Young dentists often tread a rocky road. It can take the first few years of your career to find your feet after dental school. And your mid-career years can be beset with stress as you strive – and sometimes fail – to achieve the faultless restorations you see achieved by dentists with decades more experience than you.
Dr Alice Whang knows what this is like. After 10 years in private practice, she says she’s finally comfortable and confident overcoming the multiple challenges of every-day dentistry. She is currently practising as a general dentist at Harris Dental Boutique in Bargara, Queensland. She also uses her experience to educate dentists around the world, and to mentor dental students at the University of Melbourne.
“Dentistry can be isolating because after graduating you’re suddenly in a small room treating patients and you make all the decisions,” she says. “You’re often faced with an anxious patient, you’re working for a business that needs to run smoothly and be profitable, and you’re still developing your skill sets.”
That’s certainly a recipe for some high-stress years. But Dr Whang says you can ease your journey with intentional and systematic approaches to the every-day dentistry. She shares her six tips and tricks for direct restorations.
Proper preparation is an important part of becoming a more efficient dentist – and that begins with getting the rubber dam right. Rubber dams are an effective way to isolate the tooth from moisture in the mouth, and to protect surrounding dentition. They also help to create a clearer picture of the restoration work that’s required. It’s a little like starting with a blank canvas.
“As a young dentist, a patient might come in with several cavities and you’ll have trouble working out where to start,” explains Dr Whang. “That can feel overwhelming and quite stressful.”
Dr Whang says having a clear vision of the restorations you want to achieve, then knowing the sequence of steps you need to take to achieve that helps to eliminate the stress – for the dentist and the patient. It also reduces the clinical time required and improves the treatment outcome.
“Of course, that comes with experience, and you can’t buy experience. But you can control the approach you take,” she adds. “It’s all about breaking the treatment up into an ordered sequence of chunks, then putting your full focus into each chunk before you move on to the next one.”
The rubber dam is your first chunk. Rubber dam placement can be broken down into smaller steps. The first step is getting the holes punched in the right spot. Dr Whang’s first tip is to use a 3D printed model of the patient’s teeth to mark the hole placement.
“Nobody looks like the standard models we use at dental school, so that printed model gives you a framework that helps you really see what you’re treating. You want to place the rubber dam over the printed model and mark the location and spacing of the holes. You’re essentially making your own template that’s customised to the patient.”
Getting the rubber dam holes in the right spot means there’s absolutely no moisture contamination, and the appointment will go smoother and faster.
When it comes to placing the rubber dam in the patient’s mouth, Dr Whang says it’s important to ensure all your movements are slow and intentional. Follow the same procedure each time and you’ll soon develop an agile touch.
“I use a lubricant on the underside of the rubber dam so I’m able to let it slide over the teeth without too much resistance. Then, pull the rubber dam over the frame so that the holes are over the teeth. This is so you can move onto flossing between the contacts immediately, rather than fiddling around. If you’re intentional and consistent with the movements you make each time, then you’ll develop the finesse that eventually leads to speed.”
The same goes for cutting the rubber dam. Dr Whang follows the same procedure with every treatment. She starts by cutting the top section of the rubber dam so the patient can breathe more easily. She then cuts the side corner to enable suction/saliva ejector. Many patients feel like they can’t breathe with the rubber dam in place. Attention to details like this adds to the whole patient experience.
“Developing efficiency and speed is all about consistency. Take an intentional approach and do the same movements each time and it will become automatic.”
Dr Whang says you should also pay close attention to tightening the rubber dam around the tooth to effectively protect the tooth from invading moisture and stop the rubber dam from inverting. She says allowing moisture into a restoration can compromise the bond strength and potentially cause staining and sensitivity.
“You can use floss or teflon ligatures – particularly if you’re working on multiple teeth. Ligatures help hold the rubber dam down, and also with moisture control.”
She adds that taking the time to get the rubber dam right will save you significant time through other stages of the treatment. “It might seem easier to go ahead without a rubber dam, but moisture and bleeding from the gum is actually going to make the procedure much more difficult.”
And getting the job done right the first time will be better for your patient, your employer and your stress levels: “There’s no point cutting corners, because the patient is going to come back and you’re going to have to do it again. Do the best you can in every procedure.”
Dr Whang says putting the time and effort into mastering teflon will also help with many procedures in every-day dentistry. .
“When you first start using teflon, it will drive you crazy,” she laughs. “But teflon is stronger and more robust than floss. I use it to isolate the tooth and prevent moisture from coming through to the tooth. At the same time, it’s protecting the surrounding teeth from acid etch and bonding materials.”
Dr Whang uses three thicknesses of teflon tape – thick, medium and thin – depending on the situation. The thick teflon is great for matrix stabilising, or to fill large gaps such as implant access holes. The medium or thick teflon is great with bonding procedures or as ligatures.
