advanced proficiency case studies - academy of …...secondary tooth decay of composite filling at...

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

13

n this issue of Wave-lengths, we

will feature more clinical cases

from our Advanced Proficiency

candidates, who completed the exami-

nation process at the 10th

Annual

Conference in San Destin, Florida in

March 2003.

In each case, the Essential Elements

of the Clinical Case Studies checklist

was precisely followed and each point

adequately described, in written form

and during the oral presentations.

The Academy is very proud of these

doctors and their outstanding efforts

in achieving Advanced Proficiency.

I H I G H L I G H T S

Dr. Hiroshi Umemoto demonstrates theeffectiveness of using a pulsed Nd:YAG laserfor minor gingivectomy and gingivoplasty,and an Er:YAG laser for caries removal.

Dr. Itaru Yoshida uses a gated pulsed 810 nmdiode laser to perform a bilateral maxillaryfrenectomy and oral vestibular extension.

Dr. Mitch Lomke uses an 830 nm diodelaser for a gingivectomy, and both diode andcarbon dioxide lasers for a frenectomy.

Dr. Raleigh Holt performs gingival recon-touring, decay removal, and cavity prepara-tion with a pulsed Er,Cr:YSGG laser.

Dr. Douglas Gilio shows the effectivenessof performing periodontal surgery using acombination of an Nd:YAG laser and enamelmatrix derivative.

Advanced Proficiency Case Studies

Hiroshi Umemoto, DMDKawasaki, Japan

Itaru Yoshida, DDSTokyo, Japan

Mitchell A. Lomke, DDSSilver Spring, Maryland

Raleigh A. Holt, DMDOklahoma City, Oklahoma

Douglas A. Gilio, DDSVisalia, California

v2-Wavelengths Fall03 11/20/03 1:07 PM 3

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

14

Caries Removal, Minor Gingivectomy,and Gingivoplasty Assisted withEr:YAG and Nd:YAG Lasers

Dr. Hiroshi Umemoto graduated in 1979 from the Tsurumi University School of Dental Medicine in Yokohama, Japan. He received postgraduate training in periodontology from the Tokyo Medical and Dental University in 1979. He has maintained a private practice in Kawasaki since 1982. Dr. Umemoto incorporateduse of the Nd:YAG laser in his practice in 1993 and currently utilizes Er:YAG, argon and diode lasers. He is a director and accredited member of the JapanAssociation for Nd:YAG Laser Dentists. He received his Advanced Proficiency in the Nd:YAG laser wavelength at the 10th Annual ALD Conference in Destin,Florida. Dr. Umemoto may be reached by e-mail at [email protected].

Disclosure: Dr Umemoto has no financial relationship with any dental laser manufacturer.

PretreatmentA. Diagnostic Tests1. Clinical Examination

This is a case of a 50-year-old femalewith no significant medical history.Secondary decay was recognized inthe composite resin filling of the buc-cal sides of cervical sites of teeth #6,11, 21, 22, 27 and 28. One orthopan-tomograph and four X-ray imageswere taken. The health condition ofthe patient was good. There were noparticular comments about thepatient’s status (Figures 1 and 2).

2. Radiographic Examination

An X-ray examination of the con-cerned region showed normal trabec-ular pattern of the alveolar bone.There were no pathological findings.

Tooth #17 was impacted (Figure 3).3. Soft Tissue Tests

There was almost no bleeding due toprobing. The depth of the pocketsobtained by probing was slightly lessthan 4 mm for teeth #6, 11, 21, 22, 27and 28. (Figure 4).

4. Tooth Vitality

All teeth in the lower and upper jawswere tested for vital reactions using apulp tester.

5. Hard Tissue Tests

There were no loose teeth. Inspectionand probe examination revealed no

problems with hard tissue. Tooth #17was impacted.

6. Other Tests

Tests were conducted to evaluate theamount of gingiva to be removed. Arange which did not affect the biolog-ic width was measured by probing.The result indicated the possibilitiesthat the gingiva was cut in about 1 mm and recontoured.

B. Diagnosis and Treatment Plan1. Diagnosis

Secondary tooth decay of compositefilling at the cervical sites of teeth #6,11, 21, 22, 27 and 28.

2. Treatment Plan

Removal and recontouring of gingivausing an Nd:YAG laser for exposingand cleaning of decayed regions.Removal of decayed teeth using anEr:YAG laser and reconstruction usinga composite resin.

3. Possible Treatment Alternatives

Correction of the surrounding area ofgingiva by means of a conventionalmethod using an electric surgicalknife or surgical steel.

4. Indications for Laser Treatment

The Nd:YAG laser has excellent charac-teristics for cutting and coagulating softtissue. For example, it has the capacity toseal minute blood vessels of soft tissuedue to a photothermal effect. A clearfield can be produced due to the reduc-tion of bleeding. It reduces pain duringand after operation. The Nd:YAG laserproduces “sterilization” due to its wave-

Hiroshi Umemoto, DDSKawasaki, Japan

Figure 1: Preoperative view


Figure 3: Radiographic examination

Figure 4: Preoperative periodontal chart

v2-Wavelengths Fall03 11/20/03 1:07 PM Page 14

15

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

length characteristics. Therefore the pro-cedures can be done the same day ratherthan waiting for healing with surgicalsteel. The Er:YAG laser is excellent forcaries removal and tooth preparation.

5. Contraindications for Laser Treatment

Excess removal of gingiva due toimproper use of a laser device couldresult in serious gingival damage.Pointing the fiber of the Nd:YAG laserat the root surface causes new dam-age, and fixing the fiber on the gingi-va or irradiating the same spot withthe laser for a long time results inheat-build up and causes serious dam-age on the bone. The Er:YAG laser caninteract with both tooth and gingiva,so careful aim of the beam is impor-tant so that only the intended targettissue absorbs the laser energy.

6. Informed Consent

The dentist and patient discussedadvantages and disadvantages of lasertreatment as well as alternative treat-ment prior to treatment. Writteninformed consent was obtained foruse of the lasers.

TreatmentA. Objective

The treatment objective was to exciseand recontour the gingiva using anNd:YAG laser in order to expose and cleanthe decayed region with an Er:YAG laser,obtain a smooth finish line, and ease thereconstruction of the excised region usingcomposite resin.

B. Laser Operating Parameters1. Excision and recontouring of gingiva

Laser: Free-running pulsed Nd:YAGlaser (PulseMaster 600IQ, American DentalTechnologies, Inc., Corpus Christi, TX)

Wavelength: 1064 nmOutput: 1.6 WRepetition rate: 20 HzBeam diameter: 320 mmExposure duration: 270 sec

2. Removal of decayed region

Laser: Er:YAG Laser (KEY Laser 3, KaVoDental GmbH & Co., Biberach, Germany)

Wavelength: 2940 nmOutput: 3.6 W (during enamel prepa-

ration), 10 W (during dentin preparation)Repetition rate: 6 Hz (during enam-

el preparation), 4 Hz (during dentinpreparation)

Beam diameter: No numerical value is

given because it is not a fiber-optic deliv-ery system

Exposure duration: 300 sec

C. Treatment Sequence

1. Maintained a safe environment byrestricting operating room access topersons involved in the treatment,posting warning signs, and minimiz-ing highly reflective surfaces.

2. The patient and all staff membersworking in the above-mentioned safe-ty controlled area wore protectiveglasses.

3. A high-volume evacuation wasused for tissue cooling and removal.

4. A test was conducted by irradiatinga laser beam produced by a newlycleaved fiber onto a black sheet.

5. Local anesthesia was not used.

6. In excision and recontouring ofmarginal gingiva of the cervical areas

using the Nd:YAG laser, the fiber wasapplied parallel with long axis of thetooth (Figures 5 and 6). This isbecause direct irradiation may dam-age teeth. Removal of composite resinfilling and treatment of decayed teethwere performed using the Er:YAGlaser (Figure 7).

