Lasers and cracks - Laser Dentistry Forum

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June 2, 2003 at 7:15 am #2941 Reply

Glenn van As
Spectator

Hi there: here is a case I did last week where the patient was complaining of sensitivity to chewing. No thermal sensation.

HIgh mag view of first premolar showed two cracks.

I thought they would go deeper but they didnt. I usually use the laser at a low setting (30 Hz and 70 mj ) just at the end to create a smear layer free dentin zone and then etch the enamel for a little longer than the dentin.

Just to show you the cracks……its amazing how often we find these.

Glenn

June 2, 2003 at 2:54 pm #7390 Reply

whitertth
Spectator

Glenn, u r giving me the itch to purchase a scope….. nice stuff buddy!

June 3, 2003 at 2:53 am #7409 Reply

Glenn van As
Spectator

I sometimes feel like I should have shares……..

Cracks are obvious with the scope……like decay , it is everywhere.

Thanks for the kind words Ron

Glenn

June 3, 2003 at 4:02 am #7398 Reply

ASI
Spectator

Hi Glenn,

Did you defocus for removal of amalgam or use local?

Nice work again.

Andrew

June 3, 2003 at 4:34 am #7404 Reply

Glenn van As
Spectator

Hi andrew…….I used local.

I didnt know how deep it was going to be and I was in a rush as well.

Sorry Mark……but its the truth.

Glenn

June 3, 2003 at 1:08 pm #7391 Reply

2thlaser
Spectator

Glenn, never any need to apologize. Sometimes ya gotta do whatchya gotta do! Nice though. I am finally back from 2 weeks of lecturing, need to get on the photo bandwagon now!
See ya all tonight!
Mark

June 3, 2003 at 8:42 pm #7387 Reply

Anonymous
Guest

Glenn,

Did you find decay interproximally where the 2 fractures went over the marginal ridge?

Seems like I remember seeing that 80% of the time there will be decay present when you see 2 fractures like that (Maybe in Graeme Milicich’s Cd’s?)

Just curious,

June 4, 2003 at 6:19 am #7401 Reply

Glenn van As
Spectator

Probably true especially if Graeme said it but no decay in this case………weird one.

Thanks for the post and the interest.

Glenn

June 4, 2003 at 10:58 pm #7424 Reply

Robert Gregg
Participant

Glenn,

What I noticed on second look was the fracture line appears to extend to and under the buccal cusp tip.

Was that obvious from another view not photographed? That would explain the symtoms the patient describe.

How’s the patient’s tooth and chewing now???

Bob

June 5, 2003 at 12:34 am #7421 Reply

Lee Allen
Spectator

Glenn,

Interesting as usual. I have a similar case that is bite sensitive without thermal and found a distal marginal crack (one) similar to what you are showing, but after using a waterlase at 3.5W to remove enamel around the crack and some of the adjacent composite and placing a flowable, it has not resolved. You implied that this one did. Did it take time or was it noticed immediately?

Mine is 4 days Post op and still noticable. I am contemplating removing all of the composite to check for a more extensive crack but feel that I may want to give it some time to resolve the pulpitis.

Any thoughts?

June 5, 2003 at 12:42 am #7392 Reply

2thlaser
Spectator

Lee,
What I have found in MOST of these cases is you HAVE to remove all the composite, laser the crack as far as you can see it, then place a new restoration, making REAL SURE the occlusion is adjusted correctly. I have had very good success with this. Glenn, what is your take on this?
Mark

June 5, 2003 at 6:09 am #7405 Reply

Glenn van As
Spectator

Do the endo……..here is one of my dental assistants teeth, lower left 1st molar that was sensitive to chewing, never settled down………

She had the composite done…..no better.

Gold crown done……temp cemented no better…….pain to chewing.

Did the endo yesterday……….

Note the crack……..my dental assistant Lori saw it when I was working and she saw it on her monitor and told me…and I told her thanks….I never noticed it when we were doing the open and drain……..nice curves huh.

THats why I LOVE THE SCOPE.

glenn

June 5, 2003 at 6:19 am #7402 Reply

Glenn van As
Spectator

Here is another one from yesterday slated for a crown.

Patient broke ML cusp of on old amalgam.

Showed patient crack on buccal which was asymptomatic.

Once amalgam removed (with anesthetic) then noted crack went right through to prep from buccal.

Advised patient on weakness of tooth and advised on crown…….showed him cracks…..( it was a cracked tooth kind of day)……..

Tooth not bothering him but he is booked for crown…..photos sold the crown prep which he obviously needs.

Glenn

June 5, 2003 at 2:17 pm #7422 Reply

Lee Allen
Spectator

Glenn,

Wild endo. While I realize that not all cracks are created equal and some of the most innocent looking will involve the pulp, I infer from the answer that the lack of cold sensitivity cannot be construde as an indicator that the crack is a minor leak requiring only a conservative laser prep and fill.

My patient is returning today (day 5 post op) because it is annoying her. I was hoping for a definative answer other than endo, however that is still on the DD list. I will recheck the occlusion, test with the tooth sleuth and refill looking for a crack, perhaps one that was caused by composite shrinkage.

So, how long before your patient with the dual cracks and no thermal sensitivity recovered from sysmptoms?

Inquiring minds want to know.

June 5, 2003 at 2:27 pm #7407 Reply

Glenn van As
Spectator

You Know Lee this is an interesting question……..

I havent heard back from the fellow with the dual cracks but they werent very deep at all.

I find cracks that run Mesial to distal ( the endo tooth) are bad ones and often involve endo……

In general if the patient has significant cold and hot sensitivity AND Chewing sensitivity I tell them that they are probably looking at endo + crown.

IF they have just chewing sesitivity then I tell them they MAY need endo but there is a good chance that only a crown ( or a restoration if the crack is small) will be needed.

One good thing with the scope is the ability to document these cases……..its wonderful to show the patient the crack..helps medicolegally.

I have found that some patients live with the chewing discomfort and chew on the other side while others just cant handle it.

I have tons and tons of these cases documented and Dr. David Clark has written an article for the Journal of Esthetic and Restorative Dentistry magazine that attempted to classify these cracks BEFORE they become endstage and symptomatic…….

The scope is awesome for endo , decay detection, cracks, placement of margins , crown inserts, laser dentistry (seeing how far the tip is away from the tooth, troughing on crowns effectively) just to name a few things off the top of my head.

Cracks are tough to treat at the best of times but I would strongly suggest adjust the occlusion once, remove the restoration put a temp in if you wish but patients want results and they want the pain to go away. Being able to show them the cracks and head in the right direction …….(crown +/- endo) is at least heaing them there.

Let us know how your case ends up……..hopefully it is a simple solution but unfortunately it isnt always.

One last thing……its amazing to see how many teeth crack after the bur enters into the occlusal pits…..not always polymerization shrinkage………I have seen this with my own eyes with crosscut fissure burs on occlusals.

Like a lightning storm……………

Good luck with your patient……

Glenn
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