Monday, October 31, 2011

Episode 203/500: How do you increase attached gingiva?

I had never heard of this beast.  A free connective tissue graft? A who?  I'd heard of free gingival grafts, but free connective tissue?  Well, I just post op'd a 2 month result.

The main problems, concerns w/ free gingival grafts are:
  1. Post operative pain
  2. Tire patch appearance
  3. Hair growth?  Just kidding...that's really old school when they used dermis (skin)
This patient had no attached gingiva on the facial aspect of implant #29 (FDI #45).  I inherited this case a number of months ago, to restore implant #29.  After placing the crown and completing endodontic therapy tooth #31(#47), we elected give the implant some attached gingiva.  The literature is controversial regarding attached gingiva and implants.  Some studies say none is needed to prevent peri-implantitis - others say that it is mandatory.  See the few articles below

I used a Free Connective tissue to increase the band of attached gingiva for #29 (in the following case).  The patient reported no pain postoperatively.  We gained approximately 4mm in attached gingiva on the buccal of #29.  I was excited.

Cheers

Ashley



Post crown placement. We elected to provide a band of attached gingiva through
a Free Connective Tissue Graft on the facial of implant #29
Sorry about the rotation.  This is elevating the Split Thickness Flap
on the Facial of Implant #29
Harvested Connective Tissue and Adipose tissue removed.

Suturing the harvested Connective Tissue Graft - it was my first CT graft
Go easy on the suturing.....it's tough suturing to periosteum.

No, it's not dead.  Only surface necrosis 3 days out.


2 months postoperative.  We now have a 4mm band of attached gingiva.


....the next segment on how I restored implant #29 (same case)




Turns out that in 1975, this article was published regarding Free CTGs - why the secret so long?


The use of a free connective tissue graft to increase the width of attached gingiva
Alan Edel M.Sc., B.D.S. Corresponding Author Contact Information, L.D.S.R.C.S.(Eng.)
Oral Surgery, Oral Medicine, Oral Pathology
Volume 39, Issue 3, March 1975, Pages 341-346




A systematic review assessing soft tissue augmentation techniques.
Clin Oral Implants Res. 2009 Sep;20 Suppl 4:146-65.
Thoma DS, Benić GI, Zwahlen M, Hämmerle CH, Jung RE.



Is keratinized gingiva a requirement to ensure implant health?


Int J Oral Maxillofac Implants. 2009;24 Suppl:28-38.

Local risk factors for implant therapy.


Aust Dent J. 2008 Jun;53 Suppl 1:S39-42.

Biological basis for soft tissue management in implant dentistry.


Saturday, October 29, 2011

Episode 202/500: Dental Abscess (Intraoral Incision and Drainage)

Here is a brief overview of a great hint that an Oral Surgery Residency Director showed us regarding intraoral incision and drainage.  I put together a case with the I&D video in the middle of the post.

Chief Complaint:  45 YO Male presents w/ a chief complaint of, "my left lower jaw has become really swollen over the past day.  It's really painful."
History of Present Illness: Patient had an endodontic therapy completed to the 1st mandibular left molar approximately 24 months previously.   The patient has been asymptomatic until the previous 36 hours.
Medical History:  Vitals:  Blood Pressure: 145/93, Temp:  99.1, Pulse: 65, Resp: 17
  1. Medications: Propranolol
  2. Medical Conditions:  Hypertension, Anxiety
  3. Allergies:  None
  4. ETOH:  Social
  5. Tobacco:  Smokes 1 pack per day
Clinical Exam:  
Extraoral: Left sided facial asymmetry (swelling), pain to palpation left mandible, no lympadenopathy
Intraoral:  Left Mandibular Buccal Abscess approximating the 1st md left molar, pain to palpation left mandibular dentition, no suppuration, 1st molar non restorable

A self instructional Guide:  Diagnosis and Treatment of Odontogenic Infections Hohl, Whitacre, Hooley, Williams
Radiological Survey:  1st mandibular left molar diagnosis:  Previously endodontically treated w/ symptomatic apical periodontitis.  Tooth #19 (FDI #36) non restorable, Large radiolucency apices #19


