Dental radiographic examination frequently depicts radiolucencies approximating root surfaces. Apical radiolucencies in particular tend to cast suspicion on pulpal health and are often associated with endodontically involved teeth...
By Design... Culture & Surgical Flaps Intentional Practice Culture & Effective Flap Design
“May the odds be ever in your favor” – Ruddle opens the show by giving us some perspective by examining the odds of various occurrences. Next, Ruddle and Lisette discuss the importance of intentionally defining a culture in your practice, as highlighted in the March 2021 issue of Dentaltown, and they subsequently discuss how to accomplish this. Then, Ruddle is back at the board for Surgery 101, this segment focusing on flap design. Stay tuned for the close of the show for another revealing Show & Tell.
Show Content & Timecodes00:09 - INTRO: What Are the Odds? 06:21 - SEGMENT 1: Practice Culture 24:15 - SEGMENT 2: Surgery 101 - Flap Design 47:07 - CLOSE: Show & Tell
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: What Are the Odds?
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. What are the odds that you’re in a good mood today?
Approaching 100 percent.
Great! So, we wanted to start our show off today talking about the odds, because apparently, according to a 2016 study by the University of Toronto, humans are not that skilled at understanding probability. And so, this explains why millions of Americans buy lottery tickets every year, even though they have a better chance of dying in a plane crash or being struck by lightning. So, why is this the case?
I think it’s called “optimism bias.” They have this deep belief that they will be the that wins.
But they also know, intellectually, that the odds aren’t in their favor, but they have great optimism that, if they did gamble or make a bet, they would be winning. Yeah.
Well, you’ve actually won in Las Vegas on a slot machine. So, you must have had a lot of optimism bias.
For me, it’s approaching 100 percent, again.
So, we found a list about the odds of 51 random events happening to you. And we wanted to go over this list. Not everything on the list, but we were gonna point out a – we’re gonna take turns pointing out a few of our favorites. So, I’ll start. Apparently, the odds of getting struck by lightning are higher than you think.
And it’s one of the leading causes of weather-related human death, according to National Geographic. Every year, I guess, your chances of being struck by lightning are 1 in 700,000. But over your entire life, it actually goes up to 1 in 3,000. And then, if you walk around wearing a metal hat, of course, the odds go up even higher.
Yeah. And get off the greens, during the golf storm, the lightning strikes. Don’t hold your club up.
Hold or – yeah. Or hold your golf club in the air, during the rain [laughs].
Well, I like the one about flying, because I have said several times on this show that, at the end of 2019, just because COVID, Phyllis and I had flown 5 million lecture-related miles. So, I wanted to know what the odds were of dying in a plane crash. And apparently, it’s about 1 in 60 million. So, I was pretty reassured about that. What was surprising, that you and I had to both repeat and do a little bit more investigation, is the National Transportation Safety Board, NTSB, they said that if you’re in a crash, you have about a 95 percent chance to survive. And I thought, ‘How could that be?’ But anyway --
Yeah. That seems --
-- I would say, park your car, because I noticed a little later that your chances of getting killed in a car accident are about 1 in 107. So, park the car, and get into the plane, and begin to fly.
And not 107,000, but 1 in 107!
Like, that’s pretty high of not just having a car accident, but dying in a car accident.
I normally ride in the back seat. I’m now going to the trunk.
[laughs] So, I mentioned the lottery a moment ago. And apparently, winning the 1 billion Mega-Millions Jackpot, in 2018, the odds of that happening was1 in 88 quadrillion.
Like, I don’t really even comprehend that number. And the chances of winning the 345 million Power Ball, that’s 1 in 292 million.
So, you have a better chance of dying in a plane crash, clearly. [laughs]
Well, I like sports. So, you know, I wanted to know, what are the odds if you go to a baseball game, like, professional baseball here in the United States, as an example, and for my Japanese friends, we are going to see Shohei Ohtani. Is it Ohtani? Yeah. Ohtani.
The prolific – these great – okay. You have 1 chance in 835 to catch a foul ball. And I was immediately struck by that number, because, apparently, when my grandson went to the ballgame, the odds can – he said, “What are the odds of being hit in the face?” For him, it was 100 percent.
His first ball game, and a ball found him, in a vast stadium that seats about 60,000 people, and it hit him right in the mouth.
Gosh. It did bounce first. But that, I mean [laughs], he had to go to the dentist, of course. [laughs]
You know, if you’re a big basketball junkie fan, and you like to watch the National Collegiate Athletic Association, NCAA, they have, like, a tournament. It’s called “March Madness”. And the chances of picking the bracket, you know, about 60-some teams – 64, it used to be. It’s – they’ve – they’re not playing any games now, but it’s about 1 chance to win the bracket in 9.2 quintillion.
And I thought, I don’t even have an appreciation for – I – when we get to over a million or a billion, I’m starting to grasp. So, I looked it up, and that, ladies and gentlemen, is a 1 followed by 18 zeroes.
Wow! Well, it’s a fun list, and we’ll have it in our show notes, if you wanna take a look for yourself. Are there any other ones you wanna quickly point out that you liked?
Well, this one is a Yogi Berra-ism, if you understand that. But, you know, Yogi Berra said, “When you get to the Y in the road, take it.” That would be an example.
