Keep the Contact

Bisacryl - how you are my friend.  You don't smell, taste really bad, scald patients during your set, and you're easy to work with.

Bisacryl - you're my nemesis - you seem to like to keep air trapped in weird, clinically relevant places - you tear easy if I'm inpatient, and if I'm too patient, you lock in.

Almost as delicate as the first dance...

Here, I want to show you how I've slowly developed a taste for using a #25 blade to separate/trim provisional resotrations - particularly by initiating separation of imporant provisionals from the lingual/palatal aspect.  Nice and easy - develop a separating groove in the bisacryl and slowly apply force along the fracture line you've created.

You may have to add a little bonding agent or flowable composite to "beef up" the interproximal contact.  That's way easier that hamfisting with a rotating disk and restarting all over again - after 1 hr of unsuccessful screwing around.  Been there MANY TIMES and will continue to go back there.

Hope this one helps,


Episode 106/500: Traxodent - Stop Gingival Hemorrhage

Ok - the usual - I'm not receiving any money/cash/donations from showing this stuff.  I'm trying to stay away from looking like an advertisement - however - the reality is that everything we use has been made by some company.  Again - I'm in the Army and receive nothing.

I found this stuff it in the cupboard and figured I'd try it out.  I've seen it in the throwaway journals and was curious.

While it may not work in this situation to provide adequate gingival/finish line clearance for an impression - it did stop the hemorrhage in order to facilitate fabrication of tooth colored provisional resotorations - versus - tooth/hemorrhage stained restorations.  It was easy and fast.

Maybe someone can explain this:  In the sample box, there are like 10 syringes of Traxodent, and 5 assorted sizes of the gingival cup thing.  When I say five, I mean - 5 - and that's it.  10 syringes can go a really long way (I used probably 10% of this syringe for this case).  Is there some crazy markup for the gingival splaying cup things?  Weird.

Anyways, check it out.



Episode 105/500: Composite Fiddling and a Microbrush

I'm sure you've all seen those articles in the throw away journals where there is an amazing clinician fiddling around with composite and paintbrush.  I mean - really - who has the time and patients (patience)  to do that?  I"ve always wondered how they add different colors/shades to a single composite.  I've tried and failed.  Monochrome composite addition (A2) seems to work 98.34% of the time.

However, I've found that pushing and pulling composite with a microbrush and .07 uL of bonding agent gives you more flexibility than using a composite instrument.  Case dependent (Important!)

(Just kidding about the .07 uL - I've been busted soo often in residency for stating - "you know, a little of that" - "Dr. Mark - how much are you talking about?"  Just enough bonding agent so the composite doesn't stick to the bristles.

In this video, we are adding composite to this patient's canines to acheive adequate protrusive guidance from her canines.  I"ve completed the provisionals on the central incisors.  BTW, she has continually chipped the Right Maxillary Central Incisor Porcelain - and now we're at 3 crowns later and 1 month of time before ETS.  (What's ETS - extraterrestrial smackdown).
There are a few ways we can manage the protrusion in this case, including:

  1. Shorten the anterior crown length - not cool.  Her lateral incisors are at the same length as the centrals.
  2. Enameloplasty mandibular incisors - not bad.
  3. Crown canines - up for discussion.
  4. Composite addition to canines - wears away, but easily replaced.
Let me know what you think.



Episode 104/500: Bone Graft - Elevating Recipient Site Flap and Periosteal Release

Thanks to Dr. Kris Hart for mentoring me and teaching me this technique.  Did you know he was 2nd chair French Horn player in College?  I know what you're thinking...

Disclaimer - I think it's important to point out that although the following posts relating to a ramus bone graft make the procedure appear to be simple - and - well - it isn't that hard, the true skill of a surgeon is the ability to manage post operative complications.  I am not, by any means, providing these videos for you to go out and hammer out a ramus graft without proper instruction and facilities.  I am also not responsible if you do attempt this procedure and run into problems.  I am, providing you these videos, for you to understand what is involved when you refer a patient for ridge augmentation and the surgeon has indicated a ramus graft.  Now you have an idea as to what is involved and can appear more educated when you consult a patient.  Some of the complications that could occur during/after such a procedure:  (Dr. Kris Hart formulated this list on his iPhone)

  1. Mandible fracture - which then leads to:
    1. malocclusion, non union, malunion, chronic facial pain, chronic limited range of motion, ICR, osteomyelitis, infection, bisphosphonate necrosis, nerve damage, bleeding, hematoma, airway compromise, MI
  2. Flap Necrosis
  3. Alveolar Necrosis
  4. Gingival Scarring
  5. Hardware failure - screw
  6. Dehiscence
Remember - if any of the above occur - how are YOU going to manage it?  Most likely, you'll refer to an OMS/ER and they'll ask why you were attempting such a procedure.  Remember the above - I am not responsible.

Ok - let's get to the meat of this post!

Ramus Bone Graft - a year ago - I had an idea, as to what this monster was, but I never thought I'd actually be doing one.  We're harvesting an autogenous (ie - from the patient himself) bone graft in this case b/c it is a fairly large defect.

