Dr. Daniel Vinograd has established a long and prosperous career as the dentist San Diego prefers, because of his holistic, pain-free and biocompatible approach to dentistry. What you may not know is that he has a longstanding relationship with his alma mater, the University of Southern California.
Today, he’s a professor of dentistry for the university where he received his DDS degree.
USC is a private university founded in 1880 and based in Los Angeles. It’s the oldest private research institution of higher learning in California, trains a large number of international students and fully embraces its close proximity to Hollywood. It’s also consistently rated as one of the top colleges in the nation.
Here’s a bit of trivia that makes dentists like Dr. Vinograd proud: USC’s well-regarded fight song “Fight On” was composed by dental student Milo Sweet in 1922 — although Glen Grant has to be given partial credit for the lyrics.
Even if you’ve never been on the USC campus, you’ve probably seen it. That’s because its location means it features prominently on film and on television. You may have seen it in Forrest Gump, Ghostbusters, The Social Network or The Graduate. You may have also seen it on The Fresh Prince of Bel-Air, House MD, The Office or Monk, to name only a few of the many TV series that have filmed on the campus. Even Wheel of Fortune and Jeopardy have shot there.
The University of Southern California’s close relationship with Hollywood and pop culture doesn’t mean it takes its professional programs less seriously. If you think about it, good teeth are an important part of any Hollywood career, and quite a number of the entertainment industry’s top names depend on USC dental school graduates for their award-winning smiles.
Will you be the next to turn to the San Diego dentist citizens of all types entrust with their precious teeth? Getting started is as easy as setting up an appointment.
Not really concerned what brand of toothpaste you buy? Not interested in making your own toothpaste when you can buy one at the store that works pretty well?
Perhaps the best reason of all for making toothpaste at home, or carefully choosing what brand you use, is avoiding SLS. But what is SLS and why is it so bad? Keep reading and you’ll understand.
Getting To Know SLS
Sodium Lauryl Sulfate or SLS is found a lot of personal care products. But it doesn’t really belong there. In fact, putting it there doesn’t make much sense at all.
While it serves as a surfactant — a substance that breaks surface tension so a product can penetrate — it can cause skin irritation, the worsening of skin problems and other issues. Even worse, some people have an allergy to it, causing even more severe adverse reactions. And still worse yet, it can cause canker sores — those round white sores in your mouth that sting for days — and can cause dry mouth.
If you have a problem with skin issues, canker sores or dry mouth, you need to eliminate SLS from your toothpaste and from your other skin, mouth and healthcare products. Doing so could eliminate your problems or at least make them not as bad. In fact, research has proven a decrease in canker sores when using an SLS-free toothpaste.
If You Love Food…
Perhaps worst yet if you’re a foodie, SLS in toothpaste has been shown in one study to cause a temporary alteration in your ability to taste. Have you ever noticed that food tastes strange if you eat immediately after brushing your teeth? SLS could be the reason.
The reason this issue isn’t talked about more is that most people intentionally avoid eating after brushing their teeth to keep their teeth clean, so they may not necessarily notice this side effect.
Simply put, avoid SLS at all cost to avoid its side effects for a healthier and better life.
For a great homemade toothpaste recipe without SLS, visit: http://homemadetoothpaste.net
Distal marginal ridge is frequently just a little bit closer to the cervical. We have sometimes a groove that will come up to this mesial marginal ridge and occasionally will cross it just a slight amount and this again would a mesial marginal groove. Kraus text book talks about this groove. We haven’t found very many teeth in which this shows prominently enough to really point out. It’s not a really strong groove. Our real strong one is our central pit in our central groove that comes up to the mesial. Now we can look at these cusps and we find that we have ridges coming from the cusps, not only our triangular ridge that comes down into the central sulcus area. Again central sulcus would be a valley depression between our cusps and our central sulcus area pretty much includes our occlusal table. Remember our occlusal table is the portion in which our food divides and goes to the outside of the tooth or to the inside of the tooth into the central portion of it. So our triangular ridges will come down into our sulcus, central sulcus, area here. Now with our distal buccal cusp here our triangular ridge is what almost connects up to our ridge, triangular ridge from this mesial lingual cusp. We got several ridges, triangular ridges, coming down into the central area of the teeth. We also have ridges coming from these cusps which are cusp ridges but you have to be a little bit more specific in the terminology of these cusp bridges. Fact is we have two, for instance, two mesial buccal cusp ridges.
We got a mesial buccal cusp ridge on the mesial buccal cusp. And we got a, I should say, buccal cusp ridge…we got a cusp…mesial buccal would be…mesial buccal cusp ridge on the mesial cusp and a mesial buccal cusp ridge on this distal buccal cusp. So we may have to identify these further and say mesial buccal cusp ridge of the mesial buccal cusp or the mesial buccal cusp ridge of the distal buccal cusp. Let’s look at the root structure on these teeth. Actually as a group they are probably the most easily identifiable teeth in the mouth in so much as they have three distinct roots and they are the only teeth, maxillary molars, that have three distinct roots. And the root structure is quite characteristic between first, second and third molars but it doesn’t outweigh the prominence or characteristics of the occlusal anatomy.
The occlusal and crown anatomy is much more reliable than the root anatomy. Root anatomy varies. But on these 3 roots we’ve got specific terms for all 3 roots as we did for our multiple rooted premolars and even our multiple rooted mandibular cuspids. In the molars the roots are termed simply by the location. Now if we look at the occlusal to get our orientation mesially and distally here I would hope, we would find that one root comes out right under this lingual groove. And this is right in the center of the lingual surface and this is called a lingual root. Very same term and same type of location as we had in our maxillary premolars when we had the [inaudible] a lingual root. But on the buccal surface we usually have two roots. And these are termed by the area they are located at. We have a mesial buccal root and a distal buccal root. Now where these 3 roots join we have area which we are now calling a trifurcation meaning three roots joining. We called it a bifurcation when we had 2. Now we’re calling it trifurcation or sometimes abbreviated furcation, meaning division of roots but this is a trifurcation. The actual shape of these roots I think is important for many reasons. Not only from endodontic standpoints but also from surgical standpoints, periodontal stand… many reasons. Our lingual root is usually the longest root on this tooth. It’s a single root supporting the lingual half so it’s little larger and longer than our buccal roots. And has a [inaudible] tendency to be round in its overall structure. It’s the large, round type root. Our mesial buccal root is rather a broad, flat root. This is more similar to our roots on our mandibular incisors. It’s kind of a ribbon shaped broad flat root. And actually occasionally you will have a concavity down the center of it. It’s so broad and flat on this mesial surface and very frequently it will have a concavity on the distal surface of these mesial buccal root, right down on the inside in here. And this becomes rather significant when you’re trying to remove this tooth because this really locks into some bone there and becomes quite a problem.
Our distal buccal root is the smallest root and it’s kind of in between. It’s not really round and it’s not really flat and has a tendency to be a little bit on the broad side towards the occlusal but it has a tendency to round off as it gets down towards the apex. I really should say cervical. It doesn’t really come close to the occlusal. Usually referred to the cervical portion of the root here. Make sure I get my terminology straight here too. We have one section of this root here that we should’ve pointed this out on our premolars. Before the roots trifurcate here or bifurcate which is called the root trunk. That’s actually a new term for you. The root trunk is that portion of the root before we get a division. We have a root trunk. Actually if we go back and look at our occlusal outline on this tooth, this is often referred to as being rhomboid in shape. Mesial distal surface are somewhat parallel but not necessarily at right angles to the buccal and lingual surface. And we’ll make a drawing of this or if you make a drawing of it I should say we can make this rhomboid basically in its shape. That’s what they referring to. One other prominent characteristic I think we should point out to this and that is that even though we have four rather distinct line angles, our buccal line angles are more prominent or I guess you can say sharper. A little bit sharper than our lingual line angles which have a tendency to round more. We have one line angle which rounds very sharply as it gets toward the cervical. And this is your distal buccal line angle. Right as it gets to the cervical it becomes very rounded. In fact as the whole tooth has a tendency to tuck in in this area and this again becomes quite a problem in restorative and periodontal [inaudible] and should be noted. We had this present on the distal cervical area of our mandibular laterals and cuspids. We’ve pointed this out. For this rounding occurs very sharply and prominently on the cervical third of the distal buccal line angle area here. Sometimes this tooth is referred to as having a fifth cusp. When we have a fifth cusp present it kind of joins is and grows with the largest cusp on this tooth which we indicated to you as what? Mesial lingual being the largest cusp. Sometimes we’ll get an additional cusp which will occur in this area right here and I have a few of them. Sometimes it’s not present at all as in this tooth. And it can be present in varying degrees here. Again we find none here. It’s being our mesial lingual here. We find a small crevice right in here which indicates a very tiny cusp development.
