Monday, October 22, 2012

Episode 398/500: Crown Removal - Richwill Crown Removal Tabs

There are a number of ways to remove crowns - not that you typically want to remove definitely luted crowns - but - there are the times when it "just has to be done".

Just like this morning.....

Chief Complaint: 55 YO female presents with a chief complaint, "my crown is loose - can you cement it back on?"

There are many things that run through my mind when a patient presents with this scenario, including:

  1. If it fell off, what's the success going to be if I just cement it back on?
  2. How many times has it fallen off?
  3. Did it fall off - or - did the tooth/core fracture?
History of Present Illness:  The patient's crown on tooth #13 (FDI #25) was dislodged over the weekend and caused some discomfort.  The tooth has been previously endodontically treated and the full coverage restoration was placed approximately 5 years ago.  

Clinical Exam: Tooth #13 crown was still intact intraorally and on the preparation.  By using an explorer and engaging the palatal crown margin and lifting coronally, I was able to start moving the crown.

Radiographic Exam:  Tooth #13 has been previously endodontically treated and does not appear to have a post placed in either canal.  Periradicular tissue is normal (radiographically)

So - the story continues - as I am about to remove the crown, I"m thinking that perhaps I had better capture a triple tray impression of the quadrant to ensure that if the crown/tooth fractures, I will at least have a "go-by" stent to fabricate a provisional restoration.  The other option is of course, to take/make alginate impressions - however - this is a sick parade/emergency patient and there really isn't time.  I suppose that as I reflect - I could have taken alginate impressions and rebooked her for another appointment.  Either way - here we are.

Anyways, long story short - the crown wouldn't come off and I suspected that she had fractured her core.  After provision of some local anesthetic (you'll see why if you look at the photo), I just couldn't get the crown off w/ hemostats (my crown removal forceps were at our other clinic). So, we scrounged around and found these friends - the Richwill Crown removers.  These are great little friends that only work in specific situations - and this was one of them.  Dental versions of jujubes, these guys, once heated and placed on the crown you intend on removing - make life just a little easier.  However, just like the instructions say - ensure that the opposing dentition is intact, or you may be removing a restoration from the opposing arch as well.

The little tag of tissue was most likely the culprit causing the patient some discomfort when the crown was rocked to the buccal.  This discomfort was also a great hint that most likely the tooth/core was fractured.

Now what to do?!

Here are the instructions for these green friends.
richwill crown remover, crown, removal, fractured crown, dental crown,
The crown removed from it's resting place of 5 years.  The white core material appears to be a composite core buildup.  
There was no post placed, and it's hard to determine how
much ferrule was used.

richwill crown remover, crown, removal, fractured crown, dental crown,

richwill crown remover, crown, removal, fractured crown, dental crown,
I'll be $4 that the little tissue tag was causing the discomfort when
I tried to remove the crown w/out local anesthesia.

richwill crown remover, crown, removal, fractured crown, dental crown,
Ok, the crown is off.

Now what?

Saturday, October 6, 2012

Episode 397/500: Endodontic Access Help - C+ files

I've moved into another clinic (with 12 other clinicians) and I'm really appreciative of the great things that I learned during my residency.  Such simple things that even now I take for granted - are either not shared with others - or - we have information/marketing overload.  "EVERY product is amazing" nowadays.

Our endodontic cabinet is an absolute zoo.  There are remnants of file systems and products from many other clinicians and I hope not to be one of those folks - but - I probably will.  So here I am, standing infront of this huge filled cabinet and I'm trying to determine what's required and low and behold, there are no #6 files.  Of course, there probably are folks reading this right now and think, "I don't even use #6 files".  Well, uhm....ok.

