D4

I remember being an underclassman and envying the freedom of the seniors. No more exams, quizzes, or classes in general. Nothing really do to but treat patients, go to classes of your choice, and actually relax after hours. Now that I'm here I can say it's a wonderful thing for sure.

I've taken two classes this year, one of which really helped me to appreciate the different employment options dentists have, and the importance of critically reviewing any contract before signing. Dr. Paull's "Worst Case Scenario" course encouraged us to envision what the "worst case scenario" could be for many employment options, or any decision in general. A recurring example involved thinking about compensation and incentives in your work. In school we are taught the ideal, and cannot accept anything less. However in practice it is left up to our professional judgement to determine what is best. Thinking about how practices are reimbursed for treatment, and how this affects our treatment planning abilities are factors that aren't really covered much in other courses but Dr. Paull goes into detail about all these things and more.

The one other course I elected to take is Dr. Marshall Fagin's Fixed Prosthodontics course. I'd highly recommend it to anyone interested in learning about more advanced fixed cases, or just garnering some more tips to help with simpler cases. I've attended earlier lectures from Dr. Fagin and always admired his passion for dentistry. Luckily I had a couple fixed cases left to finish up this semeseter so I was able to apply some of his hints, like packing one cord continuously until we have adequate retraction prior to impressioning, or simply vaseline-ing a temporary before cementing to make clean up easier. One trick I'd hope to recall is when altering vertical dimension with a mostly edentulous arch, we can use the end of a needle and indelible marker to tattoo the gingiva to record the VDO we want.

All in all, D4 is a chance to cultivate balance, and remember all there was to life before dental school. Having time to reconnect with my capoeira group and spend some more time outdooors has been awesome. Requirements are almost complete and the coming months should be really exciting.

When the time comes to move on out, I know I'll definitely miss Buffalo for all it has to offer. At first the city felt cold and desolate, but I've never had a place grow on me as Buffalo has. Despite incredible amounts of snow, the rich cultural diversity of the city fills the warmer months with activity. The Elmwood and Allentown Art Festivals, and plethora of ethnic festivals cannot be missed if one decides to spend some time here.

 I'll close with some photos from my recent visit to Letchworth State Park:

 Cheers.

Restoring Teeth with Implants

I had a post a while back about implants and want to follow up on that. I have a couple implant cases and wanted to share the process of restoring the implant.  As I've explained to patients at school and friends, a dental implant is basically the "root portion" of the tooth. The titanium implant is placed, and allowed to integrate with surrounding bone. Once the implant is deemed integrated and stable, then we can restore it with a crown. At UB as pre-doctoral students, we do not do immediate loading cases, but this is possible in some cases.

After 3-6 months, once the implant has osseo-integrated (bone has grown into the threads of the implant) we can begin the restorative phase. 

I. Data Gathering/ Treatment Planning

This case involves a patient who is seeking implant restoration of tooth #5. No significant medical history. 

Dx cast occlusal 

Dx casts lateral

Dx wax up #5 occlusal

Dx wax up #5 lateral

The process began with diagnostic impressions and treatment planning. There was adequate interocclusal and mesio-distal space for implant restoration. A 4.2mm Straumann Narrow Collar (NC) SLA Implant was selected for placement by the surgeon. A surgical guide made from TRIAD material and a radioopaque cylinder was fabricated to assist the surgeon in placing the implant with the correct angulation. This is important because implants must be at least 1.5mm from adjacent teeth and if implants are placed next to each other there should be at least 3 mm of bone between them.The patient returned for a try-in appointment where one periapical radiograph was taken to ensure correct angulation with regard to adjacent teeth roots, and to ensure the guide fit passively and completely. 

TRIAD surgical guide

Next, the surgeon scheduled the patient for implant placement. A full thickness flap technique was utilized and the guide was used for initial osteotomy.  The implant was placed without complication. The patient was then allowed to heal for 4 months. Upon follow up with the surgeon, the implant appeared to have integrated with bone well, and I was notified that restorative phase of treatmnt could begin.