Well, you know, they say that endodontics, properly performed, about 90-some percent of all endodontics works. And I was thinking, well, how come, for 15 years of my practice, over 91 percent of my practice was retreating all those successful cases? [laughs]
[laughs] Okay. Well, I think the chances are pretty good that we are going to give you a good show today, if we try hard and really focus. So --
Imagine the odds!
-- that’s what we’re gonna do. And so, let’s get going.
SEGMENT 1: Practice Culture
So, today, we wanted to discuss practice culture and invite you to take a serious look at the culture you have created in your dental office and assess if it is the culture you want to have. To put it in simple words, the culture of your practice revolves around the morals, outlook, goals, values, attitudes and customs that are shared by the people you work with. And we got interested in culture when we read a March 2021 DentalTown article between – it was a – it was the highlights of a Podcast conversation between Dr. Howard Farran and Jay Geier, who’s the CEO of Scheduling Institute, and it talks about the importance of defining culture in your dental practice. So, it’s interesting – I noticed how Jay Geier defined culture.
Yeah. He basically said that it’s how people in your organization see you [laughs].
That can be scary, right? So, that was what he said. But he went on to say that most offices, regrettably, operate off of a default culture. That means, everybody just shows up and, “You know, we’re doin’ a MO amalgam today. So, that’s what it’s about.” But you need to have a culture of intentionality, one that is not just by happenstance. So, the things that offices should be working towards would be a culture where there’s efficiency and technological excellence. It should be patient centered. And of course, the culture should allow us to have growth, so we can continue to contribute to our staffs and grow people around us.
Yeah. I think that’s what they’re saying is a good place to start, with patient focused, high performance, and growth potential. But to take it even further, when designing a culture, you also want to consider what your employees want from their jobs. And they – there was a study and – that Geier points out. I’m not sure what the study is. But they asked the most talented people what they most – the three things they most were looking for in a job. And what were those three things?
Well, I have to say, the first one was, they want a better boss. [laughs]
In other words, what that means to me is, people wanna be proud of who they’re working with and for. And I never told people they were working for me, that we were working together as a team, just like a sport. I played a lot of sports. You don’t say the center is more important than the guard. So, they wanna be really proud of where they’re working. They want a chance to grow and be acknowledged. And then, they wanna be some – a part of something that’s bigger than themselves.
And that’s kind of a – an aspirational, societal thing, where you wanna show up and know you’re making sick people well, and you’re part of that whole operation. When you’re at Vons, and you’re shopping, “Oh, hi, Mildred!” You know, people – you know, it’s pretty cool.
Yeah. I – I think I am pretty lucky, because I have a pretty good boss. So [laughs] --
-- I don’t have to worry about that. But then, Geier also identified a very important factor that you absolutely [with emphasis] have to have, for your culture to be successful. And it should be the foundation of your culture. So, what is this --
-- very important word?
I’ll give everyone a hint. It starts with a T. [Dr. Ruddle writing on whiteboard] [6 second pause] [laughs] Maybe show your camera, too. [laughs] Show all of the cameras. [laughs]
[laughs] Trust! You know, trust is how you get things done. Trust is like the petrol you put in the car that fuels the engine. Trust is what moves you towards excellence. Trust is what allows you to begin to implement new ideas and technologies. And one simple, little example on trust is – I’ve told this story before, on these shows. But I got my first microscope in more or less the mid-‘80s. There were no textbooks. There was no articles. There was – there was one article. There was one article. But there was nobody on the West Coast doing this. There was nobody in the nation doing it, except for a handful, maybe five people.
So, I got my microscope and never used it, because I – I was awkward, and I was clumsy. The trust was when Phyllis told the staff to help Cliff execute the vision. And all of a sudden, I had all these people around me that wanted to help me. It made it a lot easier to overcome fear.
And it’s good that you give this example, because they talked about this in the article, that apparently, it’s very common for clinicians to go out to a seminar, get exposed to new technology, acquire that technology, and bring it back to the office, and then, just never even take it out and never even try to implement it. And this – and the staff goes, “Oh, yeah. He’s never gonna do that. That’s just the same-old, same-old.” So, you kinda wanna have everybody onboard that you’re going towards this vision.
I like what you said. I have – we had hundreds and hundreds of people come through Santa Barbara seminars, and so many times, they would tell me about another course they took and how they went back, and they were all excited, and they told the staff what they were gonna be doing, and within a week, it was finished, and it never got acted on. So, trust is a big deal.
Okay. So, then, also, Dr. Farran went on to ask Jay Geier, like, how – what you should prioritize, when you’re trying to improve your culture in your office. Should you focus on marketing? Should you focus on technology? And the answer is, you should focus on your workforce. You want to hire friendly, motivated, openminded people who are talented and coachable.
You know, I was taught many, many years ago, “Hire to your greatest weakness.” You know, some doctors are very, very smart, and they’re introverted, and they’re very quiet. Well, then, that would mean, on this show, hire somebody who’s – what do you call it? Ebullient?
Mm, I’m not sure what the word is to use.
They’re outgoing, they’re smiling, they’re – they talk to people, they make connections.
So, yeah. They – you might wanna get somebody that’s really good with photography or IT or maybe somebody says, “I do OSHA.” Or “I’m really good at administering vaccines in the office. I got everybody three or four times, by now.”