For the rest of us, there are #6 files and C+ files.  C+ files are just a little more stiff than the conventional #6 files and allow you to apply just "a little" more apical pressure.  Careful - these ones have a cutting tip and who knows where that tip may cut into if you're not diligent.

k file, c+ file, dentistry, endodontic file, endo file, mirror, ndodontics
C+ files in their little carrying case. Ever used a mirror with an endo ruler milled  into the handle?

k file, c+ file, dentistry, endodontic file, endo file, mirror, ndodontics

C+ files are made in the #6,8,10 and 15 file sizes.  There are, however, a few other files out there that appear to accomplish the same thing.  The first time I heard about them was today, when I searched PubMed for any literature on c+ files.

This literature article popped up:

 2012 Oct;38(10):1417-21. doi: 10.1016/j.joen.2012.05.005. Epub 2012 Jun 29.

Mechanical behavior of pathfinding endodontic instruments.

Try these and others out - they make just make that afternoon a little easier.

Sunday, September 30, 2012

Episode 396/500: Literature Supported Clinical Decisions

In the middle of searching the literature for justification of clinical decisions (pin retained amalgams, resin bonded amalgams, provisional materials), the guy from farnamstreet blog sends out this TED talk video.  BTW, Farnam Street blog is a great place for  all sorts of things - and - I like it b/c the tag line is essentially the same as me - "Mastering the best of what other people have figured out"  I have created essentially very little - but - I have been taught a huge amount and continue to learn from my colleagues everyday.

Although the speaker (Ben Goldacre) is talking about medicine, it is definitely applicable to dentistry.  The crux of the issue is that typically only positive results in research is published.  No one cares to publish negative findings (ie -voodoo magic does not disinfect endodontic canals).  That's obvious - or is it?

Let's talk about dental implants.  There is a tip in here, so hang on.  No patient wants a dental implant.  They want a restoration....... that is perhaps supported by a dental implant.  I know, I know - I hear what you're saying - that's an obvious statement you just made.
But, what I"m really talking about are anterior, implant supported restorations - the esthetic ones.  How many times have I looked at pictures in journals (I can't read) and the author has some photos showing his/her work and I sit back and think, "the esthetics probably could have been better managed using conventional fixed prosthodontics or removable prosthesis"  Wow, going back in time?
The industry is currently at a point where any edentulous parking spot in a patient's oral cavity should be restored with an implant.  In our clinical practice (which is much different from where a patient has to pay for something), each time a patient presents with an edentulous space - they already know enough to be dangerous regarding dental implants.  "Doc, can I get an implant?"  I hear that at least 4 times a day - and that's ok.  However, so many clinical variables have to be considered before treatment planning for the "sliced bread". 

Would your treatment option be different if the adjacent teeth were
heavily restored?

(You know, the best thing since sliced bread statement... )
 How many times have I looked intraorally and thought - I don't think I could have restored/placed that implant any better - but - this restoration looks like junk esthetically.  Is this the best we can do? 
I'm for dental implants - however - there is more to prescribing this treatment than appears in the literature.  The literature only talks about survivability of implants - that is - how successful the titanium screw is - not the esthetic component.  There are no long term randomized trials discussing implant esthetics - and - isn't that what the patient really wants?  

What's esthetics?  Well - just imagine your implant patient sitting and laughing out loud, having a great time with his/her friends and at one point, a friend points and asks- "what's wrong with your gums/tooth?"  (Perhaps alcohol is involved to aid in relaxation.)  "Uh.....nothing?"
The patient may have settled for the poor esthetics b/c they sat through 8 hours of tooth extraction, impressions, implant surgery, abutment impressions, crown placement, etc.  But when the rubber hits the road - they won't be impressed if their friends can see it and they spent $x dollars.

A study titled "Prospective randomized clinical trial of dental implants: Poor esthetic outcomes"
definitely wouldn't get published.

Care of :

If you were a manufacturer of dental materials would you want a negative finding published especially -  if you paid and sponsored that researcher to do that research?  Probably not.  The Endo Blog (where I picked up the implant crown picture) has a great overview regarding endodontics and implants.  I appreciate their aspect b/c I totally forgot about treatment options before the tooth is extracted.