Here this is getting just a little bit larger. Here our cusp has gotten so large that we’re actually creating a pit between the mesial lingual cusp and this fifth cusp. In this one you can see we have a very large fifth cusp and again a deep pit. I find that this pit frequently has a tendency to become carious and actually requires a separate restoration right in this pit that occurs between the mesial lingual and this fifth cusp. This is usually called just a fifth cusp or it could be called a cusp of Carabelli. It seems to be a jingling term that has gotten quite a lot of popularity. Cusp of Carabelli or just plain fifth cusp. Not always present and it’s rather highly variable in its amount and degree in size but generally always occurring when it does appear on this mesial aspect of this mesial lingual cusp. One thing we could point out to you also is our contact areas. Sometimes on these molars they start to become rather prominent and often times they will stain quite dark. And this becomes a problem occasionally when you lose the deciduous teeth that are in front of these and parents look into mouth and find a dark contact area and they rush Johnny in because he’s got a cavity. And you get to checking it and you find that it’s hard and stained and it’s just simply a contact area that has become stained. Here again we got a contact area on this tooth right in here that has stained up a bit. Notice how this calculus is collecting here. Notice where that is. It has a big tendency to collect there. That’s where we get that tremendous rounding of that distal buccal line angle right in the cervical. Very prominent area for calculus to collect because tooth just takes a sharp dip in that area. If we go to our 2nd and 3rds we’ll do more of a comparison study here, maybe pick up a few additional terms on it. We have differences in size and within the same mouth this becomes most important. This difference in size is about a millimeter in mesial distal width within the same mouth and our 2nd molar. And within the third molar, well, this can vary. Again about a millimeter smaller than the second [inaudible] in the mesial distal width. But this third molar becomes so variable and is so highly irregular and sometimes not even present. We are not going to spend too much time in studying this.
We’ll give you a little bit of information identification of it but we’re certainly not going to spend the time on it that it justifies in relation to the amount of a variations it has because it’s got a thousand and one variations. Our second molars are usually fairly characteristic in their occlusal anatomy. They are fairly sound in their anatomy. We have about the same width from the mesial to the distal, pardon me, from the buccal to the lingual as we do in our first molar within the same mouth that is. But we’re a little shorter on the mesial distal dimension as I indicated about a millimeter. We still have the basic rhomboid shape in it although our line angles, and particularly on the buccal here, are becoming rounded. Remember this was a characteristic between the first and second premolars. Our second premolars started to get quite a little rounding in the line angles while our 2nd molar does the same thing in comparison to first. It just starts to round out in our general anatomy. In our anatomy occlusally again it’s not quite as sharp and distinct and prominent as was our first molar. That’s the same basic characteristic between the second and first premolars.
Watch the video: http://www.learnerstv.com/video/Free-video-Lecture-4747-Dental.htm
In this presentation we will discuss the anatomy of the maxillary molars. Our objectives in this presentation will be to discuss the location and position of these teeth, to concern ourselves in relation to the occlusion, to study the morphology and the terminology on these teeth and to study identifying characteristics of the maxillary molars. We’ve got 3 maxillary molars which we will be concerned with. They are simply called first, second and third. I should say we have 3 in each quadrant: 3 on the right and 3 on the left. On the right there would be tooth number 1, 2 and 3 and on the left it would be 14, 15 and 16. Our first maxillary molar is the one that comes in about age 6, very frequently confused with deciduous, baby or primary teeth. Next one, second maxillary molar, comes in about age 12. Our third maxillary molar, frequently referred to as our wisdom tooth, varies in its eruption coming in anywhere from 17, 18 up to late twenties. It’s the one that has such a reputation as being a troublemaker and frequently, I shouldn’t say frequently, about 20 percent of the time it’s not found at. It seems to be disappearing in its presence. If we look at the cutaway scull on this we can get an idea of the root structure on it. Notice that we are seeing two buccal roots on each of these molars. And we’ll also notice that the angulation is a little bit forward on all of these teeth. They are coming a little bit forward on their angulation. We should start to take more specific notice in relation to the occlusion of these teeth and how they are actually occluding with mandibular. We may have mention that our bicuspids actually are what we call interdigitating.
We’ve got a cusp-fossa relationship but more specifically we can turn this cusp-embrasure relationship because the cusp of the bicuspids is actually coming up and touching on the marginal ridge areas in our premolar areas here. We’ll define embrasure more specifically for you but this is an area associated with the marginal ridges. We still have a significant amount of difference in the width of our arches here, our maxillary arch being much wider than our mandibular arch. And the difference in this width is measure term cold which is called overjet. Overjet is the distance the maxillary teeth overlap the mandibular teeth in a horizontal direction. It is also called horizontal overlap. And we can take a look at our gauge here. We can actually put on a gauge and measure this amount by using the back side of our boley gauge and measure the specific amount that we would have in overjet and measure right down to a tenth of a millimeter or so. We’ve noticed that with these maxillary molars as they are interdigitating we are getting the combination of cusp to embrasure or to our marginal ridge and we’re also getting cusps associated with the central portion of our teeth or the actual fossas. So we get a cusp embrasure and a cusp fossa relationship on these molars. We’ll break down a little further as we go. If we look at the other side here we’ll also notice one other relationship I think we should take note of and that is that we have a maxillary sinus [inaudible] and this is [inaudible] width about apex of our maxillary molars. If we were to take our skull part here a we’d note that these roots have a tendency to be directly in a relation to these [inaudible], these maxillary sinus. [inaudible] often can effect these teeth. Actually the lingual root of this maxillary first molar is penetrating into the floor of the sinus and sometimes the roots of second or third molars may also penetrate into the maxillary sinus. This can lead to confusing clinical symptoms. If we go to our individual teeth we’ll start to identify some [inaudible] marks here.
Actually we’re picking up a lot of new terminology with these teeth here now but the terminology is not really complex because it is associated with the mesial distal buccal and lingual. Those are our four basic surfaces so we probably should identify those first. If we look at the tooth in outlined form here, this is the easiest way to really identify the buccal and the lingual because our buccal surface has a height of contour that is closer to the cervical. This height of contour can also be called the buccal cervical ridge or the cervical ridge. It is a bulbous prominence down in here and frequently will be just called the cervical rage, meaning the height of contour. And then from this area up towards occlusal we have a tendency to flatten a bit through the middle third and actually into the occlusal third until we get up to our buccal cusp. On our lingual surface our height of contour is [inaudible] through the mid portion and our lingual surface is more evenly convexed. So this is the easiest way to identify our buccal and lingual. In identifying our mesial and distal I guess the best way would really be to look at your occlusal surface because you have one cusp which is prominently larger than the other. And this is the mesial lingual cusp. And this is always to the mesial surface. Actually we have 4 cusps on this tooth and they’re identified strictly by the surfaces. We got our mesial lingual being the largest in bulk, also being the largest in height or the farthest from the cervical. We have our mesial buccal, our distal buccal and our smallest cusp usually which is the distal lingual cusp. So we are basically talking about 4 cusp tooth when we are talking about our maxillary first molar. Our second and thirds have characteristics very similar to these and as a result we’ll spend much of our terminology identification on this and then just point out the differences in second and third molars. We have basically the same line angles at the junctions of the surfaces.
We’ve got basically the same point angles on this. If we look at the buccal surface of this tooth we can see our mesial and distal outline. Our most important characteristic in this view is the height of contour. Our height of contour is similar to our maxillary premolars. On the mesial it is usually found in the occlusal 1/3. On the distal the surface is usually rounding more and the height of contour is usually found in the middle 1/3. Our overall width on this tooth is about 1 millimeter wider from the mesial…no, it’s a 1 millimeter wider from the buccal lingual dimension than it is from the mesial distal. So the tooth is usually similar to the maxillary premolars, wider buccal lingually than it is from the mesial to the distal. But the tooth overall is about 2 millimeters wider both on the buccal lingual dimension as well as in the mesial distal dimension than our premolars were. We’ve got some other rather strong characteristics on this tooth that we should identify for you and start to put some terms in. Again terms are very similar to the surfaces and the cusps what have you but the most prominent features on this tooth is our central pit. One of the biggest problems in this tooth because this central pit is usually very deep and often times has a tendency to become carious. Now we have a fossa around this pit area. Sometimes these fossas will be called triangular fossas because of the…actually apexing into this single pit. And we’re getting groove from the central groove and the other grooves that seem to apex right in this. We generally [inaudible] triangular terminology. We’re just calling it a central fossa or mesial fossa or distal fossa or whatever it is and leave the triangular out. It doesn’t seem to add a great deal to the term other than just carrying some additional jargon with it. We have a mesial pit which is usually not nearly as distinct or located quite as prominent that it would be towards the mesial aspect of the tooth. We have a distal pit which is usually fairly prominent in the distal portion of the tooth. We have a central groove that connects up to the mesial pit but it doesn’t connect to the distal pit very well because we have a rather strong ridge that crosses the tooth. Let me see if I can point out this ridge to you here.
