By Robert L. Odegard, DDS, MAGDDentists are some of the hardest working professionals in America and around the world. Every time I meet other dentists at conventions, CE courses, or symposiums, I am amazed by how motivated they are and how much effort they place toward their career, their family, and their practice. They are continuously in search of new methods, technology, or skills that will simplify or expedite their work. Radiosurgery is a prime example of a technology that I believe makes the life and work of the dentist easier and more efficient. In this article, I intend to describe how you can increase your production and decrease your stress by using a radiosurgical device in your practice on a daily basis. As wet-fingered dentists, one of the most stressful and difficult things we encounter in an average workday is the crown and bridge impression, or the capture of a perfectly powdered preparation if you are using CAD/CAM or some form of digital impression. We take tremendous pride in our work, and we know that the preciseness of the fit and ultimately the longevity of our indirect restorations are dependent primarily on the accuracy and detail of the impression. We also know that our work will be judged by the laboratory technician, possibly our colleagues, and mostly by ourselves from the production of a die that is an exact replica of our skills and effort. We love to scrutinize the dies of our own preparations with a more critical eye than that of our dental school instructors. Whenever I complete a crown or bridge preparation, I cannot help but envision my toughest dental school instructor (whom I used to call “Darth Grader”) scrutinizing my work with his loupes. After I am satisfied that he would approve of my preparation, I place the retraction cord around the prep, nervously attempting to get all of the margins well exposed and at the same time trying to keep the cord completely dry. This is not an easy task, especially when the prep extends subgingivally on people with heavy saliva flow, large wandering tongues, mouth breathers, inflamed and bleeding gums, or gaggers. If the retraction cord is not kept dry, it will swell up against the margin and the impression will be inaccurate. If you put two cords into the sulcus and plan to remove one before you impress, often you get bleeding upon removal of the first cord or the deeper cord lifts up and interferes with the margin capture.1 Placing retraction cord is a very laborious chore on many patients and one of the most stressful moments in my workday. In a busy office environment, with the hygienist standing behind me coaxing me to hurry up because she needs an exam, my stress level begins to escalate. Being behind schedule and keeping patients waiting is likely the most stressful part of owning a customer service-based family dental practice. If the dentist generates a reputation for keeping people waiting for long periods of time, it will have years of damaging results.2 As dental business owners, we know this and are constantly looking for little pearls to make us more efficient and reduce our stress. Thankfully I discovered the radiosurgical instrument from Ellman. It is infrequent when an instrument or technique becomes so valuable that we literally feel like we cannot perform our jobs without it. This is exactly how I feel about my radiosurgical devices. I am convinced that every dentist could benefit from using one on a daily basis. Dr. Irving Ellman (a practicing dentist and electronic engineer) developed the 3.8 MHz fully filtered waveform, which is a much higher frequency waveform than the 1.29 MHz electrosurge I used in dental school. The 3.8 MHz radio wave is a high-frequency waveform somewhere between AM and FM frequencies. The high-frequency radio signal is transmitted to two metallic plates. A small wire acts as the active plate, while the square-shaped metallic pad that is placed under the patient's shoulder acts as the antenna and the passive plate. The soft tissue is placed between the two plates and the radio signal is allowed to flow from the active to the passive electrodes.3There are a many types of tissue-cutting instruments on the market. Parkell, Hampton, Siemens, Whaledent, Bident, and others have made units of various operating frequencies and power voltages. Some of these have been discontinued, and others have been improved. However, in my opinion, the Ellman Dento-Surge 90 FFP (Ellman International Inc., Oceanside, N.Y.) surgical unit is the best radiosurgical instrument on the market. See Fig. 1. At 3.8 MHz, it enables a precise incision with significantly less heat and resultant thermal damage than typically found with conventional electrosurgery units that operate in the 1.4 MHz to 1.29 MHz range. It also offers four different waveforms for various surgical needs: the Fully Rectified Filtered, Fully Rectified, Partially Rectified, and Fulguration waveforms.4What this means is that the radio signal is modified in order to provide more or less hemostasis with each cut. The Fully Rectified Filtered Waveform results in a continuous, non-pulsating flow of current for micro smooth cutting without a lot of lateral heat production. This is excellent for cutting in close proximity to bone, implants, etc., but provides the least amount of coagulation. The Fully Rectified waveform is a full-wave current that has been modified to produce cutting with simultaneous