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Contemporary clinical dentistry - Dr. Abd El-Rahman Ahmed, Alexandria (2025)

02/08/2024

Hello 👋
"Do we still need crowns in 2024??"
Well.....let's just not say that crowns are totally terrible, they are just outdated i.e. when they were first introduced, they were the best option available. They're even way older than composites and bonding systems that we know..
So in this case, we had an upper centrL incisor That was endodontically treated, with missing mesial and distal walls.
The remaming was literally a l***a and lingual walls ther were not connected to each other.
--> so to "reconnect " these two walls, I applied long fibers (ribbond) in the pulp chamber (after IDS &RC, of course), making part of it touch the l***a and lingual walls from the inside
This helps to absorb stresses concentrated at the junction between the root and both walls , limiting the possibility of fractures at these sites.
Then I applied short fibers (everx posterior) on top of the ribbond to help prevent further cracking and give some strength, as well as acting as a dentin replacement.
After that I applied about 1mm of normal composite to protect the fibers we used.
And voilla!!! Now you (almost) have a tooth that can be restored as a normal, vital tooth, which was done for the proximal walls using simplified layering technique then finishing & polishing was done.
Note that the right central incisor was also endo treated, but the composite was never finished nor polished, which caused a lot of staining so I finished it and polished it.
A mistake that I did was that I over-did the secondary anatomy so it gave the teeth a wavy appearance😅😅😄
And that's it! Till we meet again, get bonded , stay bonded !!
CIAO!!

$Hello there!!Today's patient is my lovely dad😊🦷He has an abfraction lesion, accompanied by gingival recession, exposing ...$

25/06/2024

Hello there!!
Today's patient is my lovely dad😊🦷
He has an abfraction lesion, accompanied by gingival recession, exposing a part of the furcation of the upper right first molar
This caused him a lot of sensitivity, but thankfully, there was a lot of sclerotic dentin that (kind of )helped to reduce irritation.
But to restore such a lesion, we have to understand it first.....
Heavy occlusal forces cause deflection of the cusps, & microfracture of the hydroxy appetite Crystal's of enamel and dentin.
So we have to biomimetically restore the tooth structure as much as we can.
Another thing in this case is that it is very deep with a sharp angle, so it has a relatively high c factor , unlike normal class v lesions
So the first thing I did after isolation is to create a large bevel on the buccal surface, upto the junction of middle and occlusal thirds, then I placed a propylene glycol dye to analyze the condition of the remaining dentin (which thankfully , wasn't infected, but was pretty much sclerotic)
I then disinfected the cavity with 2% chlorhexidine, etched the enamel & bonded
Then normal IDS & resin coating was done & during decoupling with time I prepared the fibers:
1- due to the relatively high c factor & the very sclerotic dentin we have , I placed long fibers (ribbond) in the deepest part of the cavity , making it touch only a part of the walls.
2- then I placed short fiber composite ( everx posterior) in a thin layer in order to prevent any crack from getting into the remaining dentin.
After that I placed a composite with a modulus of elasticity similar to dentin ( sdr, here I wasn't afraid of the wear since there's no occlusion here) .
In this way, dentin is safely replaced.
The final step was to replace enamel using normal composite ( I used dentin and enamel shades)
Also notice that I made the restoration to resemble the furcation ( since it was already exposed)
And voilla !!

stay bonded!!

05/05/2024

Good morning!!
In the last case, I used heated composite for the cementation of this lithium disilicate overlay.
But does the light pass through LiDi so the composite cures?
Well....traditionally, we used to use dual cure resins to cement anything indirect, yet they have lower mechanical properties compared to light cured resins.
But recent evidence ( like this nice paper I mentioned ) proves that we can use light cured resin upto 7.5 mm thickness of lithium disilicate
So the question now is...why heated composite?
Why not just use flowable or veneer cement?
It comes to the high fillers of the packable composite that gives it better mechanical properties & way less shrinkage that we can't get with the other two.
Just be careful because some composites completely polymeriza when heated, so don't heat the full syringe..
Just heat a compule or heat a suitable piece of composite put on a metal well before heating.
Another point is that some composites return to room temperature very quickly, so be quick when applying pressure to seat the restoration & express as much excess as you can before it becomes firm again!
Another nice benefit of using heated composite is that if you have an open margin, you can close it while cementation by using a modeling brush to adapt the excess to close & seal that open margin.
That's it for now!
Till we meet again !!
Just make