And your staff might already have a lot of these hidden talents, already, that you just haven’t tapped into, because maybe you haven’t developed enough of a relationship [laughing] with them yet. So, that is – so – okay. Let’s move on. Let’s say that you’re hearing what we’re saying, and you’re thinking this all sounds great, but it sounds a little too abstract, like you’re wondering, maybe, what are some concrete, specific things you can do --
-- to improve your dental culture. So, we found another article by a registered dental hygienist, Dr. – or not Dr., Valerie McClure. And she identifies ten ways to build your practice culture.
And here’s the list. Let – and we’re gonna go over it in a second. I thought that it was interesting how Valerie McClure defined culture. She said, “It is the character and personality of your organization and that which makes it unique.” So, in other words, you’re not just looking to copy another culture. You’re actually wanting to intentionally create something that’s special. So, here’s the list. And I’ll read them, and then, you can comment on them or give an example or even pass it back to me, if you don’t want to say anything.
Okay. Very good.
So, the first one, “Show genuine concern and interest for coworkers and patients.”
That reminds me of, ‘People don’t care how much you know, until they know how much you care.’
Okay. I think the important thing here is, listen and try to show some empathy, or not try but actually, genuine – show genuine empathy. Show genuine excitement when they’re excited about something. So, it’s just a way to make a connection, and that kinda brings us to our next one, “Build relationships.”
Well, how I think you can build relationships, I mean, in the office, we’re all doing our tasks and our duties, and of course, there’s a lot of good chemistry. Like when you’re playing a game, during the game, you don’t have to have a postgame talk to feel how it’s going, during the game. But if you can do things outside the lines, outside the office, like a picnic or maybe you go to a theatrical, or you go to Las Vegas and take them to a show. Small things, picnics, potlucks, people bring food in together, eat, be community, eat some food, have a little drink. I mean, these are all things that build bonds and relationships.
And if you’re just having lunch together, maybe in the lunchroom, then, maybe have a conversation instead of looking at your phone all the time.
Kill the phone [laughs].
Kill the phone. It’s killing society!
[laughs] So, the next one, “Help to make traditions.”
Oh, I gotta say something.
I went into an office, just recently. And when I walked in, three people were on their iPhone and never looked up. Okay. Go ahead.
Was it the staff or the people --
This was staff.
-- oh. Oh! Huh.
Yeah. They were talking to each other, probably.
You – we – you must’ve been wearing your invisibility cloak. [laughs] Okay. So, “Help to make traditions.”
Help to make traditions. Well, traditions would be – a good example can be – well, I think I already sort of said this. But traditions would be like Christmas, maybe, or --
Like, you could decorate the office.
-- yeah. Like, maybe they wear something special on St. Patrick’s Day.
Or Halloween [laughs].
Okay. Yeah. So, like, maybe you have a pumpkin around, maybe you have a little tree over in the corner. And if you’re not into Christmas, you can celebrate the season. So, there’s lots of ways to have traditions that staff really get enthusiastic about.
Yeah. I remember, my gynecologist, actually, who delivered Eva, she – he – she – he was supposed to deliver Eva, and he told me early on, “You know, I’m – I’m gonna be there, except for if it falls on this one day.”
“Because this one day is when I have my annual office fiesta party.” And so, actually, it did fall on that day, and I had someone else deliver the baby, because --
-- that was very important to him, to do that annual tradition with his office.
So, his traditions were very powerful for him.
Okay. So, number four, “Have a good attitude.”
All for one, and one for all.
Yeah. I think that part of having a good attitude is being open to participate in all aspects of the business, even taking out the trash, maybe even cleaning the toilets in the bathroom. I know we have to do that at Patterson, so – and maybe don’t post your office complaints on social media.
That’s another thing.
Just sayin’ [laughs].
[laughs] Okay. “Celebrate wins.”
Oh, celebrate wins. Well, I think an office that’s really trying hard, and they’ve done a lot of training, they have technology, so they’re – they’re always doing new things, but there’s nothing like the breakthrough like when maybe you do your first microsurgical -- suturing under the microscope, and the staff is very involved in passing the instruments. And when you’re done, I mean, there’s a great sense of accomplishment. And so, praise.
Yeah. You can take everyone out to dinner or something like that, even.
Okay. “Carry out the vision of the practice.”
Well, I think to – we’ve talked about little elements of some of these things. But for us in the office, we always write down things together. So, Cliff doesn’t go in, “Here’s the goals, everybody” and I nail them to the wall. What I do is say, ‘Here’s a start.’ But I wanted you -- to see your list, and I wanna see Lorie’s list, and I wanna see Isaac’s list, and we gotta integrate those lists. And then, we have a codified list, and then, I wanna post it, and I want --
-- us to see it every single day.
Right. It – she says in her article, Valerie McClure, “Believe and live the vision.” So --
-- when your practice grows, you grow.
When you’re confronted with it every day, it’s easier to fall in line and take the course.
Okay. The next one, “Ask for a clear job description and identify strong suits.”
Obviously, when I hired people over the years, and we’ve said on previous shows, Phyllis exactly has said how it goes. I was like the last person to meet them. So, they had to get through the staff and all that. But the point is, when they got to me, of course, I – let’s just say for fun it was an assistant. So, there’s job descriptions we would talk about. But I also wanted to see what she wanted. So, I wanted her job description, so we could mesh, if possible, our joint job descriptions, to have one codified job description. Because then, they’re enrolled. It’s part – they’re voting for this. It’s who they are.
