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High folks: Here is a case I did yesterday and thought it showed a few things we have learned here but I thought I would document them to show you some of the things we have discovered about the Er:YAG from tips you have told me and from my own experience.
At the Nash Institute this weekend people were asking me whether it was my experience with using the wavelength or the high mag which has helped me through the learning curve more. I think really it is both but perhaps the ability to see at high mag over the last 5 years has helped me separate so much of the “hype” vs reality of what lasers can and cant do. I am glad that we are beyond the ” my laser cuts faster” and ” my laser doesnt bleed on soft tissue ” debates that raged on for so long in the beginning.
Enough said , here is the case. THis is a young guy of 14 or so who has a groove on the gingiva of his upper right central (#8) that was difficult to show with a photograph because of the location (on the facial plane) but the tissue was always inflamed due to food impaction and the surface rough so we decided to get him in and restore the area with a restoration and some sculpting of the soft tissue in the area to improve access for the preparation.
I used EMLA only for the tissue.
In the beginning we used the DeLight with 20 Hz and around 40 mj without water to remove tissue (note the angle of approach that is possible with this tip design, preventing any iatrogenic notching that happens if you are not parallel to the tooth). This in my opinion is not as easy to do with a handpiece head instead of this design.
I show you that the tissue was peeling away and shaving down.
Halfway through for argument sake, I turned the water on with the same settings to get a smoother cut. It will cut smoother with water with less smell but of course there is a side effect…….more bleeding.
After the gingivectomy was done and a “laser bandaid” of 30 hz and 30 mj without water applied to try and stop the bleeding, there was an improvement with only slight “oozing”.
I then turned the erbium onto the tooth at 30 Hz and 45 mj with the water on and a 400 micron tip. When wet there is no etch obvious but dry it out and it looks great. This is only 1.25 watts but you can see that an etch still occurs.
I then used a spoon on the surface to “scrape” the enamel to show you that the etched surface may not be so strong a bonding surface to begin with. Its the “deceiving laser etch”…its chalky but fragile!!
Removing the loose enamel prisms with the spoon scrape gives us a etched surface which is more predictable to bond too.
Now speaking of bond the sulcus is “oozing ” from the gingivectomy so we are doing some work with prototype small plastic cannulas that are 26, 27.5 and 30 gauge which attach into metal cannulas that we typically use for etch and liquid dispensing that are much much bigger. With the scope these flexible tips can be used to dispense small increments of flowable or in this case astringident hemostatic solution.
The only negative in this case was that I couldnt rub or burnish it in with the plastic because that initiated bleeding.
After the oozing had been halted, etched, bonded and then applied flowable in the same cannulas with precise placement. These plastic tips are cuttable, they bend (like a straw would) but they are able to dispense the flowables into small preps and minimize air bubbles. For the more viscous flowables a warmer (which we also have) will make the flowable able to be used with the larger cannulas.
Dont ask for how you can get them, they arent available yet but soon will be. I am working on a kit actually with smaller burs and bonding brushes for those using high mag and scopes.
These tips are ideal for small occlusals with 1/8th and 1/16th round burs and of course the “laser fissure sealant preparations”.
In closing the polish needed to be refined a bit but all in all not a bad result.
I just wanted to show some of the principles we have talked about here and I hope this collage although lengthy, does demonstrate some of the issues we face with lasers.
warmest regards
Glenn
