"Board Lesion"

[kellyjblodgettdmd]

As I was prepping this tooth last week with my Er,Cr:YSGG laser, I got to thinking about what we accept as the standard of care from our Regional Board examiners. Looking at this X-ray:

[img]https://www.laserdentistryforum.com/attachments/upload/classII7.JPG[/img]

I think that the national Board standard treatment would be to blow out the marginal ridge and place an alloy, a composite or if the patient is real lucky, a gold inlay based on G.V. Black prep design principles.

Looking at the tunnel prep design I used I can’t help thinking that perhaps it’s time for a change. Not only did I save a significant amount of healthy tooth structure, but the patient had the procedure done without anesthetic. See prep:

I would love to hear other dentists’ opinions on what we require our new graduates to learn prior to graduation. Have lasers not been around long enough now to be used in schools. Love to hear opinions!

Kelly

[kellyjblodgettdmd]

By the way, that was tooth #13. Prepped w/ YSGG at 5.5W for anesthesia (60/30) 1cm away from tooth for 90seconds then through the enamel. Switched to 3.0W – 60/30 to remove dentinal caries. Finished w/ #2 SS round bur to verify caries all removed. Pt. extremely comfortable the whole time (20y.o. female)

Kelly

[Anonymous]

Restored with?

Kelly, where I always find myself being unsure on these is right under the marginal ridge. I find its hard to angle and know I’ve removed all the caries.I can see and feel toward the cervical but under that ridge..

I’m convinced that saving that marginal ridge is important to the long term health of the tooth.

Did you consider an approach from the buccal?

Maybe you and Graeme can offer some tips.

[kellyjblodgettdmd]

The prep was treated w/ 10% poly-acrylic acid, the Fuji IX was injected into the prep. I removed the excess Fuji IX w/ a Gregg 4-5, Etched w/ 37% phos. acid and sealed w/ unfilled resin. It was out of occlusion, so I’m not too worried about wear.

That’s why I like using a #2 or 4 round bur to get underneath the marginal ridge. I find it works well with the side cutting action and all. Many times I’ll verify w/ one of M. Colonna’s tiny spoons & caries indicator dye.

I hadn’t considered going from the buccal, but that may have worked, too. Either way, it beats the heck out of destroying a perfectly good marginal ridge.

Kelly

[dkimmel]

You sir would flunk the Fl boards. Heck they might even tar and feather you if you showed up with a laser.

The times are changing just very slowly in dentistry.

David

[kellyjblodgettdmd]

And unfortunately, the patients are the ones who bear the burden of such slow-to-change attitudes. David, I don’t think the thinking in Oregon is any different from Florida. It simplyl makes no sense. That’s it! I’m goin’ on a crusade! Minimally Invasive Dentistry or bust!

Kelly

[Benchwmer]

Hey Kelly,
Looks like what I would do. You need to use that #2 bur to verify caries removal.
Do you use a band interproximally during the laser prep?
to restore?
Are you going to the SLC? There is a presentation: Microdentistry for the Treatment of Caries and Periodontal Disease.

<img src="https://www.laserdentistryforum.com/attachments/upload/GVB#1A.jpg%5B/img

Which tooth prep would you want in your mouth?
The EM prep was done w/ Air Abrasion.

(Edited by Benchwmer at 9:56 pm on Aug. 23, 2004)
[img]https://www.laserdentistryforum.com/attachments/upload/GVB#1AA.jpg” border=”0″>
Jeff

(Edited by Benchwmer at 9:59 pm on Aug. 23, 2004)

[whitertth]

I have been doing these the same exact way…I wonder if u left a little decay under the ridge using fuji ix would it make a difference? I think we all try and be real careful but with these small preps i think only with a scope can we know for sure it is really clean…I’m not sure loupes are even good enough…Waht do u all think…If u left a little decay would it decay further or would the fuji retard the caries?

[kellyjblodgettdmd]

I think that it highly depends on the caries risk status of the patient. If they’re low risk, perhaps not. But if moderate or high risk, you’d definitely want to remove it all. But then again, if they were high risk, I probably wouldn’t be doing a tunnel prep either.

I will say that using the scope, I am able to see a lot more when doing these preps. Much easier on the back, too!

Kelly

[N8RV]

Kelly, the only thing that would make me nervous is being sure that the origin of the decay was soley from the occlusal groove. I’ve been fooled before opening lesions like these where there’s no evidence of proximal decay on the XR, only to find that, once the decay is removed, I can see the decalcification of the proximal enamel from the inside. That’s a pisser indeed.

Since buying the laser, I’ve discovered an entirely new world of small cavities out there. I was a devoted “watch and see” dentist, mainly because I’m rather low-key and hate to tell people they have problems.

However, after two decades of being burned by these little sticky spots turning into big holes, I’ve become a believer in detecting them early and fixing them while they’re small.

What can I say? I’m a slow learner. Small is good.

[ASI]

Hi All,

Case selection is still the key for these tunnel prep restorations, along with magnification of some sort and certain eradication of decay.

In the undergrad dental curriculum, the basic GV Black principles are still good operative foundation for cast gold restorations and dare I say amalgams. They are also important for the young dental clinicans to appreciate how the new materials and tools being used are changing the approach to decay treatment. In the world of composite resins and ceramics, whether it is microdentistry or macrodentistry, those hard and fast rules are certainly not so hard and fast anymore.

Good point to ponder, Kelly.

Andrew

[kellyjblodgettdmd]

N8RV – In case I wasn’t clear, I was treating this as a DO prep, realizing that the caries on the distal were evident on the X-ray. In this case, the enamel was deminerlized, but not frankly cavitated. In this case, I then don’t open up the enamel, but rather re-mineralize it with the Fuji IX. Hope that is a little more clear.

Kelly

[Samuel Moss]

Kelly,

I hope not to put water on a fiery topic, but I used to do ALL my posterior Class 2 bonded fillings like that…the old tunnell prep. Over the past few years, many of these are coming back to bite me in the butt. It seems that the marginal ridges on more than a few have broken off after a few years of wear. Maybe on those that have fractured, the ridge left behind was too thin. I don’t rightly know what it was, but I’ve gone back to taking out the marginal ridge when interproximal decay is present. Also, vision is better and I know that all the decay is gone (a few that had fractured presented with some decay further into the wall area). I use 6.0 powered loops and am really anal about being conservative in treatment.

So maybe ya’ll can tell me what I’ve been doing wrong if this never happens to anyone else.

Mossman

[kellyjblodgettdmd]

Sam – I agree that these can fail, and again I think that case selection is key. I can only go by theory, physics and physiology at this point since I’ve not been out of school too long, but I would think that if I’m not creating vibration in the tooth by getting throught the enamel with the laser and gently removing the last bit of decay with a round bur, then this should last a lot longer than a GV Black-style prep. Also, placing Auto-cure GI may help, as it doesn’t create the same type of stresses on the enamel during curing.

Of course, in the high caries risk patient, if the infection isn’t managed, everything fails.

Thanks for the comments, Sam.

Kelly

[whitertth]

Is the poly acryllic acid really necesarry… I have heard mixed things from diffrent clinicians and the company reps themselves…what is the consensus?

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