An example could be, if you have someone that’s very skilled at writing thank-you notes and stuff like that, they could write, you know, even birthday cards. That would be --
Oh, that’s great.
-- to send your patients birthday cards.
How many people get a birthday card, except from family?
[laughs] Well, I do – the one friend you had, the periodontist who – Dr. Dick Sanders --
Oh, Richard Sanders.
-- always sent me a card, every year, for my birthday.
And did it make you smile?
And it was a complete – it was, like, a funny one, too, wasn’t it?
Yeah [laughs]. Okay. Number eight, “Communicate effectively.”
Well, this reminds me of learning to communicate versus talking. A lot of people talk and talk, and they go, “I was – I totally expressed myself. We talked about it.” No, but did you actually communicate [with emphasis] about it?
I think “effectively” is the key word, here.
Yeah. Intent listening.
This happens a lot of times in my marriage. He’s all, “Well, I’m just trying to communicate!” And it’s like [laughs] --
-- “Well, you’re doing it really badly.” [laughs] Okay. Number nine, “Help to create a safe work environment.”
This goes a long way, because safety isn’t just, you know, “Don’t get hit by a scalpel and get a puncture wound.”
It’s also about – it – things go easier in life when you know that the person’s got your back. And so, no matter what happens, you know you’re good, because you’re a team, and you’re working towards common goals.
Yeah. I think that this – this one applies for physical – like, physical safety and emotional safety, like for – of course, we want to feel safe from COVID. So, a lot of offices are taking a lot of precautions. And that – your staff sees that, and – that you’re taking precautions. They all feel safe. They – because if you’re just like, “Yes, we’re gonna just work through COVID. We’re just gonna still see patients. And I’m gung-ho for it” and they’re maybe thinking, “Well, do we have safety protocols in place?” So, you want everyone to feel safe. And you want everyone to feel emotionally safe, too, like that they can come to work and leave whatever problems they have at home or elsewhere, out of the office, and come and have a nice, positive environment to work in.
Yeah. Back to trust, when you have trust – just to play off you, one last time. Then – I mean this in the most professional sense, but then, you can be a little vulnerable.
Because if you can tell one on yourself and be a little vulnerable, because you know, the other person trusts you, and you can build off of that, because we all make lots of mistakes.
Yeah. You wanna feel like you’re not just being judged too harshly, I think, on some things.
All right. And the last one, “Have fun, and enjoy your job.”
Learn, laugh, love, and – learn, laugh, love, and --
-- no, learn, laugh, love, and – I have learned twice.
Learn, laugh --
Learn a lot [laughs].
-- learn, laugh, love, and live!
There you go. Four things.
So, okay. So, this list is very helpful. And I wanted to mention something that Geier said in the – in his podcast conversation with Dr. Farran. Maybe you’re thinking, “Well, I’m not a born leader. I can’t do this.” How – I mean, this takes a leader to be able to create a – a solid culture in your dental practice. Well, he’s saying, no, anyone can do it. You just gotta be willing to put in the work and the time. And importantly, you might wanna enlist the help of your staff, too, so you can create something that you all, together, want.
Did you ever learn to walk?
Did you ever fall?
But it was about walking. So, you’re gonna make lots of mistakes. Get on the path. It’s not the destination. It’s the journey that makes you more than you are. You’ll make lots of mistakes, but through all those mistakes, you’re always heading towards the destination. That’s how you get on the path.
Right. It’s a journey.
Progress, not perfection. And this is – this is really useful stuff, because, you know, they don’t teach you this in dental school, do they?
No. In fact, that’s great you brought that up. So, a lot of things we have to learn as business people and working with the general public are things we did not learn in dental school. We learned how to be very technical.
Maybe a hand on the shoulder, occasionally, but more or less, we could all get a lot better in our interactions with people.
Okay. Well, thank you.
People are attached to teeth, you know.
SEGMENT 2: Surgery 101 – Flap Design
Today, we’re gonna have a little lesson in flap design. That may seem like kind of a basic non-starter, but it’s a very, very important part of any endodontic surgical procedure. And how we design our flaps is going to design, a lot of times, to all of the subsequent procedures, like elevation, retraction, osteotomy, curettage, apicoectomy, retro prep, retrograde procedures, and filling materials, and then, of course, suturing. So, we’ll get to all those over the next seasons. But right now, we’ll talk about flap designs.
And we see a couple bicuspids, and you can tell that they both violate the principles that Schilder gave us for the mechanical objectives of repairing canals. You can see we have a lot of problems. And in this case, let’s just be thinking, now, looking at the film, looking where we’re probably gonna be working dominantly, up in the apical thirds. We don’t see lateral pathology. We didn’t have CBCT then, but it looked like we were working with apical pathology. So, with that in mind, we’re gonna make a very nice incision. We’re going to be scalloping, starting here, and we’re gonna scallop around these teeth, just like you’ll see. Come forward one tooth, one tooth forward, and then, we’ll make a release. That’s what we’ll be doing.