Therefore, before rushing to prescribe an implant to "fill a space", it's key to understand that it is really the restoration that the patient wants.  Yes, 95% of the time, the implant itself (ie titanium screw), will function.  However - how likely are you able to place an esthetic restoration on top of that boat anchor?  Esthetics is key, and I am by no means a master of that.

So, what am I saying here?  Clinical practice is difficult.  You are bombarded with advertisements, sales persons, reps, continuing education - etc etc.  Now, it's apparent that even the literature is biased as well (we all knew that).  How to make a clinical decision?  Talk to peers, review the literature and treatment plan thoroughly based on your own experiences.  It's called practice for a reason - and - you won't know of those products that had negative results, yet, are still available.



Saturday, September 29, 2012

Episode 395/500: Polymethylmethacrylate

Melted Plexisand.

Did you know that Polymethylmethacrylate is also used to make Plexiglass? I had NO idea.  I found this out 4 minutes ago while I was googling plexiglass to fabricate exterior storm windows for our home.

pmma, jet, acrylic, dentistry, plexiglass, fish, plastic
This beautiful fish has more in common with my stained, smelly, used PMMA provisionals than I thought!

Wow, 10 years of dentistry and I'm almost 100% positive that no-one had told me that before.  I just texted Dr. BD, asking him this question, "Do you know what plexiglass is made from?" He replied, "melted plexisand".........haha.

So, that dentistry PMMA material that you either did use or still do use to fabricate provisional (or interim, as I'm learning yet another term for the restoration we all know as a temporary restoration) is another version of industrial PMMA that is used for many other things.

Is this useful - probably not.  I'm not planning on using a Jet acrylic kit to fabricate a sheet of brownish yellow plexiglass either.  

But, it was just something interesting!

Here is what I started writing for this post - this is for next time.

During the moments that I have free time to think about dentistry, apart from work and our lovely 3 busy young sons, I've been trying to figure out why and when people choose to either restore a patient in Centric Relation, Centric Occlusion, or Maximum Intercuspation.  I know - boring - but, my real question is this:

if we as clinicians can really actually obtain an accurate, repeatable maxillo mandibular relationship records.  What am I talking about?  Well, I now share an office space (meaning, a small closet with 3 desks crammed into it) with a new prostho residency graduate, a periodontist and down the hall is our oral surgeon colleague.  Dr. Big Daddy continually shows me new tips everyday - and - once we get our lab space sorted (it's unbelievably a sad situation) I can start shooting some more videos.  However, in the meantime, he is all over the following idea: meticulous this that and the other thing.  He is about exact clinical outcomes - no exceptions - including interocclusal records.  I then ask myself - can we reaally be kidding ourselves to think that we can obtain an interocclusal record on an edentulous patient that is repeatable, exactly, from one day to another.  I practice this on the drive home and as a dentate person, my bite slightly changes from one attempt to another.  Is this clinically significant?  Probably not....ok..I have to stop here, b/c, this really wasn't the intent of this post!  I'll get back to this.


Tuesday, September 25, 2012

Episode 394/500: Final Impressions - Use Retractors

How many times have I neglected to heed this advice?  Many.  I think I've finally succumbed to a simple technique that aids in preventing the of an indirect restoration preparation.

Use cheek retractors during a final impression to ensure that the light body (if you're using a dual phase technique) "co-laminates" (that is a sweet term) with the medium body/heavy body.  If you have no idea what I"m talking about, neither did I.  Monophase?  Dual phase?  Co-laminate?

Ok, first things first.  When you are taking (or making...I still don't know which term is correct) a final impression, get the patient to hold cheek retractors to keep the buccal mucosa away from the preparations/implants/teeth, etc. So you can see below, by using the cheek retractors, I'm able to keep the preparations dry, as well as adjacent teeth, depending on the type of impression you are making/taking.