The patient was appointed for a closed tray implant impression. Prior to the appointment an impression post, cap and analog were secured from Straumann. A custom tray was also fabricated for the impression making. 

II. Soft Tissue Model Fabrication

Straumann Implant components

TRIAD Custom Tray

At the impression making appointment, the patients vitals were taken, and the procedure was explained to the patient. The healing cap was removed from the implant, gingiva was healed very well. The impression post was then inserted and screwed into the implant so that the arrows on the post were oriented bucco-lingually. The patient was given a cotton roll to bite on posterior to site #5 to prevent damage to opposing teeth from the impression post. A periapical radiograph was taken to ensure complete seating of the impression post. Once complete seating was confirmed, the yellow impression cap was placed onto the impression post, and the impression was made using Aquasil Light and Medium Bodied Polyvinyl Siloxane impression materials. 

Closed Tray fixture level impression 

The impression was inspected and decided to be adequate. The impression post and cap come out with the impression. The post is unscrewed, and in it's place the implant analog is screwed into the impression.

This impression was used as a soft tissue model. In the lab, separator was applied on the impression material around the implant analog. Gingifast was then applied around the implant to simulate the gingiva and help us plan how we will develop emergence profile in the gingiva. Separator was then applied on the Gingifast after 2-5 minutes once the material cures. Separator is applied twice because we do not want the gingifast sticking to the impression, or to the stone. The impression was then poured using Jade Stone. 

Creating soft tissue cast

Soft tissue cast

III. Provisional Abutment/Crown Fabrication 

This soft tissue cast will now be used to select our provisional abutment, fabricate a custom abutment  if necessary and a provisional crown. Provisionals will help us develop the gingival emergence profile before the definitive crown is cemented. 

The next step was to secure a provisional abutment from Straumann. The components arrived in about a week.

Provisional abutment and screw

Soft tissue cast, provisional abutment & Straumann screwdriver

The implant analog was unscrewed from the cast and we were left with a cast replicating what is present in the mouth. We can now see the gingival height and shape we will be working with. We've learned a number of times that an implant is not a tooth. It's actually nothing like a tooth. It is ankylosed, lacking a periodontal ligament, and emerges from the gingiva in a circular shape. With this procedure we are hoping to achieve a more tooth-like gingival architecture surrounding the eventual crown. The provisional abutment here is screwed into place. And any undercuts on the mesial and distal of site #5 have been blocked out with wax.

Next this provisional abutment was etched, to enhance the bond of the PMMA acrylic. 

The abutment was then marked and cut down so that my template could be used to fabricate a provisional crown. 

The access to the screw channel needed to be maintained so that I would be able to retrieve the provisional crown. A hole was made in my vacuum-formed template to accommodate the screwdriver at the correct angulation. The provisional stump was also trimmed further to accommodate my vacuum-formed template of #5

This step was particularly tricky. . The PMMA was then mixed to the "doughy" state and the template filled around the screwdriver. The template-screwdriver apparatus was then brought to the cast and seated and re-seated a number of times as the PMMA set so that the crown would not lock into any undercuts that may have been missed during the block out.  The seating and reseating was done by basically screwing and unscrewing the provisional into the implant analog a number of times gently. 

The provisional eventually self cured and was removed from the vacuum-formed template, trimmed and polished with Acrylustre. The Gingifast was trimmed minimally into an oval shape buccolingually which will allow the provisional to create the emergence profile we are looking for in the mouth. The surface of the provisional contacting gingiva was highly polished to discourage any plaque accumulation.

Occlusion was checked with the opposing cast and we are ready for try in!

