Using High Magnification Changed My Treatment Plan By: Glenn van As, BSc, DMD

I use a microscope for most of my dentistry and often I’m able to practice at 10-16x power. This gentleman patient had a ton of food getting caught between the last two molars and an overhang on the amalgam which I did back in 1993 (pre-scope).

I prepped the first molar for the crown with the intent of smoothing out the overhang and after I had done that I noticed decay on the lingual of the box. The crown and the smoother amalgam were going too close the interproximal contact.

Once the prep was completed and I had smoothed out the amalgam I noticed marginal leakage on the lingual part of the mesial box. Seeing this, I decided to replace the amalgam. The scope saved me from having to replace the amalgam in 6 months and having another open contact with resin when I replaced it.

I find I am doing a lot of work like this now and in addition with the documentation possible with the scope, patients never complain, “Hey, how come you fixed two teeth, trying to make more money?”

Laser troughing with the Argon (waiting for my diode laser) and provisional done for the first molar (Fig. 3). Direct composite on the 2nd molar.

One error on my part was that I left some decay (Fig. 9). It’s amazing how you can become so focused on one part of the tooth with the scope you miss a small spot of decay in another, like on the DL cusp tip. I will pick that up at the insert appointment for the crown.

		Figure 1: Pre-op Bitewing radiograph
		Figure 2: Notice the open contact
		Figure 3: After troughing with the argon laser
		Figure 4: Note the distal margin on the 1st molar and the overhang on the mesial on the 2nd molar
		Figure 5: Here the overhang is smoothed off. View the decay
		Figure 6: Decay around amalgam on the 2nd molar at 16x magnifiaction
		Figure 7: The decay at 24x
		Figure 8: The prep is nearing completion
		Figure 9: The resin is complete. Oops, missed some decay. Will get that at the crown insert.
		Figure 10: Medium magnification of both teeth
		Figure 11: Impression viewed at medium magnification
		Figure 12: Temp at 10x magnification
		Figure 13: Both teeth completed
		Figure 14: High magnification view of completed teeth

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Glenn has been on the faculty of the dental school as an assistant clinical professor in both the faculties of Oral Medicine and Operative and Prosthodontic sections. He has been an active member of the admissions committee for the dental school.

An active member for many study clubs in orthodontics, prosthodontics and endodontics, he has strived to continually improve his knowledge about all areas of clinical dentistry. Since 1998, Glenn has been practicing all of his restorative dentistry through the surgical operating microscope.

Glenn can be reached by email at: glennvanas@shaw.ca.

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Townie Comments on Glenn van As' Case Presentation

When Dr. van As presented this case online at www.dentaltown.com, questions were immediately raised. If you would like to see all of the comments on this case, or perhaps add some of your own, go to the DentalTown’s homepage, click on Today’s Active Cases and sign in (it’s FREE). This case is listed in the Restorative category as: glennvanas A case where high magnification helped me.

cavogel 8/30/2002 3:57:23 PM		If this was my mouth and you do this quality of care, I would want the option to have composite on 1st bi crowns on 2nd bi, 1st, and 2nd molar with possible RCT on 2nd molar. At least educate me. Inform before you perform. BEAUTIFUL WORK!
glennvanas 8/30/2002 6:19:25 PM		Hi Cavogel, thanks for the kind words and your point is well taken. Personally, after 15 years of practicing dentistry I am going through a re-evaluation of where I have been and where I am going. Your idea about the resins and the crowns is well thought out and probably the ideal. To this point I have been guilty of treating in small amounts rather than one arch, or one quadrant or full mouth. The reasons are numerous, but in reality part of it is due to my busy practice, and part of it due to my dental education and finally, some is due to the way I practiced for so many years prior to the last 5 with the scope. I think your idea of restoring the whole arch is well taken, and I am sure that eventually I will get to the same point you have mentioned, probably piece by piece and that may not be the ideal way to go. You’ve got me thinking.
babysilvertooth 10/27/2002 7:19:29 PM		Very nice presentation. What you found on the 2nd molar, the decay and open margin, imagine all that we are missing without microscopes, much less loupes! Makes me shudder to think of all the open margins on old amalgams and the decay at those areas! I use loupes and everyday, am amazed at what I find! Good job, let’s hope we are all heading in this direction.
glennvanas 10/28/2002 8:14:35 AM		Five-and-a-half years ago when I bought my first scope, I bought it to try and improve the quality of my work. I didn’t realize how powerful a documentation tool or marketing tool (showing the video from the procedure live) was. Suddenly, ergonomically I was sitting better and my neck stopped hurting at the end of the day. I too was wearing loupes before but it didn’t seem to help with my posture. Cases like this one are simple every day occurrences but it’s amazing how often I catch things now that I wouldn’t have seen before. Now, I don’t replace every amalgam I see, but it’s really amazing to see holes under adjacent restorations and around them.
doctored 10/29/2002 12:42:11 AM		Just curious Glen, aside from the talk of complete quadrant care let’s focus on the two teeth you treated. I personally think the first molar would have been better treated with an onlay. It’s a less aggressive treatment with better esthetics and less compromise of the gingival tissues. Also, your ability to follow-up post operatively with radiographs is better. No laser troughing needed to capture an impression. I like that you use a scope. I am going to get one soon. What kind do you use?
glennvanas 10/29/2002 7:45:58 AM		Hi Doctor Ed, I think you might be correct in saying that an onlay would have been better. I will say though, in my experience, porcelain onlays are more difficult to establish esthetic margins (particularly on the buccal) compared to a full coverage. I am guilty of not doing enough partial coverage restorations. Another problem is getting the dental plans here to pay for partial coverage onlays for a lot of reasons that are stooped in history. Full coverage isn’t as big a deal. It’s a long story based on the fact that onlays used to be paid under basic care percentage instead of crowns and so it got abused and now it’s still tough to get an onlay approved. As for the scope issue...I use a Global scope. They are made in St. Louis and the customer support and service is fantastic. Zeiss makes a good scope and there are other manufacturers including Seiler, Jedmed, Moller to name a few. Look at them all.
doctored 10/30/2002 11:19:43 PM		I disagree with the esthetic concerns. I think the esthetics of an all ceramic fully pressed onlay far exceed the PFM crown. I rarely place full crowns. As far as insurance coverage goes if I am covering all the cusps I see it like this. I place all ceramic crowns with supragingival margins if that’s a help with the insurance issues. I like your efforts to find usage for the laser and I hope you are not offended by my conviction to place partial coverage. I have several in my own mouth and I am glad that I “forced” my friend to do them. He thinks full coverage is the way to go. I am still working on him too.
glennvanas 10/30/2002 11:26:41 PM		I never have a problem with constructive criticism or differing viewpoints. I think you have a valid idea. I looked yesterday at a case here at www.dentaltown.com which showed a cuspal fracture. Treatment plans were so diverse from a CEREC to an MODL amalgam. Neat to see the variety, and your partial coverage crowns have a definite place. By the way, my opinions only come from the odd cases I have done. I don’t like doing inlays unless they are very small, almost always cover the cusps and am guilty of prepping full crowns more often perhaps than I should. I know that sometimes I miss a crack and then the tooth is sensitive. Bottom line is I should look at partial coverage more often than I do, and I will look at it more often now.

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