The Power of Photography (and a quick mock-up)

Posted on February 4, 2020 by The Dental Warrior

A quick blog post here.  A recently new patient has had some basic restorative treatment.  I asked him about his front chipped teeth.  The initial chips were caused by an accident when he was a kid.  He never had them repaired.  But, they are chipping away even more in recent years. 

He was reluctant to repair them, because he felt that the “imperfection” was part of his “look.”  He also mentioned that he did not want perfectly straight edges on his teeth.  He liked the imperfect look.  On the other hand, he was concerned that they may break even more.  His initial reaction was to put it off for now.

Today, he was in for a composite restoration of a cervical “abfraction.”  After I was done with that, I asked him if it would be OK to do a mock-up on the two front teeth.  It would give him an idea of what is possible with bonding.  I also told him we can “characterize” the edges so that they’re not perfectly straight. 

I did the mock-up in about 2 minutes.  I intentionally made the incisal edges “imperfect.”

I took before and after photos and gave them to the patient.  He was impressed!  He’ll be back to have it done!

For the final restorations, I’ll spend a bit more time on the central incisal embrasure. I like them a bit smaller and sharper.

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Gold is still the Gold Standard!

Posted on February 3, 2020 by The Dental Warrior

Today, I had a patient scheduled for a crown on #3.  The tooth had a couple of deep occlusal amalgams with some darkly stained cracks on the marginal ridges.  Oh sure… we can debate, “to crown or not to crown” or “when to crown” until the cows come home.  I submit it’s a judgement call, based on experience and leave it at that.

Would you crown it? Ha! Never mind. I don’t care! 🙂

Once seated in the chair, she asked if we could do gold instead of porcelain.  Her husband had recently gotten a gold crown on his 2nd molar, and he remembered well the advantages I presented to him.  He had relayed that same information to his wife, my patient today.  Admittedly, I had not offered gold, as #3 is usually near what I call the “cosmetic transition zone.”  Given that, in my experience, so few people will consent to gold, I generally limit the option to 2nd molars.  In those cases, my “pitch” on the advantages of gold is compelling. 

Perhaps, this experience was a reminder to start offering it more often for other teeth.

She said, “I can’t see it anyway, and I like the idea of less tooth being drilled away.”  Of course, I agreed with her!  Oh… she’s a bruxer, too.  After a bit more discussion, it was a done deal… gold it is!  There was no reason to prep the facial and lingual surfaces for full coverage.  The plan was for a gold onlay.

I began by removing the amalgam and cleaning up the “schmutz.”  I wanted to visualize the extent of the crack before prepping. Continue reading →

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Today I Met a Real World War 2 Hero!

Posted on January 21, 2020 by The Dental Warrior

His name was John Katsaros.  And what a lucky day it was!

Today was just another regular day at the office.  I went out to lunch by myself at one of my usual places.  I sat in a booth, facing the front of the restaurant.  As I was finishing up my lunch, I noticed an older couple being seated in the booth right in front of me.  They sat next to each other facing me.  The older gentleman was wearing a hat that said, “Purple Heart – World War II.” 

Being a patriotic veteran myself, I felt compelled to buy the couple’s lunch.   I’ve never done anything like that before, but I just wanted to do it.  There aren’t many WW2 veterans left alive today.  They are a very special group of people!  I previously wrote about another WW2 hero, Army dentist, Captain Ben Salomon.  When my server dropped off my bill, I asked him to put their lunch on my card, too.  

Since I was done eating, I got up and stopped by their table and said, “I just wanted to thank you for your service, and lunch is on me.”  They were quite surprised.  They asked my name and then asked me to sit with them.  A lovely couple.  Married 61 years!  He’s now 97 years old.

John and Mary Katsaros and me.

We chatted, and he was quite eager to share his story with me.  He was a waist gunner on a B-17 Flying Fortress (bomber).  Hard core stuff!  His plane was shot down over France.  Three of his crew were killed in the aerial gunfire.  The rest bailed out of the plane at 27,000 feet!  He said at that altitude you pass out from a lack of oxygen and hope you wake up in time to pull the parachute ripcord.  His right arm was shattered by a bullet when his bomber was shot down.  He broke several ribs and both ankles when he hit the ground. 