Assessment: 
  1. Patient is currently controlled for HTN - can elect to treat immediately
  2. Patient has a large mandibular vestibular abscess
  3. Tooth #19 non restorable
Plan:
  1. Local Anesthesia
  2. Extraction #19
  3. Aspirate vestibular abscess and submit contents to lab
  4. Incision & Drainage - Penrose drain
  5. Systemic Antibiotics
  6. Analgesics for pain (Ibuprofen, Acetaminophen, Narcotics)
  7. Followup 24 hrs, 72 hrs
Armamentarium:  
  1. Penrose drain (or some kind of sterilized rubber)
  2. #11 or #15 blade for incision
  3. Local Anesthesia: 
    1. Carbocaine (Mepivicaine) - not necessary, but it has the lowest pKa which will aid in achieving local anesthesia
  4. Hemostats
  5. Sutures
  6. Surgical Suction
  7. Syringe to aspirate abscess contents for lab submission





Thursday, October 27, 2011

Episode 201/500: Extraction of 3rd Molars and the IAN

Here is a relatively recent article regarding 3rd molars and inferior alveolar nerve exposure. I also just found this great web page regarding exodontia.

The paper describes 4 panoramic findings that are indicative that there will be an IAN exposure during 3rd molar extraction:

  1. Darkening of the root
  2. Interruption of the white line of the IA canal
  3. Diversion of the IA canal
  4. Deflected roots, and narrowing of the root


This photo is from exodontia.info - they list 5 radiographic signs


http://www.exodontia.info/DentalNerveInjuries.html

The abstract is from a fellow resident colleague:


Authors:  M. Sedaghatfar, M. August, T. Dodson

Title:  Panoramic Radiographic Findings as Predictors of Inferior Alveolar Nerve Exposure following third Molar Extraction

Journal:  Journal of Oral Maxillofacial Surgery, 63:3-7, 2005

Purpose:  To evaluate the sensitivity and specificity of using certain radiographic findings on panoramic radiographs to predict IAN exposure during mandibular 3rd molar extraction.

Methods:   This is a retrospective cohort study.  The authors selected 230 patients that had a total of 423 mandibular 3rd molars evaluated and removed between July 1998 and July 2002.  The pre-operative panoramic radiographs were evaluated by the surgeons for the presence or absence of 1 or more of 5 radigraphic sings that have been associated with increased risk for IAN exposure.  The signs were darkening of the root, interruption of the white line of the IA canal, diversion of the IA canal, deflected roots, and narrowing of the root.  The evaluators were then asked to predict the likelihood that the IAN would be exposed following surgery.  Both surgeons were blinded regarding the IAN exposure status and assessed the radiographs independently.  To measure intraexaminer and interexaminer variance, 50 radiographs were read twice by each surgeon independently, and the readings were separated in time by at least one month.  The outcome variable was IAN exposure (direct visualization after removal of 3rd molar), as recorded in the operative note.

Results:  The frequency of the radiographic signs were: 1) darkening of the root: 17.0% (n = 72 teeth); 2) interruption of the white line: 35.9% (n=152); 3) diversion of IA canal, 12.5% (n = 53) ; 4) deflection of the roots, 13.9% (n= 59); 5) narrowing of the roots, 11.8% (n = 50).  Based on these findings, the evaluators estimated that the IAN would be exposed in 75 extraction sites (17.7%).

Following extraction, the IAN was visualized in 24 (5.7%) extraction sites, and 3 sites (0.7% total, 12% of sites where IAN was visualized) had evidence of IAN injury based on follow-up examination.  All 3 cases resolved within 1 year.  It was determined that deflection of the roots was not statistically associated with IAN exposure (P = .6), but the other  four WERE statistically associated with IAN exposure.
Darkening of the root being the most reliable indication of a true relationship between the 3rd molar and the IAN was the most predictive of the 4 signs.  In the ABSENCE of any radiographic signs, there were no cases of the IAN being visualized after the removal of 3rd molar.

Discussion:  Injury to the IAN following the removal of mandibular third molars is a relatively uncommon complication, but when it occurs it can be serious.   The panoramic radiograph is the most common radiograph used to assess the risk of such a complication.  This study confirms that as the number of radiographic signs increases, so does the likelihood that a nerve exposure will occur, particularly if one of the sings includes a darkening of a root that is at or below the level of the IA canal.  However, the likelihood of exposure is still low, even when the signs are present.   The absence of these signs is also highly predictive of minimal chance of nerve exposure. 

