Lasers

Aesthetic Breakthrough: Soft Tissue Lasers

Dentistry Today December 1, 20026 Mins read804 Views

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Possibly one of the most important technical breakthroughs in cosmetic dentistry since dentin bonding is the development of soft tissue lasers. A soft tissue laser allows the dentist an opportunity to make immediate soft tissues changes that can help to maximize the aesthetic result of many cosmetic dental procedures.

There are a number of different types of lasers currently available: argon, CO2, ND:YAG, and diode are the most common lasers used for soft tissue procedures. Each of these types of lasers will cut soft tissue effectively, and each is better at some procedures than others. All of them have many of the same benefits in common1:

(1) Because of the predictability of healing of the surgical cut with a laser, it is possible to perform soft tissue alteration and the final preparation at the same appointment.

(2) Postoperative pain at a laser surgical site commonly is less, and the site heals faster than other surgical modalities.

(3) Lasers can be faster than other surgical modalities.

(4) Lasers can provide immediate hemostasis.

(5) A laser, unlike monopolar electrosurgery, can be safely used near metal restorations.

(6) A laser creates the perception in the patient that his/her dentist is up to date with the latest dental technology. This helps not only to create confidence in the dentist, but it also can help the patient justify the higher fees that are usually associated with elective cosmetic procedures.

For soft tissue recontouring many dentists have found diode lasers to be highly effective. The diode laser is considered to be an excellent soft tissue cutting instrument, it is an effective coagulator, and many of the diode lasers are small, making them easy to move from one operatory to another. Lastly, unlike some other types of lasers, the diode laser uses a standard 110-v line.


Figure 1. Preoperative condition.	Figure 7. The diode laser is used to create an ovate pontic site.

Figure 2. Evaluating the soft tissue.	Figure 8. The final restoration demonstrating a natural appearing emergence profile of the pontic.

Figure 3. The final preparations after the soft tissue has been recontoured.	Figure 9. A preoperative view of tooth No. 10 to be aesthetically enhanced.

Figure 4. The patient’s temporary veneers are finished to the new tissue height.	Figure 10. A diode laser is used to carefully recontour the soft tissue.

Figure 5. Two weeks after the recontouring and preparation the patient returns for delivery of the veneers.	Figure 11. The final soft tissue recontouring and preparations.

Figure 6. A 1-year postoperative view shows excellent tissue health and stability.	Figure 12. The final restoration at the 1-week postoperative visit.

Aside from soft tissue recontouring, the diode laser has numerous other clinical applications2:

(1) Frenectomies are quickly and easily performed, often in conjunction with cosmetic procedures.

(2) Coagulation and soft tissue retraction on anterior or posterior teeth preparations allow for better, more accurate impressions.

(3) Treatment of aphthous ulcers and herpetic lesions is possible. The diode laser can be used for the palliative treatment of these painful conditions. Laser treatment will not only provide alleviation of pain but also can decrease the duration of the lesion.

(4) Adjunctive treatment of periodontal disease is another application. Following manual scaling and root planing, a diode laser can be used to remove the diseased epithelial lining of the pocket as well as eliminate the disease causing bacteria present in the periodontal pocket.

From a financial standpoint a diode laser can provide many practices with an excellent return on the investment in the technology. From a clinical standpoint a diode laser will allow a dentist to step up the quality of his/her dentistry and improve the aesthetics of cosmetic cases.

CLINICAL CASES

Case 1

A young woman presented to the office requesting cosmetic improvement of her smile (Figure 1). After an evaluation of the patient and a discussion of treatment options, the patient chose to re-create her smile using porcelain veneers.

Prior to any preparation of the case the patients soft tissue level was evaluated to see if it was possible to remove any gingival tissue to improve the length-to-width ratio of the teeth, thereby enhancing the final aesthetic result (Figure 2). The periodontal evaluation revealed that there was room to recontour the soft tissue without violating biological width.3,4

Using a diode laser (Diolase ST, American Dental Technologies) the gingival tissue was recontoured to maximize the final aesthetics of the case. During the recontouring the bone level was repeatedly evaluated so as to not violate biological width. Figure 3 shows that a significant amount of gingival tissue was removed. The gingival recontouring effectively increased the length of the clinical crown. Also note in Figure 3 that the preparation margins are terminated at the height of the gingival margins.