This ridge runs from the mesial lingual cusp distally a bit and then crosses the tooth to our distal buccal cusp. And this ridge is termed the oblique ridge. It runs crossways of the tooth not straight crossways but goes to the distal and runs across the tooth. Remember on our mandibular first premolars we had a transverse ridge. That was characteristic of the first mandibular premolar only. This oblique ridge is characteristic of our maxillary molars and very prominently in our maxillary first. It’s sometimes also in existence in our seconds and occasionally in our third molars but very prominent in this first. This will be a very important characteristic particularly when we get into restorative dentistry and reconstructing these for crown and bridge and [inaudible] and the variety of other purposes so that’s one area I warn you we have to know and know very well, it’s this oblique ridge across through here. There are two very prominent grooves on this tooth which we should point out and identify for you. One comes out in the central pit and comes to the buccal and it’s simply called the buccal groove. And it actually crosses the marginal…or I should say cusp ridge and it divides the cusp ridge. We’ll go over these cusp ridges in a minute. And extends down on to the buccal surface about half the way down on to the buccal surface but it doesn’t cross this cervical ridge or height of contour. Actually it comes right down the center almost of our buccal surface here. The other very prominent characteristic ridge, or groove I should say, is this distal buccal… distal lingual groove, excuse me. Which comes out of the distal pit and traverses at an oblique angle and comes to the lingual surface. And actually it does cross the height of contour of the tooth down on the center of the lingual surface. And in the outlined form you can see a little dipping that exists in this height of contour down here. Fact is it not only crosses the height of contour but it frequently in the maxillary first will go down and groove right into this root surface. That’s a very strong groove, particularly in the maxillary first molar. We have the same marginal ridge basically on our molars. Got our mesial marginal ridge and our distal marginal ridge.
They’ve looked at that for the last 40 or 50 years. Here’s that case basically in the mouth. You look at the one side, you look at the other. They’ve got this one pictured…cause this is the other side of the mouth. And what they’re using here is the proximal [inaudible]. There’s the try-in and if you go ahead and get teeth processed [inaudible]. Another lateral that has a longer span. Same thing. You got a long span here. You can look at this and you can block across to the other side of the arch. The idea is when you’re looking at into a case where you might think about using [inaudible] Definitely what you want to do is talk to your faculty, take a look at the case and decide whether rotational path is the way… Now swinglock removable partial. Basically this is what the framework would look like. This fits around labial of the teeth with these little eyebars that come out vertically. These little eyebars will engage into labial surface of the lower teeth. I don’t use these all that much anymore. Pretty much now with high speed instrumentation you can reshape the contour of the teeth fairly easily [inaudible] restoration without crowding teeth you can also build up undercuts where you need them. The other thing you want to know is that these frameworks will cost at least $200-$250 more than your conventional framework. So from [inaudible] and those folks it’s not uncommon for the framework to cost alone between $650 and $800. If the framework cost alone, you haven’t added teeth on, you haven’t processed anything plastic on it, if your framework cost alone is pushing six to eight hundred dollars you want to make sure you are being remunerated enough for the partial that you are not losing money on it. Several years ago one of our grad students did for a nice patient Mr Traylor and so we got the whole thing done anatomically. It was a very complex framework that overlaid the occlusal surface and everything else. We did the case and we were charging Mr Traylor basically the graduate fee for the partial denture which is around $1250 and that framework cost us $1800.
That’s a great business plan, isn’t it? If you’re losing money on each one of these you’ll make it up on the volume. Here’s accentuation also or some of these as I say [inaudible] the number of teeth missing or number of defects you’re trying to fill up is very extensive, it may be that the extra grip with the swinglock may be worthwhile. Now this is basically just a set of duplicate cast that goes through the sequence of how long these frameworks would be made, the standard blocking out they are going to go ahead and duplicate it. Here’s our study model and we go ahead and say how we’re going to watch the framework up. Here’s the wax up of the framework. Frameworks are waxed up as there are these stainless steel spindles that are incorporated into the wax up and the reason this stick up into the air as far as it does is just so that it can fit into a dental surveyor, like a surveying tool, but what’s going to happen is after casting all of this stuff that sticks out into the air will get cut off. So all this is for is extra things to use it in the tool that seats these down so that the bottom part of these spindles will be incorporated into framework but the top 80% of these things will be just cut off [inaudible] and made smooth finishing of the partial denture framework. Here’s another view of the framework. Here’s your labial plate, here’s your maxillary labial view, here’s your two spindles. One side is going to be the gate side. That’s going to be the hinge. The only difference on these things is which side is the gate and which side is the hinge. After way up stage if you look at the cast metal this vertical part right here is the bottom part of the spindle right here. This part of the spindle right here is what you see here. The top part of where the spindle was here has been cut off and polished so this has been cut off and polished it’s what stands up in the air. Now on one side when they do the wax up of this they carry the waxing all the way around that vertical spindle. On the other side there’s going to be the snap in gate.
The wax up on that side is only going to surround about little more than 180 degrees. It’s not going to surround all the way around that spindle. So one side is waxed up all the way around it and that becomes the gate side. On the other side the waxing over here wraps around part of this spindle but doesn’t go around the 180 degrees. Then when it’s cast there is just enough surface contamination on these they will allow these things to open up and swing. Here is your hinge side so you can see when the waxing was done here unlike on the hinge side on the other side this waxing didn’t warp all the way around this spindle. Again this spindle used to go up into the air or up in the surveyor but the top part of it was cut off. So the only difference is instead of being waxed all the way around the spindle, it was only waxed partly around the spindle [inaudible] The other things is because these are totally interchangeable which side do you want to wax all the way around and which side you want to wax partly around, you should make these things open either way. Just depends how they’re waxing up [inaudible] If you’re thinking of doing one of these you want to ask if the patient is right or left handed. Which side will be easier for him to get a hold of this gate and snap them open, if they had a preferred side. Here’s the situation clinically in which you look at the teeth from the anterior. We go ahead and basically have our partial denture here. Here’s examples of them. Here’s a swinglock .Again, we don’t need to do these so much anymore because nowadays there’s a high speed instrumentation [inaudible] materials that can alter the contour of these teeth to make them more favorable fairly easily. So if you see these used at all they will tend to be used in maxillofacial situations for the most part. These are ugly. Doesn’t this bite into patient’s lip? And isn’t that the food trap? We find with most patients that these have been done on [inaudible] Isn’t that the food trap?
Yes. But because partial can be taken out and cleaned and that’s your hope that the patient will continue to clean these things. Surprisingly a lots of patients when they smile these eyebars are located fairly close to the pregingival margin, they are not esthetically unsightly. So typically… here’s a nice lady, there is her upper denture but you don’t see lower swinglock partial at all. If you’ve got the same thing but with modifications face, the modification faces can be fitted on the partial and the gates just spin around the modifications face. Again with the materials we have available to us today I can’t justify anymore spending many hundreds more dollars for a framework like that when I can recontour the teeth to get a conventional partial pretty much the way I want it. These situations might be a little more challenging when you’ve got all the teeth on the one side. Again this shows a situation where you’re trying to clasp those teeth a little more firmly. You got these teeth clasped pretty firmly and this is our replacement teeth. Again the thing that is not available during your practicing lifetime. But I’ve been thinking about rather than taking a real expensive framework would be in a situation like this…over in this area is considering putting one or two dental implants over there strategically located. And then you can have partial denture in this area here it’s just under the partial denture in this area you’d have couple of [inaudible] attachments that were just snapped on. Again when these frameworks were involved we did not have that as one other option. Here’s another one that clasps teeth in two different ways. Again these are very expensive frameworks. They worked out okay but like I said I want to show you the swinglock partials as much as anything. If you heard of them you sort of know what some indications might be. Mostly maxillofacial. And nowadays when we have dental implants available to us and the possibility of recontouring teeth much more easily either by [inaudible].
Length of the span. This just sort of looks at that one situation saying if we’re doing it front to back, if we’re doing like the upper fixture that is class 4 partial that things are going to seat here first and then rock down distally. The shorter the span is the more you got to block out. And further away you are so that radius, the radius of arch that you’re going on, as that gets longer you got less block out because the things are becoming more [inaudible] that’s upper or lower. If the rotational axis is fairly straight across the arch side to side, when looked at from the front it’s also fairly [inaudible]. What happens when this partial denture is going to rock in place is going to rock pretty straight down in place. Cause you see here depict is the situation in which posterior plane of occlusion was uneven from side to side. Let’s say for whatever reason this tooth sits farther in the air than this tooth. So instead of going like this, this plane goes downhill like that. Can you see that if the plane was tilted like this [inaudible] coming down. People follow that? So the height up and down of the posterior teeth [inaudible]. Cause if they are the same height things are made level level. They are at the same height. You see the posterior path you rock it down and your arch is seated very straight down. If the two teeth at the back that you’re using as your primary rest are significantly not at leveling height so that height runs this way. Can you see that when it arcs forward it’s going to arc that way and that can cause you problems on how you block out or how well it seats on the anterior teeth. It’s basically the position of your rotational axis both in terms of is it straight across and also is it leveled. Cause again imagine that you are on two different teeth here and it was pronouncedly angular that way. So that would effect how the rotation happens. If it just sucked nobody would do it. The thing with this is labs really have to [inaudible] and the labs have to be up to speed to work really well.