Summary:  Four radiographic signs are useful in predicting the likelihood of IAN exposure during 3rd molar removal (darkening of the root, interruption of whitlne, diversion of IA canal, and narrowing of the root.  

Episode 200/500: Dentin Bonding Destruction?

Dentinal Matrix Metalloproteinases

I had no idea what these things were until today, just before bagpipe practice.  I graduated in 2002 - I was probably taught something about these things - I doubt it.

We had to review an article for a lecture tomorrow - here are the basics:
  1. MMPs are simply collagenases - "ases" that breakdown things.
  2. During dentin formation, MMPs are frozen/buried during the mineralization process.
  3. T-IMPs keep them cool....for sometime until:
  4. Dentin MMPs can be "released" from dentin during acid etch (T-IMPs breakdown)
  5. MMPs go into the hybrid layer and like an axe, start cutting down the collagen
  6. MMPs 1-8-13 these are the MMPs that deforest the collagen hybrid layer

Fix:  Use chlorohexidine after acid etching....a possible fix......there are others.


The role of MMPs in Dentin Bonding

Review of matrix metalloproteinases' effect on the hybrid dentin bond layer stability and chlorhexidine clinical use to prevent bond failure.


Tuesday, October 25, 2011

Monday, October 24, 2011

Episode 198/500: Necrosed Flap Debridement

What to do in this situation of flap necrosis:  You can refer at this point......

Overarching Rule:  Don't Panic!
  1. Take vitals (Blood pressure, Pulse, Temp, Resp) to determine if there is a systemic involvement
  2. Confirm Diagnosis
  3. Reassure patient that everything is Ok
  4. Local Anesthesia
  5. Removal of necrotic tissue
    1. Regional debridement and dissect w/ hemostats
    2. Ensure hemorrhage 
  6. Copious Rinse w/ Saline and Chlorohexidine (0.12% or 0.2%)
  7. Systemic Antibiotics??  (This is controversial so I won't go there)
  8. Prescribe Chlorohexidine x 7-10 days, BID + Analgesics
  9. Gingival Pack?
  10. Followup
Notes: The gingival tissue will grow over the exposed bone.  Boney coverage will take some time depending on the healing capabilities, oral hygiene, oral habits of the patient.



The solution to pollution is dilution
Copious Irrigation



D-day. Implant removal and tuck/roll CT graft.

D-Day +7 days....


During debridement - Bone Exposed. Not much ridge remaining
following conservative implant removal

2 weeks post op - healing well, bone still exposed

5 weeks post op, healing well.


Sunday, October 23, 2011

Episode 197/500: Flap Necrosed...Now what?

It's all nice and dandy to couch coach b/c everyone knows the right plays when sitting back w/ friends watching a game.  It's only those fools, be it referees, umpires, coachs, players - you name it - who really don't know what they're doing - even though - they're in the heat of it.

Well - that was me until a flap necrosed.  Upon reflection - the reasons it necrosed are obvious, however, I was trying a "tuck & roll" connective tissue graft technique and implant removal...that...I will be trying differently, next time.

What would you do in this situation?
Situation:  Implant Removal/CT Graft 5 days previously
Chief Complaint:  This (pointing to surgical site), is starting to be painful, I have a bad taste and the smell is awful.
Vitals: BP 124/68, P: 68, Resp: 14, Temp: 98.4
Extraoral Exam:  No swelling, no suppuration, no asymmetry
Intraoral Exam:  Fetid odor, region is tender to palpation
Assessment:  Necrosed flap due to poor flap design during implant removal and attempted tuck/roll connective tissue technique.

Plan:  .........how would you treat this patient at this point?......





Episode 195/500: Principles of Oral Surgery (Peterson/Fonseca)

A review of the basics (board exams arriving soon)

Prevention of Flap Necrosis:
  1. Base of flap always wider than the tip
  2. Base of flap should be wider than the flap is long (x=2y)
  3. Try to include Axial blood supply (direct it towards the Greater Palatine Artery in this case)
  4. Treat the flap with care - don't ham-handle it.


