April 1, 2011
by Les Rykiss D.M.D.
There are many ways in dentistry to accomplish beautiful cosmetic results when nature does not provide an ideal canvas to paint your portrait. We, as cosmetic dentists, have the ability to create amazing things with technology that once was performed solely with a scalpel, bur and sutures. As long as we abide by the same rules with regards to biologic width, we can lengthen teeth virtually atraumatically without sutures, with amazingly quick healing, and without discomfort. This can all be accomplished with a hard tissue laser. This paper will examine the smile recreation with porcelain veneers after extensive closed flap crown lengthening using the Biolase Waterlase MD, Er,Cr:YSGG hard/soft tissue laser.
Principles of Crown Lengthening and Biological Width
Gargiulo, Wentz and Orban first mentioned biological width as a complex made up of a 1mm connective tissue attachment, a 1mm epithelial attachment and a 1mm sulcus depth.1 It is also known that the sulcus depth interproximally is closer to 3mm, and only 1mm midfacially. It is a fair statement today that it is widely known that for proper healing and healthy tissues, if we adhere to these principles and have 3mm of tissue above the alveolar crest midfacially, we will have a successful outcome post surgery. I will attempt to illustrate just that. Whether you use a scalpel or a hard/soft tissue laser, the outcome is the same. The difference is the time of getting to that point.
Why Closed Flap Crown Lengthening VS. Conventional Approach
There all several reasons why laser crown lengthening should be the preferred method to obtain amazing results. Ease of procedure is one. This is both for the practioner as well as the patient. Another is the healing time. As will be mentioned later, it is known that most periodontists will ask us to wait a minimum of 6 to 8 weeks for healing prior to impressing for a final restoration. With laser, many practioners will lengthen, then impress for final restoration immediately. These practioners are confident that the crown lengthening procedure, when done correctly with laser, will keep the esthetic crown margins exactly where they put them at the time of crown lengthening. The last is the ease of sculpting gingival curves with laser as opposed to scalpel. For anyone who has ever tried, it is much easier to sculpt with a laser, whether soft tissue laser or hard tissue laser, than a scalpel. As an added bonus, there is virtually no bleeding so it is much easier to see what you have created. There is no zone of necrosis, because of the wavelength of this laser and the use of both laser energy and water. As well, the low-level amounts of laser energy used will promote and stimulate bony and soft tissue healing.2
Immediate Impressioning VS. Healing time
Many laser practitioners are confident that they can crown lengthen, prep the teeth and impress for final restorations at the same appointment. This again is due to the lack of a zone of necrosis, absence of swelling, and the healing that the laser energy imparts to the gingiva. I decided for this case, because of the extensive amount of bone removal (3mm on 21), I wanted to follow the case and touch up prior to final prepping if necessary. I believe that waiting allows for greater control over the final results. Touch-ups can be done prior to the fabrication of the final restoration. As well, by doing a diagnostic wax up after healing, you can have a much more realistic model based on the new tissue location.
Some of the potential problems that could occur are usually related again to establishing a correct biological width. If adequate room is not given, the gingiva may remain inflamed. As well, gingival migration could occur in an attempt to regain biological width.3 Again, both sound reasons for allowing the tissues to heal prior to proceeding with the restorative phase.
As with all cosmetic cases, there are several steps that are always adhered to. Initial records including pre-op photos, radiographs, and study casts are essential. During the pre-clinical assessment, a discussion on patient expectations in terms of size shapes and contours of teeth are addressed. After this, an assessment of the patient’s oral hygiene and periodontal health is achieved. As in all restorative cases, 100% periodontal health is necessary prior to undertaking any restorative treatment.
In this particular case, Carol, a long-standing patient of mine, had originally had a class 2 division 2 malocclusion with a severely deep overbite and heavy attrition due to bruxism on her upper and lower anteriors. After orthodontics, her occlusion improved dramatically however left her with a gingival appearance that was less than perfect. We embarked on this journey together and finally decided that it was time to improve her worn dentition and mixed gingival heights
I explained that I could achieve phenomenal results for her using the Waterlase MD Er,Cr:YSGG hard/soft tissue laser to do gingival height recontouring, followed by porcelain veneers to reshape her teeth. Once a very timid patient, the mere mention of this type of procedure would send her running from my office. After many years of nurturing her, and gaining her trust, the time had come to re-create her smile.
