The Dentist's Network #87

Cosmetic Treatment Planning

I’d like to share a simple and effective protocol for cosmetic treatment planning. In the past, the term “cosmetic dentistry” was primarily associated with porcelain veneers. This era is over. As the dental community shifts away from aggressive treatment options to options that are more practical and conservative, it is more important than ever for dentists to have a variety of cosmetic tools in their tool belts. In my office, most of the treatments that I perform for my patients include use of what I call “The Three B’s”-Braces, Bleaching, and Bonding.

When a patient presents for treatment, I perform a thorough comprehensive exam in which all structural and disease issues are diagnosed. At the same time that these issues are diagnosed, I also diagnose the patient’s cosmetic discrepancies. Health and beauty are closely linked and our patients want their teeth to be both healthy and beautiful. A cosmetic diagnosis during the early stages of treatment planning is incredibly important, as it will most likely affect the manner in which the entire treatment plan is arranged. In dental school, we were taught to address disease and structural issues first and then ask the patient if they had cosmetic desires. This is an antiquated approach. These issues should be approached simultaneously so that we can provide patient care that is logical, all inclusive and clinically sound.

I like to keep the cosmetic diagnosis simple by posing three basic questions to myself as I’m examining the patient:

Does the patient have poor tooth positions?
Does the patient have poor tooth shape?
Does the patient have poor tooth color?

The answers to these three simple questions can provide us with an enormous amount of information, as well as a blueprint for our cosmetic/restorative plan. Most adult patients have discrepancies in all three of these areas. In my experience, if a dentist has the ability to effectively address each of these three areas, treatment can be very focused. In my opinion, every dentist should possess “The Three Bs.” These cosmetic tools allow us to provide conservative and cost effective treatment options for our patients.

The word “Braces” does not have to conjure up thoughts of lengthy treatment and metal appliances. Short Term Ortho (STO) is a systemized process that involves brackets and wires and is specifically designed for GPs. STO gives general dentists an ability to use clear brackets and tooth colored wires to gently and safely reposition teeth in an average time of just six months. The goal of STO treatment is to level and align the teeth and gums without making significant changes to posterior occlusion. It is an incredibly effective and accessible way for GPs to branch out into orthodontics, a field that has been traditionally untapped by general dentists. Brackets and wires provide the most efficient and controlled way to provide cosmetic tooth movement, and the systemized process allows general dentists to learn and provide this treatment efficiently and confidently. The magic combination of short treatment times and clear appliances make orthodontic treatment very attractive for adults. Visit www.6MonthSmiles.com for more information.

Most dentists already have Bleaching and Bonding as a part of their arsenals. But, joined with commonsense cosmetic tooth movement via STO, Bleaching and Bonding can be provided with new effectiveness. There is tremendous freedom and opportunity for us when we have the ability to reposition teeth quickly. Once the teeth have been moved and the gingival margins have been leveled, whitening and minor bonding can be done to put a dramatic finishing touch on the overall appearance of the new smile. Beauty is dependent on symmetry and “The Three Bs” allow us to provide the symmetry that our patients desire in a manner that is predictable. This method usually requires little or no tooth preparation.

Cosmetic dentistry is most effective when it addresses the actual items that are detracting from the overall appearance of the smile. Tooth position, tooth color and tooth shape are the main areas in which cosmetic incongruities are present. When we have the ability to address these items with the appropriate treatment modalities while saving precious enamel, we are providing a great service for our patients and our practices.

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs.

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Chris J. Lampert, DMD
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Predictable Mandibular Anesthesia

As an endodontist, I receive patient referrals for many reasons including: challenging access, curved roots, retreatment, post removal, blocked canals, calcified canals, and surgical treatment. However, patients are occasionally referred not because of case difficulty, but because of anesthesia problems. A few times each month I receive a patient that had endodontic treatment started by their general dentist and the procedure was aborted because of inadequate anesthesia. I have seen patients that have no therapeutic indication for endodontic treatment but the tooth in question needs a crown and after multiple attempts has not been “numb enough” to complete the crown preparation. The referral reads, “perform endo so restorative work can be completed.” Because endodontic treatment requires a deeper level of anesthesia than other dental procedures, block anesthesia is an absolute requirement. The following is a detailed description of how I approach lower molar anesthesia for my patients.

Lower Molars Anesthesia
For lower molars I use two carpules of 2% lidocaine with 1:100,000 epinephrine for the inferior alveolar block and one carpule of 4% Articaine with 1:100,000 epinephrine for the long buccal infiltration. I always use a 30 gauge short (1 inch) needle for both injections.

