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Ignore the date on this page we had to change the date unfortunately as it clashed with holidays. It is definitely 7th September!

For those who don’t know Chris Barrow is a very successful dental business coach. He also writes a cracking blog which is one of my most read dental blogs.

Chris has been the source of some of the best advice I’ve received about dentistry. I would probably say that writing this blog is in a large part down to him, as is my current job. Chris can be controversial but he always gets you thinking about the job from a new angle and I find that is always a good thing.

I’m not exactly sure what my role on the debate is? I probably have as many questions as anyone. I hope to share a few of my thoughts about the dental industry and some possibilities of how I see my career developing.

I hope you can join us but if not please spend some time thinking about where you want your career to go. Think about the type of days you want to spend doing dentistry, not the money or the position and then work backwards.

Hope to see you then

Chris

This is a long running case which I finally got the last photos for so it’s time to share all!

You can read about the first few steps of the case on on these blogs:

Sectional matrix band

Sectional matrix band update

The case is interesting for many reasons not least because I kept remembering to get photos!

As we discussed before both the 14 and 15 teeth need root filling and a coronal coverage restoration. I wanted to crown both the teeth really as there is not much tooth tissue left. There is a big problem with this treatment plan though. Both have seriously subgingival margins interproximally. Have a look at that 15 and how deep the current amalgam is. It will take a seriously difficult prep/ imp to get the finish line on sound tooth tissue and even then it will be invading the biological width.

Clearly the answer is to crown lengthen and remove some of the interproximal bone, migrate the gingival margin interproximally and re-establish the biological width. I’ve been fascinated by crown lengthening for a while now and asked as many people as possible for advice and I reasoned this was a good case to try it on. No chance of post op sensitivity as both teeth are non vital, not a too aesthetically demanding area, compliant young patient and not really an alternative treatment. So the plan was to:

RCT both teeth, composite core 14, fibre post and composite core 15, crown lengthen, leave for 6 weeks for gingiva to heal, prep for PFM crowns, fit… lie down

Here are the photos:

RCT completed

Before crown lengthening GIC in 15

I reflected the mucosa with a simple envelope flap. I wanted to reduce the bone level so that it was 3mm below the bottom of the box to make sure there was biological width maintained. I removed the bone with a surgical handpiece and a small round bur. I placed a looped stitch which I wrapped around the distal of the 15. I then left for 6 weeks.

After 6 weeks we have this situation. I just removed the GIC ready for a composite core and fibre post. You can actually see how the cavity margin is now just supragingival and possible to crown. I really like this picture and although this was quite a challenging treatment for me I now feel that it’s not too daunting and is a great option for crowning those molar teeth which could be root filled but which we deem unrestorable because they have one very deep margin that you can’t crown. I think I’d do this again but also would offer the treatment by a specialist periodontist if I felt it beyond me. I don’t think I’m ready to tackle crown lengthening for anterior teeth just yet but I’m hoping to go on a course to give me the confidence to soon.

Here are the teeth with nice PFM crowns! Something I have improved is just finishing the buccal margin right at the gingival margin. It’s a common mistake I see in my work from last year that the margin is a little high at first I thought it was because I was over zealous with retraction cord but I’ve got better at recently just by taking the margin slightly further down after I place the compression cord (to protect the mucosa).

Hope that is an interesting case to look at. Comments and critique welcome. I was really happy with the result in the end I think I can now put crown lengthening, in selected cases, in my toolbox of treatment options to help patients save more teeth.

Hope everyone is well

All the best

Chris

I’ve realised I will never be a very quick dentist

I don’t like patching things up, I don’t like putting things off and I like to give my patients all the options

I don’t know how you manage an emergency pain appointment in 5 minutes

I take a lot of radiographs because you should and because I believe that 1 in 10 will totally change your treatment plan

I care so much how things go that I carry disappointment of  a poor contact point around with me for hours.

I probably need to get a life

Sometimes I feel like I want to give up, I think that everyone else just does it easily, that they are better than me, that they never have bad days.

I wonder how anyone can work so fast, I wonder how anyone can be so good, I wonder where they find the time?