Prior to her appointment, I analyzed her photos and roughly mocked up the approximate future gingival margin locations. I decided to remove tissue from 15, 13, 11, 21, 22, 23, and 25, as seen in figure 2. At the surgical appointment, I determined the amount of bone removal necessary after sounding the bone with a periodontal probe and anesthesia. Using a T4 Sapphire tip on the standard MD handpiece, I traced the approximate location of the new gingival margin heights (Fig. 3). The tissue was then removed and contoured using the same tip, settings 1.0 W, 35Hz, 7% water and 11% air. Knowing that I needed roughly 3mm above the crest of gingival for healthy biological width, I marked that 3mm point on the side of a Z6 9mm zirconium laser tip, and then removed bone with the MD using the settings of 2.0 Watts, 35Hz, with 8% water and 13% air. Bone was removed to that marking by guiding the tip parallel to the root surface between the gingiva and root, with light bone contact, carefully following the curvature of the gingival crest. Once sure that enough bone was removed, reprobing was done to confirm the measurements. The tissue was thinned with a C6 sapphire chisel tip. The last step was to perform a “laser bandage” which essentially disinfects the area and promotes healing,2 using a Z6 6mm tip with the settings 0.5 Watts 30Hz and 0% water and air, and trace the wound area turning the tissue white. As you can see, there was no bleeding during the procedure at all (Fig. 4). The patient was sent home with a chlorhexidine rinse and instructed on her oral hygiene again. No pain medication was prescribed as it is usually not necessary. The patient was phoned and she remarked how easy the appointment was and that her discomfort was so minimal that she did not need and analgesia.
The patient was brought in at the 2 and 4 week intervals to check healing as shown in figures 5 and 6. Note how the gingiva appears to have healed so quickly. There was a bit of residual thickening at the gingival crest on 21, but as you can see it was much better at week 4, and by the time of prepping, completely resolved.
The treatment continued to the restorative phase. Due to the amount of erosion of her teeth palatally on 13-23, it was decided that 360 degree porcelain veneers would be the best restorations for her with facial veneers on 15 and 25. A facebow record, and shade selection were done and photographed, and then prepping was undertaken. Final impressions were taken and then provisionals were made from a siltex splint off her diagnostic wax up. This allows the patient to experience her new smile immediately. As well, this gives the operator feedback as to the quality of the preparations don
e, that is, adequate tooth reduction for the proposed restorations. Once again, this also provides another check as to the gingival heights for the previous crown lengthening. At the next appointment, the veneers were bonded, and the margins were finished and polished. The patient was brought back one week later to check occlusion, and to check for excess cement and gingival irritation. Final photos were taken (Fig. 7). While it was explained to the patient that teeth 26 and 27 would be off-colour, she opted to leave these crowns alone for the time being and replace them in the future due to finances. I believe that while ultimately replacing the crowns would be esthetically more pleasing, both Carol and I were thrilled with the results.
Closed flap crown lengthening performed with the Waterlase MD hard tissue laser can simplify cosmetic dentistry. It allows for immediate results without the trauma of a flapped case. It allows the patient to have the cosmetic results that they want without going through the unnecessary procedures that cause pain and suffering, and unnecessary waiting periods for the tissue to heal and mature. The patient has gone through major smile changes without bleeding, sutures, and with minimal discomfort. The laser also allows for easy touch-ups if the practioner is not 100% happy with the results prior to final preparation of the teeth. While this technique cannot be done for all crown lengthening cases, minor surgical cosmetic cases certainly benefit from its use. With an estimate of only 5% of all dentists using hard tissue lasers, it is hoped that more and more dentists will see the benefits of laser dentistry and use it in cases like the one presented here.OH
Dr. Rykiss maintains his private practice in Winnipeg, MB. He is a graduate of the University of Manitoba as well as a graduate and Mentor at the Nash Institute for Dental Learning in Charlotte, N.C. He has his associate Fellowship from the World Clinical Laser Institute.
Oral Health welcomes this original article.
Many thanks to Robert Passaro of the Passaro Center for Ceramics in Charlotte, NC. for his beautiful artwork on the case presented.
1. Garguilo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J periodontol.1961; 32:261-7
2. Pessoa ES, Melhado RM, Theodoro LH et al. A histologic assessment of the influence of low-intensity laser therapy on wound healing in steroid-treated animals. Photomed Laser Surg. 2004; 22: 199-204.
3. Belcastro D. Sulcus depth and the restorative gingival complex. Oral Health, April 2007.