Hi folks: nothing earth shattering. Sometimes we get caught in a case. This 30 year lady had an occlusal restoration that was around 1.5mm into dentin on the radiograph (3.5mm deep) and I thought I might be able to remove it (she wanted it out for cosmetic reasons) and replace it with Gradia. One could try it without the use of the laser, and one could also use LA either infiltrated, or a block. This was just me trying an alternative method.

I asked her if she wanted to try it without anesthetic (local) and try the laser for analgesia. Mark Colonnas technique involves high settings defocussed so it doesnt interact with the tooth or amalgam at around 4-10mm away and leave it on 6-7.5 watts for 2 mins with water on . It doesnt cut but often provides some temporary analgesia not anaesthesia, that allows you to quickly remove the amalgam. Some will hold the laser close to the tooth in one hand and the highspeed in the other while cutting. The problem is I need another hand to take a picture with the scope then!!

Anyways after two minutes I removed the amalgam with a handpiece and alot of water being careful to remove the amalgam without touching the tooth much. I noticed decay around the amalgam on the distal, now was this distal decay not visible on the radiograph adjacent to the crown I had placed 3 years ago or recurrent decay on the occlusal. Only one way to find out. I used the laser and started to cut the decay only to find it increasing in size……..darn it all, on the distal.

No anesthetic at all so now my little occlusal is a moderate DO restoration. I placed an interguard in her tooth and tried to not break the contacts buccal and lingual just following the extent of the decay on the distal as an outline (theoretically this is the widest part of the decay as it hits the DEJ) and also realizing that most times the centre of the decay is at the contact buccal-lingually.

I removed the distal marginal ridge with a 600 micron tip at 30 Hz and 160 mj trying not to touch the dentin much. After I got into the contact area interproximally I reduced the energy so as not to cut drastically below the contact because this can easily cut the gingival soft tissue and start bleeding which isnt easy to control then. Its slower at the reduced settings of 30 hz and 80-100 mj but safer.

I then used a little round bur to confirm decay removal and the laser at the end to remove the smear layer. A tiny portion of the conservative prep cracked (visible with the scope) as the enamel was undermined and that was removed without clearing the interproximal contact Buccal and lingual on the distal of the tooth. Since the contact was not completely removed and the decay was removed. I kept the interguard in place which is slightly thicker. Traditional etch and bond , followed by Dyract Flow and then Gradia was placed and the patient was dismissed after the restoration was adjusted and polished. The evacuation and dry field was created through use of the Isolite, which for laser dentistry in adults is very effective.

THis just shows a case like we all see which starts out as a ….” no problem Miss Jones , this one we can do with the laser , its not that deep” to a hmmm……..is this going to be sensitive.

The patient is a former dental assistant and so that makes it all the more interesting as a little bit of knowledge can be dangerous and she knew it might hurt once I realized it was a DO.

Again, nothing to say traditional dentistry couldnt have done it similarly with equal results, just wanted to show the thought process behind this case.

Glenn