Townie Clinical: Keeping Focused On The Finish Line… By: Michael J. Melkers, DDS, FAGD

From a clinical standpoint, dentistry has never been in a better position than it is today. As clinicians, we are able to offer our patients treatment options for better dental health than have ever existed before. These advances are evident in all phases of care. For example, chemotherapeutics can prevent, as well as reverse, disease processes; laser and imaging diagnostic tools allow for diagnosis of incipient decay before it is visible clinically or radiographically, allowing for early and conservative intervention. With electric handpieces, micro-diamonds, kinetic and laser tooth preparations to biomimetic restorative materials, chairside fabricated indirect restorations and increases in strength, aesthetics and longevity of direct restorative materials, we are truly in the midst of the platinum age of dentistry.

As practitioners explore and embrace these new treatment options, discussions can turn to debates and even arguments about which treatment is better. Which treatment is best? On the Dentaltown.com message board, comments have even been made by some that using the latest technology will make one a better dentist than those who are not using it. Malpractice has even been inferred by others regarding not using one or more of the newer technologies available. It is disappointing that some dentists get so focused on the method, they lose focus on the actual goal of treating the patient.

The following case outlines the use of both traditional and progressive technologies in a patient’s treatment.

A 23-year-old female patient presented with overwhelming concerns of advanced and progressing decay and failing restorations. Her friends and family members had experienced pain and tooth loss and, while she was financially challenged, she was committed to avoiding the same.

Clinical examination revealed extensive cervical decalcifications, cervical caries and numerous failing restorations. Following a discussion of the clinical findings, the patient outlined her chief desires concerning treatment. First, she wanted to prevent the worst of her decay from progressing to root canal therapy or tooth loss. Even at her age, she had already needed root canal therapy and was committed to avoiding it in the future.

Her second chief desire was preventing additional decay. Following initial hygiene therapy, the patient was provided with an at-home regimen of fluoride gel (Fluoridex, Discus Dental) as well as Recaldent containing paste (PROSPEC MI Paste, GC America) to not only prevent future decay but to reverse incipient lesions and decalcifications.

The patient’s immediate concern was addressing the lower right area (Fig. 1). Aside from experiencing sensitivity to cold and sweets in this area, the patient was very concerned with the extensive visible decay. Following local anesthesia and Isolite isolation, initial caries removal was accomplished with an erbium chromiam ysgg laser (Waterlase, BIOLASE Technology, Inc.) using a G4 tip at 3.5 watts, 95% water and 65% air. This allowed for precise cavity preparation without disturbing the tissue, as there was a concern with the gingival extent of the decay and isolation (Fig. 2).

Once the initial cavity preparation had been outlined on the buccal surface it was apparent that some removal of soft tissue would be necessary for visualization of the margins and placement of the restoration. Again, the laser was used with a T4 tip at 1.5 watts, 11% water and 7% air for removal of the sulcular crest for restorative visualization (Fig. 3). Subsequent troughing was accomplished using the same settings and the G4 tip to ensure clean access for placement and finishing of the restorative materials (Fig. 4). This was followed by scaling of tissue debris from the buccal root surface. While this may have been a slight violation of biologic width, the goal of initial caries control was accomplished without the additional expense of surgical crown lengthening. While traditional methods, such as a surgical blade or electrosurge could have accomplished the crestal gingivectomy, the troughing was best accomplished by the laser while maintaining a blood-free field.

The occlusal surface was prepared next. While a 10-year-old occlusal sealant appeared intact, extensive decay was visible around the sealant and in the underlying enamel. While the preparation was started with the laser (G4, 3.5 watts, 65% water, 35% air), the extensive decay was more efficiently removed with traditional round burs and micro-diamonds (Micro Prep System by Dr. William Mopper, Brasseler USA). The traditional burs allowed for two advantages over the laser. The traditional burs could be utilized to access undercuts while maintaining the integrity of the remaining occlusal enamel. The traditional round burs also allowed for tactile sensation during excavation. In combination with a caries disclosing agent (Caries Detector, Kuraray), deep and complete caries removal was possible with out mechanical exposure to the pulp chamber (Fig. 5).

In such extensive preparations, some have questioned not only the quality but the actual ability to consistently bond to deep dentin. Aside from the depth of cure required due to the limited access of the curing light, the deleterious effects of the arrangement of dentinal tubules has been brought up on the Dentaltown.com board and in literature. In such cases, the use of a traditional glass ionomer may be preferable. In the case presented here, the dentinal surfaces of the occlusal preparation were coated with polyacrylic acid (Dentin Conditioner, GC America). The acid was then rinsed, leaving a moist dentinal surface. The dentinal structure was then replaced from a biomimetic approach with traditional, autopolymerizing glass ionomer (Fuji IX, GC America) (Fig. 6).

Traditional carbide burs were also used on the buccal preparation to remove any remaining caries and expose sound healthy dentin. Once again, while the preparation was quite deep axially, the tactile advantage of the traditional round bur was used to avoid a mechanical exposure (Fig. 7). In the buccal preparation, following dentinal conditioning, traditional glass ionomer was again applied. Moisture control, as well as the ability to achieve a quality bond to cervical dentin have been brought up as concerns in such restorations. Recurrent decay at the cervical margin can also be a concern. In such situations the use of an “open sandwich” technique has been advocated to provide the advantage of fluoride reuptake through the exposed surface. The glass ionomer covers the entire dentinal surfaces and is extended down to the gingival margin (Fig. 8).

The glass ionomer was then finished back and bevels placed on the exposed enamel margins of the preparation. Light bleeding was noted from the finishing procedure. Using an infuser tip, a hemostatic agent was applied in scrubbing motion to the bleeding surfaces (ViscoStat, Ultradent) (Fig. 9) and rinsed with copious amounts of water.

The preparations were then etched with phosphoric acid for 15 seconds and rinsed. A single-bottle bonding agent was applied (OptiBond Solo, Kerr) for 15 seconds. The solvent was evaporated for 15 seconds with light air, air thinned, and then cured. The preparations were then restored with a microhybrid composite (Gradia Direct, GC America). Finishing was accomplished with rotary disks (FlexiDisc, Cosmedent), finishing cups (Enhance, Dentsply) and rotary instruments (Fahl Finishing Kit, Axis). The final polish was achieved with diamond impregnated bristle polishing brushes (Jiffy Composite Polishing Brush, Ultradent) (Fig. 10 & 11).

Using a combination of progressive and traditional approaches to treatment, we were able to accomplish the patient’s goal and provide a long-lasting, functional and aesthetic restoration. That is what is important after all, not how we chose to get there.

Dr. Melkers is a 1994 graduate of Marquette University School of Dentistry and practices general dentistry with his wife and partner, Dr. Jeanine McDonald in Spokane, Washington with an emphasis on comprehensive and restorative care. Drs. Melkers and McDonald regularly present lecture and hands on programs on direct composite artistry and other topics in the United States and abroad. Dr. Melkers can be contacted at drmelkers@aol.com or www.MichaelMelkers.com.