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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 113-116

Management of cracked maxillary first molar with erbium-doped yttrium aluminum garnet laser

Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India

Date of Submission04-May-2022
Date of Acceptance03-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Supriya Gupta
Floor No-3, Room No-6, Faculty of Dental Sciences, Institute of Medical Sciences, BHU, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_12_22

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Treatment and diagnosis of fractured teeth present a big challenge to dentists. Treatment of traumatized teeth can be done with reattachment of a dental fragment both in simple and complicated coronal fractures. A 28-year-old male patient came to our department with a traumatic crown fracture of the permanent, left maxillary molar. The patient complained of pain upon mastication, and on examination left maxillary second molar has a fracture line extending in a mesiodistal direction. Partial pulpotomy with the help of erbium-doped yttrium aluminum garnet (Er: YAG) laser was done to relieve symptoms and to reduce microleakage and increase strength, the fracture line was sealed with the help of Er: YAG laser. The cavity was then sealed with biodentin and composite. For these types of cases, Er: YAG laser is used for biostimulation of exposed pulp, and also to improve strength and reduce microleakage through sealing of fracture line.

Keywords: Erbium-doped yttrium aluminum garnet laser, partial pulpotomy, reattachment

How to cite this article:
Mittal N, Gupta S, Gupta S, Shankari T. Management of cracked maxillary first molar with erbium-doped yttrium aluminum garnet laser. J Interdiscip Dentistry 2022;12:113-6

How to cite this URL:
Mittal N, Gupta S, Gupta S, Shankari T. Management of cracked maxillary first molar with erbium-doped yttrium aluminum garnet laser. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Feb 5];12:113-6. Available from: https://www.jidonline.com/text.asp?2022/12/3/113/365606

   Clinical Relevance to Interdisciplinary Dentistry Top

This article focuses on merging the benefits of Er-YAG laser with conventional pulpotomy in the treatment of Cracked Maxillary First Molar.

   Introduction Top

Dental traumatology has a multidisciplinary dental profession that requires a number of specialized skills. In emergencies, decisions should be made over a limited period of time and the results should only be evaluated at a later date.[1] Cracked and broken teeth are presented with a diagnostic dilemma. Early diagnosis and management will lead to better chances to save the tooth. Gibbs, in 1954, first coined the term "Cuspal fracture odontalgia" to describe cracked teeth. The most common cause of an incomplete fracture is masticatory or accidental trauma. Excessive load generated due to unintentional biting on a very hard object may suddenly cause the tooth to crack.[2] Reattachment can be done both in the case of a simple coronal fracture (enamel and outer dentin) and of a complex coronal fracture (deep dentin with pulp exposure).[1]

Laser therapy provides a number of benefits in terms of bleeding control, the absence of mechanical contact, and the stimulation of regenerative cell lines in the dental pulp. The reduction of bacteria in human tissues was observed after the application of the laser.[3] Based on these factors, some authors have claimed significant benefits of the use of laser over conventional techniques for pulp therapy.[4] Because of its affinity for water and hydroxyapatite, Er: YAG laser technology allows for the efficient ablation of hard dental tissues.[5]

Maintaining the vitality of an affected tooth is the main purpose of vital pulp therapy. Depending on the extent of pulpal involvement, pulp therapy may include pulp capping or pulpotomy procedures.[6] Pulpotomy therapy aims to maintain the vitality of an affected tooth by removing the coronal portion of the infected/inflamed pulp while the radicular region remains healthy.

We presented a case report on treating fractured teeth using Er: YAG lasers to improve strength and reduce microleakage while maintaining the vitality of the tooth.

   Case Report Top

A 28-year-old male patient reported to the department of conservative dentistry and endodontics with a traumatic crown fracture of the permanent left maxillary second molar for 2 days. The patient had a complaint of pain on mastication and sensitivity to cold. On examination, the patient had a fracture line extending in the mesiodistal direction in the coronal region of the left maxillary second molar [Figure 1]a. A translumination test with the help of light-emitting diode curing light was done to see the extent of the fracture. There was no displacement of either fragment along the fracture line that divides the coronal portion in the middle third into buccal and palatal halves. The vitality of the tooth was done with the help of a cold test (Coltene endo frost) and heat test. The tooth showed a positive response to both thermal tests. On radiographic examination, no changes were seen periapically and no fracture line was evident [Figure 1]b. A provisional diagnosis of noncomplicated crown fracture was made.
Figure 1: (a) Pre-operative image, (b) Pre-operative IOPA, (c) After sealing with SDR, (d) Partial pulpotomy with Er-YAG laser, (e) Post-operative image after composite restoration, (f) Post-operative IOPA, (g) IOPA after crown placement (h) 6 Month follow-up. SDR=Smart dentin replacement, Er-YAG=Erbium-doped yttrium aluminium garnet

