lowe laserassistedcosmeticdentistry

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Edited by Dr. Robert A. Lowe

Clinical Solutions

LASERSin restorative practice

Esthetic and cosmetic dentistry deliv-ered at its optimal level often requirescorrecting both hard tissue (teeth and

alveolar bone) and soft tissue abnormalities.Re-creation of a harmonic balance betweentooth contour, position, and color is often notcomplete without also addressing soft tissuediscrepancies and gingival asymmetries. Ithas been reported that the use of lasers toperform dental procedures often minimizessurgical trauma, whichin turn reduces postop-erative discomfort andspeeds recovery and heal-

ing times. Various typesof lasers have been usedfor some time to performsoft tissue procedures inthe dental practice. Today,diode lasers can be used to perform vari-ous surgical (soft tissue) procedures such asesthetic gingival recontouring, sulcular curet-tage in periodontal pockets, excisional biopsy,gingival troughing to aid in nal impressionmaking, and frenectomy, just to name a few.The zone of necrosis is so minimal from a

laser incision that healing is very predict-ablemuch more so than electrosurgerywhich is critical in the aesthetic zone.

Lasers are also available that combine water withlaser energy, allowing them to be used on hardtissues enamel, dentin, and bone. One manufac-turer, Biolase Technologies, of the Waterlase Er,Cr:YSGG laser describes a phenomenon calledhydrophotonics whereby water particles, ener-gized by laser energy, perform the cutting on hardtissues. Unlike most laser systems that remove tis-sue through direct laser energy, the Er,Cr:YSGGl t f t f th g t th t d

ing or vaporization. Such lasers can noweffectively to remove decay and preparefor restoration with resin restorative mat

nice feature about performing operative on enamel and dentin with an Er,Cr: YSis that the laser energy causes an interruthe sodium/potassium pump at the neurmaking it possible to use the laser in manwithout local anesthesia. For some patiena major breakthrough. Using the Er,Cr:YSto remove alveolar bone can be much less tthan conventional surgical techniques. T

cuts only out of the tip, so that when placeto the tooth/root surface, only bone is remoside of the tooth/root is not affected by thaction of the instrument. Among the operacan be performed are Class I, II, III, IV, preparations, dentin desensitization, enaming, osseous recontouring during gingivaendodontic therapy, including pulpal vapand osseoectomy during tooth/root extr

ridge recontouring, to name a few. Whprocedures are performed, the laser woua sterile surface that promotes healing wpostoperative discomfort.

Here, several soft-tissue laser techniquedescribed. In Parts 2 and 3 (February anissues of DPR), several more soft- and haprocedures will be spotlighted.

Tissue recontouringWhen adequate amounts of free gingiva ent, laser contouring (gingivectomy) can princrease cervicoincisal heights of clinical c

t th ti t I th ill

PART 1

(1) An Er, Cr:YSGG laser with a 400 mic ron taperedtip is used to contour excess gingival tissue aroundorthodontic brackets. (2) The cervico-incisal heightof tooth No. 8 is measured with a caliper and the dis-parity in length between teeth Nos. 8 and 9 is noted.For a patient who displays gingiva when smiling, thiscan be very unattractive. Lasers can be used in aminimally invasive fashion to equalize the cervico-incisal heights and make the patients smile moreattractive when the new restorations are completed.(3) A diode laser (EZ Lase: Biola se Technologies) isused to equalize gingival heights over teeth Nos. 8and 9 immediately prior to marginal re nement of thepreparation and nal impressions for porcelain lami -nate veneers. A diode laser is used in a controlledsweeping motion to contour the gingival crest.

Laser technology is profoundly impacting the day-to-day practice of esthetic and restorative dentistry.Its uses expand daily. This article will discuss

some of the latest applications for lasers in clinicalesthetic dentistry and show how this amazingtechnology allows us to better treat our patients.

Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D., F.I.A.D F.E.

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Laser versatility

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The diode laser cuts soft tissue efand bloodlessly when the ber with a light paint stroke moEr,Cr:YSGG cuts soft tissue witing machine stitch-like cut. Hcan be achieved using low powair or water, but on some type(in the presence of inammationcomplete as when using a diode

Gingival hyperplasiaPatients with gingival hyperplas the patient in Figure 1 witic appliances, can be effectiveusing a Er, Cr:YSGG laser withthesia around the metallic appremove the excessive gingival improve the patients aesthetictissue contact with the tip of tYSGG laser is recommended. Iis not controlled, defocus the laseing the tip back a few millimethe tissue surface. The laser wila ne white surface on the epitthe bleeding is coagulated.

Esthetic gingival-levelcorrection

Many patients may exhibit maxtral incisors that have disparateheights ( Figure 2 ). A diode laYSGG laser can be used to ctissue levels above the affected to making nal impressions if aamount of free gingival tissue exthe periodontal sulcular envneeds to be evaluated. The degingival sulcus is measured usiodontal probe. If the biologic wbe altered due to the esthetic reqof the case, the distance from ththe sulcus to the crest of the alve

region, gingival symmetry is aesthetically pleasing, particularlywhen patients display gingival tissue when smiling. As long asbiologic width is not violated (2 mm for connective tissue and epi-thelial attachments and 1 mm for minimal sulcus depth), amounts

of free gingiva in excess of the 1 mm minimal sulcus depth canbe excised for aesthetic reasons.

