Soft-Tissue Surgery: Use of the Er,Cr:YSGG Laser

In recent years, laser dentistry has become a more accepted modality for treating conditions of both hard and soft tissue. Today approximately 5% of dentists use a laser in their practices, and as many as 18.9% say they are planning to purchase one in the near future.1 Dental schools are beginning to include lasers in their curricula, as are hospital residency programs.
CO2 and Nd:YAG lasers, primarily used to treat soft tissue, were among the first to gain acceptance in the dental profession. At the time, the number of dentists utilizing these lasers in everyday practice was quite small. In the late 1990s Premier Laser Systems received FDA approval for its Er:YAG wavelength for the treatment of both hard and soft tissue. Shortly thereafter, Biolase Technology received FDA clearance for its Er,Cr:YSGG wavelength to treat both hard and soft tissue.
Laser treatment presents too many advantages over conventional techniques for both the patient and the doctor to discount its importance. Some of the benefits include reduced need for local anesthesia, less bleeding, reduced swelling, fewer sutures required (if any), safer to use than “drills,” and less postoperative discomfort, perhaps due to the sterilization effect as the laser cuts.
Numerous indications exist for laser treatment of the oral soft tissues, and practitioners are constantly finding new ways to use lasers. Common soft-tissue procedures include but are not limited to the following: maxillary and mandibular frenectomies, lingual frenectomy, operculectomy, gingivectomy around orthodontic brackets, fibroma removal, treatment of dilantin hyperplasia, removal of mucocele, uncovering tissue around implants, exposing or uncovering teeth for orthodontic banding, treatment of aphthous ulcers, cosmetic tissue recontouring, treatment of herpetic lesions, and much more.
I consider 2 things to be essential before you employ lasers in your practice. First, you must become completely familiar with the instrument before utilizing it. This means that adequate training should occur before you start using this technology. Second, I would also implore the user to include magnification in his or her armamentarium, either in the form of loupes or an operating microscope.
Following are 3 cases I have treated with the Er,Cr:YSGG laser.

DILANTIN HYPERPLASIA

Dilantin (phenytoin) has been used to treat seizure disorders since 1938.2 Gingival overgrowth associated with Dilantin was first reported in the 1960s.3 It has been estimated that up to 50% of patients who use this medication suffer from this problem.4 The overgrowth seems to occur first at the interdental papillae and the marginal gingiva. Facial and lingual/palatal surfaces may be involved. Poor oral hygiene and orthodontic brackets may exacerbate the hyperplasia. Other factors such as drug dosage may play a role. Unfortunately, as long as the patient is on the medication, relapse is very likely. Gingival overgrowth may also result from the use of cyclosporine and calcium channel blockers.

Case 1

Figure 1. A 14-year-old patient with Dilantin hyperplasia.

Figure 2. Treatment of anterior hyperplastic tissue.

Figure 3. Laser gingivectomy, postoperative.

Matt is a 14-year-old male who has been afflicted with seizures since birth. Over the years he has been on various medications, all with mediocre to poor results. This led his doctors and family to consider a neurosurgical approach to try to control his seizures. After several surgeries and oral Dilantin (425 mg/day), his seizures have been under control. However, he has been plagued with a gingival overgrowth. Initially, he was referred to an oral surgeon for treatment. The surgeon thought the procedure might be better tolerated if lasers were employed in the treatment and management, so Matt was referred to my office.
The preoperative photo (Figure 1) shows severe enlargement of the interdental papillae in both the upper and lower arches. Inflammation is present, which correlates to poor oral hygiene. The poor hygiene can be related to (1) limited dexterity as a result of his neurosurgery, and (2) challenges to oral hygiene practices because of the gingival overgrowth.
After explaining the procedure to Matt and his father, the author obtained consent for laser treatment.  The maxillary anterior gingival over-growth was treated as follows: topical an-esthetic was applied with 2 cotton tip applicators and left in place for 4 minutes. Proper eye protection was employed. Utilizing the Waterlase laser (Biolase Technology) with a G6 sapphire tip, 20 Hz, 150 microseconds/pulse, 0.5 W, 11% air, 0% water, the anterior papillae were reduced in a motion very similar to festooning a denture wax-up.  Some bleeding occurred due to the inflammation (Figure 2), but it was easily controlled. Upon discharge there was no bleeding. The patient has returned for several follow-up visits to treat other areas. During the interim, there was some recurrence in the original treatment site. On return visits, Matt was treated with the Waterlase laser with a Z6 tip (which generally causes less bleeding and postoperative discomfort) at 1.5 to 2 W, 15% water, and 20% air. Appropriate eye protection was always employed. The patient and his family are quite pleased with the result (Figure 3). Follow-up visits are at 2- to 4-week intervals. His home care has been augmented with an electric toothbrush, Hydro Floss Oral Irrigator (Oral Care Technologies), and chlorhexidine mouthrinses.

GINGIVECTOMY DURING ORTHODONTIC CARE

Figure 4. Carious and decalcified lesions after orthodontic debanding.