Pretty much. The only thing in the question was are these so complex to put in that people have the hard time doing it? Not really. They go in as easy or easier than the conventional partial. Conventional class 3 in this situation right here you’ve got four sets of clasps all [inaudible] your teeth. So as far as how tight these things are going in you can see what’s seating it and taking it out. [inaudible] against the retentive features of four different clasps [inaudible] If it’s a rotational path then literally people toss them in after about 2 days they get really used to sort of feeling how it goes in. Cause it’s not that it’s a lot harder to put in. It just doesn’t go absolutely straight down. They got to consciously let the back part seat in first. But what really does wind up is that they’re really finicky to design and for the lab to do them so that they work well their finicky but if you find the lab that work that way they really work out well. In many of these cases [inaudible] mesially and lingually tilted molar, it’s really easy to do these kind of partials instead of trying to find some way to figure out how you’re going to get your framework to fit around those tilted molars. They are a little more challenging to design and your lab has to be on their game to make these things come out well but when they do they aren’t any harder at all for the patient to physically place or take out. Actually they are little bit easier. And the shape of the arch. The more V shaped the arch is you block out different areas. If the arch is pretty much square and straight front to back you don’t have to block out that much on the lingual of the teeth. If the arch is real V shaped [inaudible] you got little more block out to do on the distal lingual. Again, all of this stuff is in your book. If you’re looking at your undercut then what you want to see is that this class 4 partial that you were going to do is just like the one that’s on the cover of the Krol book. [inaudible] I’ve got some undercut on the mesial proximal on these cuspids. The other thing you want to look at when the surveyor is at level is to see how much undercut do I have at that back tooth. Will anybody care to tell me if I have a problem with that undercut right there what’s my problem? I’ve got some undercut but what’s wrong with the nature of the problem? You can see that my height of contour is absolutely at my occlusal buccal corner and I’d like the height of contour a little bit further down on the buccal of the tooth. [inaudible] The occlusal buccal corner of this tooth a little bit so we still had undercut down here at the cervical but undercut was softer and it was more gentle curved. Cause again if your height of contour is absolutely at that occlusal buccal corner there is no gentle curve for the clasp to flex over and seat. And then you go ahead and tilt the cast so that you are looking for your secondary path of insertion you tilt the cats posteriorly till you see the surveyor shows that [inaudible]. If I say that’s my secondary path of insertion and that’s primary path of insertion there’s whole new amount of undercut I have available to use is the difference between the two surveys. In this particular case we used as illustration, I can pretty much work out the survey that will let me use entire proximal of that as my undercut on my rotational path. Its’ the difference between the undercut between the two paths of insertion. Go ahead and put a set of marks on your cast of the level survey and you put a secondary set of marks on the tilted posterior survey. Two sets of surveying marks on these casts. One [inaudible] level level. And the other has tilting [inaudible] and pretty much eliminated the undercut on which ever proximal surface you are using for your rotational path. The rest seat preparations on these mesially tilted molars or lingually tilted molars. [inaudible] the reason we do elongated rest is because we are not having any reciprocal or [inaudible] or clasp on the buccal. When the framework engages this elongated rest over time the tooth will tilt and rotate. If I had just one tiny circle, this tiny dot for a mesial rest, over time the posterior tooth would [inaudible] around that rest but if it’s a long rest, if it’s a channel, the tooth can’t rotate or tilt at all. So in those situations where molars are [inaudible] So again if you look at these things if the teeth are tilted labially if you were to imagine taking a [inaudible] that would come straight down the lingual of that tooth, to have your framework clear on the surface of the tooth, it has a hard time resting against soft tissue. SO then your elongated rest will just use the occlusal and mesial proximal surface and you don’t care if there is no undercut on the buccal and you don’t care if the tooth is tilted labially. Here’s one of these sets of dividers that you can set up to different separations and if you can make two arms parallel to one another then you can look and set one arm [inaudible] and when you rotated down you’d see a block out. In these cases the area inside the dotted line or the area between the dotted line and the tooth, would be the areas that would need to be blocked out for the framework to be able to seat when it is rotating in. We’re going to show just some different examples of patients. Here’s basically the back to front.
So we go ahead at either one of these you just seat the framework from the back to the front, there’s your framework with set teeth on [inaudible] this seats first and rotates down the place with the clasp. We go ahead and get the teeth set up on it. So right away you see it’s all processed. We just got this elongated strap rest on the posterior molar. We got a clasp up front of these seats. [inaudible] forward, clasp goes down. So as long as this is seated the back arch can’t pull out. Front to back. You go ahead and look at these many [inaudible] We go ahead and get things set up. Here’s a framework. So this framework engages the mesial proximal of those teeth next to dentulous area. And then it locks posteriorly and seats over the posterior teeth. Here’s your replacement teeth and what you’ve got is no clasp. So you’ve got a situation where you are not showing any clasp. Here’s AP category one meaning that [inaudible] completely here and then just rock the clasp down in place. Here’s the same thing with longer spans. Then go ahead and front part of the framework seat is done. You see the distal down. No clasps. [inaudible] We got a clasp back here where it doesn’t show. Lateral. It’s the same thing that they show you in that book. Here’s one [inaudible] Basically you’re missing some teeth here so we are planning on laterally rotating from here across to here and so we will be clasping on these teeth. Here’s our edentulous span. We get our framework made. Again the framework engages the proximal [inaudible] so what do you? You first survey is what everything lateral and what you’re looking at there [inaudible] You are looking for where is your undercut on this tooth [inaudible].
How much undercut? [inaudible] More is better so that if we got much in excess of ten thousands we may not need more than ten thousand, fifteen at the most. But let’s say in the ten. If you can see some daylight when everything is levelled we see a nice undercut here and we can see daylight on either of these proximals. And when we do or secondary tilt, we tilt the laterally and I’m tilting it laterally to see if daylight disappeared and these things become perfectly parallel the that’s our secondary path of insertion. So the total amount of undercut available to you on those proximal surfaces is the difference between levelled and tilted.
I do because they’ve done many studies both for fixed partial dentures and for removable partial dentures. Depending on how tooth is tilted. [inaudible] and the tooth is tilted this much or it’s tilted more severely this much if you go ahead and [inaudible] if you are touching at all at the marginal ridge, even if there’s one undercut that you can use [inaudible] as long as it engages at that marginal ridge coming around the corner a little bit this tooth cannot fit mesially because it’s got a block there. And when they’ve done photo elastic studies on it vertical pressure right down here on these mesially tilted teeth [inaudible] fixed partial denture or removable partial that touches right there photo elastic studies tell you that the forces are directed along the long axis of the tooth. Cause it can’t lean over any more mesially if something’s in the way even if it’s just the first millimeter and a half to two millimeters up by the marginal ridge. So if it can’t fall mesially no matter how much you push down on, the forces are directed along the long axis of the tooth.
So the whole framework will go down levelled and everything engages at the same time. If there’s a curve on your path of insertion, or the rotational path, the back end seats first and then the front end rocks in. If people see if you are going to do your brock after this, one of the things you need to think through out with your brock out is on the distal side of this front tooth you can see that this is going to go off and on so if you have a pair of dividers then you put one on to the [inaudible] here and you put the other on to the [inaudible] so it just barely touched the [inaudible] the distal marginal ridge of that tooth that the arch that divided out this [inaudible] you have to brock that out. Because if your framework doesn’t fit any tighter to the distal corner of this tooth down to the cervical can you [inaudible] you try to rock it into place it wouldn’t seat at the time. That part of the proximal plate goes right here. If it wasn’t blocked out curves that line, if it fit tighter to the distal length too it wouldn’t rock into place when you seat it. So those are the things you want to look at when you want to brock it out for rotation [inaudible]. Okay, in the linear placement again all rest seats seat simultaneously. So if it’s not a curvilinear here, if it’s not a rotational path it’s just a straight up and down path of insertion for the most part, all the occlusional [inaudible] simultaneously. And you can see in this area we have brock [inaudible] where that undercut exists on the mesial of that tooth or when the undercut exists on the distal of that tooth, they [inaudible] blocked out parallel with the path of insertion. So when everything [inaudible] it just all slides down and what’s holding this partial denture framework on that tooth is an occlusal rest [inaudible]. So if you said okay in the same situation if there is a little bit of an undercut on the mesial proximal of that tooth but if I go and do a curvilinear path of insertion so that my brock out on the mesial of that tooth is entirely [inaudible] and I planned completely on having my proximal plate fit that more intimately. There’s still brock out here to allow that arching type motion to come down and clear the distal of that tooth. So if there’s not as much brock out here, there is no buccal clasp on ,there is no lingual reciprocal one. But when the partial denture is fully seated, this distal part can’t come up in the air because this proximal plate is wedged or captured in that undercut on mesial. So it’s an intentional use of that undercut without blocking it out. That’s the whole idea of rotational kind of partial. What types do you got? You got front to back, you got back to front, and in some situations you can do them sideways. So if I do basically front to back, that is very similar to the one that is right on the cover on your Krol manual. Again, if you look at that upper set of pictures it shows the case where you got a patient that’s got [inaudible] teeth being replaced when that partial denture goes into place front is going to seat first and then the back is going to rock in. So that’s going to be front to back. Okay?
