Posted by Bob F on 22 September 2013, 3:18 PM
I produced this portfolio in my second year of dental school. I have since received regular emails and have been in almost constant discussion about the techniques I present here. Of course since producing this my knowledge and skills have also improved significantly. The following is a quick "what would I change now" if I were to re-write this portfolio. This was a reply to a recent email I received:
At this point I would consider everything from the rubber dam to the final polish and finish as inadequate in my portfolio.
- - My initial rubber dam is very messy with folds all over.
- - I almost never use the 34D bur anymore. It's too small. Most common burs are the 330 Carbide (because it's cheaper than diamonds) and a crown and bridge bur for the (too common) deep class II walls.
- - The concept of an outline form is almost deleted from my mind. When beginning a tooth, I strictly aim for the caries and remove healthy tooth structure if more visualization is needed.
- - I'll then remove any undercuts and place proxima/gingival bevels with respect to the enamel rod orientation. If the prep is small, I'll break the contact with my bevels with a thin flame bur to keep it conservative. Either way, the contact must be broken. If it's not, you're just wasting time, making things difficult, and you'll most likely end up with a poor and soon to fail restoration. In the long run, that would be much less conservitive so do the job right, don't be scared to make it bigger if you need to.
- - Those standard G-rings are good, but the new G-rings are AWESOME: http://www.garrisondental.com/store/matrix-systems/composi-tight-3d-slick-band-matrices/composi-tight-3d-system-slick-bands-matric Use whatever jelly bean shaped matrix band you wish, that ring produces the perfect separation and the rubber pads adapt to give excellent contour. I recommend skipping the pricier V3 ring system.
- - In the real world, sensitivity is a HUGE issue. You don't want to talk about it with the patient, you don't want them calling, you just don't want to mess with it and give your patient a bad experience. Fifth gen bonding agents are good, but 7th gen all-in-one's are getting pretty good too. The best option is to use a desensitizer such as gluma after your etch, but before the bond. There is reserach that shows an improvement in bond strength too. I believe Gluma is mixed into OptiBond Solo Plus. Take care not to use something that interferes with your bond. Currently I often use flowable or a GI liner. The GI liner for deeper preparations because the etch is less harsh and sensitivity inducing. These liners provide two benefits...more on that later.
- - If you're doing a full etch, take EXTRA care not to etch the dentin for more than 10sec. This leads to significantly more sensitivity in my experience.
- - After your etch, suction the etchant, then wash it really well. You suction first to avoid any of the acid etch flowing elsewhere. DO NOT COMPLETELY DRY THE TOOTH. In fact, just a quick blow with the air syringe is enough. Studies show that having a damp surface actually provides a stronger bond because of the acetone in the bonding agent. Acetone is hydrophilic so it gets sucked down into the wet tubules better. Minimal water does not interfere with the bond, saliva destroys the bond. Keep it saliva free. Dry moderately to evaporate the acetone/water before curing. No need to apply multiple layers of bond but you can scrub it in, dry a bit then scrub some more before curing.
- - Place your liner or flowable. I almost always use flowable on the floor of my preparation. Not only to get really good adaption, seal the tubules and reduce sensitivity, but also to reduce your C-factor. As you may know, all resins shrink on curing. The fewer tooth walls you place an incrament of composite against, the less of a chance it has to pull away from one of the walls and weaken/break the bond. Placing something on the floor first instantly eliminates that surface and reduces your C-factor. Now there are other minute details such as the thickness of said layer being cured as well. Take care NOT to place the liner on the cavo surface or higher up on the walls.
- - If you got some liner/base on your cavo surface or made your walls untidy, you'll need to re-prep to clean the walls. You get better at keeping things neat in time. Etch+bond again if you do re-prep.
- - Place your composite, jiggle it into place as best you can. Place ~2mm layers and make sure your curing light is producing enough intensity in the correct wavelength of light (they have measuring tools or just don't skimp on your curing light).
- - Finish your restoration anyway you like but make sure you don't have an overhang and the contact flosses smoothly without fraying floss.
At the end of the day, your restoration is only as good as the care it receives over time. Decent dentistry is designed to last 7-12yrs. The best indication of future caries is a tooth that already has a restoration. The trick is preventative home care. I myself have quite the regiment and I strongly consult and advise my patients on how to care for their teeth. The methodology is called Caries Management By Risk Assessment (CAMBRA) which basically means you custom tailor care instructions for each patient.
Also, you can only do so much by hand. If you're lazy or tired, you're going to do poor work. For that reason I feel CAD/CAM inlays/onlays are an excellent option. You can focus on just perfecting your prepping skills and let the machine spit out whatever. It's got decent margins, but it comes out with excellent contours and is being cemented with a restorative resin, so all the margins get bonded anyways. If you think about it, who burnishes/polishes their cast metal margins any more? You'll still need to place a liner before your scan though. This method gives you a much more solid restoration that I feel has a better chance of success (purely my thought process and not research based).
I would add to this that since graduating dental school, I feel a bit of a void from not constantly learning. I find myself getting lost on Google Scholar reading about various topics I think about during work. Without evidence, it's all just here-say.
Dentistry is easy enough, but you're doing everyone a disservice if you just do it this way because 'that's how I've always done it.'
More about what I'm doing:
With the advent of modern 3D technologies, dentistry will hit an evolution spurt sometime soon. Since dental school, I have built a couple 3D printers and attempted to fabricate simple temporaries or in-term restorations with some success. 3D printers have huge value for a dental practice in my opinion. If not for their accuracy and speed, the sheer cost of producing a temp from a sub $1000 printer is literally less than a penny (yes, it's very accurate). Compare that to your ~$4/temp bis-acrylic. Not to mention if you're all digital with CAD/CAM, you can forego the $20 PVS impression you would normally take. There is a lot more to this so feel free to contact me.
I'm currently at the University of Pittsburgh AEGD and getting started working on a potential tech curriculum for the predoc students as well as other educational development projects. I also can't seem to budge my interest in Oral Surgery so I'll be heading in that direction. Otherwise, I have preemptive plans to produce dental management and professional networking software for the modern age. I feel that the existing software is moderate to poor with very limited functionality with a huge interface handicap.