All posts by Dr Chris Ho

About Dr Chris Ho

Dr Christopher Ho is a dentist practicing exclusively in Aesthetic Dentistry, Prosthodontics and Implant Dentistry in Sydney Australia. He is the Founder and Principal of Care Implant Dentistry and has completed his Bachelors of Dental Surgery with First Class Honours, a Graduate Diploma in Clinical Dentistry (Implant Dentistry) from the University of Sydney, and also a Masters of Clinical Dentistry (Prosthodontics) with Distinction from Kings College London. He has over twenty years of experience in complex aesthetic and implant rehabilitations, and is committed to excellence providing you not just teeth but a beautiful smile in a friendly and caring manner. Dr Chris Ho has lectured nationally and internationally and held faculty positions with the University of Sydney, the Global Institute for Dental Education, Academy of Dental Excellence and is a Senior Visiting Teaching Fellow at Kings College London. He is the current Oral B (Proctor and Gamble) Media Spokesperson in Australia. He has published in dental journals and textbooks. He is currently Senior Contributing Editor for the Australasian Dental Practice and on the Advisory Board of Dental Asia. He has also worked as a consultant and key opinion leader for several leading dental manufacturers. He is in referral based practice in implants, aesthetic dentistry and complex oral rehabilitations. Google

Full Arch Rubber Dam for Restorative Procedures

By Dr. Christopher C.K. Ho

The application of rubber dam is recommended to achieve adequate isolation for many dental procedures, helping to provide a clean, dry environment and minimises contamination from saliva and blood.

It also plays a crucial role in preventing ingestion or aspiration of instruments, tooth debris, dental materials, medicaments, irrigants or other foreign bodies. As well as the provision of isolation and moisture control, there is the added benefit of retraction of lips, cheeks and tongue. This allows improved access, visualisation and protection of soft tissues from rotary instrumentation.  The use of coloured rubber dam helps to achieve better visualisation of the teeth with a contrasting colour of the rubber dam material.

It is often commented that placement of the rubber dam is a difficult procedure and that the time it takes to apply the dam is excessive. The other concern for dentists is that it can uncomfortable for the patient while the dam is being placed due to the stretching required to seat the dam.

The author utilises a technique that has been very useful in his practice in isolating a full arch very quickly, and comfortably for the patient. This is particularly useful when working on multiple teeth with direct procedures like the removal of amalgam and caries, and placement of restorations. It can also be effectively used in the preparation and cementation of indirect restorations, e.g. porcelain veneers/onlays/crowns.

This technique is a useful one to have in your armamentarium for utilisation within clinical practice.

Upper Arch

Figure 1: Upper arch

Rubber Dam

Figure 2: Rubber Dam: use of Flexidam (Roeko) This rubber dam is non-latex and consists of a very flexible material that is able to withstand stretching and has high tear resistance. Holes are punched in the 12 and 22 positions.

slit technique

Figure 3: A slit technique is used to join the holes punched so that they are joined.

Rubber Dam Clamps

Figure 4: Rubber dam clamps are placed on the molars and depending on the isolation required, clamps can be placed anywhere from 2nd premolar to the 2nd molar.

Rubber dam

Figure 5: Rubber dam is stretched over the clamps and then the front part of the dam is carefully directed under the labial sulcus, which effectively isolates the teeth.

 

Rubber dam

Figure 6: Rubber dam in place

putty bite

Figure 7: A quick setting putty/bite registration material is then used to seal the palate.

 

Rubber dam

Figure 8: Rubber dam in place (occlusal view)

Rubber dam

Figure 9: Rubber dam in place (frontal view)

 

Ceramic restorations on Discoloured stumps around the gingival tissues

A tooth can discolour for a lot of reasons. If you ask a Sydney dentist about this, you will be advised that teeth could discolour due to age, food, beverage, medications, trauma, dental caries or exposure to highly staining compounds.