And when we get to that, you can see, this is a full thickness intrasulcular flap. Now, in this flap, we hold the scalpel pretty much with the long axis of the tooth, and we’re just gonna follow the sulcus. But you can see, we’ve taken our time to free every papilla in a very careful manner, so, at the end of the procedure, like gears, this will come right down. It’ll approximate, it’ll reorientate, and it makes suturing a pleasure, and we got primary closure, and we’ll be fine. So, it’s a full thickness intrasulcular flap. Now, this flap is very good when you suspicion fractures, coronal pathologies like resorptions or maybe a lesion of endodontic origin, like a portal of exit that wasn’t sealed. It's good when there’s bony shelves, when there’s a suspicion of dehiscence, when there is periodontal disease.
So, I’m giving you several ideas. Now, when I started doing these microsurgeries, with the microscope, in the mid-‘80s, we were using the 15C. That’s a Bard-Parker stainless steel blade. Earlier in my career – it’s hard to even tell you this, but we were using the 15. The 15 would look about twice as big as the 15C. Well, then, I started having Phyllis get me a bunch of medical catalogs, and I started leafing through those at night, and I noticed a whole new world opened up to me, from ophthalmology, neurosurgery, and these were micro blades. This is my favorite one, but there’s other ones that are – have different shapes and configurations, and those will be used in certain delicate areas, where we need to be very careful with soft tissue management.
So, even the micro blades have allowed us to do a lot less traumatic surgery. And in fact, most of the postoperative problems isn’t because you resected the root or made an osteotomy. It’s the soft tissue, the stretching, the tearing, and all the things that we try to avoid. Well, let’s get this in here. So, here I’m doing my vertical. I’m going from the vestibule, down. And I’m coming down, and I’m planning to leave the papilla. I’m planning to leave that papilla so I can catch it with a suture and throw a suture in there and sling it. Once I have my vertical, I am now taking that micro blade, and I’m putting it right in the sulcus and scalloping right around those teeth, right around those teeth. And you wanna lift every one.
And here it is in there, and you can see how scaled it is to the tooth. It’s a really small blade, very sharp, can cut either way, bidirectional. And that is a little bit about the tools that you might use to make your incision. Measure twice, because you can only cut once. All right. So, I said earlier, we might want the full thickness intrasulcular flap when you’re dealing with external, cervical, inflammatory resorption. And when you see that, you don’t want to have a different kind of a flap. You want primary closure. So, you wanna put that flap over the repair. So, we might even decide to repair this. That would be another whole discussion, what we do, but there it is.
Sometimes, the pathologies move a little bit up, but this is still in the middle one third of the root. So, nobody knows, when you go in here and lift the flap, you don’t know where the disease is, exactly. It’s – in this case, it was a portal of exit. But wait a minute. It was more than one portal of exit. So, we have to be able to have a flap that gives us forgiveness, because we wanna maintain this collar of bone. We wanna maintain bone, so when a flap comes down, we have primary closure, and we can just put it all back together. All right.
So, another idea. This is a double-abutted bridge. This is the anterior abutments. We don’t subscribe to putting these metal posts in MBs and MLs of mandibular molars. This is a tooth that was resected. The distal root has been eliminated. So, now, it’s serving as the abutments. So, when you load something like this, back to the second molar, there’s a lot of load on both of these teeth – a lot of load – but the problem is, the tooth that’s more posterior is gonna get the bulk of that load. And when you raise the flap, it’s pretty easy to see this vertical fracture in here. And notice how it is getting whiter and whiter, as we travel apical.
This was a case I’ll show at another time. It was one of the hardest surgeries I did. I remember it perfectly like, you know – it happened 35 years ago! Trying to resect the post and the root and get all this out and then, get this contour back up, so that there’s free cleansing, gotta have a lingual flap. It’s gotta have a buccal flap. You gotta ramp and bevel the bone and blend, so you don’t have pockets and create postoperative problems with cleansing the lone anterior abutment. Who knows how long that’ll last? But this will give the patient perhaps a little time, before they go to implants. Okay. So, vertical fractures, dehiscences, resorptions.
Sometimes, we’ll have like the buccal shelf. So, before you ever lay the flap, you’re not surprised, because you’re palpating. And if you feel that external oblique ridge, and it starts to form that shelf, you do not want anything but [with emphasis] a full thickness intrasulcular flap. Okay? You wanna go around these teeth, pull that back, and you can see we’ve identified now into the end of the roots. That’s pretty much a hole that is just there in the bone. That’s why, when you palpate these lesions, a lot of times, the patients will say they’re sore, because the disease has perforated through the buccal cortical plate.
All right. And then, if we look at this, if you’re doing a three-root bicuspid, as an example, you wanna maintain this. This is absolutely sacred! Maintaining that collar of crestal bone so when you put the flap back, it has blood supply from the bone, to keep the flap itself nourished with platelets, blood, stuff like that. So, here we are with our little retros. You can see we got them in the DB, the MB, and the palatal. And there’s the old sinus communication! So, there’s ways we will block that off, during surgery, with a piece of CollaTape. And it’s a collagen material, and that’s our backstop, so we don’t have things go into the sinus itself. All right.