We’ve got back to front and that’s the same one shown on the cover that you seat the back first and then you rock it to the front. So you got back to front or front to back and sometimes you can have a lateral. So that’s in teeth missing right here, so you’re missing basically your lateral incisor and cuspid. Instead of doing fixed partial denture they just thought could we fit a partial denture framework in there and then basically let this part seat down first and then arch or rock the partial denture down to get the clasp to the [inaudible] over here. So for as long as this part of the partial denture stays seated there is a couple of undercuts that have been gaged over our [inaudible] by rocking into them. So as long as this side stays fully seated, these things can’t lift up in the air because these are rocked in into a undercut. Categories. We got categories. Category one is more like the picture that we showed you at the very top of the lecture of the lower class 3 partial where the posterior rests would seat completely. The posterior rest seats would seat completely and then you rock the partial in place with those rest seats acting as a [inaudible] basically. Category 2 or dual path instead of [inaudible] rotation path… it is more similar to the picture on front cover of your book that’s the upper case. So the way that one works, if you got one of these clasps [inaudible] and you’re trying to make use of the undercuts on the mesials of the cuspids, or the mesials of the first bicuspids, you seta the partial denture in anterior angulation so that the end of the plane sits down first and then you rock it in. So the rest seats themselves don’t hit right away .You don’t sink the rest seats and then wrap it around the rest seats. In the back to front the rest seats are fully seated and then you rock it into place with the rest seats [inaudible]. That was that molar class 3. The upper class 4 the rest seats are not fully seated when you angle them from that front direction. You get the edge of the [inaudible] all seated and then as you brock it to place during the rocking to place the front rest seat sits and then just a little later the posterior rest seat sits.
But in the type 2 or the category 2, these rest seats are totally seated on the rotational part. You see [inaudible] dual path of insertion. So it would be seated at an angle and the rocked in. Here’s a category like one we talked about. It’s basically these rest seats sit completely. This would be the class 3 arch [inaudible] on the other side of the arch. SO this rest seat sits completely, you rock it down in place so when this is seated this wedges into the undercut. Okay, we look at basically category 2. Sometimes in these situations if you were to imagine this to have anterior teeth set out in the front, and that gain is the picture on the front to your manual. What would happen in these situations is as it was being seated in the front part seat first the end of the plane would sort of [inaudible] here but the rest seats themselves would not fully be seated. So we angle that on this forward angulation this way. Seat the flange in, start rocking it down and as it’s rocking down in place later on then the front rest seats come to rest and then last of all the back rest seats come to rest. So it’s first the flanges going in, then we start arching it, and then the rest seats of the front are seated a little bit later and the back rest seats seat last of all. But in the category 2 which is front to back or back to front, we don’t completely sink the rest seats and they are not [inaudible]. What we want to look at when we’re doing cast analysis. It’s basically sort of like any partial that we would be doing. You got to look at your plane of occlusion. And when you’re looking at the plane of occlusion, we sort of talked about that stuff, but as you got to set a cast…what does that really mean? If you are assessing the plane of occlusion can you see that if really goes up and down a lot that’s not a good thing? Or some teeth have gone missing. Let’s say posterior molar teeth are extremely up in the air and some [inaudible] upper teeth are going down. So your plane of occlusion [inaudible].
That’s’ not such a good thing. But if your plane of occlusion has posterior molars extremely tilted along way. So it seems like when you sort of look at your lower plane of occlusion it seems fairly reasonable at the front but as you get toward the back of the mouth it like really curves up in the air a lot so your overall plane of occlusion [inaudible] ski jump going up there. Not such a good thing. Maxillary plane of occlusion. Some posterior teeth on the [inaudible] have extremely [inaudible]. So your maxillary plane of occlusion goes level across here and then dives way downhill. Not such a good thing. So look at your plane of occlusion. How long is the edentulous span? Again many times what people look at is if the edentulous span is fairly short. One of the things you think about is [inaudible] fixed partial. There are some situations in which edentulous span gets longer. Think of the stress you’re potentially going to put on your buccal teeth. If you do a fixed partial denture there’s a lot. So those may fail over time. You might not just trash the teeth. Can people think of other possible problems with the really long span bridges that has nothing to do with losing the teeth or putting too much stress on them? How many people have delivered a crown and not that much later the porcelain fractured off? Anybody got one of them? [inaudible] The patient’s back and one of their complaints is a bunch of the ceramics fractured off my bridge that you’ve just done last year. Well, that kind of stuff happens as you build longer span bridges. How come? Cause the substructure may flex a little bit. And if the substructure flexes a little bit over a long span and the overriding ceramic doesn’t then it’s going to develop stress fractures and fall off. So the length of span is sort of an issue. As spans get fairly long they are almost easier to deal with an rotational path. Why? Cause spans get pretty long. If I were to imagine a molar and let’s say I had a short span not that I would do this with a rotational path. But I got a short span to bicuspid and I’m planning on making a rotational path and [inaudible] this first and then arching the partial denture down place. Let’s say I got a similar case. Molar’s the same way. Let’s say I miss first molar, I’m missing a bicuspid. [inaudible] The longer the span gets this way, at this thing arcs forward, I’ll need less block out on the distal of this tooth with a longer span that I’d need with a shorter span. [inaudible] As the radius gets longer any section of arch down here becomes more nearly a straight line. [inaudible] a very short radius your curvature here is pretty tight. So it takes a lot of block out right here. But when arch is a lot longer, arch is not nearly so tight you don’t need to block out so much. So can people see how longer edentulous span requires less block out when you’re doing a rotational path? And very short spans [inaudible] if you’re thinking about rotational path concept. The shape of the dental arch and how much undercut are we working with. So again what we’re looking. The plane of occlusion affects the depth of the undercut. So if we look here. Again, these are all in your books. Where do we locate the undercut on these?
Watch the video: http://www.learnerstv.com/video/Free-video-Lecture-4814-Dental.htm
Now the thing about rotational pass concepts is basically it’s the cover of your book .So those of you who have got Krol manual I mean the picture that’s right on the cover of your Krol manual shows both an upper rotational path and a lower rotational path. So that’s the cover straight off your book so we’re going to go over it. If this were a standard class 3 partial dentures, the lower picture. If you had a molar on each side and then you went up to a first bicuspid with this longer span. If it were a conventional class 3 partial it is a non-rotational path partial, the path of insertion for the partial would be straight up and down. Now sometimes some of you that had worked with [inaudible] partial dentures where you got these teeth at the back end for the lower partial, you may or may not be aware many times you got these situations in the mandibular arch this molar posterior tooth is very off and tilted mesially and lingually. How many people had one of those? [inaudible] You got this lone standing molar in the back and it’s sort of leaning mesially a bit and it’s leaning lingually a bit. So if you’re thinking of trying to [inaudible] to give you a nice straight path of insertion it’s reasonably difficult because many times where the tooth is leaning lingually if you’re trying to find a path of insertion that will let your partial denture come down past that lingual cusp of the tooth, when it gets down to interior edge of the framework it nowhere near the tissue and you say “Gee, I might have a hard time [inaudible] lingual of that tooth.” And similarly for a mesial tilt. In the upper case as it’s shown right on the cover of your book you can see many times if you have got clasp [inaudible] partial denture upper clasp [inaudible] replacing the anterior teeth, one of the downsides of in the upper partial or upper partial replacing the anterior teeth, are these guys right here, that is the clasp.
Now I would argue that the way they designed the clasp on this particular partial looks reasonably good. [inaudible] The clasp is an [inaudible] clasp so it stays up fine and it contacts the tooth very near pregingival margin so that’s not an extremely ugly clasp as clasps go. But many times you may be able to find a situation in which you can do a rotational path partial and eliminate the clasp on the anterior aspect of the partial completely. In this case it would be front to back rotation. Then the lower example that you see for the class 3 it’s the posterior seats first and then once these rest seats are in place you just [inaudible] the anterior down in and [inaudible] posterior rest seats first, [inaudible] the anterior down in and when it’s totally seated, the proximal plate back down the molar literally takes advantage of the fact that there’s a undercut on these molars. It uses it. So you start to seat the partial in the back first, rock it down so now that it’s fully seated they back can’t come up because you have engaged the proximal undercut. Then the situation here is a similar situation only from front to back and we’ll talk more about that later. So what are general considerations? If you got a rotational path all of your seats do not necessarily seat simultaneously. It’s not a straight path of placement. It’s a curved path of placement. Many times you can eliminate unesthetic clasps. The clasps are replaced by rigid retainers is what we need. In the case that we’ve talked about before in the posterior aspect no need for a clasp here because the rigid retainer being the proximal plate of this partial denture framework, once the partial denture rocks down in place there is a good occlusal rest on this and then the proximal plate rocks in to the undercut. So as long as the partial denture can’t move mesially, this can’t come up. It’s rocked in. As long as this stays down this is rocked in. So clasp in this case would be replaced by a rigid retainer [inaudible] proximal plate and the occlusal rest. So we don’t plan on the retainers flexing. If it’s a clasp you plan on the clasp flexing over the height of contour and coming to rest at the desired [inaudible] undercut. If it’s a rotational path that part of the rotational path framework it seats first and then you rock it to place. That’s what really [inaudible] rigid retainer just by going in and rocking to place [inaudible]. So the rigid retainers do engage undercuts and with many of these there is little tolerance for error because if these are off just a bit there can be problems. How many people so far have delivered as definitive partial, I mean the partial that’s got a metal framework and the [inaudible] teeth on half of it? Little less than half. So for those that have or for the people that are about to deliver some partials what [inaudible] is you try the partial denture framework in to make sure it fits okay if you take a bite registry.