A tooth fitted with a porcelain fused to metal crown may stain after prolonged exposure to the metal. This results in an unsightly discoloured stump that often reflects and affects the gum tissue. Teeth with discoloured stumps are very unattractive. It gives the patient a smile that looks dirty, old and diseased, especially since the stained appearance reflects on the soft tissue or gums too.

It is a frustrating problem because even if you place the margins at a subgingival level, the problem still remains. When we encounter a problem like this in the clinic, we suggest a few things to the patient:

1. Internal bleaching. An initial remedy for the discoloured stump that has spread to the gingival tissues is to perform an internal bleaching procedure. This is most appropriate for root canal treated teeth, with effectiveness that is quite unreliable.

2. Opaque restoration. A more definite solution that we provide involves masking or covering the discoloured stump with an opaque restorative material or composite resin. Using Kolor +- Kerr Dental we overlay the darkened area to mask the unappealing area so that it does not reflect on the crowns and on the gum tissues.

This kind of remedy is applicable for root canal treated teeth, teeth receiving dental crowns, bridges and veneers. It may be performed on porcelain-fused-to-metal crowns, all-porcelain crowns or even zirconium crowns. The result you receive is a natural-looking teeth restoration, the appears good as new. The teeth will appear beautiful, healthy and clean.

Discoloured stumpsDiscoloured stumpsCeramic restorationsCeramic restorations

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Sonic activated composite in a full arch build-up for extensive tooth wear

Extensive multi-surface tooth wear is common in several people and your Sydney dentist will explain how it may easily be caused by a different things:

  • Chemical erosion. When there is acid regurgitation or the presence of a naturally acidic oral environment, the teeth may be severely worn away so that the bite collapses as teeth height is reduced on the maxillary and mandibular jaw.

  • Bruxism. Night grinding or bruxism is a paroxysmal habit observed during night slumber, but may also be experienced in the day. It is an involuntary problem that involves the over-clenching of the teeth that often leads to wear facets and damage.

  • Malocclusion. When the patient’s bite is wrong or is misaligned, this disharmony can cause damage to the teeth. This is common with people with cross-bite, deep bite and edge-to-edge bite. The upper and the lower teeth contact each other, in damaging fashion so that teeth become excessively worn away.

  • Ideally, this issue is resolved by installing dental crowns and bridges on all the teeth to restore the bite and the appearance of the teeth. This would be acceptable when not much damage has been incurred but when very little tooth surface is left to work with, retention for the prosthetics is highly compromised.

    Dr. Chris Ho follows a different approach and it is explained in detail in the attached post. In lieu of invasive and expensive crowns, composite resin is provided to restore the worn teeth. Utilizing a template, a specialized bonding adhesive and reinforced composite resin, the patient is given a better reason to smile.

    Advantages of getting a sonic-activated composite full-arch build-up:

3M True Definition Scanner – the way of the future with Digital impressions

smallest camera with 3D technology

3M True Definition Scanner

The CAD CAM technology has brought amazing contributions to various industries and in Dentistry, Computer Aided Design, Computer Aided Manufacturing is offered in the form of CEREC, (Chairside Economical Restoration of Esthetic Ceramics). Through the CAD CAM, digital technology is conveniently and practically utilized to provide patients with a better treatment option. Removing the laboratory technician from the picture, ceramic restorations (be it crowns, veneers or fillings) are fabricated by the Sydney dentist using a machine and are delivered to the patient, on the same day.

CAD CAM CEREC is definitely impressive. Those who are able to afford it can enjoy its amazing features, but it really still remains to be costly—enter 3M True Definition Scanner, 3M’s answer to the expensive digital diagnostic technology. Especially with the developments with this technology, coming in the following years, you can expect so much more from it.

  1. Precision. Digital technology allows perfect recording of detail that no other impression material can exactly manufacture. A lot of discrepancy occur with the use of rubber impression materials—and a lot of things are at play here. The digital picture produces accurate models that will aid in the success of the overall treatment process.
  2. Ease. On the side of the patient, going digital will mean no mess and hassle-free cast fabrications. Dental impressions can be quite uncomfortable. The trays are forced into the mouth along with the rubbery material and it often brings the patient to gag. Digital imaging removes the need for this. Records and models are created easily.
  3. Collaboration. With the technology, users enjoy a cloud-based system of collaboration between the dentist, laboratory and others. This makes diagnosis and fabrication so much easier.
  4. Today there are already several machines available, but the 3M True Definition Scanner is the one that has the smallest camera with 3D video capability. Through this technology, dentists are able to capture and simultaneously view a true replica of the oral anatomy.