7. Etching, bonding and filling usingcomposite resin (3M Corp. Z250,Color A3.5), and polishing were per-formed after preparation (Figures 8and 9).

D. Treatment Record

Notation in the patient treatmentrecord included: minor gingivectomyand gingivoplasty with a free-runningpulsed, fiberoptic-delivered Nd:YAGlaser (wavelength 1,064 nm, pulsewidth 100 ms, and beam diameter of320 mm); caries removal with anEr:YAG laser (wavelength 2940 nm).Exposure duration was 270 secondswith the Nd:YAG laser and 300 secondswith the Er:YAG laser.

E. Patient Management

The patient tolerated the treatmentwithout topical anesthesia and local anes-thetic and was not uncomfortable duringand after the treatment. The followingwere prescribed for postoperative painmanagement: Soleton (nonsteroidal anti-inflammatory drug), 80 mg; painkiller 4 T(to be taken as needed for pain).

F. Postoperative Instructions

The following instructions were given

Figure 5: Nd:YAG laser-assisted gingivoplasty procedure

Figure 6: Nd:YAG laser-assisted gingivoplasty procedure

Figure 7: Er:YAG laser-assisted caries removalprocedure

Figure 8: Finished restoration

Figure 9: Finished restoration


to the patient postoperatively:1. Avoid brushing for 12 hours afterthe operation.2. Refrain from flossing or ingestionof hot food and liquid for 48 hoursafter the operation to prevent irrita-tion of the treated tissues.3. The patient may ingest regularfoods and floss beginning 48 hoursafter the operation.4. The patient should call dentist athome or at the cellular phone num-ber given with any questions or incase of anxiety.

G. Management of Complications

No unexpected symptoms due to thesurgical procedures were observed.Reconstruction under bright field condi-tions was easily performed withoutbleeding.

H. Surgical Prognosis

The surgical prognosis was good.

Follow-Up CareA. Assessment of Treatment

Treatment was assessed at 7 days(Figures 10 and 11), 1 month (Figures12 and 13), and 3 months (Figures 14and 15).

B. Side Effects and Complications

There were no side effects or compli-cations.

C. Long-Term Results

Long-term results are expected to begood.

D. Healing Assessment

The gingiva and teeth were restored toa harmonized, natural and healthy formand an aesthetic condition is being main-tained. The aim of the treatment wasachieved and the patient was fully satisfied.

E. Case Documentation

Periodontal probing sheet showingbefore laser surgery. Written informedconsent was obtained.

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

16

Figure 10: Seven-day postoperative view

Figure 11: Seven-day postoperative view

Figure 12: One-month postoperative view


Figure 14: Three-month postoperative view

Figure 15: Three-month postoperative view


17

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Itaru Yoshida, DDSTokyo, Japan

Diode Laser-Assisted Frenectomy andOral Vestibular Extension

Dr. Itaru Yoshida graduated in 1985 with honors from Nippon Dental University, School of Dentistry, Niigata, Japan. He maintains his private practice in Tokyo,Japan, and utilizes diode (810 nm) and Er:YAG (2940 nm) dental lasers. He is continuing his research of pain control by low-level laser therapy (LLLT), and he isin charge of the Workshop for Dentistry at the World Association for Laser Therapy Fourth World Congress. Dr. Yoshida received his advanced proficiency in thediode laser wavelength at the 10th Annual ALD Conference in Destin, Florida. Dr. Yoshida can be reached by his e-mail address at [email protected].

Disclosure: Dr. Yoshida has no financial relationship with any dental laser manufacturer.


The clinical examination presents a 22-year-old female patient. No sign ofmedical abnormalities or concerns.Her chief complaint was hysteresiswith root dentin exposure and sometension in her cheeks (near teeth #3, 5,and 6 and #11, 12, and 14) whilelaughing and smiling (Figures 1 and 2).


Radiographs showed no abnormali-ties, no periapical pathology, and goodosseous tissue (Figures 3 and 4).

3. Soft Tissue Status, including pocket depthmeasurement

There was an inadequate level of gin-

gival attachment that was causingroot exposure. The oral vestibule wasshallow and there were both large andsmall frenula (Figures 1 and 2).

4. Hard Tissue Tests

No percussion pain, no mobility, Class1 occlusion balance. Due to insuffi-cient orthodontic treatment, theocclusion was not tight. Each buccaltooth neck had a dentin exposure.

5. Tooth Vitality

All teeth tested vital, normal responsewith electric pulp tester.

6. Other Tests

The patient had a labial side ortho-dontic treatment 1 year previously.Caries were widespread on the lingualsurfaces because of insufficient oralhygiene. Composite resin restorationswere placed in those areas.

B. Diagnosis and Treatment Plan1. Diagnosis

Teeth #3, 5, and 6 and #11, 12, and14 had inadequate buccal attachedgingiva and malformation of buc-cal frenulum.

2. Treatment Plan

Vestibular extension and frenectomyusing an 810 nm diode laser toachieve a sufficient level of attachedgingival; local anesthesia was used.


Perform conventional apical posi-tioned flap surgery and free gingivalgrafts with anesthesia and surgicalinstruments.

Figure 1: Preoperative view, right side

Figure 2: Preoperative view, left side

Figure 3: Preoperative radiograph

Figure 4: Preoperative radiograph

Figure 5: Preoperative periodontal chart


18

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4


An indication for use of an 810 nmdiode laser is cutting and coagulationof soft tissue. Hemostasis is due to thecapacity of laser to seal small bloodvessels as a result of the photothermalinteraction with the biological tissue.


If it became necessary to cover theroot surface, a laser incision is con-traindicated and a free gingival graftwould be necessary.

While using the diode laser, caremust be taken to avoid applying toomuch heat to the target and sur-rounding tissues. The wavelength isdeeply penetrating.

6. Informed Consent

Alternative treatments, risks and ben-efits involved were explained to thepatient. Informed consent for treat-ment was obtained from the patientand written in the chart.


The treatment objective was toachieve an acceptable level of attachedgingiva and periodontal stability.

B. Laser Operating Parameters

A diode laser (LD-15, Dentek-Lasersystems Produktions, Gaisfeld,Austria) was used.

Wavelength: 810 nmPower: 5 W maximum peak, 0.29 W

average power, 9.9 mJ/pulseRepetition rate: Gated pulse mode was

used. (Duration time: 2 msec; Intervaltime: 32msec; approximately 29.4 Hz)

Beam diameter: 400 µmExposure duration: 60 sec each side


The right and left sides were treatedseparately on different days. Localanesthesia was given before cuttinggingiva. Protective eyewear was wornby the patient, dental assistant, anddoctor. High-volume evacuation wasprovided. The diode laser was test fired.The laser tip was used in light contactfor cutting and coagulating the oralvestibule, and good hemostasis wasachieved (Figures 6-9).

D. Treatment Records

Notation of the patient treatment wasdescribed in the chart: buccal frenum andoral vestibule were incised to achieve asufficient level of attached gingiva, withan 810 nm diode laser at 5 W, duration

time 2 msec, interval time 32 msec.Anesthesia was administered. Analgesicdrugs were prescribed.

E. Patient Management

The prescribed medication was ade-quate for controlling postoperative pain.

F. Postoperative Instructions

The patient was told to avoid salty andspicy foods, brush carefully and nottouch the surgical area. The patient hadthe doctor’s office phone number in casethe postoperative pain became greatenough to require treatment.

G. Management of Complications

There were no complications, and nobleeding was observed. The patient com-plained of mild spontaneous pain.Analgesic drugs were prescribed.

H. Surgical Prognosis

The surgical prognosis was good.