Prevention of Flap Necrosis

Means of Promoting Wound Hemostasis:
  1. Pressure on the wound (sterile gauze)
  2. Thermal coagulation (use of heat to fuse open vessels closed)
  3. Suture ligation
  4. Pressure Dressing
  5. Vasoconstrictive substances (epi)
Dead Space Management - dead space usually fills with blood, creating a hematoma w/ a high potential for infection

  1. Suturing tissue planes together to minimize voids
  2. Place a pressure dressing over the wound
  3. Pack the void until bleeding arrested, then remove the packing
  4. Use drains

Postoperative Care of Sutured Wounds

Extraoral
Sutured wounds on the vermilion of lips or face should be kept free of dried blood and other derbris, use:
  1. 50:50 mix water/hydrogen peroxide to cleanse the sutures (remove clots) twice daily to decrease probability of infection.
  2. Facial skin sutures can be removed after approx 4 days, then use adhesive strips to decrease scar formation and lessen wound inflammation

Friday, October 21, 2011

Episode 194/500: Sweet Bluegrass Dental Habit Appliance

This is the 2nd habit appliance that I've placed - the first was a an archaic crib/tongue thrust appliance - and - this bluegrass appliance.

I'm a believer now in this simple habit appliance.

Here's one case that I recently used it on.



Age:  7 yr old
CC:  "I want to stop thumbsucking, but I've had a hard time"
HPI:  Patient has a digit habit since birth.  Mom has tried everything to help him stop.
Medical:  No medications, no medical conditions, no allergies

Treatment:  Bluegrass Roller Appliance


What is it?  Simply a large 0.036 wire soldered to the bands with a little handmade acrylic roller that the patient can spin with their tongue.  The idea is that the patient plays with the little roller with his tongue, which decreases the need to suck his thumb - there's some deep psychology in there, but that's for another blog.

Important Points:
1.  The kids are going to become really good at spinning the roller.  After a month, get them to try to spin it in the opposite direction - that will slow them down for a while....then
2.  After the reversal technique - bend the wire towards the palate to have the roller push against the palate -this will slow down the spin action - ie - another goal to get that roller spinning fast!
3.  The minimum amount of time after habit cessation, to retain the appliance, is approximately 3-4 months.


Here's how we did it:
1.  Fitted molar bands on the maxillary 1st molars
2.  Made an alginate impression
3.  Removed bands and seated them into the impression
4.  Poured up impression in Type III stone
5.  Designed the appliance
6.  Sent to lab for fabrication
7.  Returned from lab, fitted appliance, luted w/ Ketac cement

This patient wore the Bluegrass App for a total of 10 days and it broke at a solder joint  :(  However, amazingly, he stopped thumbsucking - it has been at least 6 months.  


I need to take a photo to compare before and after wrt maxillary anterior incisor eruption.













Wednesday, October 19, 2011

Episode 193/500: Esthetic Dental Photos and Empress CAD Crowns

As a continuation of yesterday's post, here is some clinical video showing the Empress CAD crowns that I used to restore the Treatment Planning Challenge #1.  Thanks to a number of folks who submitted answers - your polishers are soon to be in your hands!  I will post those answers in the next few days.

Briefly, there are a couple of finishing touches that we would have liked to complete before placing central incisor crowns, including:

1. Esthetic Crown lengthening - even the gingival architecture of the central incisors w/ canines
2. Root coverage lateral incisors
3. Esthetic posterior restorations

Problems seen @ 400 magnification:
1.  Distogingival contour #8 (FDI #11) is more bulbous than #9 (FDI #21)
2.  Distoincisal contour #8 is slightly more rounded than #9

More to follow....

Cheers

Ashley




Tuesday, October 18, 2011

Episode 192/500: Esthetic Dental Photos



Thanks West Point - this was a great idea!

These intraoral contrasters really help to see contours of the anterior maxillary teeth.  Compare the following photos.  The subtlety of having a black background helps to develop ideal contours.  This is also effective for facial photos.


Classic Intraoral Photograph

Contraster in place - a fairly odd looking photograph actually.



This is much easier to critique contours and perhaps, shade?



Monday, October 17, 2011

Episode 191/500: Computer Aided Implant Surgery - the Finale

Well, after approximately 80hrs of preclinical work, I finally placed my first computer treatment planned implant (#9 - FDI #22).  We used a Cone Beam Computed Tomography (CBCT) scan to plan implant placement.



Hand filing Endodontics


CBCT based implant surgeries - I think it's just like rotary endodontics...I remember step back filing, and squinting at the final radiograph (obturation) to see how I did....It was Always painful.