    There remains some discrepancy with the workflow, however, but I remain hopeful that things will be resolved eventually. Today, it still takes a few days for actual models to be fabricated, which poses the inquiry of whether or not such models are actually necessary. “Do we really need models?” – if the machine is so accurate we may be able to be “model-less” for the simple cases. Let’s see what the future holds, but it certainly is exciting to see this in the flesh.

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Implant rehabilitation in the edentulous jaw: the “All-on-4” immediate function concept

When a patient loses all of their teeth, they are essentially relegated to living the life of a “dental cripple” and are compelled to see a Sydney dentist to find resolution. The teeth are very essential to any human being and when a tooth or all teeth are lost, chewing efficiency is lost, their level of comfort declines and often they appear to age prematurely. The teeth provide more than a bright smile on someone’s face. A complete set of dentition maintains the bite and keeps all the structures in harmony. When changes occur after teeth are lost, patients begin to seek the dentist.

Edentulism can be a result of poor oral hygiene and dental disease. Sometimes patients who have received previous restorations meet a failure in their cases and their teeth are deemed restorable and hopeless. A growing number of the population possess a terminal dentition and the ability to retreat is restricted due to the poor remaining tooth structure and support, combined with limitations from the financial burden of full mouth reconstruction. How and why a person is edentulous varies. When patients come into the clinic, their oral condition is assessed and the appropriate solution is planned and presented—all encompassing the health and financial capacity of the patient.

It is well recognized that an edentulous condition has a negative impact on your life:

  • You need your teeth to eat because otherwise you will be limited to a soft, unappealing diet.
  • You need your teeth to smile, to flash a confident set of pearly whites to people.
  • You need your teeth to maintain the integrity of your facial structure, otherwise your bite will collapse and along with it, the face will sag and make you look much older.
  • You need your teeth to maintain the health of the jaw. The temporomandibular joints (TMJ) rely on the teeth. When the bite collapses, the changes that occur can be very damaging to the joints.
  • “All-on-4” implants have become a leading choice in many teeth replacement cases. The text below explains it further and discusses the benefits you can enjoy.


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Kerr Demi Ultra

curing light

Every Sydney dentist makes use of a curing light. Composite restorations and resin cements are cured or are set using a light. A flowable or mouldable material utilised for restorative and luting purposes are hardened using a light that is gun or pen type and may be with or without a cord.

In the dental office, we make use of new equipment. Kerr have come out with a new curing light that utilises a very different technology in the battery. I was involved with the product evaluation that was ran about 2 years ago at Kerr HQ in the USA, and we were blown away with the new technology.

You are probably familiar with traditional curing lights. Cordless lights come with a battery console, where the battery may be charged and it takes a few minutes for the system to go from empty to fully-charged, so dental practitioners have become accustomed to pre-charging the batteries before use, even keeping a spare equipment as backup. The Kerr curing light is truly amazing. It makes use of the ultracapacitor technology to re-energize the battery to full power in under 40 seconds—this means that the waiting time is cut down significantly. Although ultra capacitors are similar in size and shape to traditional batteries, they work much differently—re-energizing in a matter of seconds, and maintaining their energy capacity year after year. The unit also has a built in radiometer to ensure appropriate power output. You have an efficient equipment that is powerful and definitely reliable.

The only downside is that the current tips that are used on the previous Demi lights cannot be used on this one, so for those of you that have multiple tips stored, be mindful that they will be deemed useless for the new Kerr curing light.

In practical terms, the U-40 Ultracapacitor-powered Kerr Demi Ultra is never more than 40 seconds away from being able to deliver 25 ten-second cures. See more at: http://www.kerrdental.com/kerrdental-curinglight-demi-ultra#sthash.Ke226rAx.dpuf.