I dream of putting little stains in my occlusal composites and the day when I never have to admit defeat when; trying to place a rubber dam for 10 minutes/ pulling an amalgam out/ not finding a canal and generally looking like an idiot to a patient.

and then I remember that I’m getting better all the time

Because I kept trying i can now most times throw a dam on

My composites are looking better all the time, so are my preps, my impressions, my dentures, my root fillings

It’s getting easier, there are no short cuts but It’s slowly getting easier

I wouldn’t say I’m getting much quicker but I’m learning my pace and I’m learning how to make that work for me

I try to do it once and do it right

I know that to get better, you have to go outside your comfort zone; and that means sometimes things get messy

I’m not afraid to try and I’m not afraid to fail

I will do so being honest and knowing I tried my best for the patient

I don’t have all the answers yet but I’m keeping the faith that one day I will

One day the hard work will pay off and people will wonder how I got so good

My patients will continue to come back for years and I will enjoy seeing my old work.

I just have to keep trying and keep believing

We are all in the same boat

We just have to keep the faith

Chris

I then enrolled on their 10 day restorative course for this year. It’s hard to exactly endorse a course over another as I haven’t completed any other restorative courses yet but I have to say that what I have learned from the Dare team has been really useful in every aspect of my dentistry so far. I use their crown preparation, dentin sealing, photography and other tips every day. I’ve found the content really modern, common sense and focused on adhesive and aesthetic dentistry. If you look through the blog you will see examples of their influence.

Anyway I put it to Andy that it would be great to have a day about posterior composites, specifically the use of sectional matrix, layering and rubber dam that we talk a lot about on the blog. I recently bought a V300 sectional matrix kit from optident and these are the kits we managed to get to demo with on the day of the course. I’ve found the system really good so far and as I bought it, in my opinion I think it’s probably the best on the market, although I also like the Garrison dental ones Neil shows.

I’m pretty excited to have got the day organized and have even managed to get the whole day course at a discount for blog readers. If you email Dare and mention you found out about the course through the site the price is £150 instead of £195. To be honest though a normal day course with anyone is normally £300-400 so I think it’s a great price anyway and obviously a chance for them to showcase their excellent presentation style.

The day is on Saturday 11/09/2010, 9:30 till 3:30 In Manchester. To book a place call LJ on 01618307300 or email suzanne@daretobedental.com. You also get 5 hours vCPD too should that be your driving force.

I’ll be there of course and I’m hoping some other readers will too so it’ll be a social as well as educational trip.

This is the first even close to commercial outing for the Inci-Dental Blog so I hope that people are not disappointed by it. To give full disclosure I get the sectional matrix day course free and have a discount for the restorative course as a result of helping Dare organise the content for this day; unfortunately, I make no money from it. I suppose it’s up to you if you think that is selling out but all I can say is you should make you own mind up about a year restorative course with Dare, that’s up to you, but this is a good opportunity to find out more about them.

As for the one day course I can happily back it 100% because at £150 I think it is an absolute steal, I’ve worked really hard to get the price that low and I know that the content will be fantastic. I hope and believe that the event will be win, win for everyone involved.

Anyway let me know if you can make it, I’m really excited to meet everyone!

Chris

P.S. The places are obviously limited so to avoid disappointment get in touch asap

p.p.s click the pictures to read better or download the PDF here Dare sectional matrix day brochure

The case is one I put on the blog a while ago so sorry for the repetition but the case report does cover a lot more details about the considerations in the case. I thought it might be useful for current VT’s to get an idea of how to lay out the case report and maybe generally a little interesting. The report is not perfect there is no image of the final co/cr denture as it was unfortunately fitted by my colleague when I was on holiday. I also haven’t included the clinical notes, mainly for legal fear, which you need to submit for VT.

Just click the link to download the document

Case Report

Hope that helps

Chris

Proactive meaning I prepared thoroughly so that I could face new problems in my stride

Reactive meaning that I could respond well to new situations and quickly develop strategies when difficulties arrive

Well last week was my first in a new job. Probably like many of you and if your anything like me you will have realised that no matter how proactive you have been there was a lot to react to! For the, “fly by the seat of your pants” folk this will have been a bit easier than for the proactive among us who like to feel in control at all times!