B-17 Flying Fortress

He was captured by the Gestapo.  Escaped.  Captured again.  And escaped again with the French Resistance.  A Jewish doctor hiding in a cellar Continue reading →

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Neil Peart – Legendary Drummer Passed On

Posted on January 10, 2020 by The Dental Warrior

A Tribute to Neil Peart, the “Professor.”

Earlier today, I watched some Rush and Neil Peart videos.  Then I dozed off on the couch for an afternoon nap.  I heard my phone text notification ding… and then ding again… and again.  Someone was blowing up my phone.  It was a combination of several text messages and Facebook messages.  Several friends were telling me the news:  Neil Peart died.  My friends know how much of a fan I am.  He was 67 years old.

Here’s the weird part…  Just a couple of hours prior, before I dozed off, I was indulging in some Neil Peart videos, which I had not done in a while. 

I’ve liked plenty of other bands over my life. But, Rush is the one that truly resonated with me.  The music.  The lyrics.  The members’ personalities.  I felt connected to them on a philosophical, if not spiritual, level.  I did not know Neil was sick.  It turns out he had been battling glioblastoma (an aggressive and incurable brain cancer) for three years.  But, some “cosmic connection” must have compelled me to listen to Neil’s percussive magic earlier today. 

I first learned about Rush in college from a friend, with the album, “Moving Pictures.” 

If I could pick a soundtrack for my life, it would be Rush.  I’ve often described Rush as “rock for intellectuals.”  If you’ve attended a Rush concert, you’d agree it’s a “nerd-fest.” 

The depth of the talent of all three members of Rush is stunning.  If you’ve seen the documentary, “Beyond the Lighted Stage,” you’ll remember all the OTHER musicians interviewed… looked up to Rush as the “gods.”  They are the musicians’ musicians.  What are the chances of THREE virtuosos coming together in ONE band?

Neil was a poet, who wrote most of the lyrics for Rush.  A voracious reader, he was also a prolific author of many books.  Of the three band members, he was the most private, who rarely gave interviews or attended fan events.  Alex and Geddy were the “PR” guys.  Neil kept to himself. 

Neil incorporated a lot of different styles in his performances, but Jazz was a major inspiration for him.  He was a big fan of Buddy Rich and Gene Krupa.  He performed at a Buddy Rich tribute with Buddy Rich’s band.  Watch the video and be blown away at his talent that went beyond the world of Progressive Rock.  There is a reason he was nicknamed, “The Professor.”  His solo starts at about 3:50.  Watch the reactions of the band members behind him at about 5:40.

His concert drum solos were legendary and considered by many to be the highlight of the event.  Here is a solo performance in Frankfurt.  If’ you’ve never seen him before, prepare to pick your jaw up off the floor. Continue reading →

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How to Add a Virtual Black Contraster to Your Intraoral Photos

Posted on November 6, 2019 by The Dental Warrior

If you’ve been doing intraoral photography for cosmetic cases, you’re likely familiar with the black contraster.  If you’ve only read articles about cosmetic dentistry, you’ve likely seen the photos of a restored arch with a black background to show off the details of the restorations.  It’s a very effective way to draw attention to the restorations by getting rid of the distracting background (tongue, cheeks, opposing arch, etc).

How do they do that?

The traditional approach is to use an instrument designed for that very purpose.  It’s basically a paddle-shaped device that is anodized in black.  When shooting photos of a restored arch, you simply place it behind the teeth and then take the picture.

Black photo contraster – “one size fits all.”

 

Ow!

If you’ve done this, you’ve probably run into cases where it doesn’t quite fit, or you just can’t get a good angle, or there are gaps.  Using a black contraster can sometimes be cumbersome and awkward.  Sometimes it’s very uncomfortable for the patient, and you just can’t get the “shot” you want.

In patients with small mouths, it’s hard to get the contraster in and behind the teeth.

 

And, if you get it in, it stretches and cuts into the commissures. It also stretches the tissues such that the lip gets pulled down over the teeth, obscuring areas that you want to photograph.

So, I’ve developed a way to do it “virtually.”  And, I dare suggest it looks even better.  My technique uses Photoshop to create the black background virtually.  It’s quite easy.  I would expect it can be accomplished similarly in other photo editing programs.