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Class II: Wedge doesn’t do anything!

Dental caries or defects on the teeth may occur on different areas. Pit and fissure caries affect the occlusal table and decay of this nature is limited to just one surface, but when caries extend to the proximal areas, a different approach is required. When the sides are involved, a barrier or matrix band is utilised to keep saliva and blood away from the area and properly restore the proximal and contact points. Ideally, a matrix barrier should be enough. It is inserted in between the teeth, is held in place with the help of wedge and the restoration is given to the tooth without any problem.

Unfortunately, sometimes you will come across those frustrating cases when you stick a wedge into a matrix and the bloody gum still bleeds as you work. This can be quite frustrating because it makes it hopeless to restore the tooth. The blood and saliva will disrupt your work, so you will take longer. Either that or the restorative work you complete will be poor.

One way of adapting the matrix more intimately is the use of another wedge (two wedges) or another neat trick is to use Teflon tape (aka plumbers tape) to adapt the matrix to ensure a clean field to place your composite. Using a Teflon tape is unusual but it offers a few benefits:

  • Teflon tape will isolate the and provide visual enhancement for results achieved. With its help, the dentist is able to shape the composite up to the proximal third of the crown.
  • The Teflon tape is very flexible and thin. It is kind of the tissues and it inserts easily through the area between the gum and tooth. It provides better barrier and protection to the tooth and gums.
  • This offers proper manipulation of the composite material, so that you can avoid creating dark triangles in between the anterior teeth you are trying to restore.

  • WedgeWedge

    wedge

     

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What is Biomimetic Dentistry?

The days of invasive dentistry that involves having to remove vital parts of teeth or cut down teeth for crowns are drawing to a close with the latest in Biomimetic technology. Biomimetic Dentistry allows a Sydney dentist to conserve teeth by treating weakened teeth that may be fractured or decayed and protecting them from bacterial invasion by sealing them with an adhesive restoration.

Better than traditional methods, Biomimetic Dentistry does not require a dentist to destroy healthy tooth structure in order to build a new restoration. Using the latest in technology, we can bond and adhere teeth together and build missing components of teeth without destroying vital tissue. Modern Dentistry believes in conservativeness of treatments and so nowadays we seek to undertake as little prep or even no prep when it comes to applying veneers or offer onlay, partial crown Biomimetic solutions in preference to a traditional crown thus conserving teeth. This means that restorative treatments are achieved without compromising health.


Indirect Restorations


The advances in adhesives and bonding materials have improved dramatically over the last 40 years, in so much that dentists can restore many cases that would have required crowns with minimally invasive conservative restorations. Although relatively successful and producing increased likelihood for success, understand that carrying out conventional crowns can lead to non-vitality of teeth due to the aggressive preparation required. By utilising the philosophy behind Biomimetics, the preparation needed is often reduced, thus minimising the biological impact to the tooth. Additionally, when this route is opted, many times the preparations can be kept at a supragingival level, leading to the preservation of healthier tissues that allow easier impressions and simpler adhesion procedures.

The Biomimetic technology involves the use of innovative materials. These new materials mimic tooth dentin so well that it even fuses to the existing tooth, offering reliable stabilisation and strength to the restoration. Biomimetic means to copy or mimic nature. For any restorative or cosmetic job done, a patient should appreciate any effort to get their smiles back in the healthiest and most aesthetically appealing manner.

Bio MimeticImage Courtesy of  https://biomimeticdentistryce.com/what-is-biomimetic-dentistry/

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The centripital layered build-up of a posterior direct composite resin

No matter how brilliant the Sydney dentist is, did you know that all composite restorations face as much as 5% polymerized shrinkage?

