AVOIDING CHAIRSIDE ENDO SHOCKERS

You start endo on #2 after a nightmare rubber dam adaptation because of a thick buccinator, interfering condyle and reduced mouth opening. You have accessed 3 canals in 3 roots and you search for the 3rd canal in the MB area. You are ecstatic that that small canal doesn't really exist in the tooth. You place your master cones in the 3 accessed canals after instrumentation and get a radiograph. What you see now throws you aback! There is a 4th canal that you completely missed!

How do you avoid such shockers?

1. Triage - Plan well. Read the pre-op radiograph well. Search for extra roots, calcifications, root anomalies, canal anomalies etc. When in doubt, refer!

2. Visualization - Make sure you work under good lighting and a clean, hemostatic field.

3. Radiographs - Always take a PA after master cones fit and when endo is completed.

4. Avoid 'herodontics' - Do not attempt to be a dental hero! Refer when you think its beyond your capacity! You are a health care provider, first and last! Do what is right by your patient and DO NO HARM!

VALUABLE LESSONS CEREC HAS TAUGHT ME

I must admit that, as a dentist, you can either fall in love with the CAD-CAM technology of CEREC or absolutely detest it.

You go through years of dental training about the 6 degree taper, and here comes a machine that shows your concept of a perfect tooth preparation on a large monitor, and you are aghast! What's more, the machine spits out a proposal for a restoration according to your preparation and it is the ugliest crown you have laid your eyes upon! Just when you are coming to terms with the fact that your dentistry needs some major tune-up, your assistant looks at you in contemptuous exasperation because the margins are off, the restoration won't seat and the occlusion is in a disastrous hyper! The nightmare ensues!

If this situation is all too familiar, then you have just been taught the first valuable lesson, in the line of many, by a new technology! Prepare the tooth for the material of the restoration!

So, what all exactly did I learn from CEREC?

1. Prepare for the material.
6 degree tapers belong to PFGs and the likes. CEREC uses porcelain. Ceramic loves to breathe, so reduce enough tooth structure to make room for the Ceramic. Ceramic does not like sharp line angles, so make everything smooth. And, make sure you get rid off all undercuts. The minimum advised thickness of ceramic is 1.5mm but I would make this 2mm. Use the depth cutting bur. And pre-measure your burs, so you know what would be most effective.

2. Be patient.
Rome wasn't built in a day. And the tooth preparation for CEREC restoration will certainly not be done in 3 minutes, or 5 or 7! Take your time to make the tooth preparation as perfect as you can. The 12-15 minutes that you spend evaluating, refining, re-evaluating your preparation, is well worth it.

3. Give adequate and prolonged anesthesia.
If you don't like to suffer an extremely sensitive tooth, so doesn't your patient! Do your patient a favor, and make sure that the anesthesia is effective till complete seating.

4. Timing is everything!
Make sure you are in tune with your assistant. Time well. Don't over schedule, prepare 4 crowns and 4 inlays and expect the patient to be out of the door in one hour! Do not over promise and under deliver!

5. Preparation is everything.
Understand this concept at different levels.

(a)As a dentist, your preparation determines how the CEREC determines the restoration. The computer is artificial intelligence and detects in pixels what the camera images. It does not have a brain to overlook your errors in preparation. And your assistant cannot build a Taj Mahal over a marsh! So, make sure every margin is crisp!
(b)Prepare your patient, yourself and your team for every possible complication. The patient should be informed of the possibility of temporization. It may be a 24 hours crown instead of a 1 hour crown, but it sure beats a 2-3 week lab turn around!

6. Effective hemostasis!
I cannot emphasize this enough! One thing I have learned is that in the battle between blood and the dentist, blood always wins! Invest in a laser or an electrocauterizing equipment. The bur or the scalpel is not the most effective hemostatic control. Anyone who has nicked bone knows that even 1:50,000 epi is not weapon enough!

7. Believe in crown lengthening!
Margins placed sub-gingivally can be troublesome in more ways than one!

Welcome to the era of precision dentistry! The CEREC is a wonderful toy to have in the clinic. Expensive and sensitive but extremely valuable. Master your dentistry and master the technology. Once you know your route very well and have traversed it multiple times, your journey becomes easier, faster and definitely more fun!

ODONTOMA? IMPACTED SUPERNUMERARY? DIAGNOSTIC CURVEBALL?

COMPOUND ODONTOMA

POSSIBLE SECONDARY TRAUMA FROM OCCLUSION

PT IN MID ORTHO TX. PAIN #19. FURCA CANNOT BE PROBED. TOOTH IMMOBILE.

EXTERN STORY

An extern dental assistant I had in one of my previous practices is the inadvertent 'artist' behind this work-of-art x-ray!