April 1, 2014
by Marc Robert, DMD
INTRODUCTION: LASERS AND DENTISTRYLasers have been used in several areas of medicine for a long time, even becoming a standard of care for many medical specialties, ophthalmology, dermatology, urology. In dentistry, the clinical use of lasers began in the 1980s. In search of the ideal wavelength for all dental needs, several manufacturers developed different systems and each had their own benefits and limitations. Overtime and research, we understood how these different lasers act on the bio-physical aspect, and that there wasn’t one laser that could answer all our needs in dentistry.
The first surgical lasers used were CO2 lasers. They are still used today, as they are especially popular with oral surgeons.
Then in the early 1990s came the Nd:YAG. Nd:YAG were originally used in dermatology and later adapted to dentistry. The evolution of the Nd:YAG laser led to the LANAP protocol (laser assisted new attachment protocol), appreciated by many periodontists.
In 1991, Argon lasers were been approved for the polymerization of composites to reduce the polymerization time. Today they have been replaced by LEDs.
Erbium lasers were introduced in the years 1997-98, Er:YAG and Er,Cr:YSGG. Their names come from the crystal from the laser radiation they emit. These lasers have a very high affinity for tissues containing water. With the Erbium Family, we finally have a laser that can allow us to treat all the tissues in the oral cavity: gums, oral mucosa, bone, dentine and enamel. Despite a promising start, the first Erbium lasers were slow at cutting teeth in comparison to the drill; many practitioners who tried Erbium Lasers on hard tissues at that time had concluded that lasers were ineffective in dentistry. The new generation of Erbium Lasers is much more effective and easy to use.
Finally, in 1999, diodes lasers were approved for soft tissue procedures, several wavelengths are available, 810nm, 940nm, 970nm, 980nm. These are the most popular lasers in dentistry due to their affordable acquisition price. Several companies produce diode lasers since they are relatively easy to manufactur. Their use is limited to soft tissue.
The clinical case presented in this article was completed with a Er,Cr:YSGG Laser producing a wavelength of 2780nm, manufactured by Biolase inc. The current version of this laser is called Waterlase iPlus.
CLINICAL CASEThe patient consulted for aesthetic reasons. The patient is 28-years-old and has an allergy to penicillin. Her health is excellent, but she is unhappy with her smile. She finds her teeth too short and her gums too visible (gingival smile). She wondered whether porcelain veneers could correct her aesthetic problem.
The patient had two gingivectomy done with a laser diode in the past by another dentist. Diode Lasers can’t be used on hard tissues, so no bone correction has been made during these interventions. This procedure likely violated the biological width, resulting in chronic inflammation of the gums, amplified by mouth breathing by the patient (Fig. 1). There was bleeding on probing in the mouth of the two central incisors. Pocket depth was normal. The general condition of the teeth was good and the color of the teeth perfectly acceptable aesthetically. The upper labial frenum has a high attachment. The band of attached gingiva was greater than 6 mm at the surgical site.
FIGURE 1. Pre-op, front view.
FIGURE 2. Pre-op, lateral view.
FIGURE 4. Immediate post-op after gingivectomy, gingivoplasty, bone correction and frenectomy, 2 sut gut 4.0 amd indermil.
FIGURE 5. Left side immediate post-op.
TREATMENT PLAN The therapeutic approach with laser is to be minimally invasive in our interventions.
1 – Buccal Laser Crown Lengthening of clinical crowns from tooth 12 to 22 with bone corrections to meet the parameters of the biological width.
2 – Upper lip frenectomy may also be necessary during treatment.
3 – Reassessment of the aesthetic result after healing and possible correction with porcelain veneers
LASER CROWN LENGTHENING & OSTEOTOMYFollowing the injection of local anesthetic (2 ampoules of Ultracaine DS 1: 200000 adr we proceed with:
1 – Gingivectomy with Waterlase IPLUS; Tip MZ5 9mm long, 1 to 2.5 W , from 20 to 50 Hz, 20% air/water 40%, H mode. Gingivectomy stops at the cemento enamel junction.
2 – Gingivoplasty with Waterlase IPLUS to create the emergence profile of the gingiva.
3 – Mini flap was done with the Waterlase to view the top of the buccal bone crest by keeping the papilla attached (if possible).
4 – Parameter change for osteotomy and osteoplasty with Waterlase IPLUS 2.5 W, 25 Hz, 60% air/water 80%, H mode without touching the bone crest with the tip of your laser. The osteotomy is in harmony (3 mm below) with the level of the gum obtained after gingivectomy.
5 – Make sure to rinse well under the flap with anesthetic or saline.
6 – Upper Lip Frenectomy with the Waterlase, 2-3 W, 20-50 Hz, 20% air/40% water, H mode.
7 – Digital pressure for five minutes at flap site, suture if necessary if the interproximal papillae were detached.
8 – Application of PeriAcryl (n-Butyl Cyanoacrylate) at the surgical site, taking care to avoid the surgical dressing to seep under the flap.
9 – Post-operative – Recommended to avoid brushing the surgical site for a few days. Preferably, gently clean with cotton swab.
10 – Control four weeks after the surgery and proceed to correction if needed.
DISCUSSIONErbium Chromium YSGG (Waterlase) Lasers, when used properly, allow us to do surgeries with minimal bleeding, while reducing inherent inflammatory responses during our surgical procedure. We obtain a faster recovery period and minimal post-operative discomfort.
Traditional Flap Crown Lengthening Techniques with extensive flap and vertical incisions are much more complex to execute for the practitioner, much more painful for the patient, and requires a longer healing period.
FIGURE 6. Four weeks post-op.
FIGURE 8. Pre-op.
FIGURE 9. Immediate post-op of papilla correction between tooth #11-21.
FIGURE 10. Waterlase iPlus (Er:Cr:YSGG) Laser used for the entire procedure.
CONCLUSIONDental Aesthetics problem is often connected to a periodontal problem. Wrongly, as restorative dentist, we often tend to offer treatment plans involving veneers and crowns, while a simple and minimally invasive Laser periodontal procedure can meet the expectations of our patients. In this case, the patient was very satisfied with the result obtained by the Laser surgery, and did not want veneers.
This case demonstrates the enormous potential of Er,Cr:YSGG (Waterlase iPlus) Laser as muldisciplinary tool for dentists. The laser has its place in dentistry as in all medical specialties. A good understanding of the physical and bio-physics of lasers allow dentists to simplify their treatment plan and allow patients to benefit from less invasive and more comfortable procedures. OH
Dr. Marc Robert is a general practitioner in private practice in Longueuil, QC. a suburb of Montreal. Dr Robert Graduated in 1988 from University of Montreal. He has been using Erbium Laser since 2005 he has a Master with the World Clinical Laser Institut, MWCLI, FACD. Dr. Robert teaches all aspects of Laser Dentistry for new users for Biolase and is also a certified trainer for Planmeca E4D technologies. Dr Robert teaches at the University of Montreal to familiarize Students with these new technologies. Oral Health welcomes this original article.
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