Optimizing visualization and ergonomics. - Academy of Laser Dentistry

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JOUR NAL OF LASER DENTIS TRY | 2007 VOL 15, NO. 3 126 COVER FEATURE Figure 8: Views relating to cavity preparation and restorations illustrating the benefits of using magnification Figure 8a: Preoperative interproximal decay Figure 8b: Decay visible on distal aspect of first primary molar at high magnification, is a wonderful technique for treating epulis and tissue tags, as well as in the creation of ovate pontics for fixed bridges where the tissue can be “melted” away (Figures 7a-7d). Hard Tissue Laser Ablation and the Operating Microscope Leknius and Geissberger 55 as well as Zaugg et al. 56 demonstrated that, when magnification was incorporated, procedural errors in restorative treatment decreased significantly. In the latter study, the use of a microscope resulted in fewer errors than loupes. Utilizing conventional instruments, the clinician can rely upon tactile means from burs or hand instruments to determine when the carious lesion is fully excavated or when old restorations have been completely removed. These same tactile methods become more unreliable in hard tissue laser dentistry where so much of the evaluation of the laser-tissue interface is based on visual cues. Caries detection dyes Figure 8c: High magnification shows decay still visible on facial wall of box Figure 8d: Preparations completed are not easy to use and can produce false readings with hard tissue laser preparations (Figures 8a-8f). Moreover, erbium lasers can use both contact tips (where the actual distance for effective ablation is 0.5 - 1.5 mm from the surface) and noncontact delivery systems, and it is difficult to “feel” the ablation process. Therefore the use of high magnification is essential to determine when the preparation is complete. There are several more reasons to employ magnification for restorative procedures. A large amount of water is needed for effective and safe hard tissue ablation, but that amount of water can obscure good visualization. Where rigid contact tips are used to deliver laser energy, their clear color makes them difficult to see. They must have a nonchipped surface, and be held at the proper working distance from the target tissue, without tactile feedback. This optimum distance can vary with different instruments, but Figure 8e: Restorations finished ablation efficiency will significantly decrease as the delivery system is placed farther from the tooth. If the laser tip is brought into direct contact with the surface the cutting efficiency decreases, and the water flow is not able to wash away ablation byproducts and cool the tissue. Charring and patient sensitivity can occur. Enamel bevels for Class III, IV, and V restorations require the clinician to “scrape” or alter the ablated enamel prior to acid etching. High magnification with the operating microscope shows that enamel bevels have many loose rods which, if not altered with an instrument (hatchet or spoon, air abrasion or diamond bur), will yield significantly lower bond strength compared to bur-cut enamel. The fragments of enamel that are scraped off are easily visible under high magnification. The operating microscope is also an instrumental piece of the armamentarium for the ablation of bone. To prevent plucking or iatrogenic notching, it is best to use lower settings (1.5 - 3 Watts, for Figure 9: Laser beginning closed flap osseous contouring van As
Figure 10: Safety filter for use with various lasers Figure 10a: Nd:YAG (1064 nm) and erbium (2780-2940 nm) laser filter Figure 10b: Placing a diode (800-830 nm) laser filter in the microscope example), a noncontact mode, and a high water flow to prevent charring and necrosis. The amount of water and slight bleeding can obscure visibility, so the ability to increase the magnification during the procedure is imperative to success. Osseous crown lengthening to gain or re-establish biologic width can be performed with erbium lasers. The microscope is especially useful for closed-flap procedures so that the clinician can more accurately direct the laser energy and avoid iatrogenic troughing of the bone. Figure 9 shows the laser beginning closed-flap osseous contouring. It is therefore very beneficial for van As magnification to be used for many aspects of hard tissue laser dentistry. The higher the level of magnification used, the greater the ability of the dentist to directly view the laser-tissue interaction and to use the lowest possible energy and power to complete the procedure. This ultimately produces less patient sensitivity and better tissue health. Laser Safety Safety is of paramount importance to laser practitioners whether they are using no magnification, telescopic loupes, or higher levels of magnification. All dental operating microscopes have holders that accept wavelength filters for eye protection. As usual, the laser safety officer must ensure that the appropriate filter is in place, and the user must be sure to make close eye contact with the oculars to avoid the possibility of irradiation by accidental stray light. Assistants and patients must wear appropriate eye protection. Figure 10a shows a typical erbium laser filter and Figure 10b shows a filter being placed into the microscope. 2. Improved Ergonomics The operating microscope allows for the dentist to sit with an upright, neutral, and balanced posture (Figure 2). This neutral and balanced posture obtainable with the D.O.M. has been discussed as being helpful in preventing ergonomic issues that plague so many dentists and seem to be an occupational hazard. 57-60 3. Ability to Capture Digital Documentation The D.O.M. can be a beneficial addition in documenting a clinical case, especially because of the detailed image (Figure 3), whether still or video. Carr, 61 Behle, 62 and van As 63-64 have written articles discussing the merits of digital documentation with the D.O.M. and the advantages of doing so. COVER FEATURE 4. Enhanced Communication through Integrated Video Dentists who have added video capability to the microscope have found it useful in providing information to both patients and to auxiliaries since they can observe treatment in real time. 65 Clinicians have found that the images from the operating scopes are a benefit to educating their patients about treatment needs and help in persuading patients to accept treatment plans. The use of video transmitted to different monitors in the operatory has initiated the possibility of working solely from a monitor, a method some surgeons now employ. The next improvement will be the development of three-dimensional displays. 65 CONCLUSION The operating microscope used for laser dentistry provides benefits for any clinician. The advantages are improved precision, improved ergonomics, ease of documentation, and the ability to more fully communicate with patients, staff, and colleagues. Practitioners using the combination of the dental operating microscope and lasers have found that the two technologies work well in tandem and improve not only the treatment outcome but the enjoyment of providing it. AUTHOR BIOGRAPHY Dr. Glenn A. van As is a 1987 graduate of the University of British Columbia Faculty of Dentistry who maintains a full-time private dental practice in North Vancouver, British Columbia, Canada. His areas of interest and expertise involve the utilization of the dental operating microscope for all of his clinical dentistry and in the use of multiple wavelengths of hard and soft tissue lasers for many procedures. Since 1999, he has lectured more than 200 times internationally, provided hands-on workshops, and published internationally on the value of JOUR NAL OF LASER DENTIS TRY | 2007 VOL 15, NO. 3 127
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Optimizing visualization and ergonomics. - Academy of Laser Dentistry

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