Sometimes we have to take a root off. So, you’re in there doing surgery, and in those instances, you realize, you know what? This is a hopeless root. You have to, as an endodontist, be prepared to do some periodontal surgery. It’s – patients don’t like it, when you close the flap and refer them to the periodontist or back to the general dentist for a second surgical procedure. So, be prepared to know how to do it. Practice doing some extracted teeth, because when you take off the DB, which would’ve been down in here somewhere, you gotta ramp that furcation.
Take that 17 Explorer, you know that 17 Explorer that has that little hook? Take that 17 Explorer and drag up from the furca, because there’s still an MB and a palatal. And drag up, apical occlusal – apical occlusal. Make sure it just skates like your skates on ice, no catches, no overhangs. Blend it out, ramp the bone, ramp the root, so you can have good approximation and good healing. Again, full thickness intrasulcular flap. Okay. Are you ready to see another kinda flap?
It's the attached gingival flap. Some people like to call it the Ochsenbein-Luebke flap. I was using this flap for about 15 years before I heard that name, but if you go back to textbooks, we’d be saying the same thing, an attached gingival or a Ochsenbein-Luebke flap. Okay. What we’re gonna do is, we have to have sufficient attached gingiva. Notice, we have miles [with emphasis] of attached gingiva – miles of attached gingiva. So, when you have a lot of gingiva, you probe. This is a little bit – you can see I’ve given anesthesia already. You can see I’ve come in from the lingual and infiltrated, so you can see our whole zone here is a little bit opaque, blanched a little bit, from the anesthesia itself, 1:50,000 Xylocaine.
But the point is, probe. And if your pocket depths are right in here, and right in here, and you can probe, you can see it blanch, then you need to go about two millimeters apical to the attachment. Okay. And that way, you’ll have attached gingiva on both sides of the incision. And that way, if you scallop and follow the tooth profile, those necks, those cervical necks, then you can see a suture here, a suture here, suture here. It’s very, very nice to approximate these. And patients like it, because they heal without scarring. There’s the flap.
So, you can see, you take your time. Again, measure twice, you only cut once. Just take your time. When I say, “Take your time,” a few moments at the front end give you peace of mind. When you start tearing your flap, and you have to readjust your incisions, there’s more bleeding. And those are sometimes really nuisance bleeders, when you’re trying to do something very, very refined, deep in the surgical crypt, the osseous crypt. So, nice attached gingival flap. This case has had previous surgery. You can see the apicoectomy. My gutta-percha cone’s tracing the sinus tract to a lesion of endodontic origin. That’s a LEO. And you can see, then, we’ve elected to do surgery, and it’s gonna be an attached gingival flap.
Again, you can see we have a big, big zone of attached gingiva – big [with emphasis] zone. You can see the scar from the previous surgery, right in here. You can see that scar. When you make scars at the mucogingival junction, when you make incisions in the lining mucosa, the tissue puckers, because reapproximating lining mucosa to attach gingiva to different tissues, that’s when the tissue bunches, puckers, and you get this scar piece. Oh, especially women will say sometimes, if they can feel it, is it okay? So, I just wanted to show that, before I did my flap. There’s my flap. Attach gingiva, measure again, every sulcus, and then, go up a little bit more, and then, you have a roadmap to carry that micro blade right around those teeth, scalloping in a very artistic way.
So, I’m showing you now 30 days’ healing. You can see, of course, the old scar’s gonna still be there. But you can see, you can’t – well, Ruddle can see. If you look really carefully, can you see the faint scar at just 30 days? Maybe you can see it. I think I see a – that’s a little bit of glare. I think I see it, right in here. And I think I see a little bit, right up in there. So, the thing is, these things heal beautifully, if you just take the time to make a beveled incision. Bevel the incision to bone, and then, lift up the flap. Okay.
So, you can see, we can use an attached gingival flap, a Ochsenbein-Luebke flap in the posterior regions. A lot of times, there’s sufficient attached gingiva, and this is good to leave the crowns alone. The attached gingival flap is a great flap, when you’re thinking about aesthetics, because when you lift up papillas, we’re not perfect, and when we put those papillas back, yeah. They remodel and things kind – and all heal. And isn’t it wonderful what the body can do, to make us look like excellent surgeons. But if you can stay away from the aesthetic zone or a porcelain fused to metal crown, everybody’s gonna be happy, assuming you have sufficient attached gingiva.
So, again, I can see a little sinus communication in here. You can see we’ve even beveled the roots, looking ahead to another lesson that I’ll do in the future. We’ll talk about apicoectomy, but they don’t always have to be zero degrees. They don’t all have to be flap bevels. They don’t all even have to be in one plane. This one’s kind of cupped out, as you can see. So, we’ve kinda come across the root to preserve root structure and root length for stable teeth. Okay. Attached gingival flaps.
The last flap I’d like to show you today is the combo flap. It’s a combination of your full thickness intrasulcular flap and the Ochsenbein flap itself, those two together, now. Think it’s not one or the other, it can be both. So, if you’re worried about a dehiscence, if you’re worried about crestal recession, you don’t wanna have to suture and bring tissue together over a denuded root. That’s asking for sloughing of the more coronal tissue, a periodontal vertical defect, and that would be an aesthetic nightmare. So, you might want to use the idea where you leave the tissue in your attached gingival flap. You can leave all this, not even touch it, stay away from the margins of the crown.