Cheek retractors, final impression, crown, dentistry, dental crown, implant, pvs
Cheek retractors keep the cheeks out of impression taking..making everyone's life a little easier

Ok, so to clear up that dual phase vs monophase impression technique, here are the basics.


If you are using the same viscosity (ie heavy body/putty) for the entire impression (final denture impression), then it's called a monophasic impression technique.  One type of viscosity.

Dual Phase:

A great example is classic final impressions of fixed, indirect restorations such as a single unit crown.  You typically "wash" the preparation with a light body material (#1 of 2) and then use a medium/heavy body material in a custom tray/stock tray/triple tray to pickup the wash.  Two types of viscosity.

If at any time during the dual phase, moisture (from cheeks, tongue, etc), comes in contact with one of the "phases" - ie the light body, then the heavy body won't stick.  It won't "co-laminate" with the other phase (type).  Hence, the cheek retractors will help prevent that problem.

Next up - the dry angle and keeping the tongue out of the way.


Saturday, September 22, 2012

Episode 393/500: Provisional Crown Repair

When we were shooting the block provisional technique of Dr. K, he continued on (to my excitement), to discuss one method of repairing a provisional restoration.  Keep in mind that he's using Snap - PEMA material and this may not work with bis-acryl.

Provisional Restoration Repair

In addition

Crown Margins

Dr. Big Daddy recently graduated from a prosthodontic residency, and by golly, he is excited to hand out hints as they come up.  Even though he's a prosthodontist, he mentioned a tip that he used for finding MB2 canal before his residency.  Once I find the requisite material, I'll post a video.

Most of us travel through dental school with the light on at the end of the tunnel - ie - you just can't wait to get out and do your own thing.  However, once you get there, at some point, you'll be wanting to learn more - useful things.  I"m going to backtrack during this post b/c several basic concepts that I learned.....I never really knew who coined them.  Is that important?  Not sure.  Here is a great review of basic concepts by Dr. John Kois in his 1995 article in Peridontology 2000, "The restorative periodontal interface: biological parameters"

Thursday, September 13, 2012

Episode 392/500: Endodontic Diagnosis and Terminology (AAE)

First, before reading the characters below, take a look at this great powerpoint from the AAE regarding diagnosis.  I have the link to the AAE and to my google docs.  Like everything in life, the AAE link will probably change and will render this entire post useless.  The Google Docs - I hope - will not!

aae diagnosis, tracing the fistula, fistula, endodontics, root canal

American Academy of Endodontists - Diagnosis PowerPoint

In preparation for a lecture next week, I was reviewing the literature regarding some of the small endodontic tips that I was fortunate to learn.  Some of those include:  

  1. Diagnostic Tips - I was reviewing the AAE site and came upon the powerpoint as shown above - wow - what a great overview.
  2. Radiographs - ie - how to describe what I see on a radiograph to a shark sitting in the room waiting to sink his teeth into any perceivable errors that I made - it happened often.  Also include a basic number of radiographs and when to take them.
  3. Root fractures - how to clinically and radiographically determine if there was a's dicey at best.
  4. Sodium Hypochlorite - used in full strength these days - but why you ask?  One article suggests that that dilution by 50% decreases its effectiveness by 2/3rd (Hand 1978) - but that's only one of a few.  Oh yeah, and, it doesn't matter if you use spring fresh either....I'll find that reference somewhere.
  5. MB2 findingMB2 discovery white board
  6. Gates Glidden Drill Sizes - I didn't wonder about the sizes ever.
  7. Current thoughts on File Separation -
  8. Shift Shot Assistance 

As well, I am intending on reviewing the American Academy of Endodontists Diagnostic Terminology.    Since it's publication in JOE (2009), it's slowly made its way into mainstream.  The terminology is broken down into a pulpal diagnosis and an apical (periradicular) diagnosis.

The following radiographic images are from a review article published in JOE 2009. Identify and Define All Diagnostic Terms for Periapical/ Periradicular Health and Disease States. Remember, a diagsnosis is a complete procedure and radiographs are an adjunct to a complete clinical exam.  (thanks dad.)