So you say “Gee doctor this framework fit pretty good, we got the occlusion adjusted and we took a bite.” Now you come back and you go to deliver the partial with the teeth processed on. And very many times when you go to deliver the partial now that the teeth are processed on you come and get me “Gee, my partial denture won’t seat. I can’t get it into place.” What’s the only thing that’s changed? It’s that we got teeth and plastic on it. So in many of those situations what happens is where the plastic has being processed meaning where there is a tooth set out here and there is pink plastics processed in here, many times as you are trying to seat partial the pink plastic plate interferes with the undercut you are trying to engage. As with many of these there’s not a lot of tolerance for error. Why do we always have you people [inaudible] or your partially [inaudible] on the surveyor table? So that it’s leveled front to back and leveled side to side. We talked about this over and over. Sometimes in the preclinic even, and in the books they were talking about at the time I was in school, I was always sort of left with the impression when I took partial denture undergrad that if you put a cast, just took a model out of the patients mouth, took an alginate [inaudible]. If I fiddled with this thing enough on the surveyor [inaudible] I can find some orientation of this cast that will satisfy all the requirements necessary to make a nice partial denture framework. I was just always too dumb to find it. But supposedly if I [inaudible] enough…well what really what should have been happening is just orient the cast so that the occlusal plane is leveled front to back and leveled side to side, draw a design that would be my most ideal framework design that I would like to draw, forget the contours and the teeth. Just draw a nice design.
Now go back and look at the teeth. Now if you got your design drawn you say “Which areas in the teeth are going to work with the design I’ve drawn? And which contours on the teeth, typically axial contours, are fighting me, are not working with the design I’ve drawn?” Now the reason we want to orient the cast leveled front to back and leveled side to side is if I want an undercut where I’m looking for the desirable undercut for the clasp, again, where do we want those clasps to engage? We want the clasps to help hold the partial denture in place, to resist the tendency for the partial to be pulled out of the mouth when people eat sticky foods. So any time you’re eating sticky foods once your teeth come together when you start to open your mandible, open your lower jaw, during the first millimeter to two millimeters of opening of your lower jaw can everybody see that the direction that your lower jaw is going to be in is pretty much perpendicular to the occlusal plane. I know the jaw opens on the arch. I know that. But can you see just the first 2 millimeters of movement? That first bit is pretty perpendicular to the plane of occlusion. And once you’ve opened 5 or 6 millimeters, the partial is already off the teeth be it a jujube or a gummy bear for the time your front teeth are 5 millimeters apart, the partial is already completely unseated. So it’s just during the first couple of millimeters of opening is when you want that resistance to displacement. So since during just the first millimeter or two of opening if there’s [inaudible] the direction of the vector is pretty nearly perpendicular so I got to find out what the desirable and undesirable undercuts are for my proposed partial perpendicular to the plane of occlusion. See if I can do a lot of gymnastics, if I can really orient the surveyor table all over the place to try to find some orientation where I can [inaudible] the point is that‘s not the direction that people are going to chew. Okay?
When they open their jaw the vector is not going to go over this way somehow, it’s going to come straight up here. So if I orient my cast in some odd orientation to find an undercut but when I bring my cast back level level front to back and side to the side, if that undercut now goes away that’s a false undercut. Because a false undercut is one that you can orient the cast somehow to find it, the question is does this still exist when the occlusal plane is leveled front to back and side to side? Cause that’s the direction that the removal [inaudible] is going to fall on the partial. People call that [inaudible]. as easy as can be. Put it on the darn framework, level front to back and level side to side and then start analyzing the contours of your proposed [inaudible] teeth. [inaudible] do they tilt lingually? Do they tilt lingually so far that it would be difficult to seat the framework? Cause there is difficulty if you’ve passed the tooth and still haven’t touched the gum. Many times if they lean lingually so that the lingual of the tooth is in the way, what do you suppose is the situation out at the buccal of the same tooth in terms of undercut for your [inaudible]? It ain’t there. There are things leaning lingually so just looking at the orientation of the teeth when we got things oriented when we…when basically our cast is leveled front to back and leveled side to side. Then again these pictures. I’m not going to go over these things [inaudible] because these are all straight out of your book. I just stand them. So the thing here we’ve talked about if you got linear path of insertion everything goes up and down at the same time. If there is a mesial undercut here we brock it out parallel. If there’s an undercut here we brock it out parallel.
Matt: Lorne just one other thing the same tips that Rd. Wilson was speaking about that do not have to be cleave d are also use on the I -Lays. There are disposable, different lengths, different diameters that easily interchange on and off.
Lorne: That’s good to know. Don another question about using the laser tips for indo. Is there are risk of those laser tips breaking off in the root canals?
Don: They are very flexible Lorne. I’ve never had one that break. We use both the 200 and 400 micron tips. You never want to force those in the canal. We usually go about too about 2mm short of the apex and we’re careful about our settings but that has not been an issue but you never want to wedge them into the canal either but they are very flexible and they are designed to be one use.
Lorne: Another question you showed a specific case about teeth whitening. Was there any sensitivity on the patient after the whitening and if so how was it treated?
Don: We didn’t. If we had we would be treating it with some fluoride butt we didn’t have any post-operative sensitivity at all. I have had the exact same procedures done on myself and I can tell you it was very comfortable. We go through two cycles, the laser will expose abbot a quadrant at a time and we do about j 30 seconds on each quadrant and then we move. It just take a few outs to activate the bleaching solution and then once its activated we leave it alone for about 5-7 minutes , rinse and the we do it again.
Two cycles accomplished what you saw there and I don’t think I really mentioned it but with the bleaching wand that you saw their on the photograph it can also be used as a low level laser tool and you can set the Boar laser and use it for treating TMJ . That’s another nice function of the Easy Lays that you would not be able e to use the bleaching wand on the new I-Lays. It only would allow you to use disposable tips.
Lorne: Great we’re down to three questions here. We’re going to finish on time. Have you done any guided tissue regeneration using the laser?
Don: I have not personally done that. I have seen Brett Dear present some really nice case on that but in I have not personally done this.
Lorne: Another question about the removal of epithelium layer for the peril reattachment. You might give a quick recap of that and the other question they had was if they could get the slide show. I want to remind everyone that we did record the entire webinar. I’m going to have it on my site, I imagine Schein will have it as well. there’s certifiably will be ways for people l to … When we see you the CE forms as well as the follow up I certainly will let you know when whew available to download and watch the who presentation . Can you do a quick recap as far as what you recommend there as far as that epithelia layer?
Don : I can run and I would like to say to those of you when you purchase the lase and you get a radio fire perio tip Boa Lays u has some really good and concise material that comes with he tip . It gives you the settings and some diagram sand sort of the step by step in he procedures so if you need to have that little cheat sheet there as you go along and do this for the first few times,
The first step is to trap around the tooth, going down in between the tooth and the tissue and because it is a radio filing tip it will shoot energy at an angle towards the tissue which will deapethliaze the lining of the pocket. If you remember form the diagram there is a little blunted in that will allow some energy to go down towards the bottom of pocket.
The first thing we’re gapping to deapethelize the lining of the pocket then after that we will tilt the tip very slightly toward the tooth to get a little more favourable direction on our radio fire tips , still down inside the pock and we will use that to go around using an ear water spray , we will use that to go around an remove calculus that I down inside the pocket from the tooth . You will actually see those little bits of calculus coming off.
That also property this trot surface for goo reattachment. Then e move outside the pocket and we deapethliase the outer portion of the pocket, we’re enough inside of the pocket now. So we’re deapethilasing outside the pocket and we are taking those cells back away from the top so they have to grow further before they can turn and go down in the pocket so we don’t have the [Inaudible] in the pocket again to prevent reattachment . What we are allowing to happen is that the functional epithelium we are giving it a little more time to reattach at the bottom and grow up then once we had done that we use moist tiles and awe compress very firmly for five minutes to get a blood clot to form underneath there. That’s a very important step in this I procedure.
Then after five minutes we’ve got a nice dry environment and we seal up around the necks of the teeth , the top of the tissue wit derma bond and seal that up and then send the patient home .
Lorne: When do you bring them back to remove that surface epithelia again or do you?
Don: We do , we bring them back in one week and if there is any residual derma bond left on there we would go ahead an d clean that up . We will deapethlize just the outside of that pocket. That portion doesn’t use anaesthesia by the way to do that. It’s very comfortable for anybody .We don’t have to sue topical on there. We do not put derma bon on that next time unless it’s in the case of a smoker that we might but derma bond on it. One more week of we get somebody that smokes.
Lorne: When you are deign that RST procedure in your option is that amusing any kind of etching into the trot surface.
Don: No, not at the settings that you are using. Another thing with ought getting too technical, the angle of the laser. If we were using a regular 400, 5000, 600 micron tip , regular tip and wife we were directly perpendicular to the roots surface then i would be very much concerned about that but because we are going g won into the pocket parallel and values we are using radio fire tips and we are using the appropriate e setting s , meaning the wattage and the pulses per second and air and water because we are using all of the correct setting as recommended then know that’s not a concern
Lorne: Final question. I guesses this is partly for Don, partly for Matt as well. For someone that really just neat to get more information about laser is there a good website that they should go to or any video out there, what would either of you recommend for eosin who is just thinking about it and really wants to get a little bit more information online .