Steps for Lower Molars Anesthesia:

Apply topical anesthetic to injection sites. This is purely for the psychological benefit of the patient and has no pharmacological basis.
Have the patient open as wide as they can. This moves the musculature into a more favorable position for the injection and helps minimize an intramuscular injection.
Place your thumb over the pterygomandibular raphe and pull the buccal tissue taut towards the lateral direction.
Inject high and wide. This is the best pearl of advice for lower molar injections.
Do not dispense anesthetic during needle insertion, save it for the final destination. Dispensing anesthetic during needle insertion does NOT make the injection more painless but it does create bleeding in the insertion track and uses precious anesthesia that should be saved for the block.
As we learned in dental school, aspirate and inject slowly.
Inject two carpules of 2% lidocaine with 1:100,000 epinephrine in this manner.
Instruct the patient to open wide and close slowly two times.
Change to 4% Articaine with 1:100,000 epinephrine and inject one carpule as an infiltration in the buccal vestibule distal to the tooth being treated.
Wait ten minutes. Nine and a half does not work, trust me.
Anesthesia check. This is perhaps the most important step because it will ensure that the patient has a painless endodontic procedure. Place a sharp endodontic explorer in the lingual gingival tissue into the periosteum. Next place the explorer into the periosteum on the buccal tissue mesial to the canine. The patient should feel nothing. If they feel anything at all then I proceed to an intraosseous injection such as X-Tip or Stabident.

Intraosseous Anesthesia
I find intraosseous anesthesia to be more predictable than intraligamentary injections, and it produces less post-operative pain. There are two intraosseous injection systems currently on the market in the U.S. that utilize a standard slow speed handpiece and a traditional dental injection syringe: X-Tip from Dentsply Tulsa Dental Specialties and Stabident from Fairfax Dental. Both systems work by penetrating the buccal soft tissue and cortical plate with a small perforation needle bur which then allows for a small injection needle to be placed through the soft tissue and cortical plate opening into the cancellous bone space to deliver the anesthetic solution. This technique, if done properly, rarely fails.

Commonly used anesthetics for intraosseous anesthesia are: 2% lidocaine with 1:100,000 epinephrine and 3% mepivacaine plain. Anesthetics with epinephrine provides about 30 to 40 minutes of pulpal anesthesia but does produce transient tachycardia and occasional weakness in the legs. Anesthetic without epinephrine avoids these transient effects, but only provides 15 to 20 minutes of pulpal anesthesia. Because anesthesia onset is immediate and of short duration, the pulp tissue must be removed promptly. I typically use one carpule of 3% mepivacaine injected distal to the tooth being treated. The manufacturer of the Stabident system recommends to never exceed an aggregate of two carpules per patient per visit. The Stabident system is also not recommended for pediatric patients.

Steps for Intraosseous Injections:

Anesthetize the attached gingiva over the desired injection site.
Perforate the cortical plate by placing the perforation bur perpendicular to the buccal cortical plate and use a “pecking” motion until breakthrough into the softer cancellous bone is achieved. Using a “pecking” motion helps prevent overheating of the bone during penetration.
Insert an esthetic needle into perforation site at the same angle the perforation bur was used.
Inject anesthetic slowly and gently. When the needle is properly positioned in the cancellous space, the syringe plunger can be operated with only light pressure.

Nothing in dentistry is guaranteed, especially deep pulpal anesthesia on a tooth needing endodontic treatment. This technique however has allowed me to achieve predicable mandibular anesthesia on nearly every patient I treat. I hope you find it beneficial and that your endodontic experiences are more successful.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University.

Dr. Lampert can be reached at drlampert@thedentistsnetwork.net

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Louis Malcmacher
DDS MAGD
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Dentistry Needs A Facelift!

In times of a recession, there are certainly a number of things that you should be doing for your dental practice. Even as the economy is finally recovering, we can look back and say that perhaps there was a silver lining for dentistry and your office.

What is essential is that you take the time during this economic turnaround and give yourself and your practice a facelift. Dentists often ask me what to do during a recessionary time. The answer is obvious. You have some extra time on your hands because you are not as busy as you were before. Unfortunately, many dentists have squandered this time and have just kind of folded their hands hoping for the best. The smart dentists are the ones that take this opportunity and refresh their dental office, go to continuing education to learn skills so that they can offer their patients new services and train themselves and their team on how to become better dental providers. What we have always seen in the past is that during a recession, dentistry as an industry takes two steps back and then ten steps forward. Most of you will remember the market crash in the year 2000 and then the absolute boom years between 2001 to 2007.