Normal pulp 
       A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing.

Reversible pulpitis A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.

Symptomatic irreversible pulpitis  A clinical diagnosis based on subjective and objective finding indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain.

Asymptomatic irreversible pulpitis A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma.

Pulp necrosis A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing.

Previously treated A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal

Previously initiated therapy A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy).


Normal apical tissues Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament
space is uniform.

root canal, radiograph, xray, dental xray, bone, pulp, crown
Symptomatic apical periodontitis Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area.

root canal, radiograph, xray, dental xray, bone, pulp, crown, symptomatic, acute, periodontitis

Asymptomatic apical periodontitis Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms.

root canal, radiograph, xray, dental xray, bone, pulp, crown, asymptomatic, chronic, periodontitisroot canal, radiograph, xray, dental xray, bone, pulp, crown, asymptomatic, chronic, periodontitisroot canal, radiograph, xray, dental xray, bone, pulp, crown

Acute apical abscess An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of
associated tissues.

root canal, radiograph, xray, dental xray, bone, pulp, crown, symptomatic, acute,abcess, apical, periodontitis
Chronic apical abscess An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge

root canal, radiograph, xray, dental xray, bone, pulp, crown, asymptomatic, chronic, periodontitis

But then I read this article (from the AAE website and published in 2009 (JOE) and I was confused - is it really supporting the current terminology - or not??


Wednesday, September 12, 2012

Episode 391/500: Endodontic Radiographs

Before the residency, I"ll be honest, it was infrequent that I made a habit of taking a shift shot radiograph to aid during my endodontic exam.  Yes, I know what you're thinking, but I have to be honest.  
I was talking with a new grad a few weeks ago - she was asking me about endodontic rotary systems, etc, etc.  I wanted to talk about the tooth she was about to continue her endodontic therapy on, and asked to see her radiographs.  I had deja vu - was I really looking at only 1 preoperative radiograph - just like I used to do?  Dang - hence the reason for this post.

Our endodontic mentor described an interesting case regarding a postoperative complication following calcium hydroxide placement into a mandibular molar....that somehow found its way into the mandibular canal (IAN)'s in the video.  The point is that there is probably a minimum number of radiographs that should be taken during endodontic therapy.  What do you think?

Further to this video, a viewer mentioned something about the possibility of a fracture into the furcation in the second photo.  I took a look at the CBCT shot that I have on this patient (I removed a non restorable implant from her earlier) to see if there was indeed any fracture.

So, here are a few more radiographs that I was able to pull up.  Can you see how the superimposition of the tooth onto itself (PDL space as well) could be responsible for that "crack" in the furcation.  I looked on the CBCT, but the resolution is too poor to be diagnostic.

What do you think?  We'll talk more next time.

Monday, September 10, 2012

Root Fracture or Root Superimposition

A viewer on youtube mentioned that perhaps there was a root fracture in the furcation of tooth #19 (FDI #36).  The video was in response to a discussion that I had earlier that day to a recent dental graduate - the topic - you guessed it - endodontics.  Specifically, she was asking about rotary endodontics and file systems - that's an opinion filled hornet's nest that I really don't want to get into here.  On that note, dentistry is like the rest of life - many things are based on opinions by experts who try to be justified by some "research"......don't get me wrong, research/evidence based dentistry is important.  My problem is this: just that how much of the literature is a true representation of what really was observed - or - was observed to fulfill a financial obligation to a sponsoring company...I've always wondered as Seth Godin wonders..."if everyone wanted a reliable automobile that gets them from point a to b - why wouldn't you drive a Honda?"  