Now, with rotary endodontics - predicability is much higher - at least in achieving that "esthetic endo".

Perhaps, CBCT based implant surgery is the rotary endodontics of endodontics.....the next step.

I have tons of video, but, need to sleep.

Here is a snippet of implant placement, before restoration.

Cheers

Ashley


Saturday, October 15, 2011

Episode 190/500: Dentigerous Cyst Explanation

I'll be honest - I study oral path for exams, and then, like the rest of us, it disappears within 5 days.  However, when something funky shows up - I hit the books...fast.  I use the back pages in Neville & Damm to figure out a differential diagnosis - and off we go - I"m totally going to get burned on Monday for writing that...

Here, my resident colleague - Dr. Saini, explains in human language, a dentigerous cyst.  This was Friday afternoon @ 1640hrs and we were reviewing a CBCT.....the love of his life, before wife and kids.

Please enjoy.

Ashley



Friday, October 14, 2011

Episode 189/500: AAOMS 3rd Molar Paper Brief Overview

Overview:  Thanks to Dr. Dave MacPherson for this - if he's wrong - blame him.  I'll get you his cell #.

Quick:  Local Anesthetics:
What determines Onset of Action, Duration, and Potency?  (Bottom of post)


Here are the key points from the AAOMS Paper
  1. 3rd molars visible in the oral cavity will affect overall periodontitis, and periodontal status of 2nd molar (increase prob depths, inc root resorption)
  2. 4,5mm probing depths btn 2nd/3rd = predictor of periodontitis
  3. Consider access to 3rd molars for patient hygiene
  4. 2nd Molar:  Extraction of 3rd molars will affect 2nd molar based in age, pre-existing bone defect, poor OH
  5. MicroFlora - erupted 3rd molars - red/orange complexes (bad)
  6. Absence of symptoms does not equal absence of disease
  7. Age: Increase age = increased risk in dev caries, perio dis, and post operative complications
  8. Patient Symptoms: Pain, swelling, food impaction, purulent discharge
  9. Germectomy Removal of a tooth that has one third or less of root formation and also has a
  10. radiographically PDL is visible, usually Ages 12-17, dec mobidity, dec IAN damage
  11. Coronectomy - crown removal only - (few studies)
  12. Lingual retraction - use larger retractor than smaller, inc incidence of lingual nerve damage, 1-2% infections
  13. CBCT -jury is still out
  14. IAN Damage - Overall, 0.3% IAN damage.  50% cases recover spontaneously


Onset of Action - pKa
Duration - protein binding
Potency - Lipid solubility

Thursday, October 13, 2011

Episode 188/500: "Doc, I have a wedding tomorrow"

This is a classic no pain, urgent case that presents at 0730hrs (or insert your time of choice):

"Doc, I have a wedding to attend tomorrow"


Thanks to Dr. Hueffner's blog for the above image.  Here is the blog post http://www.sensational-smiles.com/blog/2009/03/saving-a-broken-front-tooth-by-orange-county-cosmetic-dentist-dr-huefner/  The final restoration looks incredible, and I"m curious to know how he managed this case - interim and final.  I'll email him btn this and studying for a quiz tomorrow. :(

The textbooks, lit articles, don't teach hands on "what the h#ll do I do in this case in 2 hours?"  Normally, there is not enough time when these patients present to provide them any kind of definitive treatment.  It's on the fly - hope it works...or not.

How would you treat this case in 3 hours?

Post treatment options to comments (the little pencil at the bottom of this post):


Assumptions

  1. Low caries risk patient
  2. No financial limitations
  3. Patient is not a regular patient of yours - so - you do not have previous diagnostic models, nor radographs
  4. Patient must attend wedding tomorrow as a bridesmaid
  5. Esthetics are essential
Limitations
  1. You have a full day of patients, including a case you've been waiting to finalize for months
  2. Patient has only a few hours for treatment, then must catch a flight to the wedding
I'm excited to see what some folks would do.

Cheers

Ashley



Wednesday, October 12, 2011

Episode 187/500: Implant Temporary Crown


Today, I finally provisionalized a #10 (FDI #22) anterior implant.  I placed the implant approximately 4 months ago, provisionalized that w/ a Ribbond adhesive FDP - and now - used a plastic abutment w/ the technique below from Dr. Scott MacClean.  It worked perfect.  I couldn't remember what he used to block the screw access hole, so I used a Cotton Tip Applicator with a putty stent (versus vacuum formed stent).....it was a little different, but essentially the same.