Removal of gingival tissue can be accomplished using a diodelaser or by using the Er,Cr:YSGG laser with or without anesthesia.

(4) This is a 2-week postoperativeof the surgerized area shown in Fi3. Notice how well the area is heaThe margins for the porcelain venrestorations are located at the cresthe free gingiva, precisely where tissue was lasered. Unlike when uelectrosurgery where tissue necrobe unpredictable, the negligible znecrosis from the laser wound is oa few cell layers thick. Therefore, impressions can be taken at the timsurgery with predictable margin pment after healing.

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must also be measured by sounding. For the average 3-mm sul-cus, leaving a minimum sulcus depth of 1 mm is required, whichmeans that there is 2 mm of free gingival tissue that can be alteredfor aesthetic needs. In general, it is aesthetically desirable to have

the gingival tissue over the maxillary central incisors slightlyhigher (apically) than the tissue over the maxillary lateral incisors.The tissue over the maxillary cuspids should be slightly higherthan the tissue over both the lateral and central incisors. The height

Continued from page 2of contour of the gingival tissuezenith) should be located towartolabial line angles. Accordingthis gingival architecture is a rethe underlying alveolar crest. Thfrom the alveolar crest to the rmargin (free gingival margin) foteeth should be 3 mm facially ainterproximally. Taking these pinto consideration, a diode laserYSGG laser can be used effeartistically create these changesof the minimal zone of necrosis of the laser wound, healed tissue be very predictable and impresbe taken immediately after laseWhen using a diode laser, aneusually recommended, althougLase diode (Biolase Technologia comfort pulse setting, the incan be used without local anesth

author uses hydrogen peroxide the surgical site following diodegery ( Figure 3 ). In general,power to adequately remove th

recommended. A two-week ptive view of the surgical area isFigure 4 prior to placing porcerestorations.

Soft-tissue removalaround implantsAnother valuable use for laser teis the removal of excess gingiaround healing abutments and forms of dental implants ( Figuable to perform this procedure bwithout a scalpel is very convenirestorative dentist during the im

and restoration phase of implastruction. The use of a laser, untrosurgery, is safe around metallisuch as titanium or metal restorarials. When removable ippersraries) are used as interim restorimplants, it is not uncommon to gingival hypertrophy around thabutment due to the contact of thtion during function. This phcan even happen when the reare adjusted to avoid implant coEr,Cr:YSGG laser, or diode lasused in these instances to remo

THE USE OF A LASERISSAFE AROUNMETALLLICSURFACES


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without danger of altering the titaniumsurfaces or interfering with the osseointe-gration process. Also, when healing abut-ments become loose, the gingival tissuescan migrate into the space between theabutment and the implant platform. Whenthis occurs, it is impossible to properly

place implant components on an externalhex platform. On radiographic examina-tion, the space between the platform andabutment is apparent. It is essential to clearthis tissue from the platform of the implantso that the restorative components willt properly. Once the implant platform iscleared, the restorative components aremore easily placed.

Summary Some techniques have been describedusing both diode and the Er,Cr: YSGGlasers in the esthetic/restorative dentalpractice. As time goes on, more uses willbe discovered for this wonderful adjunc-tive technology to aid the dentist in cre-ating beautiful and functional smiles forpatients in a more comfortable manner. 2 InFebruary and March, Parts 2 and 3 of thisarticle, several more laser technique willbe outlined, including gingival troughing,frenectomy, root desensitization, osse-ous recontouring, cavity preparation, andalveoectomy. DPR

Robert A. Lowe, DDS, FAGD, FICD, FADI,FACD, maintains a private practice inCharlotte, N.C. A Diplomate of the Ameri-can Board of Aesthetic Dentistry, Dr. Lowelectures internationally and is co-chair of

Advanstar Dental Medias continuing edu-cation advisory board. He can be reached at704-364-4711 or at [email protected].

References1. Kois JC, Altering Gingival Levels: The Restorative

Connection Part 1: Biologic Variables, Journal Of Esthetic Dentistry , Vol. 6, No. 4, 1994, pp. 3-9.

2. Lowe RA, Lasers In Cosmetic Restorative Practice:

66-68.

(5) The Er, Cr: YSGG laser is used aroundthis titanium healing abutment to removeexcess gingival tissue prior to removal fora xture level impression. This simpli es

placement of impression copings andesthetic tissue contours around the nalabutment and restoration.

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Clinical Solutions

LASERSin restorative practice Delivered at its optimal level, cosmetic doften requires correcting both hard(teeth and alveolar bone) and soft-tissue

malities. Re-creation of a harmonic balance betooth contour, position, and color is often not cowithout also addressing soft-tissue discrepancigingival asymmetries. Using lasers to performprocedures often minimizes surgical trauma, in turn reduces postoperative discomfort and recovery and healing times. Various types ofhave been used for some time to perform softprocedures. The zone of necrosis is so minimaa laser incision that healing is very predictable more so than from electrosurgery which is cri

the esthetic zone.Last month, in Part 1 of this article, I described several s

sue procedures using a diode laser. Here, and in the conPart 3, I discuss additional soft- and hard-tissue applicationboth a diode laser and the Waterlase Er,Cr:YSGG laseBiolase Technologies .