Thursday, September 6, 2012

Episode 390/500: Dental Radiolucency Endodontic Diagnosis

Case Study:

Chief Complaint:  31 year old male presents with a chief complaint of "I"d like my front teeth fixed"
History of Present Illness: Patient was in a soccer incident when he was 14 years old.  The central incisor (#8 or FDI #11) was avulsed and not reimplanted at the time.  The patient has been asymptomatic ever since.
Medical History:  No Medications, no medical conditions, non smoker, BP: 115/65, Pulse: 72
Extraoral Exam:  Non remarkable
Intraoral Exam:  Soft Tissues non remarkable
Endodontic Tests:  (shortened version) #7 (FDI #22) tests non responsive to cold and EPT.  No percussion pain.  Miller mobility 1, Probing depths <3mm, no palpation pain, no swelling apical region #7.

What is your radiographic diagnosis for tooth #7 (FDI #12)?

fracture, root fracture, crown, radiolucency, endodontics, extraction, dental trauma
fracture, root fracture, crown, radiolucency, endodontics, extraction, dental trauma

fracture, root fracture, crown, radiolucency, endodontics, extraction, dental trauma

Endodontic Irrigation - Sodium Hypochlorite

This morning, I had a discussion with a relatively new grad regarding his endodontic irrigation protocol, "Dan, what irrigant do you use and when?"  Well Dan, as I'm finding out, there is controversy regarding almost everything we do in dentistry, including endodontic irrigants.  With that said, I believe that most of the practicing population would agree that it is the intent of endodontics to ensure a "as close to bacteria free" canal system prior to obturating.  Does that happen - maybe?

During our residency, we were guided to use full strength Sodium Hypochlorite (5.25% or 6% depending on where you reside in the world).  Again the literature is abound with opinions and some evidence and quite frankly, you have to

Wednesday, September 5, 2012

Endodontic Radiographs

Is there a minimum number of radiographs required during endodontic treatment?  I"m not sure there is an exact standard, however, I've b

Monday, September 3, 2012

Episode 389/500: Dental Emergency Kits

Annually, (above and beyond our BLS requirement), the clinic typically has a round robin afternoon where each of the clinic members (approximately 60 members) go through basic scenarios including anaphylaxis, syncope, seizure, MI, etc.

In the process of familiarizing myself with the clinic's medical emergency kits (ie the location of the oxygen tanks, emergency kits - and - the procedures for initiating the emergency medical system), I stumbled upon the bees nest also known as the medical emergency kit.  Now, I must be honest, this is the medical kit for a satellite clinic, and, it really needs to be simplified.  I've been in a few emergencies and the simpler the protocol and kit -  the better.

Keep it simple, stupid.

Here is an example of a card that can be put into a ziploc bag along with the appropriate medications.  I attended an amazing medical emergencies course put on by Dr. Haas a few years ago and I've never looked back with regards to setting up a medical emergencies course.
Please understand that protocols do change and if you're viewing this in the year 2290, things may have changed.

syncope, hypotension, dental emergency kit, medical emergency kit
Ziploc Bag example from Dr. Haas' superb continuing education course



Medical Emergencies in the Dental Office, 6th edition, Malamed
Dental Emergencies, 2007, Dr. Haas, University of Toronto

Saturday, September 1, 2012

Episode 388/500: Alveoloplasty Part 2

Here is part 2 in a 2 part series regarding the alveoloplasty for Aaron and his immediate denture.   There are a few learning points that are included in this video, however, overall - it's a fairly simple procedure.  Next time I'd use a continuous suture - less knots = less irritation under the denture.

D McT has taken over the case and I'm excited to see post "new denture" photos.  I believe that Aaron is currently being worked up to be presented to the implant board for 2 mandibular implants to support, retain, and stabilize some sort of mandibular prosthesis.

More to follow.


Monday, August 20, 2012

Episode 386/500: Local Anesthetics

Local Anesthetics - ...and dentistry.  Imagine if these drugs were not available and we had rely on other methods of pain management:

acupuncture, local anesthetics, pain control


vodka, local anesthetics, pain

jimi hendrix

and when I googled vodka, a picture of Jimi appeared..... so we might have had to use some of the chemicals that he was on as well to aid in managing pain if it weren't for Dr. Halsted and his "championing" of local anesthetics.  