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On the first visit, the isolation of tooth was done with the help of a rubber dam. The fractured segments at the fracture site were etched with 37% phosphoric acid for 15 s. Both the tooth fragments were separated with the help of explorer so the etchant and other agents can flow inside. Then, the etchant was rinsed, tooth was gently dried, and a universal bonding agent was applied to both the separated fragments and cured. Then smart dentin replacement (SDR) flow+ (Dentsply Sirona USA) was used to bond the two fragments as it can be cured to a greater depth [Figure 1]c. Then a band was applied to secure the tooth. The patient was recalled after 1 month. Patient-reported no improvement in symptoms and the tooth showed hyper response on thermal testings (both heat and cold).

Partial pulpotomy with the help of erbium-doped yttrium aluminum garnet (Er: YAG) laser was performed. In addition, microleakage was reduced by sealing the fracture line with an Er: YAG laser. Lignocaine with 2% adrenaline (1;80,000) was used for local anesthesia before treatment isolation was done with the help of a rubber dam. The cavity was prepared using a high-speed rotary instrument under a water coolant. The exposed pulp tissue was removed to a depth of 2–3 mm using a high-speed handpiece and a sterile #2 round carbide bur (Mani, Japan). In the exposure area, bleeding was stopped within 5 min after the application of 5.25% sodium hypochlorite. Before laser application, the patient and the dentist put on safety glasses. After bleeding was controlled in the exposure area, the Er: YAG laser was applied with a cylindrical sapphire tip (diameter 1.3 mm, length 8 mm). Er: YAG laser (Fotona, Slovenia) of 2940 nm, 30 mJ, 50 Hz, 1.50W, SP mode, 300 μs pulse duration with air/water spray (3:6), and H14 Handpiece (angle of 90°) parameters were used. This was done for 10 s, and this procedure was repeated thrice [Figure 1]d.

In the same visit, the visible fracture line, after access opening, was also resealed with the help of Er: YAG laser at different settings of 2940 nm, 150 mJ, 10 Hz, 1.5W, 100 μs pulsed duration. Then Biodentine (Septodont, USA) was prepared and placed over pulp according to the manufacturer's instructions. After its complete setting, coronal restoration was done with the help of resin-modified glass ionomer cement (GC Fuji II LC) and composite resin [Figure 1]e and [Figure 1]f. After 1 week, the patient was delivered with a permanent stainless-steel crown. This was done to further secure the joined fragments [Figure 1]g.

A follow-up visit was performed at 6 months to examine and determine the vitality of the tooth [Figure 1]h, which showed a normal and positive response to the cold test as compared to the control tooth. The patient also showed improvement in symptoms and tenderness on percussion was absent. The limitation of this case was that follow-up period was only 6 months.

   Discussion Top

Incomplete tooth cracks usually run in a mesiodistal direction (81.1%). Horizontal, vertical, or orovestibular cracks are seen rarely. These cracks are either limited to the crown or may progress to the root. Important diagnostic evidence is a sharp pain on chewing hard substances. It is hypothesized that this short and sharp pain is generated by an alternating stretching and compressing of odontoblastic processes located in the crack.[2]

Following a correct diagnosis and appropriate pulpotomy technique, high emphasis has been placed on the final restoration, which seals the tooth from microleakage.[7] Decontamination, hemostasis, coagulation, and biostimulation are the main benefits of laser therapy on the tissues suggested by various authors in vital pulp therapies.[3],[8],[9] It contributes to the construction of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp.[10] Various studies concluded that the pulpotomy with laser showed better integrity of the odontoblastic layer; a lower number of odontoclasts; and less hemorrhage, inflammation, internal resorption, tissue necrosis, vascularization, and abscess formation when compared with formocresol.[11]

In the treatment of partial pulpotomy, the status of bleeding in the exposure area is important because it provides information about the health of the pulp. Prolonged dark red bleeding is indicative of infected pulp. If the bleeding cannot be stopped in 10 min, then it can be assumed that the coronal pulp is infected and should be removed. According to Webber, if pulpal bleeding lasts longer than 5 min then the pulp is irreversibly damaged.[12],[13]