I will screencast the occlusion problems that we ran into w/ this case.  Partial edentulism for extended periods of time can create minor bumps in the road when restoring implants - ie - supraerupted teeth into the space.

Thanks Scott,

Ashley
The Ribbond provisional w/ the implant healing abutment playing
hide and seek.
Here is the Ribbond Adhesive Provisional.  Compare the length/size of the
crown to the picture below (implant provisional). Why do you think it's different?


Yes - it's a different color. That's as A1 as Luxatemp gets...
Evaluating the esthetics (apart from shade) considers crown contour, length, width,
Palatal-Facial positioning - I'm also comparing w/ #7 (FDI #12)

Here is my cotton tip applicator to keep the access hole open. I had to
cut the CTA to approx 5mm b/c I was using a putty stent. I will
cut a video showing what I mean.



Tuesday, October 11, 2011

Episode 186/500: What I"ve accomplished in an AEGD-2 Residency - after 14 months

Well,

Here is a basic list of what I have accomplished in this Army 2 year Advanced Education in General Dentistry.  Essentially, I set my goals prior to starting the residency and have almost achieved all of them - and by far - have gained more than I could have ever imagined.  Thanks to our mentors, Drs. K, Dray, Manimal, Latte Ice, West Point, Muscle Milk (Pedo guy), No Rep, Pzo, and of course, my wife.

It's been a looooooooooong 14 months.


  1. Implant surgery and restoration (incl CAD/CAM restorations)
  2. Sinus augmentation - (lateral window and summer's technique)
  3. Surgical endodontics (anterior/maxillary molar)
  4. Ridge augmentation (ramus graft, xenograft)
  5. Hybrid complete dentures (screw retained bar w/processed acrylic)
  6. All on 3
  7. Surgical periodontal plastic surgery (connective tissue grafts, open debridement, apically positioned flap)
  8. Complex prosthodontics - including full mouth rehab (increase VDO)
  9. Basic orthodontics (Fixed Mx/Md) to include diastema closure, molar intrusion, tooth extrusion, rapid palatal expansion,
  10. Implant supported removable partial dentures
  11. Trauma
  12. Maxillomandibular fixation (Ivy Loops)
  13. Complex CAD/CAM multiple restorations (CEREC AC and 3, and E4D)
  14. Complex exodontia (3rd molars) 
To be completed

  1. 3 x full mouth rehabsOperating room to complete a hip harvest and graft placement to prep sites for 6 implants
  2. CBCT Based surgical implant placement - ie - the surgical guide has been planned using software and milled to exact specs 
  3. Titanium mesh to increase vertical height on an edentulous ridge
  4. Board examination

Monday, October 10, 2011

185/500: Preparing Crown and Bridge Dies

Here are a couple of tricks to help you out when preparing crown and bridge dies.  Maybe in 40 years, we'll never see these again, thanks to CAD/CAM.......I"m not sure.

Points

  • Use a pear shaped lab bur to trim C&B dies - it just seems easier to do.


  • Here is one way to saw/separate super close dies without ruining die margins.

Episode 184/500: Dental Bone Graft Fixation

Here is the final installment of the Ramus Bone Graft.  Thanks to Dr. Kris Hart and Dr. Latte Ice for your mentoring, instruction and assistance.

Points:
  1. No movement of fixated graft - critical.  Just like building a patio deck - you don't want any movement of the wood.
  2. Use 2 screws to fixate vs one screw - this will prevent rotation.  I only used one....bad choice.
  3. Use a lab bur to carve/mold the graft to facilitate easier placement into the defect.
  4. No sharp corners/edges of the graft once in place - whittle.
  5. Membrane Placement....where to start.....I"m going to cut a video on this.
  6. Suture w/ something that will not resorb quickly - try vicryl 5-0.
    1. Don't forget to suture donor site!
  7. Steriods....the periosteal releasing incision is going to become angry - fast.
  8. Analgesics
  9. Followup
Look for the the membrane video soon.