What is the point?  Well, a few days ago, a couple of dental students were in the office and we were discussing what the order of neuronal blockage is for sensations following the application of local anesthetics.  Proprioception, pain, heat, cold, etc magically disappear in a specific order and reappear in the reverse - can you recall that order?

The relevance of this post has to do with the following image:

SIP, symptomatic irreversible pulpitis, cold test, endodontics, anesthesia, anesthetics

Translation:  For a mandibular block, a numb lip does not indicate pulpal anesthesia - however, a cold test/ept on the tooth about to receive endodontics will aid in determining if you indeed have pulpal anesthesia.

Perhaps there is a reason why (in the specific order of neuronal blockage) a cold test is an effective method of determining if you have pulpal anesthesia........TBC

Friday, August 17, 2012

Episode 385/500: Provisional Restoration (temporary) Block Technique

Avu23 - your dream has come true.  Ok, maybe not - but - as you mentioned - I didn't forget!  Avu23 requested some footage on the block provisional technique.  I"ll be honest.  I keep as far away from this method of doing things as possible.  I'd rather take some rope wax, carve a crown intraorally, fabricate a stent (putty or triple tray), then use that stent to fabricate a provisional restoration.

I had a race with Dr. In.Saini one day at 1600hrs.  He was sitting in his usual position (head down), struggling with the fabrication of a provisional restoration without a stent.  There was a glob of some sort of old school methylmethacrylate sticking to his hands while he was trying to roll it in a ball.  Yikes.  Glad I wasn't on the receiving end of that mess.  Mind you, he'd had a long day of sipping gin and juice at the computer and his hands may have been slower than he was expecting (just kidding).

So, just like my wife does - I offered to race and see who could complete a provisional restoration the fastest....well, it wasn't really a race.  I gently pushed him aside to give him a break and used this technique that I've used for some time.

I haven't watched this for a few months and I already miss Dr. In.Saini watching from his desk - aiding? to the videos!

So, I finally tracked down Dr. K who agreed to show you and I how to fabricate a provisional restoration out of thin air.  He is an amazingly kind and gentle man and was a pleasure to consistently learn from.

Dr. K likes to use SNAP (which is what type of acrylic?) when fabricating a restoration like a magician.  At times, I honestly thought that he'd have to reline that restoration due to polymerization shrinkage - but alas - I learned that SNAP has a very low polymerization shrinkage (I still can't find any literature about it), which may aid in preventing the need to reline one of these.  What do they say about assume?  Something about making an ass out of you and me.  So again, I learned another tidbit about PEMA (poly ethyl methacrylate).  Dr. K actually prefers to use bisacryl (Maxitemp or Luxatemp) when he has a stent, but, when magic is required, so is SNAP.

Thanks Dr. K.  

Monday, August 13, 2012

Episode 384/500: Alveoloplasty - Aaron Part - 1 of 2

Alveoloplasty - a simple preprosthetic surgical procedure that can facilitate the fabrication of an esthetic and functional denture (or FDP).  I always looked at the photos in surgical textbooks and wondered how difficult the procedure was.  It's typically not that difficult - there is a fair amount of planning involved - but - the procedure (like many), is straightforward.

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Preprosthetic cast surgery

We started off with a number of preprosthetic planning items, including cast surgery (as completed by Dr. Dray), and a wax try in to determine if preprosthetic surgery was indicated.  It was.  However, it's difficult to determine how much to remove vs how much mother nature will remove.  The maxillary right central incisor had been extracted a number of years ago and there was very little ridge resorption.  Perhaps, the surrounding teeth maintained the ridge - but - we elected to remove some maxillary osseous tissue.  Remember, we will obtain some extra ridge resorption by simply elevating a flap.

Here we go.