Inammatory-tissue control and troughingWhen replacing failing restorations, it is not uncommonunhealthy marginal gingival tissues, even when the phomecare is adequate. Localized chronic inammatorycan be removed and hemorrhage controlled by using a lasto the impression-making process. The laser allows theto control the tissues and take impressions at the same ament. The resultant healing will be predictable, and a placed at the time of surgery will remain in the same rto the gingival crest after healing occurs. This can be espcritical when using PFMs in the esthetic zone. Troughiprocedure by which a laser is used to create a space betwpreparation margin and the tissue to aid in the proper retion of master impressions. Many laser users claim to

PART 2

Laser technology is profoundly impacting the day-to-daypractice of esthetic and restorative dentistry. Its uses expand

daily. This article will discuss some of the latest applicationsfor lasers in clinical esthetic dentistry and show how thisamazing technology allows us to better treat our patients.

Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE

(1) The Er,Cr:YSGG laser is used to trough around tooth No. 10. This will simplify placement of retrac-tion cord and enhance access to the restorative margins and root surface beyond to the impres-sion materials. (2) A labial frenectomy is being performed between teeth Nos. 8 and 9 to correct alow attachment, which could in turn lead to gingival recession. Because of the ease of completion andunremarkable healing when performed with a laser, this can be done as a preventive measure whenlow frenum attachments exist. (3) The Er,Cr:YSGG laser is shown cutting enamel and dentin on a max-illary premolar that has occlusal and distal decay. Outline and convenience forms are established. Car-ies can be excavated with hand instrumentation and slow speed round burs without local anesthesia.(4) Attrition that exposes dentin on incisal edges of anteriors is easily treated with the Er,Cr:YSGG laser. Thisslows wear and helps maintain disclusive patterns, further slowing posterior wear as well.

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PART 1 (January) Tissue recontouring

Gingival hyperplasia

Esthetic gingival-levelcorrection

Soft-tissue removal aroundimplants

PART 2 Inammatory tissue control

and troughing

Frenectomy

Class II cavity preparation

Incisal edge restoration

Class V cervical erosionand root desensitization

Osseous recontouring andsurgical removal

Eliminating excessive

PART 3 (March) Surgical crown

lengtheningopenclosed techniques

Alveoectomy prior extraction

Laser pulpectomy acanal therapy

ON OUR WEB SITE All of the above

Aphthous ulcer trea

Laser pocket debrid

Cavity preparation

Preventive resinrestorations

Featured laser applications


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Laser versatility


Clinical Solutions

retraction cord. Troughing alone is reliable only when there isenough horizontal thickness of tissue that troughing around thepreparation does not result in loss of vertical tissue height. That

said, when gingival troughing is indicated to aid in gingival dis-placement, use of either the diode laser or the Er,Cr:YSGG laser ismuch more predictable than electrosurgery. When troughing withelectrosurgery, the unpredictable zone of necrosisparticularly in

a thin sulcular environmentcexcessive recession and gingival following healing. Because it ithat the necrosis resulting frowound is only a few cell layers is much less likely to happen wheing with a laser. It is still a gooto use mechanical tissue retractpossible, particularly in the esthand use gingival troughing wized gingival excess or chronmation is present, and in areas oesthetic zone. In general, a diodeprovide more consistent coaguthe case illustrated in Figure 1, is being performed interproxim

retraction cord was placed to cof totally patent sulcus for plalight-bodied impression materialtually assures a perfect impresstime. The goal is not only to cmargins, but also 0.5 mm of roapical to the margin so that the lcan create the proper emergencethe restoration. 1

Frenectomy Maxillary labial frenum posaffect the periodontal stability tion of the central incisors. Howelow frenum attachments go unbecause of the need for a surgicaWith a diode or Er,Cr:YSGG lasfrenectomy (Figure 2) can be peasily, with very little postopercomfort and without the use osia. For patients with a diastemathe maxillary central incisors, hspace closed with esthetic restora

have a better, more stable resufrenectomy is performed. The laser is held parallel to the alveat the point were the frenum inteattached gingiva. The instrumenback and forth as the brous attasevered. There is little bleedinglaser wound and sutures are notThe patient can expect minimafort and rapid healing.

If the lingual frenum is attachedto the tip of the tongue, a patienmay be affected. A lingual frenecoften help a patient who is ton

NECROSISRESULTING

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Laser versatilityClinical Solutions

sure to begin the laser incision disalivary gland ducts (Whartons the tongue upward toward the palaser cuts the attachment bers. Sthe ventral surface of the tongue ior when sufcient mobility of tis realized. When the Er,Cr:YSGused at a setting of 2 watts or lesanesthesia is usually required (topNo sutures are needed. Mild posdiscomfort is often handled withcounter NSAIDs, such as ibupro

Class II cavity preparationFor conservative Class II intecarious lesions without occlusament, a tunnel preparation caangling from the nearest pit (distal) toward the carious lesiusually located just apical to thThrough this approach, the marg

can be preserved while gainingthe caries lesion. Air abrasion round bur can be used to removeThe laser is used to disinfect anenamel and dentin, and the restocedure is completed.

For larger lesions, the Er,Cr:Yis used to complete the outline anience form (Figure 3). Slow spburs can be used to remove cariepreparation is sterilized and etca dentin setting in the lasers dmode.