We start with a retracted photo of the upper arch, without the contraster. 

And, here’s how we create a black contraster virtually…. Continue reading →

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Trim Your Own Dies???

Posted on October 28, 2019 by The Dental Warrior

Who does THAT?  Why would you?

I started my own practice renting space in an existing dental office (shared space).  The other dentist took a lot of pride in his work, and deservedly so.  One of the many things he felt strongly about was trimming his own crown and bridge dies.  He had a stereo-microscope set up in his lab just for that purpose.  So, I started doing it, too.

Eventually, I moved into my own office space, which happened to be next door.  For many years, I continued to visit my friendly neighbors to borrow their microscope to trim my own dies…. and well… to socialize! Recently, I finally got my own microscope.

Why trim your own dies? This isn’t dental school!

I send my Impregum impressions to the lab to be poured and dies pinned and cut (but not trimmed).  They return the models for me to trim the die margins.

I found that you learn a LOT about your preps and your impressions when you study your models / dies under a lab microscope.  It’s very objective and different than observing them in the mouth.  First, you can spin the die (prep) in any direction for viewing angles not possible in the mouth.  Furthermore, as you trim the die, you can’t help but pay very close attention to your prep margin (and learn from it). 

By the way, you can also use the lab microscope to inspect your impressions. The lighting is better than what you have intraorally.  Also, the magnification is much higher.  My lab scope goes up to 45x.  That’s ten times higher than my Designs for Vision 4.5x surgical operating telescopes.  Though 45x is well beyond the practical magnification for trimming a die.  I find 7 – 10 X works well for general / gross trimming.  I use up to 15X for fine tuning or trimming delicate concave areas like buccal furcations of a lower first molar or mesial concavity of an upper premolar.

Untrimmed dies.

 

Trimmed dies.

Holding the prepped “tooth” in your hand and inspecting it (while trimming the margin) under high magnification will make you acutely aware of any shortcomings and precipitate an effort to make your next prep and impression even better.

So, the first benefit is that by seeing your work in the form of a die under high magnification, you become a rather fussy “critic” of your own work.  Accordingly, you can’t help but IMPROVE.  Seeing your preps in the form of a die under a microscope is like listening to an audio recording of yourself.  You sound different on the recording than when you sing in the car, right?

Nothing but the tooth, so help me G.V. Black.

Click on quote above to learn more about their seminar: “Simplifying Complex Cosmetic & Restorative Dentistry!“

That margin you thought was smooth and contiguous when you prepped it…. maybe not so much when you look at the die under the microscope!  If you think your preps are smooth after prepping with a coarse diamond, you’ll change your tune when you see the die at 10x or higher.  The axial walls look like a grooved asphalt road!  The axial-occlusal line angles are sharp rather than nicely rounded.  Next thing you know, you’ll be ordering some fine diamonds to polish your preps!

That impression you thought captured the margins perfectly… maybe not so much.  Next time you’ll spend a bit more time with tissue management, including gingival retraction and hemorrhage control.  You might be more careful to not lift the tip of your wash material syringe, creating bubbles at the impression margin.  It can be humbling!  It’s an objective way to evaluate your work, much like reviewing photos of your cosmetic cases.  Your lab will thank you!

Trimming Dental Dies with a Microscope Video:

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Is the Other Bracket About to Drop?

Posted on October 6, 2019 by The Dental Warrior

I wrote about DIY orthodontics not long ago.  While it felt good to “unload” my feelings about DIY orthodontics, I had to admit to myself that it was unlikely we (dentistry) would stop this multi-billion dollar juggernaut.  I figured it would meet its demise only if the market (consumers) eventually realized the folly of using their product.  I confess I did not have much confidence in the market doing that any time soon (or later).

Now, there are some signs that the DIY ortho companies may just self-destruct.  Recently, SmileDirectClub (SDC) went “public” with an IPO stock offering.  Subsequently, there have been some reports of some rather interesting, if not questionable, activities and history of SDC.  See the following articles:

The first article is mostly a summary of the 2nd article, which is more than a little damning of SDC’s business practices.  Rather, it is a full-on indictment of their business practices and even the legality of their business model. 