Figure 5. Swollen papillae during orthodontic treatment.

All too often, general practitioners may see decalcifications, pitting, and carious lesions when orthodontic brackets are removed (Figure 4). These types of sequelae can be prevented. It is up to both the treating orthodontist and the general practitioner to stress frequent “cleaning” appointments and good home care. The parents must play a role in this as well. Home care is often inadequate due to increased difficulty and lack of motivation. This unfortunately may lead to enlargement of the gingiva, which in turn compounds the problem of home care (Figure 5). Recontouring and/or removal of the swollen gingival tissue may facilitate better home care and make the occurrence of caries less likely.

Case 2

Figure 6. Er,Cr:YSGG laser treatment of swollen papillae.

Figure 7. Immediate postoperative photo of laser gingivectomy.

A 12-year-old female was undergoing orthodontic therapy when she returned to my office for her recare visit. Upon examination I noted swollen and inflamed papillae in the maxillary anterior region of her mouth. Her oral hygiene was poor and a prophylaxis was performed. Home care was stressed, and the mother was instructed to bring her back for re-evaluation and possibly gingival recontouring. When she returned, the inflammation was reduced but her home care still needed improvement. The papillae were enlarged, and my concern was that caries might develop under the swollen tissue. I explained this to the parent and received consent for laser recontouring.
Topical anesthetic was placed with a cotton tip applicator and left in place for 4 minutes. Necessary eye protection was employed. Utilizing the Waterlase laser and the Z6 tip, I carefully began to remove the swollen tissue (Figure 6) with 1.25 W, 12% water, 15% air. An immediate postoperative photo was taken (Figure 7). The patient felt no discomfort, experienced no bleeding, and upon a follow-up phone call, I was told she had no pain.

TRAUMATIC FIBROMA

One of the most common lesions found upon oral examination is the fibroma. Generally, it appears as a result of trauma or irritation. Fibromas may be round or ovoid, usually from 1 to 10 mm in diameter. The surface is usually smooth but may be hyperkeratotic or ulcerated if the trauma or irritation persists. Fibromas are firm and may be sessile or pedunculated. They usually are found on the buccal mucosa, lip, or tongue.

Case 3

Figure 8. Preoperative photo of lip fibroma.

Figure 9. Immediate postoperative photo of laser biopsy of lip fibroma.

Figure 10. A 6-month follow-up of biopsied site on lower lip.

A 50-year-old male presented with a 4-mm round, firm, pink sessile mass on the right inside of his lip. He stated that he bit his lip in the past and the “bump” had gotten bigger as he repeatedly bit his lip (Figure 8). A decision was made to remove the lesion with the laser and send it out for biopsy. Consent was obtained. Appropriate eye protection was used, and topical anesthetic was applied for
3 minutes. With a college plier, my assistant grasped the fibroma and pulled on it to create tension. The Waterlase laser was used with a T4 tip at 0.5 W, 0% water, 11% air to dissect out the fibroma from its periphery. There was no bleeding, the patient felt no discomfort, and no sutures were necessary (Figure 9). No postoperative medications were given. He was instructed to take acetaminophen as needed (he didn’t). The patient returned for a 6-month recare appointment, and a photo of the treated area was taken (Figure 10). The area appeared smooth and free of any recurrence.

Conclusion

While dental lasers are still in their infancy, there is no doubt that the profession has become more accepting of them as an alternative to traditional therapies. While most patients are unaware of the uses of lasers in dentistry, they seem quite pleased with the results. It is appreciated when treatment can be completed without the use of needles for anesthesia, and without the complications of bleeding, swelling, and pain. The Waterlase dental laser has made the treatment of various soft-tissue conditions easier for the patient and the doctor. In the past, these patients would likely have been referred out to a specialist. Now, specialists are referring these cases to the laser dentist.


References

  1. Harrison W. Beginning the journey n laser assisted dentistry. Dental Economics. October 2006.
  2. Cacek AT. Review of alterations in oral phenytoin bioavailability associated with formulation, antacids, and food. Ther Drug Monit. 1986;8:166-171.
  3. Vacharotayangul P, Lozada-Nur F. Drug-induced gingival hyperplasia. http://www.emedicine.com/derm/topic645.htm. Updated December 15, 2006. Accessed October 28, 2007.
  4. Drug-induced gingival overgrowth. Australian Adverse Drug Reaction Bulletin. June 1999; vol 18. http://www.tga.gov.au/docs/html/aadrbltn/aadr9906.htm. Accessed October 28, 2007.

Dr. Tracey has been practicing laser-enhanced dentistry since 2002. He currently utilizes a Water-lase, a LaserSmile, a DIAGNO-dent, and a PerioLase. He is a member of the AGD, Academy of Laser Dentistry, and the ADA, and has achieved Fellowship status in the AGD and the World Clinical Laser Institute. He lectures on the clinical applications of hard-and soft-tissue lasers as well as marketing laser dentistry. His office has been located in Rockland County, NY, for 23 years, and he can
be reached at (845) 362-2200 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: The author owns stock in Biolase.



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