Incisal edge restorationWhen anterior teeth show signsattrition, the dentin cups out lunsupported enamel susceptibther fracture and shortening of tcrown. Eventually, anterior guicuspid disclusion is lost, leadinmature posterior tooth wear. Inusing hybrid composites has neasier than when using the Er,Crser without anesthesia. The expoand enamel is prepared with the ure 4). The enamel is beveled bthe 600-micron tip at 45 to theface margins. Hybrid composit

the lost enamel on the incisal can add years of life to the postetion by maintaining proper guidisclusion.

Class V cervical erosions/rodesensitizationExposed dentin in the cervical thclinical crown can cause hypeity, particularly when dentinal tuopen. Many topical remedietemporary relief, but the sensitivireturns with time. The Er,Cr:YScan be used to permanently oc

but when performed with a scalpel or surgical scissors, requireslocal anesthesia and sutures. For some patients, especially children,this may dissuade them from having the procedure done. Now

with the Er,Cr:YSGG laser, this procedure can be easily performedwithout anesthesia or sutures and with no discomfort or postopera-tive difculty. The tip of the laser is oriented toward the dorsumof the tongue along the brous attachment of the frenum. Make


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(5) The cervical area of a maxillary rstpremolar has been treated for dentinhypersensitivity using the Er, Cr: YSGGlaser. The obliteration of open tubulesby the laser energy will decrease sensi-tivity almost immediately. If restorationis required, the surface is already pre-pared (laser etched) to receive an adhe-sive resin and composite restoration.

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areas. The 600-micron tip is used for thedesensitizing procedure. Start with thetip 5 to 10 mm from the affected surface.Move the tip in a circular motion towardthe tooth surface for a total treatmenttime of about 30 seconds (Figure 5). If noerosion or abfraction is present, coveringthe surface with composite resin may notbe necessary. If needed, bonding adhe-sive and composite resin can be applieddirectly to the lased surface.

Osseous recontouringand surgical removalThe use of Er,Cr:YSGG laser for bonyrecontouring is going to revolutionizetraditional osseous surgery. Because the

tissue over the maxillary central incisorsis slightly higher than the tissue over thelateral incisorsand the tissue over thecanines is higher than both. Also, gin-

laser cuts only at the end of the tip, controlof osseous removal is maximized. Withdiamonds, the rotation of the instrumentcould damage adjacent root surfaces.Also, because the surgical laser wound isless traumatic there is less chance of bonydamage due to frictional heat, which isalways possible when using rotary instru-mentation without proper water-cooling.This translates into less postoperative dis-comfort and quicker healing times. Oncethe bone immediately adjacent to the toothis safely removed using the laser, an osteo-plasty bur on a slow speed handpiece withwater spray can be lightly and sporadi-

cally used to smooth and contour the lasedbony interface with the adjacent untreatedbone. The diode laser or Er,Cr:YSGG lasercan be used to recontour the gingivalcrest prior to ap reection and the Er,Cr:YSGG laser can be used to incise the apand perform osseous recontouring duringcrown lengthening. Surgical provisionalsare placed after the laser surgery.

Eliminating excessivegingival displayIt is generally perceived that the estheticsmile shows 3 to 5 mm of gingival dis


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gival display should be symmetrical onboth sides of the midline. Many patientsexhibit asymmetrical gingival levels, have

gummy smiles (greater than 3 mm ofmaxillary gingival display), or both. Forthese patients, surgical correction prior tothe placement of restorations will lead to

a greatly improved esthetic result. If ade-quate amounts of free gingiva exist, minorasymmetries can be corrected with gingi-voplasty alone. To give the appearance of

bodily moving teeth in space toexcessive gingival display, osseoution (facial ostectomy) must ofte

(6) This patient has a surgical pldrawn on the attached gingiva rect cervicoincisal height and cremore esthetic balance of the hardsoft tissue display. (7) Surgiction of the gingival zeniths over tNos. 8 and 10 has been accomplwith the Er,Cr:YSGG laser. (8patient required removal of osseocrest corresponding to the amounfree gingiva removed to create esharmony and re-establish properlogic dimension. The Er,Cr:YSGGallows crestal bone to be shaped rately following the restorative mof the provisional restorations apmately 3 mm apically. (9) A post-op view. The porcelain venewere bonded three weeks after lacorrection. The healing is remarkas the gingival seeks out and re-elished the 3-mm biologic zone, cincisally back to the restorative m


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in conjunction with soft tissue resection.When planning the surgery, the nished maxillary central

incisors should be 10 to 12 mm in length. The incisal edges canbe shortened when adequate free way space exists, however theamount depends on the disclusive pattern of the patient. The

shortened incisal edges must still disclude the posterior teeth inall eccentric movements to maintain occlusal harmony. A tissuemarker can be used to plan the soft tissue surgery (Figure 6).Following the rules for esthetic tissue levels previously stated,the perceived nal gingival level is traced creating heights ofcontour at the distolabial line angles. The Er,Cr:YSGG or diode

laser can be used to remove thtissue and create symmetry follproposed surgical plan (Figurethe preparation margins are adjunew heights of the tissue. Biolowill be encroached upon, so ittant to subsequently remove amount of bone to recreate nologic parameters. An intrasulculbevel incision is made and a fullmucoperiosteal flap is elevateperiosteal elevator. According to soft tissue architecture (gingival follow the alveolar crest below 3cal to the free gingival margin. correction is made using the Er,laser and a 600-micron tip. Sinconly cuts at the tip, it is set againof the root parallel with the long ure 8). This prevents damage to surface. Only the alveolar bon

ablated by the laser-energized wroot surface is then planed usiaction chisel. The alveolar arcshould now mimic the restoragin 3 mm apically, allowing fowidth restoration. The interproxon facial esthetic correction caaltered, the ap is sutured backsilk and interrupted suture techsection of the ap needs to be adjusted after suturing to blendlevels, it can be done with the Er,or diode laser. The denitive reon tooth Nos. 7 through 10 areFigure 9 seven weeks after bonwith the Er,Cr:YSGG laser.