This phenomenon lead to:

  • Internal debonding and the inevitable dislodgement of the restoration.
  • Marginal openings that causes leaks and re-infection or recurrence.
  • Cuspal flexure and microfractures which causes consequent permanent deformation due to the load subjected by the restorative material.
  • Postoperative sensitivity that may be the result of tissue exposure due to microleakage.
  • Marginal staining, also caused by microleakage.
  • In the clinic, I make use of nanofilled composites to remedy these noted discrepancies with hybrid composites. Nanofilled restorative materials have particles that are as minute as 0.02 microns. With this, restorations are more successful, with recorded shrinkage as low as 1.6%. More so, it allows the dentist to create better restorations.

    The article below does not only count the number of benefits one can enjoy with nanofilled composites. It also discusses the importance of proper manipulation and layering. This technique involves the incremental addition of restorative material into a cavity. Instead of packing a bulk of composite into the tooth, the filling is brought in, little by little, in a technique called “layering”. With the use of a nanofilled composite, you already improve success rates; when you perform the layering technique, you increase polymerization depths, improve aesthetic results and decrease polymerization stress.

    This follows a precise process:

    Step 1: Shade selection. To ensure aesthetic satisfaction, proper shade is selected.

    Step 2: Rubber dam placement. Proper isolation of tooth is performed to improve results.

    Step 3: Preparation. Tooth is drilled to remove diseased tissue and to prepare it to receive the filling material.

    Step 4: Etching. Application of the etchant prepares the tooth to receive the bonding material. Successful etching improves success.

    Step 5: Internal Adaptation. Making use of flowable composite that better penetrates the tissues.

    Step 6: Incremental Layering. Composite resin is added in small amounts.

    Step 7: Building the Proximal Contact. If the restoration involves the proximal areas, the proximal contacts should be restored harmoniously.

    Step 8: Building the Artificial Dentin. Dentin composite is placed in the right shade.

    Step 9: Building enamel layer. Enamel composite is then provided in the right shade.

    Step 10: Occlusal staining. Whether you like it or not, it is done to satisfy aesthetic appeal.

    Step 11: Finishing and Polishing. The tooth is moulded and polished to mimic the appearance of the natural tooth.

    Step 12: Rebonding. For an even more impressive finish, additional shine is provided.

    This process is explained in much detail in the paper attached on this post.


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USEFUL APPS FOR DENTISTS AND PATIENTS

The world as we knew it has changed. We are in the digital age and to better survive, one has to fully integrate the changes into their lives. The same could be said with dentists. These days, we have multiple technologies in our grasp, and one of the easiest for patients to understand is using a tablet like an iPad. Being able to demonstrate images on a tablet is just so much more high tech for a patient. This sets you apart from another Sydney dentist and helps educate your patients in a more effective manner.

Here are just some apps for dentists and patients:

DDS GP

DDS GP

DDS GP is an app for dental professionals that allow them to show dental conditions and treatments to their patients using an iPad. It is probably the most comprehensive of all the applications that I have seen.

  • You can TAP and DRAG items on the screen, to easily show severity of decay, periodontal disease, cracks, and numerous other conditions and procedures.
  • You can DRAW right on the screen with your finger and you can save your drawings for future use.
  • You can also ADD your own images or photos from your photo library, then draw on and save them.
  • Finally, you are allowed to SEND or PRINT custom treatment plans to your patients using this app.
  • Check here for details & download
  • Dental Navigator

    DENTAL NAVIGATOR

    Dental Navigator is an interactive application, which can be used by dentists to explain different methods of treatment to patients. If you have the new Apple iPad, you can use an HDMI adapter to project the whole application onto a large screen for better viewing.

    Check here for details & download.

    Dental Expert

    DENTAL EXPERT

    This application is an excellent app for patients as it explains the different treatments available in dentistry, and the best thing is it is FREE! Check here for details & download.

    Pediatric Dental Expert

    PEDIATRIC DENTAL EXPERT

    This application is a food guide that parents could use to be able to understand the proper dental care that their children need. It is FREE and it is easy to use, so you can download it today. Check here for details & download.

    Dentistry ProConsult

    Dentistry ProConsult

    Dentistry ProConsult is designed to provide dental students with a quick and easy way to review procedures they may have to perform in clinic. It is Free!

    Check here for details & download.