Follow-Up Care

A. Assessment of Treatment

Figure 6: Laser procedure underway

Figure 7: Laser procedure continuing

Figure 8: Immediately postoperative

Figure 9: Immediately postoperative

Figure 10: Right side, five-day postoperative view

Figure 11: Left side, two-day postoperative view


19

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Photos show the right side at 5 days(Figure 10), and the left side at 2 days(Figure 11).

Both sides are shown at 1 month(Figures 12 and 13).

The right side at 5 months (Figure 14),and the left side is shown at 4 months(Figure 15) after laser application.


Postoperative pain was reported.Analgesic drugs were used.


The gingival margin healed well. Somefrenulum areas had relapsed but attachedgingiva was gained. The patient said shecould laugh and smile easily.


The clinical appearance was of a goodhealing state.

F. Case Documentation

Photos, radiographs, periodontal chart.Figure 12: One-month postoperative view


Figure 14: Right side, five-month postoperative view

Figure 15: Left side, four-month postoperative view


20

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Mitchell A. Lomke, DDSSilver Spring, Maryland

Diode Laser-Assisted Gingivectomy, and Diode and CO2 Laser-AssistedFrenectomy

Dr. Mitch Lomke graduated from the University of Maryland, Baltimore College of Dental Surgery in 1979. He has been in private practice in Silver Spring,Maryland since 1980, emphasizing laser and esthetic dentistry. He has achieved Advanced Proficiency from the Academy of Laser Dentistry in Er:YAG and diodelaser wavelengths. Dr. Lomke was awarded status of ALD Educator in 2000. He has lectured throughout the United States on laser clinical applications usingargon, diode, erbium and carbon dioxide laser wavelengths. He has recently published articles about Er:YAG lasers.

Disclosure: Dr. Lomke lectures and conducts training for OpusDent, Benco, and Patterson Dental Companies, for which he receives an honorarium. He has pur-chased certain laser supplies at a reduced fee.


A 55-year-old white female CEO of aland surveying firm in Rockville,Maryland presented with severeattrition of the mandibular anteriorteeth resulting in short, unaestheticteeth with undesired diastematabetween them (Figure 1). The patientcomplained of decreased ability toincise and chew food as well asincreased sensitivity to sweets andthermal changes. She had a positivehistory of cigarette smoking andsocial drinking. She claimed to be ina high-stress occupation.

The patient also stated that she notedincreasing recession in this area as shegot older. Upon examination, an aber-rant mandibular anterior frenum pullwas evident (Figure 2). She has alsobeen unhappy with the unaestheticyellowish brown shade of these lowerteeth. Attrition resulted in the loss ofup to one-third of the clinical crownsof these teeth. The patient did notwant to have teeth #21, 22, 27 or 28prepped for any restorations, although

she was not happy with their darkershade. She did consent to have teeth#23-26 prepped for custom veneers.Due to the short nature of the clinicalcrowns of these teeth, it was explainedto the patient that it would be neces-sary to gain additional tooth surfacearea to bond to for stability.

It was agreed that a crown lengtheningprocedure would be done with thediode laser as well as a frenectomy per-formed to obviate the frenum pull andstabilize the gingival margin positionof the teeth in treatment long-term.


There was generalized mild horizontalalveolar bone loss evident on the radi-ographs. The crown-to-root ratios onthe treatment teeth were borderline,unfavorable. No periapical pathologywas detected on the radiographs. Anintact lamina dura was present in theareas to be treated. The pulp chambersin the teeth appeared to have calcifieddown just enough to be out of harm’sway during tooth preparation toavoid endodontic therapy.

3. Soft Tissue Status

In general, the gingival tissues werehealthy. Pocket readings averaged 3-4mm with two molar teeth measuring5 mm. There was no bleeding on gen-tle probing. The mandibular anteriorfrenum exerted excessive pull on themarginal gingival tissues in that area.Periodontal probing also determinedthat there would be adequate biologi-cal width remaining after the margin-al gingiva was removed.

4. Hard Tissue Status

Tooth Vitality: Teeth #20-28 testedvital to cold testing as well as to elec-tric pulp testing. There was no sensi-tivity to percussion on all the teeth tobe treated. Tooth mobility patternswere generally mild.

5. Other Tests

The patient had Class I occlusion in askeletal relationship with evidence ofbruxism. There was no history of tem-poromandibular joint disease, the jointexhibited no noise upon palpitation,and the patient had no pain. However,an occlusal splint was included in hertreatment plan due to a deep overbiteand an impressive bruxism habit.

B. Diagnosis and Treatment Plan 1. Provisional Diagnosis

Generalized mild gingivitis. Previoushistory of mild-to-moderate horizon-tal bone loss. Short, discolored, attrit-ed, unaesthetic mandibular anteriorteeth. Aberrant mandibular anteriorfrenum pull. Moderate-to-severe para-functional habits – bruxism.


Figure 2: Preoperative view showing anterior mandibular frenum pull


21

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

2. Treatment Plan

Gingivectomy and gingivoplastyusing a diode laser. Crown lengthen-ing procedure. Placement of porcelainveneer restorations on teeth #23-26.Frenectomy using a combination ofdiode and CO2 lasers. Fabrication of anocclusal splint.


Referring the patient to a periodontistfor conventional periodontal surgeryusing a scalpel and sutures. It was deter-mined that the raising of a full thicknessflap in this area could induce furtheralveolar bone loss in an already peri-odontally compromised area. Thepatient could have chosen no treatmentat all. These alternatives were offered tothe patient, but were declined.


Given the determination that ade-quate biological width would remain,indications included:

• to increase the patient’s existing bondable surface area of her lower front teeth

• to be able to lengthen the final tooth length inciso-gingivally and thus improve the esthetics and function of the lower anterior teeth

• to improve the esthetics of the patient’s smile and raise her self- esteem

• to relieve the aberrant frenum pull and prevent further recession.

The diode laser would be able to per-form the soft tissue surgery very well,with precise and predictable height of tissue.


Preservation of biological width isessential for the periodontal health,given that the treated teeth have somecompromise. The diode laser must beused with care when in contact withthe root surface of the teeth, and pro-longed contact with any dental hardtissue must be avoided. The diodewavelength deeply penetrates the softtissue, and the underlying bone can bethermally damaged if care is not taken.

6. Informed Consent

The patient was informed of the pos-sible need for endodontic therapy onthe teeth to be treated, as well as the

possible need for further periodontalsurgery. The relative risks/benefits andtreatment alternatives were also dis-cussed with the patient, who gave ver-bal informed consent.

TreatmentA. Treatment Objectives

The objectives of this treatment were:• perform a crown lengthening pro-

cedure on the patient’s lower front four teeth (teeth #23-26), thereby increasing the length of the avail-able bondable surface area

• improve the overall esthetics of the patient’s smile

• relieve an aberrant mandibular anterior frenum pull.


An 830 nm diode laser (Opus 10,OpusDent, Norwood, MA) was used atthe repeat pulse setting (0.l sec on, 0.l secoff) using a 360-micron quartz fiber at 3.4W for 2.0 minutes total treatment time(TTT), 3.0 W for 4 minutes TTT, then 2.0W for 3.0 minutes TTT.

A 10,600 nm CO2 laser (Opus 20,OpusDent, Norwood, MA) with a 90-degree handpiece was used to assist in thefrenectomy, using 3 W and a focused lensin the SP mode for 2 minutes TTT.


DentiPatches (topical lidocaine) wereapplied to the area apical to the mucogin-gival junction bilaterally in the mandibu-lar anterior area for 10 minutes. Localanesthesia was administered (using threecarpules of 2% Carbocaine with 1:20,000Neonordephrine). The diode laser proce-dure was done under 2.5 magnificationwith protective lenses. With this tech-nique, the teeth were prepared for thetemporary veneers first so as to avoidspewing debris from the tooth structureinto the surgical area. Adequate reductionwas confirmed using a preoperativeomnivac shell.