Summary As time goes on, more uses will bered for this wonderful adjunctivogy to aid the dentist in creatingand functional smiles for patientscomfortable manner. 6 Stay tunapplications next month.

Robert A. Lowe, DDS, FAGD, FFADI, FACD, FIADFE, maintains

practice in Charlotte, N.C. A Diplthe American Board of Aesthetic D

he lectures internationally and is c Advanstar Dental Medias continucation advisory board. He can be r704-364-4711 or at boblowedds@

References1) Lowe RA, Predictable Fixed Prosthodon

nique Is The Key To Success, CompendiIssue Vol. 23, No. 2, 2002, pp. 4-12.

2) Dr. David Hornbrook Interviews Dr. JohnDental Practice Report, Vol. 10, No. 6, Jupp. 36-43.

Laser versatility


Clinical Solutions


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Clinical Solutions

LASERSin restorative practicePART 3

Laser technology is profoundly impacting the day-to-daypractice of esthetic and restorative dentistry. Its uses expand

daily. This nal installment covers surgical crown lengthening,aveoectomy, and pulpectomy.

Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, FIADFE

(1) A 14 millimeter 600 micron periodontal tip is used on the Er, Cr:YSGG laser to remove the soft and hard tissue during a localizedclosed crown lengthening procedure to correct a biologic width vio-lation caused by previous preparation design. (2) An incisal view ofthe maxillary lateral incisor shown in Figure 15 shows the surgicalsite after osseous correction. Final impressions can now be taken,as the area will heal by secondary intention. (3) The maxillary lat-eral incisor shown in Figure 15 three weeks after corrective lasersurgery, prior to the delivery of the restoration. Note the completeepithelialization of the surgical area. This area now probes a 1-mil-limeter gingival sulcus without bleeding.

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In Parts 1 and 2 of this article, I described several soft- and hard-tiprocedures (see index on facing page). This nal installment spotlifour procedures using a the Waterlase Er, Cr:YSGG laser from Biol

Technologies. Editors note: In addition to the procedures described here, foadditional applicationsaphthous ulcer treatment, laser pocket debridementcavity preparation, and preventive resin resotrationsare described by Dr

Lowe in the unabridged version of this article that appears on our Web sitewww.DPRWorld.com.

Esthetic and cosmetic dentistry delivered at its optimal level often requires correctboth hard-tissue (teeth and alveolar bone) and soft-tissue abnormalities. Re-creationa harmonic balance between tooth contour, position, and color is often not compwithout also addressing soft-tissue discrepancies and gingival asymmetries. It has bereported that the use of lasers to perform dental procedures often minimizes surgitrauma, which in turn reduces postoperative discomfort and speeds recovery and hing times. Various types of lasers have been used for some time to perform soft-tissprocedures in the dental practice. Today, diode lasers can be used to perform variosurgical (soft-tissue) procedures, such as esthetic gingival recontouring, sulcular curettain periodontal pockets, excisional biopsy, gingival troughing to aid in nal impressmaking, and frenectomy, just to name a few. The zone of necrosis is so minimal froa laser incision that healing is very predictablemuch more so than from electrosgerywhich is critical in the esthetic zone.

Lasers also are available that combine water with laser energy, allowing them to

used on hard tissues enamel, dentin, and bone.

Surgical crown lengtheningOpen techniqueOpen surgical circumferential crown lengthening can be performed using the same tenique described last month for the cosmetic recontouring of gingival tissue and alveobone. It is important to keep Ferrule Effect5 in mind when crown lengthening tbroken at the gingival line. At least 2 millimeters of tooth structure needs to be presincisally or occlusally to the restorative margin after the surgery has healed.

It is sometimes necessary to use a 12 or 14 millimeter 600-micron periodontal tipthe Er, Cr: YSGG laser to gain access interproximally and maintain the proper oriention of the tip to remove the bone adjacent to the root. If an osteoplasty diamond is uto festoon interproximal bone (not next to the root) and blend adjacent bony surfaces,laser is subsequently used to create a laser wound, which will promote healing.

Wh thi g th t i t i ll W dl t dt hi l d S g

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When designing the optimal es-thetic outcome for a patient during thesmile rejuvenation process, the clinicianmust create a symmetrical and harmo-nious relationship between the lips, gin-gival architecture, and the positions of the natural dentate forms. Spear 1 has re-ferred to this diagnostic methodology asfacially generated treatment planning,where the maxillary central incisal edgesdetermine where the soft tissue (ie, gingi-va) and bony crest should be positioned.