Indian Health Service - Seneca Nation

Little article for an ASDA Buffalo publication -

“Opportunity, adventure and purpose” - this is the tagline of the Indian Health Service’s (IHS) dental externship and after this summer I know why. IHS offers an incredible opportunity for pre-doctoral students to serve in a culturally diverse and unique setting. Located about 40 minutes from UBSDM, the Cattaraugus Indian Reservation Health Center is one of two primary medical and dental facilities for the Seneca Nation.  The dental facility features digital radiography, electronic health records, a variety of materials and excellent staff. The externship is a great way to experience dentistry, and give back to an underserved population

As the “Keeper of the Western Door” the Seneca people have strong sense of community and culture. From the signs written in Seneca language, to patients sharing stories of their family lineage, serving this population proves to be most rewarding.   For those interested in public health dentistry, or experiencing a different patient population, the Seneca Nation is a great place to start!

Remote Area Medical (RAM) - Scott County, Tennessee

RAM is a non-profit group who operates solely under donations of time and support to provide medical care to rural areas in the U.S. mainly in Tennessee, and disaster affected areas of the world.

Scott High School, where clinics were held

RAM trucks unloading supplies

I just returned from my first ever RAM trip and it was nothing short of exhausting, inspiring and incredible. I made the 10 or so hour drive down with a few other classmates and we stayed at a church a few miles away from Scott County High School, where the clinic was held.

Friday night was spent settling in but clinic started early Saturday morning at 6:45am. By the time we arrived RAM volunteers had the dental clinics in full swing and patients registered and waiting, while others were already being seen. We were briefed on the way the clinics run, how we review the patient's form, retrieve supplies, complete treatment and complete what was accomplished before handing the patient their form to check out with.

Southern hospitality

Church where we were lodged

I had an amazing assistant Paula, whom stuck it out with me all day Saturday. We started off doing restorative, rebuilding teeth with composites and amalgams. We later switched over to extractions. While the patients were all tremendously grateful and pleasant, the underlying despair was ever present. Patients had waited all night, and toward 5PM, all day to be seen. Many I spoke with talked about their need to care for their families, or had other situations which made dental care close to impossible for them to access. While their situations were desperate, the ability to relieve pain, and restore dentitions that may have soon been lost was incredibly rewarding. One conversation that will stay with me was with one patient we completed a few fillings for who was very phobic and had not been to a dentist in many years. She expressed concern about a small cavity where a previous filling was lost, and said she was scared she would just have to wait to get it pulled. I was taken aback since the cavity was quite small and was easily restored. But the patient explained that sometimes we are so concerned with caring for our loved one that our own bodies are neglected and there may not be resources to care for ourselves. I felt for her and told her it was wonderful meeting her and she expressed her grattitude before heading off with her grandson.

RAM in full swing

The trip really made it clear to me that there's so much to still be done right here in the U.S. to improve oral healthcare. But oral healthcare is so closely related to mental and physical health. I don't doubt the involvement of drugs and mental unrest in many patient's destroyed dentitions.

Sunday Clean-up 

Sinus Elevation Site #3

With this spring extension marking the start of fourth year, I've been in the clinic 5 days a week, and getting some cool exposure to procedures we've learned about. I'll probably be writing more about procedures from this point on as we'll hopefully be doing lots of dentistry from here on out! Since I had some open appointments this week I was able to fit in observing a sinus lift in the implant clinic.

Sinus lifts are necessary in certain cases when a patient wishes to replace a tooth with an implant in the posterior maxilla. The maxillary sinus sometimes extends lower down than we'd like and to avoid placing the apical portion of the implant into the sinus, the sinus lift procedure is necessary prior to implant placement. 

Heres a couple informative graphics I found online which clearly show what's going on. This patient is also missing teeth they wish to replace in the posterior left maxilla. The sinus has undergone pneumatization which leaves the dentist with little bone to work with. Through a sinus lift procedure they were able to place three implants to restore those teeth 

[http://www.capedental.com/2013/sinus-lift-and-implants/]

[http://www.capedental.com/2013/sinus-lift-and-implants/]

The patient today however was a single 10mm x 4.8mm implant placed in site #3. The patient had nonsignificant medical history and the tooth was lost due to caries some time ago. There was 8mm of bone present and therefore needed a lift of 2mm to place the implant. 