Matt: Certainly there are a number of different ways that we would love to help you with him education process. Again I know Don has it on the screen. We would love to come out certainly to youth office and present some different applications and list all the benefits to you and your staff, come in and do a presentation for you ring your lunch. We have seminars throughout the United States, North America koi that matter.
Lorne: re these hands on course matt?
Matt: Some of them are hands on and then some of them are certainly just luncheon presentations but you can go to again the Henry Schein website and find one or the Boa Lays website near you , a location that’s convenient and words for tour schedule and again we would be more than happy too come into the office ad do an in office demo is that is something that you also need to get information .
Dan: Ladies and gentlemen what is old really recommend to you is to let one of the reps come in and bring a unit in and work with it right there in your office. I think that’s a great way for you to learn. You will get a lot of experience just by having it in your own office and they are happy to do that. There are some wonderful courses, they are designed dos that once you purchase the laser you can come there and take those ads you basic learning but you can also go to those and sit in on them as a learning experience before you purchase the laser. If you like that so that you can sort of kick the tires and cleome more familiar with the overall technique I would invite you to go to one of those courses and participate in it .
Lorne: On more question for you Don, clinical question. If a patient is taking any type of Vida dilators do you see the advantage of using the other lasers such as it relates to equalisation time.
Don: There rely isn’t any concrete indication to use in the laser. That the wonderful things about it, even during pregnancy. Bleeding is not a big problem or us so it is a huge advantage for us being able to do that I recently was in a situation where we did seem crown lengthening on a patient that was 6 month pregnant and owned some blood thinners and did a little own lengthening and even at that time it was just not a problem. Good question.
Lorne: I want to thank bout of you. Don that was an excellent orientation, very informative, we had a lot goof great k questions here. Matt tanks for being on the call as well. Soon you call all see the phone number bad the website. If you want to get more information, get any office demo, I would highly recommend it. Thanks very much Dr Schein and Boa Lays for helping us with it. Any of you who have ever done a lecture or a webinar know that these things are not easy to put together and it made my life much easier, especially Don it makes my life so much easier when I can just sit here and listen to an expert rather than me having to ring through all these kind of stuff here. Thank again Don. Many of you keno I do these webinars on a regular basis .Thesis is certainly not the last webinar that we are going to do on lasers. When you find out you should have a chance to let us know if you need a little bit more information, some comments. Some of you would like some more advanced courses, just in soft tissue lasers we can customize anyway you want but certainly every 3-4 months I think I would like to do another laser webinar.
As I said it will be available on my website. We will let you know about any locations for them. Thank you everyone for being on the call and we will see you’re shortly for the next webinars
The impossible is nothing .It so the reality of lasers for every day dentistry. For those of you that had been with sus the whole time I want to thank you for your time again tonight. It has been a pleasure woo join you this way tonight. I hope that I provided you with some information that you’ll find very helpful in making lasers part of your very day , every way practise and I will be on the line now with Lorne to fill as many questions as much as we possibly can and feel free to contact me in the future. Lorne?
Lorne: Thank you doc that was great and you are not done yet. We have a lot of questions here. I’m going to get to it because we do have a number of questions and they are still pouring in. Thanks again that was just fantastic information. Matt are you still on the line as well?
Loren: There may be a couple of questions that I’m going to ask you as well. One of the first question we got Don was how was the learning curve for you? How difficult was it for you to start incorporating this into your practise?
Don: Please bear in mind that when we started lasers it was back in 1998 and we had to learn by asking all the mistakes. There really weren’t good course for me to go to back then and so those of use two were using lasers around the country sort of had to learn by trial and error . I’m going to tell you I think we’ve made this big mistake around laser and I wane say that I think I’ve been a part of that as a laser educator. Folks this is just not hard and we’ve have some wonderful courses around the country , we have this great course in charlotte that Patrick Brim does , Bill Chin has one in St Louis and there are others around the country . Those are just two that I personally attended. Brett Dior is a wonderful periodontist. There is plenty of help out there but you already know how to do this procedures it just a matter of adapting the techniques. I want to tell you the learning curve in my opinion is not steep at all.
Lorne: I guess this question is more for mat? Matt is there a formal trading program that sis typically recommended for people that are getting to lasers?
Matt: Yes there is .When you purchase the Water Lays and the Odessa 100 it comes with a day and a half to 2 day training course and they’re going to go over all the ins and outs of how to add the water , woo to change the tips but importantly going over the basic procedures, how you’re going to class one through six cavity preps , how you’re going do periodontal procedures, things of that nature to get you very comfortable with the basic procures day in and day out that you are going to encounter .
Lorne: Great thank you, Don did you change your fees when you started using lasers?
Don: No we really right at first. I felt like I needed time to establish them in my practise and really we have not increase because we own a laser per say. I think out quality of dentistry have improved and we have increased our fees across the board annually as I’m sure that each of you do but the laser becomes a tool in the toll box and it really pays for itself . I will tell you that think, I know that my patients perceive this as a wonderful thing. There is not a day that goes by that I don’t have a patient tell me that you know why I come here doc? It’s because you use a laser, I really appreciate it. So I think they are willing to pay y more. We don’t charge a laser fees we just incorporate that into our regular fee schedule.
Lorne: I guess this question is for both of you, there is a question about the new Boa Lays laser which I assume is the I-Lays. I thought in Chicago when you manage it now I know it just got FDA approval when I first saw it.
Matt: Yes. The I-Lays is currently shipping. We have had a very strong response form he market and we arte juts about caught up with all the back orders which is good thing .Now if you order a boa lays that will be shipped very quickly after the order comes in . The answer to that question is yes, and we will be happy you talk to you mire about that.
Lorne: Don have you had a chance to see the new I-Lays?
Don: I do not have one in my practise yet, I want to put it on there. I saw it just before it was released and I think it is a remarkable tool I think it’s amazing to have that much technology in something that can fit inside your pocket.
Lorne: Another question for you Don, how do you keno when you are going to need anaesthesia and how common is it for you to stop and give an injection after you start?
Don: I don’t always know in advance that we won’t need the anaesthesia. I make the assumption that we will not. You a kind of tell by Workington some patients that they are a little but more nervous, or a little bit more fraud perhaps than others. So we explained to all of our first time patients who are suing the laser for the first time what to expect and if the patients have some sensitivity the first thing that I don’t do is to grab for my syringe. Once you got through some laser training you can learn how to adjust your settings and you can keep adjusting those settings until you can get almost anyone comfortable and as you go into the procedures, then a lot of time you an up your pulses per second or you can up your energy per pulse and you can go on at a good speed.
There are things that you csan do to help regulate that but if I have a patient that requires anaesthesia I want to tell you guys that it takes very , very little . They do not have to be just profoundly number. Even the ones that are really skittish about that.
Lorne: What about the up keep on the laser. Are your staff the ones that are doing that and do they need any special straining?
Don: When Boar Lays install a laser they will come in and give training to you and your staff on site plus when you go to the training courses you get even more but I have an wonderful staff, my girls are highly trained in laser use because we’ve used it so long but they do all the maintenance and the day to day cleaning and do it very appropriately an take care of our hand pieces and tops a den that sort of thing and off course we have boa lays to come in and check tour laser at least on an annual basis .
Matt: Ok this is an orphan question now. Can you do a transection friberaotmy for post orthodontist tabulation easily with this units?
Don: Yes you really can. On one of the trice things that Boar Lays offer are some really small tips. You can go down to 200 microns and yes you can do a transperol frioberontomy using these smaller tips. It’s actually a very great way to do that.
Matt: This other question I guess it came right around the time of you were showing your first peril case and the question is do you need tot the patient number for those procedure that you are showing.
Don: Yes you do. We talk about anaesthesia fee dentistry. I do that operative and there are some fast tissue procedures where you can use anaesthesia free or application of maybe just a typical but in a peril procedure like that no I do have amnesties and we dint have to have as much as we were dignity conventional l with the blade and seatrain and that sort of thing but yea I have amnesties for that.
Matt: There is another question related to that procured what do you believe ease the eulogy for the pocket and access on number 9 with [Inaudible] removes during the use of the RFT.
Don: I think mainly the eulogy of that was traumatic exclusion for an extending period of them when this patient when it perfusion she was really riding heavily on that tooth and the reason I said that is because the surrounding teeth as you remember in the photograph they look and her over all dental health was good so this was an isolated teeth so for that reason I think it was due to the traumatic allusion that she had and I don’t know that I remember specifically. I would say that we had some cactus come out of there bit I don’t think much. It wasn’t like there was a lot of calculus under the tissue there.
Lorne: Another question here, what about using a Boa Laser to treat perusal pockets?
Don: You definitely can use a BAO laser in treating personal pockets. That’s a very common practise in my state in Alabama as well as a few of the other states. I don’t remember how many they are now. I would say probably 10-12 where hygienist cannot use a Boa laser. In my state if I want to use a Boa laser in routine perio therapy I ‘m going to have to do that not my hygienist.