The versatility of the erbium, chromi-um: yttrium, scandium, gallium, garnet(Er,Cr:YSGG) laser and its ability to re-contour both hard and soft tissues createsthe opportunity for a minimally invasiveapproach in many clinical situations thatrequire repositioning of the periodontalstructures for esthetic or restorative rea-sons. Surgical techniques using the laseralso have been shown to decrease the needfor suturing, reduce postoperative dis-comfort, and shorten healing times. 2,3

This article demonstrates and discussestechniques for the use of the Er,Cr:YSGG

laser for osseous crown-lengthening pro-cedures, specifically highlighting the as-sociated biologic principles as well as theopen-flap and closed-flap techniques.

THE ESTHETICS OFGINGIVAL DISPLAYTHEDENTOGINGIVAL COMPLEXThe dentogingival complex consists of connective-tissue attachment, epithelialattachment (or junctional epithelium),and the gingival sulcus. As described by Kois,4 the most critical relationship forbiologic health when the clinician is plac-ing a restoration at or below the free gin-gival margin (FGM) is the margin locationrelative to the bony crest.Kois stated thatthe distance from the free gingival mar-gin to the osseous crest on the facial as-pect should be 3 mm. Interproximally,on anterior teeth, this distance should be4 mm because of the curvature of the ce-mentoenamel junction and the positionof the bony crest relative to it.The heightof the interdental papilla also can be pre-dicted to be maintainable 4-mm incisal

to the osseous crest betweenanterior teethwith normal root proximity,which is ap-proximately 2 mm to 3 mm at the osseouscrest.With these parameters in mind, theclinician must first decide where therestorative margin will be placed. For all-ceramic restorations that do not need toblock out undesirable dentin (preparation)colors or core materials, it may be desir-able to place the restorative margin atthe free gingival crest or slightly supragin-gival. If an intracrevicular margin is re-quired for esthetic reasons, however, itshould be placed no farther than 0.5 mminto the gingival sulcus to avoid adversebiologic responses caused by encroach-ment upon the attachment apparatus.

Coslet et al 5 and Kois6 also have de-scribed a variation in biologic width thatcompares the distance from the alveolarcrest to the FGM and divides this distanceinto three categories: (1) normal crest;(2) high crest; and (3) low crest.In sim-plified terms, normal crest patients (about70%) have approximately a 2-mm com-bined epithelial and connective-tissue at-

tachment and an average 1-mm to 3-mmsulcus depth. If the sulcus depth is > 1mm, the free gingival excess can be re-sected safely and, on healing, will resultin a dentogingival complex measuring3 mm on the facial aspect. Patients witha high crest often have a shallower sulcusdepth and a combined epithelial and con-nective-tissue attachment < 2 mm. Thesepatients have relatively stable FGM posi-tions and are not prone to recession uponmanipulation of the tissues. Low-crest

patients often have normal su(1 mm to 3 mm) and a combineand connective-tissue attachm> 2 mm.These patients are higrecession and must be treatmeaccordingly. The FGM of lotients will tend to reposition aturn into a normal crest situgingival retraction or surgerythe most important factor in ative gingival health and staposition of the restorative mative to the bony crest, not tative health and/or positiongival tissues.

LASER-ASSISTEDCROWN LENGTHENINUse of the Er,Cr:YSGG laserand bony recontouring has a timpact on the way periodontaperformed. Because the laserthe end of the tip, the user hcontrol of soft- and hard-tissuUsing the Er,Cr:YSGG with allows the operator to mak

gingivectomy incisions with cision and no bleeding. Wheditional rotary instruments tosseous resection, there is athat their rotation will damaroot surfaces. Additionally,surgical laser wound is lessthere is less chance of bony dfrictional heat, which is alwble when using rotary instruwithout proper irrigation. Tmally invasive technology tra

Use of the Er,Cr:YSGG Laserfor Osseous Crown Lengthening:Clinical UpdateRobert A. Lowe, DDS

ABSTRACT

CONTINUINGe Duca Tion

LEARNING OBJECT

After reading this article, thereader should be able to:

describe the dentogingivacomplex.

discuss the closed-flaptechnique.

compare laser-assistedcrown lengthening withlaser-assisted open-flapcrown lengthening.

explain remodeling of thbony crest.

Robert A. Lowe, DDSDiplomat, American Board of Aesthetic Dentistry Private PracticeCharlotte, North Carolina

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Surgical techniques using the laser have been shown to decrease the need for suturing, reduce postoperative discomfort, and shorten healing times. This article demonstrates and discusses techniques for the use of the Er,Cr:YSGG laser for osseouscrown-lengthening procedures, specifically highlighting the associated biologic principles as well as the open-flap and closed-flap techniques.


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28 INSIDE DENTISTRY JACONTINUINGe Duca Tion

less postoperative discomfort and quick-er healing of the patient. 7

LASER-ASSISTED OPEN-FLAPCROWN LENGTHENINGFor an esthetic gingival display, it is criti-cal that symmetry (right and left) existsas far as cervicoincisal tooth height andgingival zenith positions are concerned.Patients who exhibit asymmetrical gin-gival levels may be candidates for surgicalgingival and/or alveolar bone reposition-

ing to improve their esthetics (Figure 1).Typically, these patients have adequateamounts of attached gingiva so that, af-ter the resective procedure, the mucogin-gival junction will not be encroached upon.If adequate amounts of free gingiva exist,minor asymmetries can be corrected withgingivectomy or gingivoplasty alone. Aminimum sulcus depth of 1 mm must al-ways remain after any tissue resection un-less the alveolar bony crest is also reposi-tioned in the apical direction as well. To

give the appearance of spatially movingteeth in the cervical direction to alleviateexcessive gingival display or asymmetry,os-seous correction must often be peformedin conjunction with soft-tissue resectionbecause of sulcus depth violation.