Cheers

Ashley

Saturday, October 8, 2011

Episode 183/500: Case Discussion - "My implant sucks"

I have always been dissatisfied with the way we are trained in treatment planning.  Unlike medical schools - rounding w/ other residents - we as dentists - are typically one on one w/ our patient and try to hack out a treatment plan.

I don't want to bad mouth the general dentists patrolling the clinic floor when I was in dental school - but after 1.5 years in a residency....man...I was really led down the wrong path.  They were led down the wrong path as well.....

Treatment planning is often limited by economics.  I'm not a fool - got it.  However, sometimes, it's nice to dream beyond dollars/cents to see what really is available out there, wrt new technology, materials, etc.

I wanted to create a place where we can review cases and add our 2 cents and get ideas from other folks.  A comprehensive look at a patient, rather than forum posts about a specific situation regarding patient treatment -

Take a look here at the first case that I've placed as a wiki space.  This patient's treatment is in process and I will post how I provided comprehensive care to her.




https://allthingsdentistry.wikispaces.com/My+Implant+Sucks

Let me know what you think.

Ashley


Friday, October 7, 2011

Episode 182/500: Aviation and the Mark Family

Here we are at Episode 182. It just dawned upon me that I should have mentioned the various planes that I have flown over the years at the corresponding episode numbers:

140:  Piper 140 - I was raised in a piper 140 - my dad flew off our field strip in Manitoba.  I've flown several hours in the hershey bar wing.

150: Cessna 150 EGM - Petawawa - Flown many hours in the C-150 in Petawawa.  I love this plane.  Simple.
Acutally here is a video that I posted before we left for Belgium, my wife and I dawdling around beautiful Petawawa, Canada:

160:  Piper 160 Warrior: When I was attached to Wainwright, AB - my wife and I flew around in a 160 - and up to Cold Lake, AB

172:  Cessna 172 - I learned to fly in a 172 - the workhorse - out of Simcoe Regional Airport near Barrie Ontario.  No video unfortunately....days before kids....

 Cessna 182 - the luxury 4 seater 360 hp, constant speed prop, high wing cadillac of cessna.  I've only sat in a 182 - I don't think I could afford the fuel...remember, I"m Canadian!

Ok, now to dentistry.....well...I'll wait until episode 183.

Thursday, October 6, 2011

Episode 181/500: Steve Jobs and Mac integration in the Mark household

I was fairly hesitant to blog about Steve Jobs.  Yes - he was an icon...and there are millions of people blogging about him - great.

What I really wanted to add to the millions of mac-addicts - is my own perspective on using Apple based products in our family..and..in a residency.

No, we don't have an iPad.  We don't have a need in our household for a tablet....and... I believe our 4 and 2 year old will have many days ahead of them to sit in front of a screen without my help.  Yes, many of our friends w/ young kids have iPads for their kids to watch videos/play games.....no.  Just a few literature articles I found supporting my insensitive stance!




"Linking obesity and activity level with children’s television and video game use"  
Elizabeth A. Vandewater*, Mi-suk Shim, Allison G. Caplovitz,



"We found a fairly strong relationship between time spent playing electronic games and
children’s weight status"
https://docs.google.com/viewer?url=http%3A%2F%2Fmedi506.pbworks.com%2Ff%2Fsdarticle-3.pdf


"Video Game Playing increases food intake in adolescents: a ramdomized crossover study"
Ame J Clin Nutr, 2011 Jun


I'll cross the video game - increased obesity bridge when I have to.  Not now. They can go and play outside like we all used to.


However, both my wife and I use a macbook (white) and a macbook pro.  Her macbook has travelled all throughout Europe with us during our posting there - using it to keep in contact with family.  It has been repaired several times under Applecare (in Belgium and in the US) due to wear and tear - and - each time, the service has been fantastic.  Amazing.  No questions asked.  I don't believe there is a better warranty out there for anything.  Yes - you can argue cost of Applecare vs new PC notebook each time.  However:

Let's face it - my wife opens the lid on her macbook and it works.  No problems - just function.
 Do you realize how much that is worth?  I have sufficient grey hairs from the past 4 years....

My MBP is fast, durable, always functioning - and easy to edit video with. 