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Initial Incision

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Surgical Stent Try in

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Flap elevated - the osseous ridge prior to alveoloplasty

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
 Round bur about to be put to use

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Ridge following alveoloplasty

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Sutured.  Next time:  Continuous

Friday, August 10, 2012

Episode 383/500: Composite Matrix - Custom

Dr. Queso - thanks for this composite matrix tip.  For those times/situations/locations where you don't have a sexy composite placement ring system - bets are that you have a tofflemire matrix floating around in some drawer or cabinet.

Dr. Q shows us how to modify that tofflemire to aid in placing a composite interproximally.

Thanks Ryan - you're a solid chap and I"m thankful for your support.


Tuesday, August 7, 2012

Episode 382/500: Checking for Denture Sore Spots

There are probably thousands of ways to check for pressure spots on the intaglio surface of the denture - Pressure Indicating Paste (PIP), Thompson Sticks, Wax, etc.

Aaron is back after one week following several maxillary posterior teeth extractions and anterior maxillary alveoloplasty.  Considering this was my first alveoloplasty, Dr. Partridge was nearby providing advice when required - a really simple surgical procedure that will help this young man.  The entire surgical procedure will soon be posted - the video production is in process.

Alveoplasty, extraction, denture, complete denture
Elevating the mucosa and periosteum after posterior extrations.

Alveoplasty, extraction, denture, complete denture
The type of bur/chisel you can use is up to you. I just found this round bur
easier to manipulate - cover up your arms b/c the debris goes everywhere!

Alveoplasty, extraction, denture, complete denture
Alveoloplasty ccompletted

Alveoplasty, extraction, denture, complete denture

Check with the surgical stent - it appears good to go.

Alveoplasty, extraction, denture, complete denture

Dr. Dray's biggest tip with regards to PIP was to ensure that the PIP is placed with light brush strokes in the same direction.  This stuff is difficult to work with on a good day (ie, there are many false positives - spots rubbed away during placement or removal).

alveoloplasty, extraction, denture, complete denture
Ouch. That just looks painful.  A sore spot on the canine eminence.

We'll talk Thomson Sticks next time.

Wednesday, August 1, 2012

Episode 380/500: Oral Sedation

I want to thank you for continuing with this blog.  We're in the middle of moving homes and with 3 young boys - wow...I can't upload videos b/c the bandwidth is super thin.

In the meantime....

One small, but fairly useful tip that was given to us by Dr. Hargreaves a looong time ago was with regards to oral sedation.  

oral sedation, benzodiazepenes

Before attending a great continuing education seminar by Dr. Haas in Toronto (Dental Anesthesiologist) (arounds 2007),  I would have the patient take their medication 1 hour before their appointment (at home, or wherever), and have their escort bring them to the appointment and wait.  I always wondered why some folks didn't really show any effects of the medication when they arrived.

Paient: "Yes Doc, I took the medication 1 hour ago. I don't feel any different"

Me: "Weird."

Turns out that perhaps, like myself, the patients may have been procrastinating - or - not taking the medication exactly on time.

For some of you - yes - you're thinking why didn't he just have his patients take the medication in the office and wait?

I'll try to one up you.  Ever heard about the gastric emptying reflex?  I hadn't either.

It turns out that the stomach empties itself automatically (hence "reflex") once it is filled to a specific amount.  I've tried to find some literature on the amount, but I can't - if you know some lit, please post it in the comments.

What is an average amount?  Maybe 8 ounces (236 mL) - some other websites have sited 12 ounces.  

Anyways, the point is that the faster you can get the medication into the small intestine, the faster the patient will succumb to its helpful effects....and several things including food will slow absorption.

So, what's the tip?

Have the patient fast for at least 8 hours before the appointment and drink approximately 8 ounces of water with the medication.  This has been my routine since learning of this tip - and I have noticed a difference in the speed of onset - it's faster.

Of course, there is the sublingual route and intravenous.  Just a note...some medications are not absorbed sublingually.

Thanks Dr. Hargreaves.