You can see quite a bit of inflammation in here. So, I don’t like to cut and incise in periodontally involved tissue. But on this guy right here, I wanna go through the sulcus, to lift it all up, so when I close, I’ll get primary closure, and then go right back. Plan it! You could’ve brought this down, like this, and then, you could’ve sutured here. But sometimes, we don’t want to lift the papilla. So, this one’s how we did it. The vertical release is always about a tooth away.
So, if we’re doing this guy, right here -- this guy right here, let’s get this cleared out, so we can see. I guess – yeah. So, if we’re doing this one, right here, usually, you go about a tooth on one side or the other, and then drop a release. The release shouldn’t be obtuse. It should be vertical, because the vessels are coming down in the soft tissue. I said, “the soft tissue vertically,” so when you start cutting obliquely, you cut across more vascular elements, and you have more bleeding. So, if you cut vertically, you’re cutting, a lot of times, in between the vessels, and there is less bleeding.
You know, I like all these lines, because I have the impression, I’m doing a lot of work. And so, I like a messy board, because it means we’re interacting pretty good together. So, let’s look at some of these combo flaps, full thickness intrasulcular and attached gingiva. How about this one? Now, this is pretty cool just to look at, because you can see, we’ve left – there’s all jackets in here, porcelain fused to metal crown. So, we want to stay away from the margins. Want to stay away from the margins. But here, the suspect tooth, notice, you saw this one, immediately. And most of you saw this big lesion. These are osseous defects.
This – these lesions are big, and it suggests that there’s more than one kind of a problem with this tooth. I know, you’re going, “Where’s the xray, Ruddle?” I’d like to kind of know what you’re’ – no, wait, wait. You’ll be too distracted if we talk about too much. We’re just flaps, flaps. Can you spell it. Flaps. That’s what we’re talking about today. So, when you have crestal pathology, go through the sulcus.
And this is my last case for today. And I think what you’ll notice is, this is a tooth that’s been treated by two different endodontists. This is my preop. I suggested going back in, because I do think a couple millimeters makes a big difference! But a lot of people, because of their training, they think one millimeter short, standard of care, it’s perfect. It should all work! I can show you thousands of cases that didn’t work one and two millimeters short and had residual lesions, just like this case. Just like this case has pathology here, and you’re thinking, it’s maybe not so big. Maybe something in here. Maybe there’s something in here, not so big.
Well, notice the sinus tract goes into the furcation. There’s my preop. Do you notice the parulis? Do you notice the parulis? What do you notice coming out of the parulis? Purulence! You can just take your gloved finger and massage that, and you can express purulence. So, there’s a big lesion, and notice how the crown’s constructed. It dives deep over that MB root because of caries. So, they had to cover it. Eliminate the caries. But what you have here is what? You have a big zone of attached gingiva! A big zone. So, I’m not gonna go through the sulcus, here.
I’m gonna come like this. And then, I’d be able to suture in here, and I’ll be able to suture in here. And then, I’m gonna go intrasulcular around this, because there’s no attached gingiva, maybe just a millimeter. And that would be very dangerous, to be trying to carry your attached gingival flap around like that. You’d be suturing lining mucosa to attached gingiva. Okay. Flap’s back! Wanna focus on flaps today.
So, you can see we’ve left that big collar. That’s really fibrous connective tissue. It’s got good stipple. It’s gonna be a good suture site. But now, we even have more recession below the crown. And if you look carefully, you’ve got to see this, but this is your osseous fistula, that you never get to see. You just saw a little bump on the gum, right? And that’s what we’d stick our gutta-percha point in, to trace the fistulous tract. But now, there’s the osseous tract! I don’t see that a lot in books, so I hope you’re enjoying this. There I am, cleaning out the osseous. But I gotta get down here and do an apicoectomy, somewhere in this area and somewhere over in this area. So, you can begin to see a lot of bone’s gonna get lost, making surgical access into the apical theater.
So, as we do that, you can begin to see I’ve sculpted away the bone. I’ve gotten access to your distal system, and it was one central system. We had about equal amounts of tooth structure on either side, so that makes us think that it’s not two merging systems or two separate portals of exit, just one apical. And what was odd is, everybody’s expecting the inner connector. Where’s the isthmus? Because they almost all have it. Based on the level of the bevel, you can sometimes resect right across an isthmus, and it has to be prepped. It’s a large sheath of tissue in that inner connector, and the isthmus has to be prepped and filled. So, in this case, though, with vigorous dye, use methylene blue, Chinese red, no dye, no uptake into any kind of an isthmus, washes off clean. So, I’m done.
Now, another time, we’ll get into barriers. I am pretty excited about some of the surgery we’ve done over many, many decades. But learn to use things like CollaCoat, CollaTape, there’s CollaPlug. These are collagen membranes. These are resorbable. And when we’re doing guided bone regeneration, we might sling this in there. I’ve just got it tied off. This is all gonna resorb. The suture’s gonna resorb. All this is gonna be left behind. Primary closure, gotta get that flap over and see none of the membrane!
So, this membrane has to now be pushed down and approximated and positioned so that it won’t be moving. But the membrane, it causes platelet aggregation! It causes stabilization of a clot. It brings in fibroblasts! And it’s gonna be gone in just about two weeks. Okay? Some of these membranes are in there for, like, months! So, pick the membrane based on how much time you want just to get stabilization of your clot. Soft tissue’s healing nicely. You want that material to be not too inflammatory, but it’s carried away rapidly. So, that’s what I’ve been using for years. I learned that from the periodontists, in the ‘80s. So, that is a CollaTape membrane being positioned.