“When you’re using a lot of air and water, the teflon can move around, which can get quite frustrating and slow down the procedure because you are constantly repositioning the teflon,” Dr Whang explains. “Using a liquid resin to stabilise the teflon will solve that problem for you.”
It’s another case of investing a small amount of time in proper preparation to save considerable time – and stress – later in the treatment process.
A matrix system should be in your daily tool bag, but Dr Whang says using teflon to support the outer side of a matrix can help you achieve next-level restorations. First, she explains that it’s important to understand exactly what you’re trying to achieve with a filling.
“You’re not filling up a square box. Rather, you’re trying to recreate the natural contours of the tooth,” she says. “If you use teflon to support the outside of the matrix, it’s going to make sure the resin will go exactly where it needs to go without flowing over.
“If resin flows over the matrix and the adjacent tooth isn’t protected with teflon, you can get decay in the gap and it will feel super rough to the tongue. When you do this step well, there’s also less polishing to do, the clinical time is shorter, and you get a better outcome.”
When using a matrix, it’s also vital to take a well-thought out approach. Invest time and effort in getting this step right, and you’ll likely start to see a vast improvement in the quality of your restorations. Again, Dr Whang says it’s all about giving yourself the time and space to develop a clear vision of the result you want.
“Filling multiple holes can be stressful if you don’t take a step-by-step approach. First, remove everything that shouldn’t be there, including existing restorations, caries, oblique cracks and thin cusps. Then, look at where the defects are and decide on where the marginal ridges, cusps and contact points need to be.
“Teeth are not two straight boxes side-by-side – they are curved with a touching point. To get that right, take time to pick the curvature of the matrix that recreates the natural shape of the teeth. Different matrix systems will create different heights and degrees of convexity. It’s okay to mix and match different systems to achieve the desired outcome.
To master the every-day challenges of dentistry, Dr Whang says it’s also critical to understand tissue control. Again, moisture is the key enemy here and preventing it contacting the tooth you’re restoring is the name of the game.
“If you start drilling a subgingival lesion, you’re going to get blood everywhere and it will be impossible to bond,” she explains. “So I’ll use a thin retraction cord dipped in 25% aluminium chloride, then place teflon as a moisture stop. Then I’m able to clean out the cavity without any bleeding affecting what I’m doing. The filling can bond on a dry surface, so it’s stress free. It’s important to work quickly as the acidity of aluminium chloride can cause some tissue damage.”
Dr Whang says it’s all about using the teflon to make sure the gum is retracted and controlled. But to do so, the teflon must sit below the gum line.
“The teflon is going to control the moisture and the gum is going to retract away from the tooth, so when you’re doing the resin veneer, the teflon has to extend past the restorative margin. If the teflon is poorly packed, the veneer won’t bond, which then can stain and chip at the margin.”
Shaping composite restorations is where real artistry comes into dentistry. While it takes time for dentists to develop the aesthetic dentistry skills, Dr Whang says taking a systematic approach can certainly help you get there.
“The number-one thing I think about is the margin,” she explains. “I use a tapered diamond bur at a slow rpm to smooth the margins. Once all of the excess is gone from the margin – and only then – I think about the facial surfaces of the teeth. This is to ensure every step has been executed well before moving onto the next. If you think about too many things at once, it can be overwhelming. Next, I ask myself ‘how do I make the restorations actually look like teeth?”
Dr Whang says this step is all about getting the line angles right. She explains that there are generally three shapes that define the facial side of teeth – oval, square and triangular.
“For example, with the oval shape, the angle lines on the front face of the tooth curve in, and the lines at the base where the gum and tooth meet are further apart as compared to a triangular shape. So if you want to make that tooth look triangular, make the lines diverge and make the gum area closer together. Or if you want a square square shape, make the lines more parallel.”
Dr Whang says you can also play with the width of the tooth’s line angles to create an illusion of uniformity. She shares another trick of the trade: “When you put the angle lines further apart, the tooth appears wider. But if you put the angle lines closer together, the tooth appears narrower. That means if the patient’s teeth are slightly different widths, you can make them appear similar.”
Finally, you can use a number 12 scalpel blade to remove any excess between the filling and the tooth. But Dr Whang recommends using a wedge to separate the teeth slightly. This will help to prevent a gap developing between the two front teeth.
But, at the end of the day, Dr Whang says young dentists should try not to put too much pressure on themselves in the early days of their career. Rather, commit to an intentional, systematic approach, and the results will follow.
“Dentists are high achievers and we generally want to do a great job,” Dr Whang concludes. “Therefore, we put a lot of stress on ourselves. It comes from a place of wanting to do well. You’ve got to be patient and kind to yourself as you put in the hours to practice, and keep improving on the skills you already have.”
If you’d like to learn more about this topic, register for our free dental webinar and watch on-demand: 6 expert tips for direct restoration mastery.
Want to find out more about how Avant can help you master every-day dentistry? Please email [email protected] or phone 1800 287 336.