Initially the patient was anesthetized with an infraorbital block, posterior superior alveolar injection and a greater palatine injection with 2% lido with 0.034mg epi per carpule. Once anesthetizd, the patient was draped and scrubbed extraorally with an alcohol swab, and intraorally with a chlorhexidine saturated sponge. 

The initial incisions were intrasulcular around teeth #2 and #4. The second was a crestal incision and a full thickness flap was reflected to expose the alveolar bone. The osteotomy was made using the Straumann kit drills to a depth of 7mm, and a width just shy of 4.8mm leaving 1mm of bone between the osteotomy and the Schneiderian membrane of the sinus. The sinus was then lifted using osteotomes and a mallet. Osteotomes were placed in the osteotomy site and lightly tapped to lift the sinus. Progressively larger osteotomes were used to complete the osteotomy. Two pieces of resorbable collagen membrane were placed at the apical extent of the osteotomy before the implant was placed. This membrane will resorb within 6-8 weeks. 

The implant was then placed at a speed of 35RPM into the osteotomy site to a depth of 10mm so the implant was placed at bone level. The final insertion of the implant was completed using hand wrenches rather than the motorized drill. The healing cap was placed and flaps re-adapted to the alveolar bone and three teflon interrupted sutures were placed. 

Cool experience overall. Post op radiograph looked great and hopefully all goes well with the restorative phase!

ECHM: Dedication/Ribbon Cutting

UB ECHM Team w/ dental director Dr. Nguyen at center

Friday was big. Not only were we in the midst of our final, final exam weeks ever, the Erie County Health Mall was officially dedicated and declared re-opened. While the dental clinic will not be seeing patients until June 2nd, our other partners in the building will be fully functional soon.

Ribbon Cutting!

Richie Ross representing our student team

Dr. Michael Glick, dean of UBSDM 

D3 Spring - Mid Semester Review

We're rounding up what was 3 weeks of midterms this week and finishing it off with a well deserved Spring break. I've personally been much less busy this semester compared to last, as I completed a few removable cases that are currently healing, and my implant cases are currently awaiting placement and healing. Nonetheless, the learning never stops as we have a quite a few classes to keep us busy. In most however, we seem to be going into a little more detail, and focusing on the clinical aspects of practice, while classes are also re-emphasizing important points that have been covered before. Luckily, we have one lab class in orthodontics that has been great.

Our lab instructor Brian Willison, is a renowned lecturer and orthodontic lab technician who is incredibly talented and helpful. Our first project in the top photo involved bending wires to a pattern on a piece of paper. The "snowman project" was given also as a supplemental project to get us used to bending wires around a model. The next project was a little more involved- bending wires to create clasps for a partial removable denture. We're currently in the midst of working on an active plate to reposition displaced maxillary lateral incisors that makes this project look terribly simple. But the first tim around, anything would be challenging. Its great learning through these projects because when we see patients in need of interim appliances, its great to know we are capable of creating something quickly and efficiently for them.  

Our midterms "month" comprises exams in: Special Needs Dentistry, Geriatric Dentistry, Surgical Periodontal Therapy,  Orthodontics, Anesthesia and Pain Control, Fixed Prosthodontics, Removable Prosthodontics and a take home exam in Temporomandibular Disorders. I don't think I've ever had this many exams, or been so mentally taxed, but it's going to be wonderful when we're through. 

Outside of this dental realm, I've managed to sign up for an online class in Social Entrepreneurship through the Social Work school here at UB. I caught sight of this opportunity via email shortly before my trip to Haiti and felt it was something I was meant to do. So far it's been a very enlightening experience, hearing the ideas and views of others who seek to improve society in their own special ways. As we're learning currently about the different models of non-profit and for-profit enterprises, it makes me feel as though any school hoping to breed dentists interested in community service should encourage students to take a class such as this. The class has definitely changed my perspective on non-profits and makes the prospect of giving back through an enterprise of my own seem more feasible. 

That's about it for now. Back to the books.