A few of the highlights of the investigation done by Hindenburg Research: (Hover or click link to learn more about them.)

  • SmileDirectClub’s practices have earned it over 1,200 Better Business Bureau complaints in just 5 years as a company. We communicated with one customer who was forced to use wire cutters to remove SDC products after he struggled to breathe. Review sites are replete with other horror stories of customers who had to take emergency dentistry into their own hands.

  • We were told by a former SDC store manager that the company was sending 75 to 100 cases to one orthodontist’s phone, per day, to “crank out” case decisions.

  • The company is another profitless, cash incinerating “unicorn” that we believe has significant added financial headwinds to face as a result of regulatory, legal and customer satisfaction liabilities.

  • All told, we believe SmileDirectClub will wind up as a case study in why it’s a bad idea to invest in a company that attempts to fit a complex, dangerous medical process onto a low-cost, high volume assembly line.

  • We see downside of 70% purely on a valuation basis, and downside of 85% given the above headwinds. We have a one-year price target of $2.

The above excerpts only scratch the surface.  Read the (rather long) article.  It is brimming with a litany of disturbing allegations. 

But, if I was to emphasize the most telling and disturbing part of the report, it would be this: Continue reading →

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All My Training and 31 Years of Experience Have Led to This!

Posted on October 2, 2019 by The Dental Warrior

About a month ago, we had a close call with Hurricane Dorian, which was a “Cat 5” and got within 100 miles of us.  In the process of putting up my shutters, I smashed the tip of the ring finger on my left hand.  It hurt, but I “walked it off” and continued putting up the shutters.

It never turned black and blue, but it just kept hurting, especially if I put pressure on the distal end of the finger.  I wrapped it in tape, but that wasn’t stabilizing it very well.  I tried a number of finger splints from the drug store.  I even got some off Amazon.com.  They were all bulky and didn’t fit well.  Putting on an exam glove over the splint was difficult. 

The first splint I got at a drug store. Got in the way of everything… slipped off a lot.

Commercially-available finger splints are bulky, don’t fit well, and limit function.

The discomfort (with any pressure) continued, so I took an x-ray.  It clearly shows a fracture of the distal phalanx.

This morning I got to the office early and the light bulb (in my head) went on.  I could make a custom splint!  But, how?  With which materials?  Acrylic?  Bis-acryl?  Hold on a sec… what about using clear retainer material?  Thin and stiff!   OK… here’s a pictorial of how I did it. Continue reading →

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Why I Like Guns

Posted on September 8, 2019 by The Dental Warrior

Why do I like guns?

  • They are simple mechanical devices and among the few durable items that can be as functional 100 years later as the day they were made.
  • They are powerful.  It’s an explosion you can hold in your hands.
  • They are a tool that enables me to defend the lives of my loved ones and my own.  It’s a seat belt for life!
  • They represent independence and self-reliance.
  • They are functional art.  Some firearms are beautiful to behold.
  • They go BANG!  They are loud.  Did I mention it’s an explosion you can hold in your hands?  What guy doesn’t like blowing shit up? 🙂
  • Science, bitches!  They are an effective and practical demonstration of Continue reading →

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Golden Proportion Template for Treatment Planning and Case Presentation

Posted on August 23, 2019 by The Dental Warrior

There are a number of ways you can use Golden Proportion to plan or present an anterior cosmetic case:

  • You could just print a photo of a retracted view of the anterior teeth and draw on it directly with a white “Sharpie” marker.  
  • You could purchase one of the apps out there (actually, I think they are an annual subscription). 
  • Or you could do this… Use a template and Photoshop (or similar photo editing software).  That’s what I did.

The reasons to do this might include:

  • Show a patient the degree of occlusal / incisal wear.
  • Show patients what is possible with restorative cosmetic dentistry.
  • To help you (the dentist) plan a case virtually.

I have found this simple demonstration very effective with patient case presentations.   Here are a couple of examples.  I’ll attach a “how to” video below.

Retracted anterior view.  There is significant anterior wear.

Here is the photo I printed to show the patient:

Golden Proportion template added.  This helped the patient visualize the amount of incisal wear and how it could be restored.

Another example: Continue reading →

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