For me, it was a difficult first week but enjoyable and as a proactive person I have been working out how best to meet the challenges I faced so that next week is easier. One of the hurdles is that I now work across 2 surgeries and although I went in and stocked the surgeries as best as I could before starting work there is some equipment that I have to move between the surgeries.

To counter this I have stocked up my own dentists trolley! Laugh if you will but this little fun box (from wicks) is the answer to my dental equipment dreams. It contains all my favorite stuff: bur kits, dam sheets, loupes, camera, vitrebond, sectional matrix kit and much more! In time I will have all the crown stuff in a separate compartment the endo stuff in another and the white filling stuff in another… can you imagine the bliss of it?  Being able to work in any surgery, anywhere, at any time!

I hope you can agree it is something to aspire to and having just shelled out for my very own digital camera and worked hard to research and order all this stuff it with some pride I look upon my trolley and how far I have come.

I also just want to mention that the best thing of all the kit I have bought in was some schottlander bur kits: See here.

Of them i can highly recommend the finishing bur kit and the eastman crown prep kit which have both been a joy to work last week!

I know most people won’t have this particular problem when they start their job but it might be something else. Or maybe you can envisage a problem you can see coming up that you could prepare for. If I’m honest I wish I was more of a reactive person but I think I struggle when I face hard new situations. I have to have my trauma guidelines on hand, know what is the surgery and have cheat sheets on how to use all the bonding materials ready. It’s not easy, no one ever said it would be; stuff will happen, but at least I know I’ve tried my best. Just remember that if you are out of your comfort zone maybe the best thing you can do it to take a step back temporize as best you can and be ready for another day. Patients will understand this and the most important thing always is that we avoid at any cost doing any harm!

Anyway, I wish all those people like me good luck with their second weeks, it’s got to be easier than the first… right???

I am now prepared to react!

Chris

I suppose the most common way to do non vital bleaching is the “walking bleach method” in which you remove gutta percha to below the cervical level, seal and hen seal sodium perborate into the pulp chamber. This dressing is then changed every 2 weeks until the colour change is sufficient. I have had a bash at this technique and found it effective but very slow. I think the problem is that the bleach you seal in looses potency very quickly and most of the 2 weeks are redundant.

In/ Out bleaching is a variation to this technique in which you ask the patient to syringe bleach into a sealed but open access cavity and wear a bleaching tray to greatly speed up the process.

There is a fantastic Jounel article from dental update on this technique. Managing Discoloured Non-Vital
Teeth:The Inside/Outside Bleaching Technique: May 2004 by NEIL J.POYSE et al. You can get the PDF of this if your are an dental update subscriber on the back catalog… or steal it from a friend. It is well worth a read and is a useful guide to keep in surgery.

To give a quick overview the technique is:

1) Make sure the root filling is adequate or revise it. If the tooth needs a root filling first then make sure you have removed all the pulp chamber especially the pulp horns.

2) Remove GP to below the cervical level with heat plugger

3) Seal the root filling with GIC, zinc phosphate or zinc polycarboxylate

4) Construct a, well fitting, suck down splint with reservoirs buccal and labial to the target tooth.

5) Ask the patient to rinse then fill the access cavity with 10% carbamide peroxide every 2 hours before adding a small amount of bleach to the tray and seating.

6) Review after 2-3 days. At this point the bleaching should be completed and you can seal the access chamber temporaily. The patient should be instructed to cease bleaching if the process happens quicker than this. Slight overbleaching can be preferable as some relapse is anticipated.

7) The final composite restoration should not be placed until 1 week after bleaching is complete to ensure that the bond is not effected by residual oxygen from the bleaching process.

The draw backs to the technique are;

1) the patient must be able to syringe in the access cavity

2) During the bleaching process there is a increased risk of tooth fracture. This necessitates full time wear of the bleaching tray and a soft diet which must be adhered to.

3) It has been shown, though only with high concentration bleach (30% hydrogen peroxide with activating heat) That there is a low incidence of cervical resorption.