05/05/2024

Hello there !🐿🦷
A case of molar rehabilitation:
The tooth number 4.6 was diagnosed with necrotic pulp with apical periodontitis.
Endo was done easily...except for narrow mesial canals & curved distal canal😂😂
After endo comes the tough restoration:
Immediate dentin sealing & resin coating using a highly filled flowable composite, then waiting for 5 minutes to allow decoupling with time.
Then deep margin elevation was done using saddle matrix ( couldn't take a shot of it due to limit accessibility.
Then long fibers ( ribbond) were placed in the floor while touching part of the buccal & lingual walls to " hold tight of those two walls" , since the tooth was badly destructed
Then short fibers (here I used everx posterior) were placed the replace dentin & prevent future cracks into the tooth
Then a layer of composite was placed to protect & isolate the biobase.
In the next visit, finishing & polishing of the biobase was done using composite discs & rubber cups & a polishing brush, then an impression was made for a lithium disilicate overlay ( I forgot to mention that I reduced the cusps as they were compromised)
In the final visit, isolation was done & the overlay was cemented using heated composite.
Wait for More discussion on this case in the coming days😊🦷
Till then, see you!🦷

24/04/2024

Hello there!!
We haven't met for a while😊🐿
Today we have a diastema closure case!
I put the caption on the photos, but I also have some tips:
1- I used a posterior sectional matrix , cut in half to get 2 dome- shaped parts 🛎
I put the cut half in the gingival sulcus , with the cut ( straight ) border facing the gingiva.
Then you put a small piece of composite and adapt in very well then cure.
This way, you have a step that not only prevents black triangles, but also gives you a more predictable midline
Then you repeat the same procedure with the other tooth.
2- I used the celluloid strip to build the proximal walls, not only the palatal shells.
It gives you a more rounded proximal wall with no sharp line angles as with the metal matrix ( this saves a lot of time for finishing)
3- I build the proximal wall in two steps, labio-lingually.
This way, you get a thinner proximal wall that gives you more space for the body to layer. You could also use multiple shades for the proximal wall. ( I used clear composite for the lingual part & a2 enamel for the l***al part of the proximal wall)
** but if you're going to use monoshade, you can easily build the proximal in 1 step , no need for the 2 steps.
& that's it for now... CIAO😊😊🐿👍

31/12/2023

Just a reminder to rub the acid etchant of enamel for 20 seconds.
Not only does it increase the shear bond strength, but it also gives you nice bubbles 🧼😊

16/12/2023

Hello there!
"How to deal with high c factor restorations?"
Before we start, I want to note that my university is old schooled & any type of fiber reinforcement is considered a taboo.
In this case, there was a slightly deep cavity, with not so much flaring.
My plan was to do an indirect restoration, but my supervisor didn't allow me to go indirect for no obvious reason 🤡
So I decided to isolate the composite in the dentin from that in enamel in order to minimize the chance of composite separating from dentin.
So what I did was placing the composite till the ADJ , or just below it , then placing glycerin gel & curing. The next step is air abrasion (I used pumice with prophy cups as a -not so good - substitute) in order to eliminate the oxygen inhibited layer. After that I etched & bonded again then placed the enamel composite (I used enamel and dentin shades, but you could build both layers with body shade).
In this way, each layer of restoration will be attracted to its substrate. In other words, the dentin composite will be attracted to dentin & enamel composite will be attracted to enamel, thus minimizing the chance of separation of composite from dentin

26/11/2023

Hello there!
" to endo or not to endo"
As usual, I am not satisfied with people "sticking" to old - schooled themes, just because they are " used to it & have some experience in it"
In this case, the main diagnosis was symptomatic irreversible pulpitis. Once I did the access cavity, there was a lot of bleeding, indicating that there was still " life" in this pulp.
I had to do an endodontic treatment for this premolar, yet I believed all it needed was a pulpotomy.
Some papers , like the systematic review I put here, reported up to 90% success in the 5 year follow up.
Despite my lack of experience in adult pulpotomy, I wished I did it instead of the conventional RCT, just to keep some of this tooth's life :(
Ciao!