The laser was first test-fired outside ofthe patient’s mouth using a power of 1 W,continuous wave (CW). The diode lasergingivectomy technique was then per-formed to recontour the gingival tissueand expose more tooth surface area forease of bonding. The diode laser was usedinitially at 3.4 W in the repeat pulse mode(RPM) at 0.1 sec on and 0.1 sec off usinga 360-micron tip. The diode laser wasthen used at the same RPM setting vary-

ing the power up and down, as needed, toreduce pocketing and to recontour vari-ous areas. After several passes at the targettissue, it was important to maintain afresh operative field by using a wet gauzeand/or a curette to remove lased tissue. Ifexcessive buildup of this lased tissue werenot removed, collateral tissue damagemay have occurred due to thermal con-duction. It was also important to main-tain a freshly cleaved fiber to preventexcessive heat as well as inefficient cut-ting (Figure 3).

Next, a frenectomy was performed

using the carbon dioxide laser at 3 W witha focused lens, using lip traction as a guideas to the proper clearance of the musclefibers. The diode laser was also used at 2 WCW to assist in clearing stubborn fibers aswell as achieving hemostasis (Figure 4).Provisional crowns had already been fabri-cated and cemented (Figure 5).D. Patient Management

Figure 3: Laser-assisted gingivectomy procedure underway

Figure 4: Laser-assisted frenectomy procedure underway

Figure 5: Immediately postoperative withprovisional crowns cemented


WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

22

The patient was comfortable through-out the procedure with the local anesthe-sia. During the healing phase, she wascompliant with the use of chlorhexidinegluconate rinses as well as with standardhomecare (brushing and flossing).

E. Postoperative Instructions

Avoid eating around the surgical area.Use ice packs for the first 24-48 hourspostoperatively. Avoid crunchy or hardfoods. Chlorhexidine rinses twice daily.Vicodin or acetominophen every 4-6hours as needed for discomfort. Gentlebut effective homecare was stressed.

F. Management of Complications

There were no reported complications.

G. Surgical Prognosis

Good to excellent. The patient must becompliant with proper homecare.Maintenance of the gingival healthwould be greatly enhanced by the use ofchlorhexidine-soaked SuperFloss Oral B3D electric toothbrush.


Treatment outcome was assessed at 12days (Figure 6), 17 days, 4 weeks, and 6weeks (Figure 7) postoperatively. Thetreatment was successful.


The patient was phoned at home as apostoperative check that evening. Thepatient experienced mild pain and nobleeding.

The available clinical crowns werelengthened safely and effectively. Thefinal veneers were of the desired increasedlength. The frenum pull was eliminated,thus the gingival margins should remain

stable. The patient was extremely satisfiedwith the result.


The postoperative healing was com-plete. Five- and seven-month postoperativeexaminations (Figure 8) revealed excellentgingival health. The patient was instructedto wear an occlusal splint at night to avoiddamage due to parafunctional habits.


Gingival margins are stable with nobleeding. The final restorations have beenplaced. The patient’s smile and self-esteem have both been restored.

E. Case Documentation

Photographs, clinical notes, radi-ographs were inclluded in case documen-tation.

Figure 6: Twelve-day postoperative view

Figure 7: Six-week postoperative view

Figure 8: Five-month postoperative view

Join Us Today!

P.O. Box 8667 • Coral Springs, FL 33075 USA954-346-3776 • Fax 954-757-2598

www.laserdentistry.org

THE ROADTO HIGHERSTANDARDS

THE ROADTO HIGHERSTANDARDS

• Upholding standards for education and certification in the use of lasers in dentistry

• The preeminent voice for lasers in dentistry


WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

23

Gingival Recontouring, DecayRemoval, and Cavity Preparation with an Er,Cr:YSGG Laser

Dr. Raleigh Holt is a Professor at the University of Oklahoma College of Dentistry and has been conducting research with lasers for more than 10 years.He has published several articles and made numerous presentations on his laser research. He has recently had an IRB approved for clinical trials for treat-ment and prevention of root caries at the University of Oklahoma. His focus also includes composite bonding with laser vs. acid-etched technique.

Disclosure: Dr. Holt and the University of Oklahoma College of Dentistry have received discounted equipment and free supplies from BioLaseTechnologies, Inc. BioLase has also sponsored Dr. Holt for travel to a national meeting.


A 70-year-old white female presentedwith high blood pressure, arthritis,hypothyroid problem, and seasonalallergies. Her medical problems werecontrolled by medications. She was tak-ing Norvase, Synthroid, Allopurinol,Lipitor, Extradiol, and Medroxyprog.She had a history of periodontal prob-lems with recurrent root caries.

The patient was missing teeth #1, 2, 4,14, 15, and 16 on the maxillary archand teeth #17, 18, 19, 20, 23, 24, 25,26, 29, 30, 31, and 32 on themandibular arch. Teeth #3, 13, and 27had been restored with full porcelain-metal crowns, tooth #3 had a can-tilever (mesial) replacement for tooth#4. A mandibular removable partialdenture replaced teeth #18, 19, 20, 23,24, 25, 26, 29, 30, and 31.

Teeth #5, 6, 7, 8, 9, 10, 11, and 12 hadreceding gingival margin, exposing 2-3mm of root surface on the facial area.Mandibular teeth #22, 27, and 28 alsohad receding gingiva exposing 2-4 mmof root surface. These teeth had devel-oping carious areas, which formed foodpockets causing chronic gingivitis(Figures 1 and 2).


The pretreatment radiographs showedno periodontal bony pockets or inter-proximal caries. The pretreatment X-rays did not show the periodontal radi-olucent lesion, mesial root #3.

3. Soft Tissue Status

Probing depths were 2-3 mm aroundher remaining teeth except #3 whichhad a 8 mm mesial pocket, and therewas bleeding upon probing in allprobing points. The marginal gingivalcrest covered the apical portions ofcarious lesions. The gingival tissuesappeared inflamed and irritated withplaque. Tooth #3 developed root carieswith a fractured mesial root after treat-ment began. This tooth was extracted.

4. Hard Tissue Status

All teeth were within normal limitsfor pulp testing except teeth #3 and21 which had received root canaltreatment. Tooth #3 had a radiolucentlesion apical to the mesial root. Therewas no mobility.

5. Other Tests

Occlusion normal, temporomandibu-lar joint normal.

B. Diagnosis and Treatment Plan1. Provisional Diagnosis

Root caries facial (at or below gingivalmargins) of teeth #5, 6, 7, 8, 9, 10, 11,12, 22, 27, and 28. Acute generalizedgingivitis was present.

2. Treatment Plan

Gingival contouring for good peri-odontal architecture and access tocaries. Restoration of carious areas,and preventive fluoride application.

3. Treatment Alternatives

Conventional periodontal surgicalprocedures for gingival areas with sub-sequent healing period before restora-tion. Removal of decayed areas with ahigh-speed drill and bur. Restore withcomposite resin filling materials oramalgam. Place patient on home flu-oride as part of preventive care.Prognosis appears poor for standardrestorative treatment.


Reduce gingival inflammation andrecontour tissue properly for access tocaries; eliminate carious areas andplace properly contoured and sealedrestorations.

The Er,Cr:YSGG laser wavelength willallow soft and hard tissue treatmentwith the same laser instrument. Thegingival margins can be contouredslightly above/below the apical mar-gin of the cavity preparation withlaser. The gingival apical margins canthen be placed above the gingivalcrest which will reduce the chance ofrecurrent root caries. Carious areascan be excavated, and root surfacesand enamel margins can be etched





24

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

with the laser. The margins and treat-ment of subgingival root surfaces canbe finished with a resin-fluoride mix-ture and laser exposure. The root sur-face margins and the root surfacetreatment will have an increasedresistance to decay. Restoration ofthese areas should increase thepatient’s ability to maintain homecare at a preventive level for chronicperiodontal disease and recurrentcaries problems.