This is a case  did the non vital bleaching on. I actually did this before I did the extra research to write the blog so the technique I used was. Remove GP to below cervical level I then placed a seal of vitrebond (light cured GIC) and a second layer of zinc phosphate. this was pretty belt and braces and I would probably just use a capsule mix GIC to seal the GP. I think due to this the seal was too thick in the case I did and with a single GIC layer I might have been able to bleach the very cervical area which is still a little dark on the follow up. I also left the review of this patient for a week as I thought the tooth was so dark it wouldn’t be fully bleached before that. In a weeks time the colour has really come up and it’s likely it was probably fully whitened before I reviewed the case which means I left the cavity open for a few days longer than I needed to. We also didn’t stock 10% sodium perborate at the time so I used 20% hydrogen peroxide gel. Nothing I have read makes me worried that this concentration is too high but I suppose it is always best to keep the risk of cervical resorption as low as possible. Having said all that though I just think this is the most amazing result for just a weeks bleaching and I think I would always do the in/out bleach technique if possible when non vital bleaching. 

To think this is such a simple procedure but the difference it makes to the patient is huge. I love this type of dentistry!!

The way I sealed the tooth was also interesting. I used a new material by densply on the market called SDR, which I’ve heard some really good, independent, reviews about. I’m not a material scientist and I am very cautious of new materials so I will sit on the fence with this one however I ordered a trial of the material as I was keen to use the “flowable, bulk fill, reduced shrinkage material” A deep access cavity liked this seemed the perfect place to experiment with it. My observations were that the material was lovely to handle like a slightly thick flow and certainly seemed to adapt well to the deep access cavity. The material is quite translucent which I suppose is why it can cure for a depth of 4mm in 20 secs and this means that for posterior teeth you should layer conventional composite over the top. I’ll keep an eye out for independent reviews of the material but the potential for this material if it does do what it says on the tin is very exciting.

The best of luck for those, like me, starting their new jobs tomorrow

All the best

Chris

As the blog is voluntary and can be quite time consuming I feel a little odd defending my absence but I will because I genuinely feel I’ve let down the people who read it, write comments and make it what is is. It’s been great to see people commenting in my absence and makes me very proud of what we have set up, and by the way the blog has its 1 year anniversary last month so yay to that! I also turned another year older so I’ve written a new  profile page but kept the same photo so I can pretend I’m getting wiser but not uglier!

Here are my excuses:

1) I had my MFDS part 2 exams to revise for (all passed now thanks), and work to complete to finish my VT (done!)

2) I was staring s Norman in the play “A Nightingale Sang” (and growing sexy mustache)

3) I went on holiday to see my sister who lives in Germany

4) I was feeling a little burnt out to be honest and really needed to spend some time with loved ones before I moved from Newcastle to Sheffield to start my new job! I found the easiest way to do this was to just take a total break from the dental social media scene and try to hide from emails

5) I’ve moved to Sheffield and have had to prepare for the new job which I start tomorrow (gulp)

It doesn’t mean I stopped having ideas for blogs or getting photos of cases. In fact I’m hoping to have a productive August of stuff to put up. The thing was the longer I waited the more I wanted to get back to blogging with a bang and I’ve actually spent the last 3 weeks researching porcelain bonding and crown types and manufacturers for a new guide on what i think is a very confusing subject. I’ve written about 5 pages on it on word so hopefully I’ll split it into blogs and post with pics soon but I’ve not quite got there yet and I can’t wait to post something any longer!

I also just want to say that I am really committed to keeping this blog running long term as I love writing it so please subscribe and stay with it! I cant promise an article every week or anything but I will do my best to keep the content useful, clinical and only occasionally whimsical.

Chris

P.S If you have emailed for advice or blog related things in the last month or so, I’m sorry for the delay, I will be working through them shortly.

I thought I would just show you a small case that I did a few days after case 1. It is a massive compromise, I know, to the technique that I use in most situations and described before. At risk of losing all credibility I still think it’s worth seeing because until recently I used to find it easiker with large composites to do the mesial and distal walls at different times. Sometimes you have to break your own rules and usually it’s because the patient pushes you into it.

In this case the patient was reluctant to have the rubber dam placed because she was worried she would feel she couldn’t breathe and so I ended up using cotton wool and suction in order to achieve moisture control. The second compromise was that the case is a replacement for an indirect precious metal onlay and so an indirect restoration was indicated with cuspal coverage. The patient demanded an aesthetic alternative to metal and financial constraints meant my planned ideal bonded indirect composite onlay was not on the cards. I gave in and with significant warnings given to the patient tried to build up a direct composite onlay. I don’t think this case was a great example but it shows the 3D-ring and compositight sectional matrix in a large MOD situation; demonstrating its use in getting tight contact points. In my hands this I used to find this pretty much impossible with a normal Siqveland band.