10/11/2023

Hello!👋😊
"Activation of irrigation"
From the papers that I've read so far, I believe that passive ultrasonic irrigation (PUI) remains the gold standard for activation of irrigation.
But what if you can't afford an ultrasonic activator or even an air scaler?
My go to option (which I have used) is the xp endo finisher from fkg .
With this file, you can get an acceptable amount of smear layer removal ( not as efficient as the ultrasonic activation though), which is better than just shaking your needle inside the canal
My protocol was as follows:
Naocl
Saline
Edta
Saline
Naocl
Saline
Edta
Saline
Naocl
Saline
Please note that this case was diagnosed with irreversible pulpitis (I wish I were able to do a pulpotomy instead, yet I don't have enough knowledge).
In cases with an abscess , necrosis or rttt, one must do a more intense irrigation protocol .
Ciao!👋

08/11/2023

Hello!👋
So you've decided to bond your crown....
There are a few things to put in mind:
1- the location of your finish line, if you have an equi-gingival or a subgingival finish line(like in this case), you have to place a retraction cord in the sulcus prior to the punching of rubber dam, then remove it just before the placement of the rubber dam.
2- the clamp: for premolars and anteriors, I believe that the gold standard clamp is the 44 by ksk or b4 by hygenic or tor vm, you need a retraction clamp ,not a retentive one
And such a small clamp will be perfect
For molars, there are more options, including the w2a, b1 or even the w8a, though I prefer the w2a.
3- the rubber dam itself: you need the smallest punch hole for the premolars and anteriors, and the second smallest hole for molars.
4- the seating of the crown: you have to check the seating of the crown after you place the rubber dam and the retracting clamp and make sure it's margins are well adapted
5- for zirconia (like in this case):
The gold standard for surface cleaning is the air abrasion, yet if you don't have it (like me) ,you can order the lab to sand blast it then put a zirconia cleaner e.g. zirclean by bisco usa or ivoclean by ivoclar vivadent in the intaglio surface for 30-60 seconds, it acts by neutralizing the phosphate ions in the intaglio, gained from the saliva.
Then you apply a primer, containing 10-MDP on the intaglio surface then leave for 30 seconds then air thin
For the tooth surface, you apply your adhesive without curing, then you apply the resin cement into the intaglio then place it onto the tooth.

03/11/2023

Hello !👋
Dental photography is not only for showing off your work, one must also learn from it.
In this case, I was stressed out and didn't really realize I haven't removed those flashes till I came home and looked at my photos.
It can be a bit frustrating to have your day ruined by such a small detail, yet always remember, no pain , no gain
Ciao!👋😊

29/10/2023

"CROWNS"
It has become common nowadays between us dentists to debate whether endo treated teeth need a full coverage crown .......
In my humble opinion, one must be very conservative & only reduce when necessary.
What does that mean ?!
In such case as shown ( which was done by me), the premolar only had distal caries, & an overlay was more than enough
It's not only about pericervical dentin (even a verti prep would be considered too much) but the fact that a more than enough biorim was present upsets me😢
Although I liked how the crown ended, it is very unsatisfying to see oneself reduce an almost sound tooth because as a student, not all types of restorations are allowed 💔
Ciao!

Contemporary clinical dentistry - Dr. Abd El-Rahman Ahmed

02/08/2024

25/06/2024

05/05/2024

05/05/2024

24/04/2024

31/12/2023

16/12/2023

26/11/2023

10/11/2023

08/11/2023

03/11/2023

29/10/2023

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