What area should you begin concentrating on now to give your practice a facelift? Here are some of my suggestions:

1. Learn faster, easier, better restorative techniques. Restorative dentistry is the bread and butter of every dental practice and certainly has kept us going during more difficult economic times. Self-etching bonding agents such as G Bond by GC America, www.gcamerica.com, is an example of excellent self-etching bonding agents which can be used for a myriad of applications. Get great posterior composite contact with the V3 Ring by Triodent, www.triodent.com – simply the best system in its class. Exalence, the first ever vinyl poly-ether siloxane dental impression material, now combines the best of poly-ether and vinyl polysiloxanes and is the first new category of impression material in years which produces outstanding impressions with incredibly hydrophilic properties and great tear strength. Also by GC America comes Kalore, a new category of composite resin material, with a new DuPont monomer technology with chameleon properties that are unmatched by other composite resins. With the right equipment and materials, you won’t have to do these restorations over and you will save a lot of time.

2. A laser in every practice – laser dentistry has been growing and growing, as more patients find out that dentistry can be done without the dreaded shot. The consumer demands for minimally invasive techniques will push most dentists to incorporate some kind of laser into their practices. I have been using the Powerlase AT Laser by Lares Dental very successfully for awhile now as it has the two proper wavelengths for excellent hard and soft tissues. It is literally a laser operatory in a box with an ND-YAG laser for soft tissue applications and an erbium laser for restorative treatment on teeth requiring no local anesthesia. Lares Dental will even let you try out their laser – contact them for more information at www.laresdental.com .

3. Botulinum Toxin (Botox) and dermal filler therapy for every dental practice – Over half of the state dental boards are allowing dentists to enter this arena of total facial esthetics. This presents a unique and tremendous opportunity for dentists to be able to expand their dental practice and the services they provide to really enhance and complete esthetic dental cases, and adjunctively treat TMJ and bruxism like we have never been able to before. There are many well known therapeutic and cosmetic uses of Botox and dermal fillers which make these procedures an excellent fit into every dental practice. You can go to my website www.commonsensedentistry.com and click on the Botox tab for more information, dates, and locations on our live patient hands-on training courses.

4. No prep/minimal prep veneers – esthetic dentistry has had its ups and downs, but in this economic recovery, esthetic dentistry will grow quickly as so many patients are aware of the options of the esthetic dental options that are available to them. New advances like Aurum Ceramic Cristal Veneers will continue to rapidly grow in this market as most patients now look for conservative ways to permanently receive a great-looking smile. Aurum Ceramics, www.aurumgroup.com, is the best kept secret in dentistry and has been providing top of the line esthetics to LVI for quite some time. They have now entered the general dental market with the Cristal Veneer and with their esthetic expertise, have eliminated the problems associated with other thin veneers. You will love working with this dental laboratory as they are incredibly responsive and will guide you step by step through your case.

5. Physics Forceps – this is the first advance in exodontia in 150 years! Once you pick these up and do a few extractions, you will never go back to traditional forceps again. Go to www.physicsforceps.com and tell them that Malcmacher sent you!

6. Narrow Diameter Implants – I have just one word for you here: Atlas. Made by the Dentatus company, www.dentatus.com, this is simply the best and easiest system out there when it comes to securing lower dentures. You can toss out metal copings for a much simpler system of using a special silicone liner they developed to grab the specially designed implants. Take one of their courses and you will be well on your way to changing your patient’s quality of life if they wear dentures, as well as changing your attitude towards denture patients. They are distributed through Henry Schein so ask your Schein representative about Atlas Narrow Diameter Implants.

Now is one of the most unique times that we have had in recent dental history to get trained in new areas that can really add to the services that you can now provide to your patients. The trend is definitely to more conservative and comprehensive dental and facial esthetic restorative treatment. If you miss this opportunity to get retrained, you can still have a good dental practice if you take the time now and seize this opportunity. Only then, in years to come and for the rest of your dental career, can you have a dental practice of the future instead of dental practice of the past.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, Dr. Malcmacher is a consultant to the Council on Dental Practice of the ADA.

Interested in having Dr. Malcmacher speak to your dental society or study club? Click here. To reach Dr. Malcmacher, email him at DrMalcmacher@thedentistsnetwork.net or call 1.800.952.0521.

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