Yes it does work very well. If it’s a 4-6 mm pocket we would still follow up with the new erbium technique using the radio fire tips on the YSGG. Those are the perfect cases. You will get reattachment on those but yes a Boa laser can be used.
Lorne: Are there a variety of tips that are available for Boa Laser?
Don: Yes there are quite a few different tips that were available now. For those of you that are in the audience now that have an existing Boa Laser you probably are accustomed to using your Boa Laser of having to cleave the fibre. The fibre is your tip and sometimes it’s difficult to get a really good cleave. With the Easy Lays it has removable, supposable tips. No more cleaving , just screw it on and thy come in different diameters bad different lens and I don’t think I showed one in my PowerPoint tonight but you can bend that tip to get a true right angle so that you can reach distal to number 3 or number 15 very easily .
Lorne: This question is more for Matt. We have a number of questions here about the cost to purchase from entry level all the way up to the MD turbo would be best for the local Schein reps to contact those individuals ?
Matt: That would be great and again I know Dr Wilson has left the slide on the screen. You can either call us or go to the website and we can address all of j the different financing options that we have e, different terms, different lengths and any promotion that we currently have going on the product. If you have specific questions Lorne I can address those as well.
Lorne: We do have a few questions on the pricing, we know who ask them so we will be able to give that information to you in case the Schein reps want to follow up with that.
Now then a gingivatomy per quadrant, again maybe a procedure that you are not currently doing but a very simple procedures that you can do with the lease. I you add one per week $33 350 added to this practise. Gingiva flat surgery. This is the perio procedure that I was just showing you just a few moments go. Maybe you currently send toss out to the periodontist. You can do them in house. No cut, no sew m peril surgery. if you can do just one power week and I know how many of your patients have periodontal tissue j but if you just did one per week you could add $4 150 to this practise.
Clinical crown lengthening .If you do very much cosmetic dentistry I know that you are going to run in to the need for crown lengthen or if you work with crowns in the posture part of the mouth with large deep amalgams that go down near the born level it know you’re going to need the crown lengthen to not violate biological width in your restoration . So we do far more that one of these power week but if you just dis one per week you could add $38 750 to this practise .
Osco surgery with the graph. These things just come up from time to time. This is every day, every way dentistry. We see patients with these problems, we have a solutions if we just did one per month we could add $19 896 to this practise. An apical rectum y you think might be beyond your scope. I will tell you the first time in my life my career that it ever did in apicalectomy I called a good friend of mine in California on Sunday night t he gave me directions how to do it with a laser . I did it on money and since then we’ve been doing apical atomies all the time even m on molars .So if you just do one per month you could add $23 352 to this practise . In new procedures that will total up to $170 8978 that you can add.
Let look last of all at time savings .We definitely can save time with lasers, no waiting door anaesthetic in at least 80% of the cases in restorative work, faster restorative procedures. . I’m not trying to say the laser is going to cut faster than a hand piece I’m just saying that because we don’t have to wait for anaesthesia the overall process is short, we can treat multiple quadrant in one visit j instead of having to have multiple visits that it such a savings and over hit for our office and gingival trifling your crowning bridge instead of having to pack cord. . Faster soft tissue surgical procedures. No sauterne following a lot of them the way the laser works, a lot of times we would have to serene things it the past we don’t have to do that now. surgical and restorative procedures in one appointment for example if we are going to do a flapless or a modified close flap crown lengthening if we need to we can go ahead an d make out r impression for our crown at that same appointment . Surgical and restorative procedures during hygiene , if we have a hygiene patient that needs a little procedure done and we have a equity chair in a fee w minutes we can move that person over and just do it there instead of bringing them back for a separate appointment and more efficient treatment of emergencies and non-schedule patients if you remember the photograph earlier of the kid who fractured the central incisor . We did not have an appointment for them, we work them in and we did definitive treatment instead of just temporary.
One appointment root canal most of our root canals we are able to do in one appoint and confident that we have sterilise the inside of the canal because of the laser in faster and improver cosmetic procedures and I think we have shown several examples of those this evening already .
So one hour per day at 950 an hour times 200 days per year we can add about $190 000 to this practise so all total we will be able to add $580 048 to this $750 000 practise. That is a 77% increase. Now you say you’re crazy those are not realistic numbers actually they are realistic numbers h because those are numbers these have actually taken from our own practise but if you think it’s too much , if you think it really, of the all that lasers can do that lets cut it in half. Even if you can only y do half that much that’s still a 39% increase $290 000 increase on this practise. That’s enough to pay for a laser and all the canned ham or smoked ham that you can possibly eat during the year and still have $175 000 in your pocket.
Briefly it want you to think outside the box, think outside the box for the gentlemen in our office to night. Won’t you look at the bigger precise by expanding ding your practise by adding partners or associates. If it ask you the question what’s the back bone of a good practise? There are a lot of correct answers but it think the most correct answer r is a strong and consistent flow of your patience. These are actual numbers from our practise, we put a laser in our practise in 1998 and the only thing that we did differently from here to here is that we put laser dentistry into our practise and we properly marketed it and during that time we were averaging 189 new patients over month and all we did jaws to market the fact that we had a laser to our community.
Our production also increased. We went from one million to 2.4 million in production during that same time period. Again the only difference between here and here is the laser in the practise and proper marketing. New patients do equal near partners or associates so we j grew a regroup practise from 97 to 2003 we were able to add two partners into the practise from 2004-2007 we wren bale to have 5 different associates in the practise. 2008 I sold out two partners and started a new practise and nice that time we now have go grown that practise over a million per year and we were talking about a buying associate. In fact it got a phone call from two people ahoy are interested in coming and looking at the practise to join us as associates.
In the end are the results worth the effort and the answer is you bet they are. As some of you may know or may have gathered from an earlier slide I do like to fly and if I’m going to trust my life to an air plane I don’t want to settle for second k best l I chose a serious aircraft to be my own [personal aircraft for a reason and one of the reason is a parachute. If all goes wrong while we are flying and there are no other solutions we can pull a handle it rocket launches, a parachute that gooses out behind the lane, it opens up and safely floats the plane to that’s the only aircraft that has that .Even though it cost a little but more money I don’t ant to fly second best when my life depends on it. If I’m going to trust my practise through a laser well you know the rest of the story , I want the very best and after having used all the lasers that are on the market today my feeling is that the Water Lays MD is by far the best laser out there and I have used all of them .
I want to conclude tonight with laser marketing. We must learn to think like our patients think, not like dentist we must think like patients. Stewart Sink why is frim our are here in fact his parents olive right down the street from us he drives for show but you put for dough and in talking about that and comparing that too laser marketing we can do all of our marketing relative to operated dentistry . As you can see we do many, many procured besides operative dentistry but thinking like the patient thinks. When a family member goes to see their dentist for a recall visits and they get home the first question that is asked is how many blank you had. The answer for the blank is how many cavities you had because patients equate the dental office to fillings. That’s what they think about. I now we do all toads other wonderful procedures but the patients think about how many filling s I need.
With that in mind we did all off our marketing really based upon filings. No shots at the dentist suite, we talked about no shot, no drill, and no numb lift. [Mumbles] I should have used the lasers, translated I should have used the laser. Again talking about anaesthesia free restorations, not shot no drill, no numb lip. Seven R campaign was how refreshing talking about laser dentistry and aso2008 a reason to smile and then No shot No drill No numb lip. So you can see all of our marketing that’s focused around that patients think about and that is restoration. In our 2009 we have switched to a little bit different twist, lasers and cosmetic destroy because we switch to our nee practise signature smile and then 2010 falling in love with your smile.
We do a lot of marketing. These are some of out marketing campaigns that we sues. If you don’t like this , talking about if you don’t like an injection or if you don’t like a drill or if you don’t like a numb lip then we have those to offer you. no problem campaign , real life situations a dental filling , a free clean up no problem because a lot of our patients do leave here and go to a school function our a luncheon meeting or a church function or an outing and they are able to go without a numb limp an they really like that .
The no , no, no campaign , no shot , no drill , no numb lip and this can’t be dentistry campaign and then we did get with the times. We did ads that related to the months in which they ran. This was our January add , anaesthesia is so last year, talking about the fact that can do Anaesthesia , free dentistry , sweet campaign , no shots at the dentist, eating right after a filling, you can still feel your face sweet and these were one of my favourites . These ads were not ours, issued a company of DR. Olsen was away dental but self-confessed ads .Talking about people that have phobias about coming to see h the dentist and how the laser releases their phobia.
I don’t know if you can hear this one our not… I front believe it’s going to. I had one of the radio spots I ants sure that you would be able to hear that or not. We also have post cards, brochures, direct mailers, talk about laser destroy. Feel free to copy anything that we do in our practise. Our marketing is done by a dental promotional group that is here in the Florence areas. You can contact them at the number you see or Angela Bailey, email@example.com. She does a wonderful job for us and she has laser campaigns that are available for purchase if you would be interested in one of those once your purchase your laser. No fluff with proper marketing, the results can absolutely blow you away. I encourage you to take you practise to the next level. Let that rocket and enter the world of laser dentist. You mission if you decide to accept it is very possible. This is every day, every way dentistry and I’m here to tell you that if a guy in Alabama can do it then you can certainly do it too.