Hi all, just a little apology blog that I am pretty bogged down with work at the moment so blog posts may be a little thin on the ground for the next few weeks. Luckily I have lined up a guest blogs and a new contributor to fill the void.

Today was just another regular day for me in practice except I’m now in week 3 of my rubber dam challenge to do every restoration under quadrant dam. So far I have had one failure but otherwise I’m doing OK, bit stressful at times but I’m amazingly keeping to appointment times. This picture is just a sample where I have placed the dam then prepped the 26 occlusal cavity for restoration. For those who haven’t tried it placing the dam before preparation is awesome, saves so much time and really improves your cavities!

It turned out I used composite to restore but I’m trying to do the amalgams the same way now too. It is a lot harder than doing things the way I know but there is a satisfying feeling that I am developing a skill that I can use whenever I want and should improve my work (I believe anyway). I’ve also had some really good feedback from patients about the technique which more than anything else spurs me on.

I’ll go through some tips on dam placing when I get a chance (and when I have some) but just thought it’d be cool to show my slow progress and hopefully show that it is possible to change the way you work even if it’s hard at first.  See here for an audio blog on the subject last week.

In other news the inci-dental blog was voted in the 50 best blogs in Dental Sphere my nursing schools.net. See the link here it includes some other great blogs out there too. Thanks go to everyone who reads the blog and even more the people who contribute to the site!

That’s all for just the second

Hope everyone is enjoying the sun

Chris

I’ll be honest I’d never heard of a sectional matrix until Zaid wrote his blog about them on June 9th 2009. I probably should have done but the knowledge  must have just slipped though my fingers.

Well, the picture Zaid put up is here. Just look at it a beautiful rubber dam, lovely sharp contact point, excellent moisture control and contoured to the box beautifully. I look at that picture and I just want to grab some composite and get painting. You can really have fun with your aesthetics when you have that kind of control with your matrix.

Here is something I’ve realised: control= aesthetics. Control the environment and you then have the time to control your aesthetics.

Since the day I saw that picture I have been obsessed with gaining that kind of control and it has been a difficult journey. Your first thought is that no one can possibly work like that all the time, surely it takes too long, it’s too expensive, too fiddly and technically difficult. I also had to get hold of the kit, get better placing rubber dams, placing normal matrix’s and generally get better at placing composites to make this worthwhile. One of my rules is that I need to try and master all the basics before I pay out on expensive new kit or it won’t be worth the while. Get good for cheap before I splash out on fancy pants stuff, I’m not good enough to use.

It felt like a mountain to climb but I am determined to get their eventually.

Well this week I placed my first sectional matrix, it feels like a big moment and I thought I’d share the case with you. I’ve also finally worked out how to save our digital radiographs as J-pegs so I can finally show some root fillings. I’m not always sure showing root fillings is very exciting, you just know the person showing them only ever puts up the good ones. Well my root fillings are not always perfect and I’ll try to show some ups and downs as I go but generally the standard of this case is what I’m aiming for (at the moment) but I know there is room to improve.

The Case

So this case is on a 40 ish year old lady who was having some pain from her upper right tooth, she also had some food packing in the area and was not especially happy with her old dentist. When I examined the 14 tooth had a large defect I could probe right into distally and was tender to percussion. I could flex the distal portion of the tooth a little and I summarised that the tooth had a oblique vertical fracture, caries and acute apical periodontitis.

I was pretty worried that the fracture may run a long way subgingival so I made a deal with the patient that I’d remove the decay and fracture and see how deep it was. If I though I could restore it, I would. If not we’d have to look at other options but these were far from great: implant too expensive, didn’t want denture, 13 very poor root filling/ suspicious looking screw post. No chance of RBB from the 13, I didn’t fancy doing a fixed fixed on that 13 so a conventional cantilever off the 15 would probably have been the only option but I wouldn’t love the sound of that. So all in all I was pretty keen to try to save the tooth!

so next appointment we went in and removed the caries and fracture thankfully it was  alot higher than I feared maybe 1 mm below the gingival margin and well within my comfort zone. I root filed the tooth both canals were narrow so I prepared the taper using my standard endo technique to a size 25 6% taper. The obturation is with AH Plus and matched points all done under rubber dam of course. Once I’ve sealed the canal I always condense vertically with just a glick instrument (I’m saving up for a system B), I then seal the tooth with vitrabond another material clever old Zaid taught me about and which I love to use to instantly get a good coronal seal even if I then temporise the tooth before final restoration.

However I was a bit nervous of just temporising this tooth as the margin was so subgingival and I wasn’t sure I could control my GIC there. I also didn’t want to have gingival overgrowth and poor cleaning as I was planning to crown the tooth later. Finally the patient had a complaint of food packing and when you look at the 15 amalgam it’s easy to see why. I wanted to replace this restoration. Ideally before I crowned the 14 so I could get a nice contact and to do that I’d ideally need something to build against.

So all in all it was time for the sectional matrix. I whipped off the dam added 2 new holes and took the dam back to the 16, added my sectional matrix and hey presto. I know it’s not as good as the one from zaid’s blog but it’s a great start. I had great moisture control in a difficult area, a good curve on the matrix and tight adaption to the margins. Only about ten minutes ago I did, however, realise that I’d got the sectional matrix ring the wrong way round but you live and learn (and it still worked)!!

I don’t have a post op as I ended up running a bit late the composite looked good, you can sort of make it out on the post op radiograph?! It’s just a simple one shade composite (flow-able at the very bottom of the box) but well adapted and I hope it will last well!

Next visit I’ll replace the 15 filling but looking at that obturation picture it doesn’t look too clever endodontically. Also what would you do with the symptomless 13 the patient has previously wanted it changed for aesthetic reasons but was put off by one of colleagues which I think was fair enough but what would you do? Finally would you, having done that nice composite, crown the tooth? I regret to say hugely that I didn’t reduce the 2 cusps and take the composite over them (stupid I know). If I had would you leave it?

I’d love to know your thoughts?

I’d just like to make one more point. I read a lot of geeky dental books and I always think “wow it would be amazing to work like that” but that’s not real life dentistry. But then you start watching and talking to people who really do work like this everyday, all the time and once you know that it’s possible and you believe in the techniques…. I just have to challenge myself to use them everyday, all the time.

The trick is to get quick enough at them to make them everyday, fast and efficient. I really do think it’s possible; I’m working more and more under dam, polishing cavities before filling, bonding crown preps pre impression and other great ideas. You have to get efficient and find the time to make them part of your routine and not an extra hassle.

Maybe you already do all this stuff: to these readers I’d like to say, “I salute you, and ask you to please let me shadow you, I want you skills!” To others I urge you to give them a go, if you believe in them of course.

Chris