A tissue marker can be used to planthe soft-tissue surgery (Figure 2). Fol-lowing the guidelines for esthetic tissuelevels, the perceived final gingival level istraced,creating heights of contour at thedistolabial line angles. The Er,Cr:YSGGlaser was used to remove the gingival tis-sue and create symmetry according tothe proposed surgical plan (Figure 3).Then, the teeth were prepared to the re-spective corrected free gingival margins.Asthe biologic width would be encroachedupon, it is important that the same amountof bone be removed to recreate normal

biologic parameters. 7 After thprepared, the Er,Cr:YSGG lato trough around areas whegivectomies had been performfor retraction needed for massions to be made (Figure 4).tic agent and tissue deflector aid in tissue management durpression process (Figure 5).retraction technique was usesue was prepared for the imprcess (Figure 6).The completedpression is shown in Figure the entire restorative margin aof tooth or root surface apicalgin needed to be captured inimpression. A plastic matriwith a bis-Acrylic provisionand placed on the preparatiocate the provisional restoratio

Figure 2 A black marker was used to delineatethe surgical plan.The patient had chosen to treat only tooth Nos. 7 through 10.The tissue level over tooth No.8 needed to be positioned more apicallyto be symmetrical with tooth No.9. The gingivallevel above tooth No.10 also needed to be raisedslightly to better match the tissue level of tooth No.7.

Figure 1 Preoperatively, the patients smileshowed a full gingival display and asymmetricalgingival levels in the maxillary anterior region.Although the gummy smile may not be able tobe eliminated completely, better symmetry of thetissue levels was one of the goals of treatment.

Figure 4 Troughing was performedisplacement to allow access to the sarea for the impression medium.

Figure 3 A gingivectomy was performed using an Er,Cr:YSGG laser to harmonize the soft-tissuelevels. Biologic width was encroached upon and,therefore, a repositioning of the bony crest wasalso needed to prevent a relapse of the preoperativetissue position.

Figure 6 A two-cord technique was used to com-plete final tissue retraction.A No. 00 cord was placedaround each preparation to the base of the sulcus,followed by a No.1 cord placed adjacent to eachmargin circumferentially around each preparation.

Figure 5 A combination tissue deflectorandhemostatic agent (Expasyl,Kerr Corporation) wasused after troughing and before the registration of master impressions.

Figure 8 After initial closed-flap boa full-thickness mucoperiosteal flap wvisualize the accuracy of the osseous cobserve the tooth surface and conditiocrest as a result of the procedure.It canthe surface of the root is unscathed.Tcrest was accurately repositioned 3 mmthe restorative margin, following its e

Figure 7 The completed master impression.Note that a 360 margin was present as well as0.5 mm of tooth or root surface apical to therestorative margin.

Figure 10 Facial view of the gingival tissues9 weeks after open-flap surgery and at the time of placement of the ceramic restorations (original mag-nification 2x). Note the symmetrical positioning of the gingival zeniths of tooth Nos. 8 and 9.The levelof tissue health 9 weeks after surgery is excellent.

Figure 9 Facial view of tooth Nos.7 through 10after completion of the surgical phase of treatment.

Figure 12 Six months after surgefull smile showed improvement in gitry and the gingival papilla between and 9 had completely reoccupied theembrasure space.

Figure 11 The all-ceramic restorations (Venusporcelain,Heraeus Kulzer, Inc,Armonk,NY) in placeat the delivery appointment. (Ceramic artistry per-formed by Mr.Vincent Devaud, CFC, MDT,Pasadena,CA.)

THE MOST IMPORTANT FACTOR IN POST-

RESTORATIVE GINGIVAL HEALTH AND

STABILITY IS THE POSITION OF THE RESTORATIVE

MARGIN RELATIVE TO THE BONY CREST...


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32 INSIDE DENTISTRY JACONTINUINGe Duca Tion

tooth Nos. 8 and 9. The definitions are shown in Figure 12after corrective gingival angery with the Er,Cr:YSGGgingival tissues matured nicthe definitive restorations anillae filled in the gingival between the teeth. It is importhat conventional treatment would probably have the patvisional restorations at the 6-low-up visit.

THE CLOSED-FLAP TECFor minor, localized biologicor esthetic gingival zenith cthe Er,Cr:YSGG laser can beform a closed-flap surgical te

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JANUARY 2009Use of the Er,Cr:YSGG Laser for Osseous Crown Lengthening: Clinical Update

Figure 22 Radiograph taken 8 weclosed-flap resective surgery was perthat the bony contour was good,but unevenness was apparent.

Figure 21 The completed restoratfrom the facial aspect at a 2-week povisit. The connective-tissue graft woumature over the next several months.porcelain-to-metal restoration was faMike Felgenhauer, DAL Precision LVenus Smile Center, Peoria, IL.)