Well - as my mentor Latte Ice loves to say, "Here we go"

This is the initial video of probably 4 clips that will illustrate clinically, the ramus bone graft.  This video shows elevating the recipient site full mucoperiosteal flap and periosteal releasing incision.  The periosteal release is the most important concept!

The links refer to some table top examples I posted regarding a ramus graft.

Table Top Ramus Graft Explanation

Table Top Periosteal Releasing Incision Explanation



Thursday, August 25, 2011

Episode 103/500: Orthodontic Extrusion Setup

We're trying to extrude the Maxillary Right Canine.  This tooth has topped off at the gingiva crest and we can either crown lengthen or extrude the tooth.

Clinical Video to be processed, Table top next.

Let's try option B this time.

Max Right Canine Remnants
Round .014 Niti Wire to extrude Canine.  Note Powerchain and where it
 attaches to the bracket wings left central incisor

Episode 102/500: What's wrong with this image?

This is the implant that I removed yesterday and placed a "roll technique" connective tissue graft.  Any reason you see why we removed it?

Here is the Cone Beam Video for you to compare:

The video is in process.



Episode 101/500: I"m confused and need your opinion on site layout

This is my passion.  If I didn't need to sleep, I wouldn't.  But - I have to - we all have to.
I've been working diligently on trying to develop a user friendly site.  I"m on the fence.  Some friends including my wife like this layout, and my colleagues at work like this one:

The links to the pages aren't working and the fonts are messed up for now.  However,  before I spend even more time finalizing and moving this site, I'd really like to know what you think.

1.  Is the text useful, or a waste of time (ie - more verbage that is skimmed over and not read)
2.  Stay with this layout
3.  Go with the video style of layout.

Your comments are greatly appreciated.



Episode 100/500: Bone Graft - Periosteal Releasing Incision

Of the top 3 things critical for successful bone grafting, this is almost #1 - Periosteal Release.

If you can't hide the big pile of dirt under the carpet - everyone will know it's there.  The essence of a the periosteal release during ridge augmentation.

I'm intending to place the clinical version soon.



Episode 99/500: Easy Dx Waxup using Taub Tooth Molds

This mold for waxups is invaluable.  You can use it to create provisional acrylic restorations as well.  Here's how I use it.



Episode 98/500: Stabilize the curing light with your fingers

This hint was from a mentor of mine a number of years ago.  Instead of watching the curing light through that cheesy little orange window - just hold the light onto your restoration.  Start a few mm's away to cure the surface, then place the light on the restoration - there is a significant reduction in the efficacy of cure when the angle/time/power and distance is changed.  Keep the light close and tight.


Hold the curing light in place with your fingers - DON'T WATCH THE LIGHT! from Johnny chickenfoot on Vimeo.

Episode 97/500: Complete Denture Processing - Making the Invisible, Visible

Thanks to Dr. Alwen Dray for this video on Complete Denture Processing.  I'm trying to see how many weird ways I can spell Alan.



Tuesday, August 23, 2011

Episode 95/500: Sutures - what size is what?

Until I entered the residency - I only knew 3 types of sutures - gut, silk and something called vicryl.  Don't even ask me about needle size.

Now, I know a few more and even less about needle selection.  Here are a few types of sutures that I scavenged from the drawers around the building to show you and me the different types.

Basics in a nutshell:

Oral Surgery: (Extractions - Posterior) - Chromic Gut - 4.0 - with an FS-2 needle
Periodontics:  Posterior - Vicryl 4.0/5.0 w/ FS-2 needle
                       Anterior - Vicryl/Gortex - 5.0 w/ P3 needle
Skin:  Polypropylene/Gortex



Episode 94/500: Adjusting Denture Rims

Thanks to Dr. Alan Dray for this video.  Let's adjust denture should see the mess I make when I attempt this!

Marko - this one is for you.  Thanks for inspiring me to post this.



Episode 93/500: Literature Review - CAD/CAM

Here is a fairly basic CAD/CAM review article from Dental Clinics North America 2011.  I'm also going to compare the results of our CEREC 3 and E4D on prepping a #14 e.max crown.

Let the race begin!



Monday, August 22, 2011

Episode 92/500: Create an Implant Surgical Stent - Fast

I watched an iTunes University episode on this method of developing an implant surgical stent using a surveyor.
What you need:
  1. Surveyor
  2. Cast
  3. VLC Triad
  4. 2mm Twist Drill or Round bur + 0.02″ undercut gauge with the end cut off
  5. Pencil
  6. Light curing unit
This is the primary method by which I create my surgical stents now.  BTW, I’m looking to get a computer aided surgical stent in a month to place a flapless implant.  Can’t wait!

Sunday, August 21, 2011

Episode 91/500: Comprehensive Case #2 Treatment Plan

Well, I presented my Treatment Planning Case this past Friday - and it went fairly well.  As residents, we spend hours in the lecture cave, so, I try to make my presentations a little more lively - wore the kilt - no bagpipes this time.  I have attached the treatment plan that I presented and will update with a modified version.  The modified version has some basic changes - let's see if you can figure out my errors and we'll compare them afterwards.

I've been slow to post b/c I've been coding for the iPhone app - which is now waiting for approval from Apple.  I'm excited!

Comprehensive Case #1 Post