Case: 59 year old lady. (Sorry no pre-op photos – photographing was an afterthought).

Failing onlay on 25 that I had been warning her for the past year needed replacing. I could get a spoon excavator in at one of the margins probably due to poor original fit and cement washout. There was no radiographic or clinical evidence of caries though. The onlay was ‘flicked’ off with a probe after some gentle persuasion at the edges, clearly showing how much this restoration needed replacing.

The preparation had thin buccal and palatal walls which would require cuspal protection. I reduced these slightly in order to provide an occlusal thickness of composite of at least a millimetre. I was confident that an occlusal thickness of composite would never offer anywhere near as much resistance to loading as metal so I decided the composite would need to be thicker to serve as an onlay material. Otherwise I did not alter the cavity form other than to freshen the dentine slightly. The following photos show me placing (admittedly in the absence of rubber dam) wedgewands and mesial and distal 3D-Ring and normal Composi-tight ring. I etched, rehydrated dentine, bonded as in case 1 and used a flowable composite lining. I built up the proximal walls first in an enamel shade after burnishing the matrix bands outwards. Dentine shade composite was then placed in incremental buccal and palatal sloping shapes up to the cusp tips with a superficial 1mm thick layer of a lighter enamel shade placed finally. The restoration was then finished placing some secondary occlusal features and polishing with greens, reds and soflex discs. 

I think the result was reasonable and certainly bettter than the previous restoration. It’s longevity will remain unknown for some time! Most importantly the patient was very happy.

Thanks,

Neal

It pretty much sums up my current thoughts on UK dentistry for young associates and I would love to hear what you think about it!

Also as you know things are kind of busy at the moment so struggling to put up all the recent cases I’m finishing. In the mean time I really enjoyed hearing Neal’s thoughts on Class 2 composites below. I would just like to take the opportunity to reaffirm that the blog is always looking for new contributers and if you are keen to write and be part of what we do here then get in touch!

Still hopefully you will be glad to know that the 3 wear cases I put up a while ago should all be finishing in a few weeks. That means I will finally finish my guide to wear cases i started.

I actually just wrote one of them up for my VT case report so I can steal some text from that…

I’ve put a couple of pictures of one of the cases below showing the patient before and after provisional restorations. I built all these with direct composites free hand and a quick acrylic denture. However due to the sheer amount of composite and the amount of staining being picked up (heavy smoker, that acrylic shade was taken from the composite!), I’m moving the chap into upper PFM crowns and a precision attached denture.

These have now been in place 4 months (getting darker) so I’m happy with the occlusion and now getting in to the crown work. I show the results when i get them but so far so good. In brief the stages for this case are. Make a level incisal plane and decide how much to increase the VD by. Here I’ve let the aesthetics of the lower incisors and 13 contact determine the VD. I always over build the lower incisors just slightly so i can take them down a touch if I’m struggling with anterior guidance.

Then build the upper anteriors for maximum aesthetics, I build one without bond before the dam is placed and adjust this then I dam build the others and take the temp off. Obviously you can pay for wax ups if you want a quicker procedure but I like doing them free hand. It’s certainly cheaper for me right now and improves my knowledge of occlusion. It also means no record errors from articulators get incorporated. I overbuild the palatal surface slightly then I painstakingly grind in the anterior guidance. This takes on average for me 45 mins.

That is the flip side of doing things free hand; time. The reason I didn’t get the 22 and 23 completed first visit was that I’d already been working for 2 hours and a half! Still its a great way to work as a VT and keep your lab bills down and  it’s also just pretty fun!

Please feel free to debate about putting the case into crowns. I debated with myself about it for a long time but I made my decision for maintenance reasons (that and the never ending stain). I appreciate the conservative point of view and certainly I have left several patient in composites but I think we have a duty to meet our patients long term aesthetic expectations and I don’t feel I have here entirely (even when i chnage the denture shade!).

Actually there is a good dental update article on this if you want more info.

Have a great week!

Chris