Er: YAG laser technology has an affinity to water and hydroxyapatite, which allows for efficient ablation of hard dental tissues.[5] The wavelength of Er: YAG laser has an antimicrobial decontamination effect which leads to the destruction of both aerobic and anaerobic bacteria.[14] The fracture line which was visible in the access opening, was sealed with Er: YAG laser. Sealing of the fracture line will increase bond strength and reduce microleakage, which provides a bacterial-tight seal.[15]

   Conclusion Top

In addition to biostimulation on exposed pulpal surfaces and sealing of fracture lines, Er: YAG lasers improved bond strength which leads to a reduction in microleakage. The use of Er: YAG laser for such cases has a defined advantage of better healing of pulp, repair of fracture line with the increased bond strength, and reduced microleakage with better patient comfort and compliance.


Early diagnosis and management have better chances to save the tooth in cuspal fracture odontalgia

The Er: YAG laser bonds fracture segments together, resulting in improved strength and reduced microleakage

Decontamination, hemostasis, coagulation, and biostimulation are the main benefits of laser therapy.

Declaration of patient

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Andreason FM, Adreason JO, Tsukiboshi M, Cohenca N. Examination and diagnosis of Dental injuries. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth. 5th ed. United Kingdom: Wiley; 2018. p. 295-326.  Back to cited text no. 1
Mittal N, Sharma V, Minocha A. Management of cracked teeth-a case report. Endodontology 2007;19:39-44.  Back to cited text no. 2
  [Full text]  
Hasheminia SM, Feizi G, Razavi SM, Feizianfard M, Gutknecht N, Mir M. A comparative study of three treatment methods of direct pulp capping in canine teeth of cats: A histologic evaluation. Lasers Med Sci 2010;25:9-15.  Back to cited text no. 3
Bergenholtz G, Spångberg L. Controversies in endodontics. Crit Rev Oral Biol Med 2004;15:99-114.  Back to cited text no. 4
Fornaini C. Er: YAG and adhesion in conservative dentistry: Clinical overview. Laser Ther 2013;22:31-5.  Back to cited text no. 5
De Coster P, Rajasekharan S, Martens L. Laser-assisted pulpotomy in primary teeth: A systematic review. Int J Paediatr Dent 2013;23:389-99.  Back to cited text no. 6
Huth KC, Hajek-Al-Khatar N, Wolf P, Ilie N, Hickel R, Paschos E. Long-term effectiveness of four pulpotomy techniques: 3-year randomised controlled trial. Clin Oral Investig 2012;16:1243-50.  Back to cited text no. 7
Olivi G, Genovese MD. Erbium chromium laser in pulp capping treatment. J Oral Laser Appl 2006;6:291-9.  Back to cited text no. 8
Riccitiello F, D'Ambrosio C, Simeone M, Rengo S. Pulpotomia: Indicazioni,diagnosi,terapia. Dentista Moderno 2005:23-47.  Back to cited text no. 9
Tozar KN, Erkmen Almaz M. Evaluation of the efficacy of erbium, chromium-doped yttrium, scandium, gallium, and garnet laser in partial pulpotomy in permanent immature molars: A randomized controlled trial. J Endod 2020;46:575-83.  Back to cited text no. 10
Toomarian L, Fekrazad R, Sharifi D, Baghaei M, Rahimi H, Eslami B. Histopathological evaluation of pulpotomy with Er, Cr: YSGG laser vs. Formocresol. Lasers Med Sci 2008;23:443-50.  Back to cited text no. 11
Tan SY, Yu VS, Lim KC, Tan BC, Neo CL, Shen L, et al. Long-term pulpal and restorative outcomes of pulpotomy in mature permanent teeth. J Endod 2020;46:383-90.  Back to cited text no. 12
Bogen G, Chandler NP. Pulp preservation in immature permanent teeth. Endod Top 2010;23:131-52.  Back to cited text no. 13
Schoop U, Moritz A, Kluger W, Patruta S, Goharkhay K, Sperr W, et al. The Er: YAG laser in endodontics: Results of an in vitro study. Lasers Surg Med 2002;30:360-4.  Back to cited text no. 14
Fornaini C, Petruzzella S, Podda R, Merigo E, Nammour S, Vescovi P. Er: YAG Laser and fractured incisor restorations: An in vitro study. Int J Dent 2012;2012:617264.  Back to cited text no. 15


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