hemostasis. The Partially Rectified Waveform is an intermittent flow of the high-frequency current, which is excellent for producing hemostasis of the soft tissue. The drawback with both the Rectified Non-Filtered waveforms is that they create much more lateral heat and tissue shrinkage. They should be used with quick, intermittent strokes and never close to bone. The Fulguration waveform is like a spark that jumps off the tip of the instrument. The tip of the instrument is held slightly above the tissue surface. It is a half-wave current that has a dehydrating effect on the tissue. It is used for destruction of cyst remnants, etc., and although it produces the greatest amount of lateral heat, it can be used close to bone because the tip never actually touches the tissue. The Ellman Dento-Surg has an attractive steel housing, easy control knobs, various controllable functions, and a multitude of electrode sizes that can easily be inserted for just about every situation (Fig. 1). My favorite tips are the 113f and the 110. The 113f is a little thicker for troughing around crowns when the tissue is thick or if the preparation extends subgingivally (Fig. 2). The 110 electrode tip is perfect for troughing interproximally when there is tight clearance between the shoulder of your prep and the adjacent tooth (Fig. 3). The many electrode tips are relatively inexpensive, and they can be flexed and curved with gentle pressure unlike other units in which the electrode tips are rigid and non-flexible. Ellman has recently introduced a new advanced alloy for all its electrodes. This new patented alloy that matches perfectly with the frequency and waveforms reduces the tissue alteration, which results in faster healing, especially in thin gingival areas. I also prefer the Ellman unit because it offers a linear power progression power dial, weighs only 7.5 pounds, and the handpiece and all the electrodes are autoclavable.
Fig. 1 — The Ellman Dento-Surg 90 FFP
Fig. 2 — The Ellman F113 electrode tip for troughing around the crown margin
Fig. 3 — The Ellman F110 fine-tipped electrodeYou can scan the literature about the 3.8 MHz to 4.0 MHz high-frequency radio wave and its ability to produce pressure less, micro-smooth incisions with hemostasis and minimal tissue alteration; however, you merely have to try it for your next crown and bridge impression to be convinced of its value to your practice. I am not a dental scientist — don’t ask me to explain all of the scientific information regarding exactly how the passive electrodes transmit the high-frequency radio waves that cause the tissue to heat as a result of its natural resistance to the radio signal, but I can tell you that it is safe, painless and very effective. I like things that are easy, reduce my stress, and work every time, which is why I have a radiosurgical unit in every operatory. If you own a CEREC machine, then having a Radiosurge instrument is a must and an ideal instrument for your armamentarium. Trying to place retraction cord and then perfectly powder and capture your crown margin is a task that can cause you to become apoplectic. It is often difficult and time-consuming to get the crown margin exposed enough (and dry) to dust it with powder, and then to be able to distinguish it from the retraction cord in your optical impression. A simple pass between the tissue and the preparation margin with the electrode tip of your Radiosurge will clearly and cleanly expose the margin. This takes only five to 10 seconds and then your preparation is ready for powdering. You will be amazed at how clean your optical impression turns out and how easy it is to mark your margins (Fig. 4). You will also be happy with the improved fit of your CEREC restorations and with how fast you can complete the restorative procedure.
Fig. 4 No more cutting cords and laboring over how to precisely and perfectly place them! No more worry about saliva, blood, or subgingival margins. No matter how thick or deep the gingival tissue, no matter where in the mouth the tooth is, and no matter how difficult the patient, I will get a perfect capture of my preparation the very first time with a radiosurgical instrument. The radiosurgical unit has cut a lot of time out of my crown and bridge procedures and saves money in wasted impression material from retake impressions.TechniqueHere is my technique for effectively using the radiosurgical unit for my crown and bridge impressions. After I complete a crown or a bridge preparation, I very gently inject 2% lidocaine with 1:50k epinephrine into the papilla on the mesial-distal and the buccal-lingual of the prepared tooth or teeth. This ensures good tissue anesthesia and helps with hemostasis. Then I grab the wand of my radiosurgical device and using my high-powered telescopes with a headlamp (Orascoptic, Kerr Corporation, Middleton, WI 53562), I gently and smoothly trough around the margin of my preparation. I remove very little tissue, just enough to expose the margin and provide a thickness of impression material around it for a perfect capture. I try to stay just 1 mm apical the margin and not invade the connective tissue attachment. In most instances, there will be no bleeding and you will have a very clean operative field. As I am performing this very delicate tissue surgery, my dental assistant is suctioning with the HVE to remove the odor and drown out the sound. You want to be sure