5. Contraindications for Treatment

Standard Treatment: Whenever peri-odontal contouring and tissueremoval are involved, attention mustbe given to the preservation of the bio-logical width. The patient’s home caremust be very good to establish healthyperiodontal tissues and prevent recur-rent caries. Past history indicated thatstandard treatment did not greatlyimprove control of periodontal or car-ious activity in these areas.

Laser Treatment: This wavelength eas-ily interacts with both hard and softtissue, so care must be taken to avoidremoval of healthy tissue.

6. Informed Consent

Oral consent with witness wasobtained.


Use the Er,Cr:YSGG (wavelength 2780nanometers) to contour gingiva to exposethe apical margins of root caries, removedecay, prepare cavity for composite fillingmaterials, and perform preventive treatmentto fillings and root surfaces with resin/fluo-ride application and laser exposure.


Laser: Erbium, Chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG)(BioLase, San Clemente, CA)

Delivery System:(1) fiber-optic system to a terminal

600-micron diameter sapphire tip withadjustable air-water spray deliveredthrough handpiece

(2) a terminal 750-micron tip with a“defocus hood” to produce an even spotsize of 2.5 mm, no air or water

Wavelength: 2780 nanometersMode: free-running pulsedPulse width: 140-150 microsecondsPower: 0.0-6.0 Watts

Beam Diameter: 600 and 750micrometers

Repetition rate: fixed at 20 Hz.

Laser Settings:Enamel cutting – 4-4.5 W (75% air,

65% water) 4 W = 200 mJ / pulse, 4.5 W= 225 mJ/pulse

Enamel etching – 2 W (45% air, 30%water) 2 W = 100 mJ/pulse (work from 1to 3 mm from the site area)

Dentin cutting – 2.5–3 W (65% air,55% water) 2.5 W = 125 mJ/pulse, 3 W =150 mJ/pulse

Dentin etching – 1.5 W (45% air, 30%water) 1.5 W = 75 mJ/pulse (defocus 2-4mm to seal dentinal tubules and cleancavity)

Gingival contouring – 1.75 W (20%air, 15% water) 1.75 W = 87.5 mJ/pulse

Gingival clotting – 0.75 W (11% air, nowater) 0.75 W = 37.5 mJ/pulse

Preventive treatment750-micron (3 mm) sapphire tip with

the “defocus hood” at 0.75 W (no air orwater).

C. Treatment Delivery Sequence

Preliminary to patient treatment:Secure operating room – place proper

laser warning signSet-up laser and test proper laser oper-

ationSupplies dispensed, equipment and

instruments (sterile) arrangedPatient’s information: review charting,

X-rays, etc.Patient seated – review treatment plan

and informed consentSafety – eye protection placed for

patient and operating personnel.

NOTE: The patient requested no localanesthesia.

Each tooth was treated individuallywith the following settings:

Soft Tissue: Test fire laserUsed 600-micron diameter sapphire tip,

with laser settings at 1.75 W, 20% air, 15%water, to contour and remove gingival tis-sues from the apical margin of the cavity –Time: 3 minutes – reduced settings to 0.75W, 11% air, no water, defocused beam (toaid in the clotting of the small amount ofbleeding – 10-15 seconds).

Hard Tissue:Laser test-fired into a styliform trayDecay was removed using a 600-

micron diameter sapphire tip:(1) With laser settings of 2.0 W, 65%

air, 55% water, the laser was positionedapproximately 1 mm from the carious siteon the tooth for 1 minute.

(2) Settings were adjusted to 3.0 W,

65% air, 55% water to complete removalof decay. Time: Approximately 5 minutes

(3) Cavity examined for decay –remove any decay, and prepare dentinalcavity walls, if needed – at setting of 2.0W, 45% air, 30% water, for 2 minutes.

(4) Etch enamel coronal margin at 2.0W, 45% air, 30% water, for 30 seconds.

(5) Etch apical root surface margin andrefine gingival contours at 1.75 W, 20%air, 15% water, for 10 seconds.

(6) Used a defocused beam (3-4 mmfrom target tissues) for 10 seconds toincrease clotting (Figures 3-6).

The laser was returned to standbyposition.

Figure 3: Laser caries removal and toothpreparation procedure underway





25

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Restorative Treatment

The cavity was rechecked for decay(visibly and mechanically), irrigated withwater from unit syringes, isolated andrestored with Herculine light cure com-posite resin per manufacturer’s directions.Finished and polished with a series ofburs and disks using high- and low-speeddental instruments.

Preventive Treatment

Laser settings:Used a 750-micron (3mm) sapphire tip

with the “defocus hood” at 0.75 W (no airor water) – spot size 2.5 mm.1. a mixture of light-cure pit & fissuresealant (clear) and sodium fluoride pow-der (25%) (mixed in a capsule with anamalgamator).2. a thin coat was applied to the mar-gins of the composite/resin filling andapical to the root surfaces (and into thegingival sulcus).3. Used a defocused beam of 2.5 mm at asetting of 0.75 W, no air or water, timewas approximately 15 seconds to coverthe margins and root surface areas. Twoapplications and two laser exposures wereused. The facial (distal-mesial) and lingualroot surfaces were also treated with theresin/fluoride mixture and laser energy.

NOTE: The defocused laser beam isalways test fired on black photographicpaper to confirm the spot size and even-ness of the defocused beam.

D. Treatment Records

The treatment record reflects the treat-ment outlined above.

E. Postoperative Instructions

The patient was instructed to continuehome care as in the past. Rinse withBiotene mouthwash twice daily. Floss andbrush very gently with a soft tissue brushfor 48 hours, return to normal home care.No limitations on eating or drinking. Thepatient was to call if any problems

occurred. Reappointed for one-weekrecall, 24-hour appointment by phone(older lady who lives out of town) (Figures7 and 8).

F. Management of Complications

There were no complications.


The patient was assessed at one day,one week, one month, two months, fourmonths and six months.

One Day – no problems – the patientsaid,“My teeth feel great – so clean.”

One Week – no problems – the patientindicated that her teeth never felt better,she could brush and floss without hurting

her gums (Figure 9).One Month – continued to improve

her home care (Figure 10).

Two Months – the patient continuedto do very well (Figure 11).

Six Months – the patient reported no

problems. Oral hygiene was greatlyimproved (Figures 12-14).


The patient reported no side effects orcomplications.


There was no sensitivity, and the fill-ings were retentive and smooth.


Prognosis of treatment is excellent, ifpatient can continue good oral hygiene.She is also pleased with the esthetics.Figure 7: Restorations completed

Figure 8: Restorations completed


Figure 12: Six-month postoperative view

Figure 9: One-week postoperative view


Figure 11: Two-month postoperative view



26

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Er,Cr:YSGG Laser-Assisted MarginalSealing: A Preliminary Report of InVitro Research

Subject: Preventive treatment:Sealing of teeth and restoration (com-posite) surfaces using an Er,Cr:YSGGlaser and a mixture of light-curesealant and sodium fluoride.

The problem of microleakage of rootsurface composite restorations has twocontributing factors. They aremicroshrinkage of composite materialagainst root surfaces, and recurrentdemineralization of the adjacent rootsurfaces. The theory is that laser energypushes resin-fluoride mixture into themicro-marginal defect and the adja-cent root surface. The accompanyingclinical case shows the caries removaland tooth preparations (refer to Figures3-6 of the clinical case, page 24) withthe final step of the laser etching themargins. The photos show the applica-tion of the sealant to the finishedrestorations (Figure 1) and the laserenergy applied (Figure 2). As men-tioned in the clinical case, a 750-micron sapphire tip with a proprietary

defocused hood was used with 0.75 Wof power at 50 mJ per pulse for 10-15seconds, using no air or water.