My critical points:
  1. Any video camera w/ H.264 encoding plays directly into quicktime - no questions asked.  No conversion and quicktime can easily edit, fast.
  2. My clinical photos are well organized in iPhoto - my PC friends are waaay behind on this issue.  Their clinical photos are all over the place.
  3. Keynote - simple integration of media into slides (I hate ppt/keynote presentations).  I make many presentations.
  4. Time Capsule - 600 Gb of video needs to be stored somewhere
  5. No crashing, no crashing, no crashing.  I don't have time for downtime.
So, based on that.  Thanks to mac for not only creating a number of products that are user friendly but now also have more apps available to them as compared to 1998 - my first mac.  It was...painful to find software.
Early morning blogging.....the picture on my phone was 2 years ago
in Southern France w/ Uncle Ed.  We backpacked from Portugal to Belgium w/2 young kids
b/c an Icelandic volcano stopped European Flights.

Episode 180/500: Temporary Bridge - Ribbond

I remember when I first graduated and wanted to try some sort of composite-bonding-tooth-pontic thing.  I was trying to replace a 1st maxillary premolar and I didn't want to whittle the adjacent teeth down to toothpicks.  I had no idea about implants - so - my options were pretty limited - as instructed by my dental school:

  1. Conventional FDP
  2. Removable prosthesis
  3. Resin retained FDP - Maryland bridge - although, we were warned they were situation dependent and this was not that case....mind you....I don't think anything qualified for a maryland bridge...

I was like - why can't I make a tooth out of composite and bond it in there?  Long story short, the bonded tooth lasted 2 days before it just spun around like a sideways disco ball in the patient's mouth.  I had to cut it out!  It was worth a try.  The patient was entertained!

Enter Ribbond.....You either hate it or love it.  But - it can provide some restorative flexibility based on economics, clinical situations or just fun.  Frolow - if you've read to this point, facebook me - then I'll know you actually read these things!

Here are 3 cases that I've used Ribbond succesfully - 2 cases involved replacing an anterior tooth, and the 3rd case was to strengthen a posterior FDP.  I actually have another case soon that we will fabricate bilateral 4 unit FDPs using Radica and Ribbond.  Not ideal...but better than nothing.

Watch the company's technical video - it is - much better than anything I could provide - and is much easier to figure out than reading the instructions....life in the millenium.

Please enjoy.

Cheers

Ashley



The first video is the Ribbond Playlist - there are about 5 videos wrapped in one viewer.




This is the actual video from the Ribbond website.






Wednesday, October 5, 2011

Episode 179/500: Dental Implant Poor Position

Here is a poorly positioned #30 (FDI #46) implant.  This is my case and the oral surgeon mentor was assisting me - I used a stent and CBCT and 2 sets of clinical eyes and still - the position of the implant could be better.....or could it?

Key Points:

Implant placement is a ballet between biological limitations and prosthodontic requirements....

Critical points during implant placement including bone quality, quantity - and in the mandible - that pesky undercut that could lead to a lingual plate perforation.  The IAN (Inferior Alveolar Nerve) is just as important as well.  Just some pointers to remember when treatment planning for an implant.  It is MUCH easier to restore using a stock implant abutment - however - custom abutments are avail for a reason....

Cheers
Ashley


Tuesday, October 4, 2011

Episode 177/500: Dental Implant Board - Patient Presentation


Tomorrow is a great day.  Ortho in the morning and an implant board in the afternoon.  Our Crossfit workout at lunch is fixing to be something painful….or pleasurable perhaps?  No Rep is back in action..Our PT test is coming up in a few weeks.

Before every patient presentation/lecture to mentors and residents, I try to spend some time practicing.  We have to be exact - or - the wolf pack (mentors) will pounce.  It's not a gentleman's sport by any stretch of the imagination….

With screen casting, I can actually present to an audience and then show it to the world.  I just imagine the wolf pack sitting in front of me in my office waiting to pounce and sink their teeth in.  The possibilities are endless for personal attacks on residents - from spelling to attire to wordage (layman vs specific dental terminology) - it's really fun to be the centre of attention when the wolves are piggybacking on each other….maybe it's insecurity?  Probably not - just fun.

Life as a resident
May the wolf pack (mentors) dig deep and take some of my liver tomorrow....

In any event, here is a case that I'm presenting tomorrow.  It's a great case b/c it's not straightforward and involves several disciplines concerning implants only (OMS, Endo, Prostho, Perio).  If all goes well, we will see 4 implants and a bone graft from the patient's hip.