that the patient does not smell any volitized tissue or hear anything that could sound invasive.5The radiosurgical device works perfectly for posterior teeth, but if I am in the esthetic zone (anywhere from the maxillary first molar forward), and if the gingival margins are ideal in height, I place retraction cord on the labial only and do not radiosurge the labial margins. I find that the buccal and facial tissue is an easy area to place the retraction cord. With a gentle touch, I can better control where the tissue margin will end up. You must be careful not to permanently alter the facial tissue level (if you cut away facial tissue on a tooth with a deep sulcus, it may not come back).6I then begin the impression procedure after all of the preparation margins are clearly exposed. I am confident that my impression will be good because there is no bleeding, the margin of my preparation is clear of the gingival tissue, and the trough provides room for the impression material. You simply dry your prep with the air/water syringe, inject your impression material around it, fill the tray, and take your impression. Voilà! ... a quick, clean, and easy impression. Your lab technician will also appreciate how easy your dies are to trim.6 Giving the lab technician a little space between the margin of your preparation and the gingival tissue makes it easy to detect the prep margin without errors, which ultimately makes for an excellent casting or ceramic fit. Since I have been using a Radiosurge on a regular basis, I find that my crowns seat much easier and quicker with little detection of the margins. I use my Ellman Dento-Surg for many other dental procedures besides the crown and bridge impression. I have used it to expose gumline decay, tissue removal for matrix band placement, reshaping and contouring pontic sites, frenectomies, coagulation and hemostasis, removal of papillomas and fibromas, etc. One of my favorite uses for the Radiosurge is removal of amalgam tattoos or hyper-pigmentation. The discolored gingival tissue is lightly grazed with the small electrode until the color is gone. After healing, there is no scarring or evidence of any surgery. It's amazing. I love to remove papillomas or irritation fibromas. I just pick up the fibroma with tissue forceps and use the small electrode to cut along the base of the sessile lesion. The fibroma is removed very cleanly with minimal bleeding and can be easily dropped into a biopsy bottle. There is no postop pain or complications, and healing occurs without scarring. Procedures like this make your dental practice special and more profitable because you are able to offer your patients a wider range of services. I am not saying that the radiosurgical instrument is a replacement for the scalpel; however, in many situations it is so much easier and quicker with less tissue trauma.7There are some contraindications to radiosurgery that you need to be aware of. Supposedly it is not to be used on people who have cardiac pacemakers. However, this has been challenged lately.8 The problems with interference have been primarily with older models of pacemakers. More recent pacemakers have improved electronics, filtering, and shielding that make them resistant to outside signals. I don’t use my Radiosurge on patients with pacemakers just to be safe. If you are a successful dentist with a successful dental practice, you are most likely searching for ways to reduce your stress. I find that since my dental practice has matured (as have I), and my production has reached a level that I am comfortable with, I am more interested in methods that can reduce my stress level and improve the service to my patients than I am about methods that can increase my production. However, you will find that the use of a radiosurgical unit in your practice on a daily basis will decrease your stress level, and at the same time increase your daily production. That is why I believe that a radiosurgical unit is a valuable asset to us hardworking dentists and should be an instrument in every dental office.Robert L. Odegard, DDS, MAGD, is a solo general practitioner in Renton, Wash. He is a graduate of the University of Washington School of Dentistry, a master in the Academy of General Dentistry, and a diplomate in the International Congress of Oral Implantologists. He is also an alumnus of the Pankey Institute and subscribes to Cerecdoctors.com and Dentalxp.com. Dr. Odegard can be contacted at [email protected].References1. Lowe RA. Successful management of the gingival tissues for aesthetic restorative procedures. Dentistry Today. Oct. 1997; 16(10):40-1, 44-8.2. Levin RP. How to win in this economy with great customer service. Dental Economics 2009; 01-01.3. Sherman JA. Oral Radiosurgery: An illustrated clinical guide. Third Edition. 1992; Taylor & Francis Group, N.Y. Ch. 1,2,3.4. Sherman JA. Oral Radiosurgery: An illustrated clinical guide. Third Edition. 1992; Taylor & Francis Group, N.Y. Ch. 1,2,3.5. Moore DA. Electrosurgery in dentistry: past and present. USA DENTAC, Fort Riley, KS 66442-5043, USA.6. Coeldo DH, Cavallaro J, Rothschild EA. Gingival recession with electrosurgery for impression making. J Prosthet Den 1975; 33:422. 7. Willams VD. Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports. J Am Dent Assoc. Feb. 1984; 108(2):220-2.8. Sebbin JE. Electrosurgery and Cardiac Pacemakers. 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