Laboratory research is ongoing. Oneproject was to complete Class V restora-tive preparations on opposing sides ofextracted human teeth. The apical mar-gins of the restorations were placed onenamel, and gingival margins on theroot surface. One side was completedwith a high-speed bur and the opposingside was completed with an Er,Cr: YSGGlaser. They were filled using either theacid-etched or laser-etched techniquefor composite restorations. Margin androot surface treatment was completedwith laser and sealant fluoride or acidetched and sealant fluoride. The teethwere cycled in an acid solution on atimed scheduled (14, 24, 42, and 60days). A dye was used to identifymicroleakage. Scanning electron micro-scopic examinations were prepared toidentify conditions of the marginalareas of the composite fillings beforeand after acid cycles.

The “post-acid” microscopic viewshows damage to the bur-preparedcomposite margin and adjacent rootsurface versus little or no defects in thelaser-treated side (Figure 3). These twoviews are examples of specimens cycledin acetic acid, buffer solution to pH4.63 for 42 days. Analysis showed thatthere was a significantly less marginalleakage in the laser-prepared and laser-treated margins versus the bur-pre-pared and acid-etch treated margins.

Dr. Raleigh Holt is a Professor at the University of Oklahoma College of Dentistry and has been conducting research with lasers for more than 10 years.He has published several articles and made numerous presentations on his laser research. He has recently had an IRB approved for clinical trials for treat-ment and prevention of root caries at the University of Oklahoma. His focus also includes composite bonding with laser vs. acid-etched technique.

Disclosure: Dr. Holt and the University of Oklahoma College of Dentistry have received discounted equipment and free supplies from BioLaseTechnologies, Inc. BioLase has also sponsored Dr. Holt for travel to a national meeting.


Figure 1: Application of sealant

Figure 2: Application of Er,Cr:YSGG laser Figure 3: Restoration margins compared


27

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Periodontal Surgery Using Nd:YAGLaser and Enamel Matrix Derivative

Dr. Douglas Gilio is in private practice limited to periodontics and implants. He is an assistant clinical professor at the University of Southern California School ofDentistry Advanced Periodontal Department. He is also a consultant in periodontics at the Veterans Administration Hospital in Fresno, California and heads thePeriodontal Department for the general hospital residency program. Dr. Gilio holds Advanced Proficiency in Nd:YAG and has achieved Educator Status from theAcademy of Laser Dentistry. Dr. Gilio may be reached at (559) 625-4911 or [email protected].

Disclosure: Dr. Gilio has no commercial or financial interests in any laser companies.

Abstract

The goal of periodontal therapy is toreverse the disease process and return theperiodontal attachment apparatus to ahealthy state. Ideal therapy should allowthe regeneration of the periodontal liga-ment (PDL) to healthy status. This articledemonstrates the combination of recenttechnologies, the Nd:YAG laser andenamel matrix derivative (EMD), and thebenefits of each when used in tandem.This combined procedure is comparablewith traditional results, optimizes EMDproperties, and reduces patient discom-fort and healing morbidity.

Materials and Technique

A new bone graft-replacement product(Emdogain

®, Biora, Sweden) has recently

entered the marketplace. It is an EMD withexcellent regenerative potential for use intraditional periodontal surgery.1-7 Thisproduct is of a fluid nature and lends itselfwell to the treatment of periodontal pock-ets. The Nd:YAG laser, which has a longhistory of use in dentistry,8-11 has a wave-length of 1064 nm in the near-infraredrange. The emitted laser light is invisible,nonionizing, and therefore nonmuta-genic, an important point to remember.

A flexible quartz fiber optic is used withthe laser, which is an advantage for ease oforal access. The energy is highly absorbedby periodontal pigmented tissue, and isideally suited to irradiate the defect site.8-9,

11-14 The contact delivery system allowssimultaneous cutting and coagulation oftissue with excellent visualization, requir-ing minimal flap reflection.

The laser device used in this article isthe Pegasus 20 Nd:YAG laser (PremierLaser Systems, Tustin, CA). Unfortunately,as of this writing, the manufacturer is no

longer in existence, but the instrument isstill in service and is used by many pro-fessionals. The aforementioned 1064 nmwavelength is delivered through a 400-micrometer diameter quartz fiber. Thepower setting is 4 W in a gated pulsedmode of 0.05 seconds. The fiber is heldparallel and adjacent to the long axis ofthe root as the entire sulcus depth is irra-diated for approximately 10-15 seconds.Minimal heat buildup occurs during theprocedure since the operator uses a rapidsweeping motion and makes parameteradjustments based upon visual fiber-tis-sue interaction. The root surface is neverintentionally irradiated in focal contactas indicated in early periodontal stud-ies.17, 43 This wavelength is absorbedstrongly because of the optical propertiesof the inflamed red edematous tissuepresent in periodontal disease, and thusthere is minimal transfer of heat to theroot surface.9, 12-14 The infected tissueabsorbs the laser energy effectively.9, 43

The laser phase of treatment is fol-lowed by conventional debridement,creating an ideal blood-free reservoir forthe EMD gel.10 Therefore the Nd:YAGfiber is an excellent adjunct to peri-odontal soft tissue treatment, and canbe used in combination with tradition-al surgical techniques.11-13 The laser ben-efits include sealing small sulcularblood vessels, thus creating a drier field;“sterilizing” tissue from heat buildup atthe laser-tissue interaction site; andsealing off nerve endings, resulting inreduced postoperative pain.14-16

Presently, many periodontal surgicaltechniques are utilized to regenerate orincrease attachment levels.17-20 This isaccomplished by treating a previouslybacteria-contaminated root surface andthe resulting loss of bone and attach-ment.21-24 There are several citationswhich suggest that the Nd:YAG laser hastherapeutic benefits and bacterial elimi-

nation potential.25-27 The pigments ofbacteria found in the diseased sulci orimbedded in the infected periodontaltissue are irradiated by the laser photonsas they transmit through the tissues.This photothermal interaction destroysharmful subgingival flora, and has littleeffect on the surrounding collateral peri-odontal tissue.

The periodontist’s surgical goal is theregeneration of the periodontal attach-ment apparatus with new bone, cemen-tum and periodontal ligament.28 TheNd:YAG laser, using low energy delivery,may possess detoxification potentialthrough vaporization of these harmfulbacteria and their products on the con-taminated root surface.29-33 The key to asuccessful outcome when treating theperiodontal defect is to clean the root sur-face thoroughly, removing all contami-nants. Hand scalers, sonic, ultrasonic,rotary instruments, or combinations canaccomplish this.2-5, 34-35

Next, the smear layer is cleansed fromthe root surface with a neutrally bufferedEDTA (ethylene-diamine tetra-acetic acid)for two minutes.5-6, 36-41 The assistant irri-gates the root surface with large quanti-ties of sterile water or sterile saline.43 Atthe same time, high-speed suction and airsyringe are applied as the EMD gel syringeis held ready. The assistant then ceases theinstant root cleansing and drying, andthe surgeon expels the gel via a cannulaonto the clean and dry root surface.