And then, if you look at the postop, here we are postop, and this is about 10-year recall. But you can see how great the bone’s come in, because we knew how to handle the flaps. We did all the little surgical procedures, lined them up like dominoes, take care of every one, and it’s amazing, the capacity of the bone to heal and for your patients to get well. So, I hope you’ve learned a little bit about flap designs today, and you can integrate it, starting tomorrow morning.
CLOSE: Show & Tell
Okay [laughs]. So, we’re gonna close our show today with another Show and Tell. And this time, we each brought a photograph to show you. So, we’re gonna show the photograph and tell about our experience. You might see a couple of other photographs that they’re gonna lay in, as we’re talking, that might explain a little bit better what we’re talking about, maybe give you a better understanding. Anyway, you’re gonna start. And what photo did you bring?
Well, the context for this photo is, we were – I was with Phyllis and Daniel Nobs, and we were on a three-country tour, and we were in Madrid, Spain. And our – the big ballroom thing got over about 2:30, and Daniel Nobs said, “Would you like to go across the street and say what – see one of the most famous stadiums in Europe?” And I said, ‘What would that be?’ And he said it was Santiago Bernabeu, where Real Madrid plays. So, that’s what I saw.
And just a little bit about it. It was so cool. I’ve been in a few stadiums in my life, but I had never been into a stadium that had, like – well, we spoke about culture. They had a whole past, a whole museum about the great games, the great players, and it was interactive. And I just thought it was a marvelous – well, you know, they won 28 World Championships or whatever the words would be, it was 28 championships of the Santiago Bernabeu trophy. And that trophy they won 28 times. It reminded me of the New York Yankees, because they’ve won 27 World Series. So, I always am fascinated with teams whose culture allows them to win, and it’s always about winning or being close to winning. So, I loved it.
Yeah. I – that’s pretty cool that you got to visit the stadium when it’s empty, like that.
We got the whole tour, and they had the big machines going to give sunlight and water. And it’s – there’s five levels. So, it’s very impressive. It seats about 88,000-plus people. So, you could just imagine, if that was filled up. That day was a very quiet day, but it would be probably a thrill.
Did you feel like giving a big yell and seeing if it echoed?
Yeah. I actually did. And I wanted to run around in the grass, but they said I should probably just stay --
-- stay where you saw me [laughs].
What about you?
Well, the photo I brought is this one. And it is --
-- this picture is of me and Isaac. It’s ten years ago. And this is on the Great Wall in China. So, we went there in 2011 with our karate group. And at that time, I – I was divorced, and I was not remarried. So, I was a single mother with a 12-year-old – Isaac’s 12 in this picture. He looks a lot younger.
And Eva was 10. So, we were there on a karate trip, and I actually – one thing that made this trip even more unique was that I was also supposed to be participating in karate on this trip. We were going to China, and we were going to train at the Shaolin Temple. And we were going to also rank test. And I tore my ACL, one week before the trip. So, in this picture, you can see that I actually have my leg brace on, and it was very challenging to walk the Great Wall with my leg brace and a torn ACL [laughs].
Maybe to fly, the airplanes, the transfers, the trains, the buses.
They do not have the same handicap accessibility in China, on the Great Wall, as they do in a lot of places in the United States. So, it was very – just – I had to be careful how I walked. I – there was so many people there. It was so crowded. And Eva’s actually taking the picture. And I actually think, in the picture, I look a little tense. I – tension on my face, because it’s – going to China and experiencing that completely different culture – and I’m using that word again – it’s really – that kind of trip is not just a vacation like going to Hawaii.
It’s an adventure.
It’s more an adventure, and there’s a lot of challenges. And just going to the other side of the world, where I only spoke two words of Chinese, “Hello” and “Thank you” and with my kids, who were pretty small, and as a single mom, I – and with a torn ACL, I kinda had that feeling like -- after that trip, I had a feeling of confidence and strength that I got from it, that I could pretty much do almost anything. And we actually did go back to China, two years later, and I was able to compete at that time – or not – rank test and got my Black Belt shortly after that. So, it’s – it just was a very big experience in my mind. It stood out as a life-changing experience.
And I think a lot of it is just being exposed to a completely different culture. It kinda gives you like a more global mindset. I really was proud of myself for exposing my kids to that kind of culture, too, and to – they’ve traveled a lot, all over the world. And I’ve made it a point, even when I was by myself, and not married again, to – that I wanna get my kids out and show them the world, even if I have to do it on my own, with no help. So, anyways, that was a very special trip to me. And even now, just looking at this picture, I just can’t even believe that we’re standing on the Great Wall of China. But [laughs] we were.
Well, I was really proud of you, because I think many Americans, what’s missing is they haven’t gone out and gone forth to see how other people eat, sleep, what they think about, their architecture, customs, all that stuff. It really grows you. So, that was good growth for you.
Yes, and I guess both of our pictures actually have a little bit to do with culture, international culture. So, that’s our show for today, and we hope you enjoyed it.
And get your culture going!
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