Figure 23 Radiograph taken 6 moresective surgery and placement of thprosthesis.Note how the bony crest rwas much smoother than seen in the 8operative radiograph.By making the stion using the closed-flap technique apreparation and impression taking, a samount of operative time (> 6 monthsand an excellent biologic result was a


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fractures where clinical crowns are lostand the remaining tooth structure is lo-cated below the gingival tissue at the bony crest, an open-flap crown-lengtheningprocedure may be preferred for access,adequate instrumentation, and predict-able healing.

CONCLUSIONTechniques have been described using theEr,Cr:YSGG laser for periodontal crown-lengthening procedures. Using the bio-logic parameters discussed in this article,it is now possible to perform open-flapperiodontal procedures both facially andinterdentally and predict to what levelthe tissues will heal based on the posi-tion of the restorative margin. It is im-portant for the clinician to use a peri-odontal probe and sound from the freegingival margin to the alveolar crest todetermine the biologic parameters of thepatient before preparing teeth for restor-ative materials. This step enables the cli-nician to make final impressions on theday of preparation and surgery, deliverthe definitive restorations several weekslater, and be confident that the gingivaltissues will heal to the appropriate esthet-ic levels. Patients and dentists can enjoy ashortened treatment time by avoiding ex-tended time in provisional restorationswhile the tissues mature around their new ceramic restorations.

REFERENCES1. Spear FM, Kokich VG, Mathews DP. Interdis-

ciplinary management of anterior dental esthe-

tics. J Am Dent Assoc. 2006;137(2):160-169.2. Jetter C. Soft-tissue management using an

Er,Cr:YSGG l aser during restorative proce-

dures. Compend Contin Educ Dent. 2008;

29(1):46-49.3. Ishikawa I, Aoki A, Takasaki AA. Clinical appli-

cation of erbium:YAG laser in periodontology. J

Int Acad Periodontol. 2008;10(1):22-30.4. Kois JC. Altering gingival levels: the restor-

ative connection part 1: biologic variables.

J Esthet Dent. 1994;6(1):3-9.5. Coslet GJ, Vanarsdall R, Weisgold A. Di-

agnosis and classification of delayed pas-

sive eruption of the dentogingival junction in

the adult. Alpha Omegan. 1977;70(3):24-28.6. Kois JC. New paradigms for anterior tooth

preparation. Oral Health. 1988;88(4):19-30.7. Dean DB. Concepts in laser periodontal the-

rap y: using the Er,Cr:YSGG laser. 2005. The

Academy Of Dental Therapeutics and Sto-

matology. Available at: http://www.ineece.com/coursereview.aspx?url=1428%2fPDF

%2fConceptsInLaserPerio.pdf&scid=13714.

Accessed Aug 26, 2008.8. Lowe RA. The use of dental lasers and ridge

preservation to maximize esthetic outcomes.

Contemporary Esthetics and Restorative Prac-

tice. 2004;8(7):48-53.9. Lowe RA. Clinical use of the Er,Cr: YSGG

laser for osseous clinical crown lengthening:

CONTINUINGe Duca Tion

1. Surgical techniques using the laser also have beenshown to:

a. decrease the need for suturingb. reduce postoperative discomfortc. shorten healing timesd. all of the above

2. If an intracrevicular margin is required for estheticreasons it should be placed no farther than how far intothe gingival sulcus to avoid adverse biologic responsescaused by encroachment upon the attachment apparatus?

a. 0.5 mmb. 1.0 mmc. 2.0 mmd. 3.0 mm

3. Low-crest patients often have normal sulcus depth (1mm to 3 mm) and a combined epithelial andconnective-tissue attachment that is:

a. > 1 mm.b. > 2 mm.c. < 1 mm.d. < 2 mm.

4. Using the Er,Cr:YSGG with what allows the operatorto make scalloped gingivectomy incisions with surgicalprecision and no bleeding?

a. a football shaped tipb. a tapered tipc. a flat tipd. b and c

5. A minimum sulcus depth of how many millimetersmust always remain after any tissue resection unless

the alveolar bony crest is also repositioned in theapical direction as well?

a. 1 mmb. 2 mmc. 3 mmd. 4 mm

6. Conventional treatment modalities would probably have the patient in provisional restorations at:

a. for shade and contour purposes only.b. 1 week.c. 1 month.d. the 6-month follow-up visit.

7. The criteria for clinical health of the dentogingivalcomplex are:

a. pink color (absence of inflammation).b. reestablishment of a probable gingival sulcus.c. absence of bleeding on probing.d. all of the above

8. Critics have noted that the technique does not leavethe bony crest as smooth as when performing surgery with an open flap and smoothing the bone with handinstrumentation. However, the real question is one of:

a. biologic width.b. biologic height.c. clinical relevance.d. it is in a critical esthetic zone.

9. Using the biologic parameters discussed in this article,it is now possible to perform open-flap periodontalprocedures both facially and interdentally andpredict to what level the tissues will heal based on:

a. periodontal biotype.b. the position of the restorative margin.c. patient history of smoking and diabetes.d. use of laser surgical procedure.

10. It is important for the clinician to use what todetermine the biologic parameters of the patient

before preparing teeth for restorative materials?a. digital radiographb. panoramic radiographc. a periodontal probe and sound from the free

gingival margin to the alveolar crestd. cone beam CT imaging

Use of the Er,Cr:YSGG Laser for OsseouCrown Lengthening: Clinical UpdateRobert A. Lowe, DDS

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