It is critical that the Emdogain be thefirst protein to contact the freshly cleanedroot surface.2, 5, 7 The smear layer is a com-bination of bacteria and their toxic prod-ucts, and is also composed of diseasedhypermineralized periodontal ligament,collagen, dentin, and cementum debrisspread over the root surface. Several stud-ies indicate the smear layer must beremoved so that there is the best chance

Douglas A. Gilio, DDSVisalia, California


WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

26

of a predictable surgical result.24-25, 36-39 It ispossible that the Nd:YAG laser con-tributes to the root cleansing processwhen used at very low energy. Severallaser studies have indicated this phenom-enon may facilitate healing.19-20, 26, 29

The EMD protein, when combinedwith surgical advantage of the Nd:YAGlaser, is an ideal treatment technique thatcan produce significantly improvedpatient comfort during treatment.10, 34-35

The laser/EMD combination can alsoeliminate some of the limitations ofEMD, and enhance its versatility com-pared with the traditional methods.1-3, 5-7

The laser/EMD combination resultsappear to be identical to the traditionalsurgical methods, but with faster recoveryand normal function. EMD allows formore predictable periodontal regenera-tion compared with the normal healingrepair process associated with open flapsurgery only, or with use of allogeneic,alloplastic, and xenogeneic graft materi-als.28 Other graft materials can appear toact as biologic fillers, with connective tis-sue encapsulation of the graft particlesand limited new bone formation.2, 44

Those tissues that have healed byrepair are more subject to re-infectionand continued attachment loss thanthose generated by surgical proceduresdesigned to produce regeneration.Healing by repair does not result inrestoration of the original form (newcementum, periodontal ligament andalveolar bone), nor is the original func-tion of the periodontal attachmentapparatus restored. Periodontal regener-ation refers to the restoration of all theelements of the periodontium – bone,ligament, cementum – to their originallevels before the damage of disease tookplace.7, 28 Because true regeneration canonly be evaluated histologically,researchers must rely on the variousmeasurements of clinical levels (CALs)and re-entry surgeries in order to evalu-ate and analyze the results of regenera-tive periodontal surgery techniques.2, 44

Enamel matrix proteins (EMPs) are agroup of proteins thought to be impor-tant in the development of the dentalorgan, especially as it contributes to theformation of cementum, PDL, and bone.5,

7, 34-35, 44-45 The potential of employing EMPsin periodontal regeneration thereforedoes exist. It has been shown thatporcine-delivered EMPs enhance the pro-liferation and protein production ofhuman periodontal ligament cells invitro.7 These same EMPs have also beentested as a new periodontal regenerative

treatment modality in animals andhumans. They have been shown to besafe and effective in improving CAL andradiographic bone fill.46 Two humanbiopsy reports revealed that true peri-odontal regeneration can be demonstrat-ed with topical root application of EMPs.2

It has been suggested that one of thepotential limitations inherent in theEMPs is related to their viscous consisten-cy after reconstitution of the EMP andcarrier.2, 7 Because of the EMPS’ semi-fluidand viscous nature, these products do nothave the capability of making and main-taining space, as is associated with solidor particle-type graft materials such asdecalcified freeze-dried bone allograft(DFDBA) from human bone or bovinemineral.4, 7

Mellonig2 has reviewed use of a col-lagen/DFDBA combination using colla-gen fragments of less than 1 mm,which is added to the EMP gel beforeplacement. However, care is requirednot to suture the wound too tightly,since the collagen has tendency toswell, and may cause tissue necrosisand wound dehiscence. The concernswith the viscous consistency ofEmdogain are eliminated or reduced bythe laser uni-flap procedure. The singleflap reflection allows for opposite sidefixed scaffolding, which ensures asecure immobile suture point for thereflected flap. This secure suture tech-nique provides predictable coronal flappositioning. The flexible fiber-opticfiber allows for minimal flap reflectionand opening, creating a small, clean,osseous crypt site ideal for the EMDviscous gel to enter, filling its space viacannula syringe. Minimal bleeding,which is vital for visual assessment, isfacilitated by laser coagulation on theflap connective tissue underside siteand coagulation by sulcular irradia-tion, which ensures a clean dry rootsurface for coating with EMD.

Case 1

The patient was a 50-year-oldCaucasian male, nonsmoker, in excel-lent health. There was a defect betweenteeth #2-3 and a large palatal defect ontooth #3. The probing was 9 mm distaland palatal on #3 (Figure 1). One yearpostoperatively, the probing depth was3 mm, giving a probing depth reduc-tion of 6 mm, and a clinical attach-ment gain of 5 mm. The 18-monthradiograph showed moderate osseousfill (Figures 2, 8, 9). The surgical tech-nique is shown in Figures 3-7.

Figure 1: Radiograph showing osseous periodontaldefects around the right upper first molar.

Figure 3: Nd:YAG laser is being used to thinthe gingival tissue prior to the flap elevation.

Figure 5: Facial view of the surgical site afterroot debridement is accomplished.

Figure 4: Palatal view of the elevated flap,showing the osseous defect on the distal of

tooth #3, before root debridement.

Figure 2: One-year postoperative radiographshowing improved bone height.


29

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Case 2

Radiographic response is very posi-tive in this case of a 52-year-old malefollowing Nd:YAG laser and EMD treat-ment. The postoperative radiograph

was taken 18 months post-treatment(Figures 10, 11).

Case 3

This patient was referred for treatment,a hopeless prognosis had been renderedfor tooth #28, and an implant was rec-ommended (Figure 12). This 80-year-oldwoman did not want an extraction.Figures 13, 14 and 15 show the EMPtreatment, following the protocol speci-fied above. The treatment was successful,and 24 months postoperatively the toothis serving as an abutment for a partialdenture (Figures 16, 17).

Figure 6: Emdogain (enamel matrix protein)material is dispensed with a cannula into

the cleaned mesiofacial osseous site.

Figure 7: Palatal view of the surgical siteclosed with sutures.

Figure 9: One-year postoperative facial viewof the healed site.

Figure 8: One-year postoperative probing,palatal view, of the healed site showing

pocket depth reduction

Figure 10: Radiograph showing large osseousperiodontal defects around both upper right

molars.

Figure 11: One-year postoperative radi-ograph showing significant improvement of

bone around both molars.

Figure 12: Preoperative facial view of tooth #28, showing severe inflammation

of the soft tissue.

Figure 13: Facial view of the elevated soft tis-sue, showing both an osseous defect

and an area of external resorption on theroot of tooth #28.

Figure 14: Facial view of the root and bonetissue debridement completed.

Figure 15: View of the cannula dispensingEmdogain material onto the root and into

the osseous defect.

Figure 16: Facial view, two years postopera-tive, showing the tooth and tissue in a

healthy and stable condition.


30

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Conclusion

The cases in this report are presentedto demonstrate the efficacy of combiningNd:YAG laser and EMD to treat periodon-tal defects. The laser wavelength and itsbacterial reduction effects provide a keyto tissue healing and regeneration.

References

1. Mellonig JT. Autogeneous and allo-geneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med1992;3(4):333-352

2. Mellonig JT. Enamel matrix deriva-tive for periodontal reconstructive surgery: Technique and clinical and histologic case report. Int J Periodontics Restorative Dent 1999;19(1):8-19.

3. Garrett S. Periodontal regeneration around natural teeth. Ann Periodontol 1996;1(1):621-666.

4. Lekovic V, Camargo PM, Weinlaender M, et al. A comparison between enam-el matrix proteins used alone or in combination with bovine porous bone mineral in the treatment of intrabony periodontal defects in humans. J Periodontol 2000;71(7):1110-1116.

5. Heijl L, Heden G, Svardstrom G, et al. Enamel Matrix derivative (EMDO-GAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997;24(9 Pt 2):705-714.

6. Gestrelius S, Andersson C, Lidstrom D, et al. In vitro studies on periodon-tal ligament cells and enamel matrix derivative. J Clin Periodontol 1997; 24:685-692

7. Wilson TG Jr. Periodontal Regeneration Enhanced: Clinical Applications of Enamel Matrix Proteins. Chicago, IL: Quintessence Publishing Co., 1999.

