Lasers and CEREC - Laser Dentistry Forum

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August 30, 2004 at 5:24 am #2948 Reply

kellyjblodgettdmd
Spectator

I wanted to share a case I did this last week and get feedback. It’s not a “conventional” case, whatever that means. Please share your thoughts.

By the way, I just tried to post this damn case on dental town. I can’t figure that place out!

Case description: I patient had come to my office w/ complaints of a “filling” falling out. In actuality, he had had RCT done on #28 and a build-up placed, and never had a crown or onlay placed. Due to scheduling conflicts this patient desired having the tooth restored in one visit. The RC needed re-treatment, a post & core was needed as well as gingival recontouring on the distal where the build-up had come out and some sort of crown or onlay to unify the stresses to the coronal aspects of the tooth.

The gingivectomy was performed w/ an Er,Cr:YSGG laser at 1.0W (30/15) for bulk reduction and 0.75W (11/7) for hemostasis. Final hemostasis was achieved w/ a 810nm diode, 0.8W continuous mode w/ initiated tip. The root canal was re-treated using chloroform & NiTi rotary instruments and finished w/ the Z-2 tip on the YSGG laser at 1.25W (34/24) used in a circulating fashion on the outstroke. No power delivered on the instroke. This greatly assisted in opening the last one millimeter of the canal, which was blocked to conventional instrumentation (#6, 8, and 10 files). The post-op X-ray shows the small amount of sealer and warm GP filling the lateral canals. A CEREC post/onlay restoration was created and bonded to the tooth w/ Variolink. The patient only occludes on the buccal surface of #28, leaving the CEREC post/onlay out of occlusion. The whole case took less than two hours. The patient was greatly appreciative of the succinctness of tx.

Kelly

August 30, 2004 at 5:28 am #7502 Reply

kellyjblodgettdmd
Spectator

By the way, sorry no post-op X-ray w/ restoration cemented. I asked my assistant to take a “final X-ray”. She said, “I already did.” So I said great! I had to leave to do an exam right before I did my final polish. Unfortunately, she thought I meant the final RCT X-ray, not the post-cementation X-ray. I’ll have to get it when I see the pt. next time. You guys ever experience communication barriers? (Rhetorical question, I know!)

Kelly

August 30, 2004 at 2:31 pm #7511 Reply

N8RV
Spectator

Kelly, it looks great!

However, I do have one elementary question. Why did you not opt for a full-coverage restoration? The inlay doesn’t offer any cuspal protection, and I think I’d be concerned that the patient will come back in a couple of years with the inlay in his hand and a vertical fracture of the remaining tooth structure.

I have little faith in bonding agents adding significant strength to brittle teeth, as you can tell from my question.

As for office communication, we have zero problems. My staff, as in most offices, is composed of women. I’m from Mars, they’re from Venus (or is it the other way around?). They stay on their planet, I stay on mine.

— Don

August 30, 2004 at 4:13 pm #7503 Reply

kellyjblodgettdmd
Spectator

Don – it’s a good question. Here’s my thinking: How many times have you seen a tooth like this that’s had an amalgam post and build-up that hasn’t been restored with a crown, yet the tooth is intact. I believe that in keeping as much natural tooth structure as possible, and re-unifying the coronal enamel with a bonded ceramic restoration this tooth will last a very long time, particularly considering the occlusion.

It’s hard to imagine that he’ll fracture the mesial marginal ridge when he doesn’t occlude on the occlusal table.

Another thought about bonding materials is this. How much should be expect of bonding agents when we constantly place composite restorations that place the bond in a tensile loading situation. If proper C-factoring isn’t considered, the walls of the prep will be loaded in a tensile fashion, which always leads to bond failure.

With this CEREC restoration, there is only a 60 micrometer gap between the restoration and the tooth. The amount of shinkage created with the resin cement is negligable which placed very little tensile load on the bond. This bond is much more likely to last long term.

Just my thoughts.

Kelly

August 31, 2004 at 3:32 am #7507 Reply

whitertth
Spectator

Kelly,
Beautiful case and great documentation…Nice Job!

August 31, 2004 at 6:03 am #7508 Reply

ASI
Spectator

Hi Kelly,

Are you sure you are just a few years out of school? Great treatment and excellent result.

Andrew

August 31, 2004 at 6:36 am #7505 Reply

mickey frankl
Spectator

Great result!
As a cerec and laser user I agree with your explanation for preping an Inlay.

Can you detail the endo section please?
Thanks
Mickey

August 31, 2004 at 6:48 am #7510 Reply

Glenn van As
Spectator

Kelly, a very interesting case and well documented. I enjoy seeing how people are using their lasers, not maybe to replace traditional means (heck there are alot of things that we are doing now that are wonderful) but as an adjunct to traditional means of practice.

This was a neat combo of treatment and something I think really offered the patient a service.

Thanks for putting it together Kelly , it was a neat case.

CLAP CLAP CLAP.

Glenn

August 31, 2004 at 1:38 pm #7506 Reply

Samuel Moss
Spectator

Kelly,

Awesome combo use of laser technology, not to mention Cerec use. I guess you don’t sleep much with posting, practicing, raising a family, CE, etc.

My only concern was not covering the cusps, as his bite is anteriorly placed due to lack of molars, and I see fracture in his future. Only time will tell, and he may be a “rat” and all will be hunky-dory!

Thanks again for showing multiple uses of technology that we have in our hands today.

Mossman

August 31, 2004 at 2:32 pm #7512 Reply

arrowsmith
Spectator

Kelly,

Do any of your patients ask for any type of guarantee with these restorations? Either way, what do you tell them? Let’s suppose that this does fracture in . . . say . . . 2.5 years. Do you think any patient will come back and complain?

aaroN

September 1, 2004 at 10:21 pm #7504 Reply

kellyjblodgettdmd
Spectator

One thing I try to do is to show the patient all of the pictures I’ve taken so that they understand how much work went into the tooth. I also explain that the more a tooth gets reduced, generally the shorter life it will have. I emphsize that one a tooth has treatment initiated on it, its going to be a lifelong issue of management.

My general rule is that if a patient is making their regular recalls and something of mine falls apart, I’ll fix it at no charge. But if they are not a “regular attender” or their a pain in my a-s, they may get charged. Honestly, though, I don’t see this case faililng due to fracture. Obviously, a great deal of why I say that is because have the patient here and can see his occlusion.

If this forum’s still around in 5 years, I’ll post this case again to see where he is.

Kelly

September 2, 2004 at 12:56 am #7509 Reply

Benchwmer
Spectator

Kelly,
Wonderful case and presentation.
I agree with you on tooth preservation, once it’s gone its gone.
My normal restoration for indirect cases are lab composite onlays, I do not cut down healthy tooth to cover cusps, you need to believe in bonding and balanced occlussal forces. After 12 years I still believe, but occasionally a cusp will fracture, I repair a non-functional cusp or I give the patient credit towards the crown (maybe a handful in those 12 years).
Why not the Nd:YAG to retract the gingiva, better hemostatis?
Thanks for sharing.

Here is a photo taken last month of a Concept Microfill Onlay #3, I know the MB and DL cusps weren’t shoed only bonded, but this was placed in 1992.
Jeff

September 21, 2004 at 1:43 pm #7501 Reply

emc85
Spectator

kelly

awesome!!!

i am close to that cerec decision…what was the milling time?

i agree with you wholeheartedly with full crowns even on endo teeth. with the bond strengths now, i do very few crowns. they look nicer, fewer adjustments, and you save a heck of a lot of tooth.

good job!
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