8. Myers TD, Myers WD, Stone RM. First soft tissue study utilizing a pulsed Nd:YAG dental laser. Northwest Dent 1989;68(2):14-17.

9. White JM, Goodis HE, Chavez EM, et al. Photothermal laser effects on intraoral soft tissue in vitro. J Dent Res 1992;71(Spec. Issue):221, abstract 925.

10. Gilio DA. Periodontal regeneration with enamel matrix derivative and neodymium laser: A case report. Lasers Surg Med 2001(Suppl 13):15, abstract 62.

11. White JM, Goodis HE, Rose CL. Use of the pulsed Nd:YAG laser for intraoral soft tissue surgery. Lasers Surg Med 1991;11(5):455-461.

12. Miserendino LJ, Levy GC, Abt E, et al. Histologic effects of a thermally cooled Nd:YAG laser on the dental pulp and supporting structures of rabbit teeth. Oral Surg Oral Med Oral Pathol 1994;78(1):93-100.

13. Gold SI, Valardi MA. Pulsed laser beam effects on gingival. J Clin Periodontol 1994;21(6):391-396.

14. Miserendino LJ, Pick RM, ed. Lasers in Dentistry. Chicago, IL: Quintessence Publishing Co., 1995.

15. Tseng P, Liew V, Chan A, et al. Nd:YAG laser in periodontal surgery: Clinical use and microscopy studies. J Dent Res 1992;71(4):983, abstract 51.

16. Lin PP, Beck FM, Matsue M, et al. The effect of a pulsed Nd:YAG laser on periodontal pockets following subgingival application. J Dent Res 1992;71(Spec.Issue):299, abstract 1548.

17. Gregg RH, McCarthy DK. Laser ENAP for periodontal bone regeneration. Dent Today 1998;17(5):88-91.

18. Neill ME, Mellonig JT. Clinical effica-cy of the Nd:YAG laser for combina-tion periodontitis therapy. Pract Periodontics Aesthet Dent 1997;9(6 Suppl):1-5.

19. Ando Y, Aoki A, Watanabe H, et al. Bactericidal effect of erbium:YAG laser on periodontopathic bacteria. Lasers Surg Med 1996;19(2):190-200.

20. Ben Hatit Y, Blum R, Severin C, et al. The effects of a pulsed Nd:YAG laser on subgingival bacterial flora and on cementum: An in vivo study. J Clin Laser Med Surg 1996;14(3):137-143.

21. Carranza FA Jr. Reconstructive osseous surgery. In: Carranza FA Jr, Newman MG, ed. Clinical Periodontology. (8th ed.) Philadelphia, PA: W.B. Saunders Co, 1996:622-639.

22. Hatfield CG, Bauhammers A. Cytotoxic effects of periodontally involved surfaces of human teeth. Arch Oral Biol 1971;16(4):465-468.

23. Armitage GC. Biologic basis of scal-ing and root planning. In: Armitage GC. Biologic Basis of Periodontal Maintenance Therapy. Berkeley, CA: Praxis Publishing Co., 1980:78-115.

24. Aleo JJ, De Renzis FA, Farber PA. In vitro attachment of human gingival fibroblasts to root surfaces. J Periodontol 1975;46(11):639-645.

25. Thomas D, Rapley J, Cobb C, et al. Effects of the Nd:YAG laser and combined treatments on in vitro fibroblast attachment to root surfaces. J Clin Periodontol 1994;21(1):38-44.

26. Ito K, Nishikata J, Murai S. Effects of Nd:YAG laser radiation on removal of a root surface smear layer after root planning: A scanning electron microscopic study. J Periodontol 1993;64(6):547-552.

27. Tewfik HM, Garnick JJ, Schuster GS, et al. Structural and functional changes of cementum surface following exposure to a modified Nd:YAG laser. J Periodontol 1994;65(4):297-302.

28. American Academy of Periodontol-ogy. Glossary of Periodontal Terms.(3rd ed.) Chicago, IL: American Academy of Periodontology, 1992.

29. Yamaguchi H, Kobayashi K, Osada R, et al. Effects of irradiation of an erbium:YAG laser on root surfaces. J Periodontol 1997;68(12):1151-1155.

30. Schoop U, Moritz A, Goharkhay K, et al. The impact of Er:YAG laser irradiation on root surfaces and the adjacent soft tissues: An in-vitro evaluation. Lasers Surg Med 2001(Suppl 13):17, abstract 68.

31. Rechmann P, Henning T, Golden DS. Calculus removal with an Er:YAG laser and a frequency doubled alexandrite laser. 6th International Congress on Lasers in Dentistry, Maui, Hawaii. The International Society for Lasers in Dentistry, 1998:218-222.

32. Rechmann P, Hennig T, Reichart PA. Dental pulp reaction after irradiation with a frequency doubled alexandrite laser in dogs. 7th International Congress on Lasers in Dentistry, Brussels, Belgium. The International Society for Lasers in Dentistry, 2000:41, abstract.

33. Crespi R, Barone A, Covani. Fibroblast attachment on laser treated root surfaces. 7th International

Figure 17: Facial view of the tooth supporting a partial denture, two years

postoperatively.


31

WA

VE

LEN

GT

HS

■FA

LL20

03 ■

VO

LUM

E11

, IS

SU

E4

Congress on Lasers in Dentistry, Brussels, Belgium. The International Society for Lasers in Dentistry, 200010, abstract.

34. Hammarstrom L, Heijl L, Gestrelius S. Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol 1997;24(9 Pt 2):669-677.

35. Heijl L. Periodontal regeneration with enamel matrix derivative in one human experimental defect: A case report. J Clin Periodontol 1997;24(9 Pt 2):693-696.

36. Nalbandian J, Frank RM. Electron microscopic study of the regeneration of cementum and periodontal connective tissue attachment in the cat. J Periodontal Res 1980;15(1):71-89.

37. Blomlof J, Blomlof L, Lindskog S. Effect of different concentrations of EDTA on smear removal and colla-gen exposure in periodontitis-affected root surfaces. J Clin Periodontol 1997;24(8):534-537.

38. Blomlof JP, Blomlof LB, Lindskog SF. Smear layer formed by different root

planning modalities and its removal by an ethylenediaminetetraacetic acid gel preparation. Int J Periodontics Restorative Dent 1997;17(3):242-249.

39. Blomlof J, Lindskog S. Periodontal tissue-vitality after different etching modalities. J Clin Periodontol 1995;22(6):464-468.

40. Blomlof J, Jansson L, Blomlof L, et al.Long-time etching at low pH jeop-ardizes periodontal healing. J Clin Periodontol 1995;22(6):459-463.

41. Blomlof J, Lindskog S. Root surface texture and early cell and tissue colonization after different etching modalities. Eur J Oral Sci 1995;103(1):17-24.

42. Blomlof J, Jansson L, Blomlof L, et al. Root surface etching at neutral pH promotes periodontal healing. J Clin Periodontol 1996;23(1):50-55.

43. Ball, K. Lasers: The Perioperative Challenge. St Louis, MO: C.V. Mosby, 1990:98-100.

44. Froum SJ, Weinberg MA, Rosenberg E, et al. A comparative study utilizing open flap debride-

ment with and without enamel matrix derivative in the treatment of periodontal intrabony defects: A 12-month re-entry study. J Periodontol 2001;72(1):25-34.

45. Hakki SS, Berry JE, Somerman MJ. The effect of enamel matrix protein derivative on follicle cells in vitro. J Periodontol 2001;72(5):679-687.

46. Zetterstrom O, Andersson C, Ericksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodon-tal defects. J Clin Periodontol 1997;24(9 Pt 2):697-704.


advanced proficiency case studies - academy of …...secondary tooth decay of composite filling at...

Documents