The provisional restorations (B1, Luxatemp, Zenith/DMG) were finished to the new tissue height (Figure 4), and the patient was allowed to go home. A postoperative phone call was made to the patient that evening. She stated that she was comfortable and did not need to take any analgesic medications.

When the patient returned for her delivery appointment 2 weeks later the provisional veneers were removed. Figure 5 demonstrates the soft tissue has healed at exactly the same level as the surgical incision that was made at the preparation appointment. The soft tissue irritation present around tooth No. 9 is a factor of an overcontoured provisional restoration, and not a result of the use of the diode laser.

A 1-year postoperative photograph of the veneer restorations (Figure 6) reveals excellent soft tissue health. Also note that the soft tissue margins have remained stable over the course of a year.

Case 2
A 16-year-old female was referred to our office by her orthodontist. Tooth No. 7 was congenitally missing. The orthodontist correctly chose to maintain tooth No. 6 in its natural position and create the appropriate amount of space to allow placement of a prosthesis replacing tooth No. 7.

After discussing the treatment options with the patient and the parent it was decided to replace the missing tooth No. 7 with an Encore bridge.5 Upon closer clinical evaluation it was noted that there was some excess gingival tissue present at the tooth No. 7 pontic site. To create a more natural emergence profile of the pontic, the diode laser was used to create an ovate pontic site (Figure 7).6

Figure 8 shows a natural appearing prosthesis that defies detection.

Case 3
A 24-year-old woman presented to our office with cosmetic concerns associated with tooth No. 10 (Figure 9). According to the patient, 8 years ago upon the completion of her orthodontic treatment, her general dentist placed direct-bonded composite resin on her peg lateral. The patient expressed a desire to have a more natural appearing restoration placed on tooth No. 10.

The malposition of the gingival margin was as much a factor in the cosmetic failure of this restoration as the improper contours of the existing restoration. The ideal height of the gingival margin of a maxillary lateral incisor should be 1 to 1.5 mm below the gingival marginal height of the centrals and canines. In her case the lateral incisors gingival marginal height was 2.5 mm below the central and canine.

After the patient was anesthetized a periodontal probe was used to determine the bone level. It was determined that it was possible to remove 1 mm of gingival tissue without violating the biological width of the tooth. The diode laser (Diolase ST, American Dental Technologies) was used to raise the gingival height of tissue to a more appropriate level (Figure 10). Because of the confidence in the healing position of the surgical site it was possible to immediately place the new direct bonded composite resin veneer. The additional benefit of the laser surgery is that the preparation site has complete hemorrhage control (Figure 11).

Figure 12 shows the final direct bonded veneer (B1, XL and T1 shades, Point 4, Kerr) at the patients 2-week postoperative visit.

CONCLUSION
When used properly a soft tissue laser can become an important piece of equipment for many cosmetic and restorative procedures. For those who use a laser on a daily basis it has become an invaluable instrument to provide higher-quality dentistry. The uses of the laser go far beyond the cases demonstrated here.1,2 It has been shown by many laser users that the routine use of a laser is economically beneficial to the practice as well.1,7,8

Each dentist needs to closely look at his/her practice and practice style to determine if the purchase of a laser is correct for him or her. But if you ask those of us who have a laser if it was worth the investment, I’d bet an overwhelming majority would tell you that they could not imagine practicing without it.

References
1. Miyasaki M. No laser? Here’s what you’re missing. Dent Econ. February 2002;70-74.
2. Benjamin S. Dental lasers: Part 2. Soft tissue laser applications. PPAD. 2002;14:328-330.
3. Kois J. Altering gingival levels: the restorative connection. Part 1. Biological variables. J Esthet Dent. 1994;6:3-9.
4. Robbins JW. Esthetic gingival recontouring: caveat emptor. Cont Esthet Rest Dent. April 2002;66-74.
5. Radz GM. Beyond the maryland bridge. AACDJ. Spring 1996;18-22.
6. Lowe RA. Ovate pontic design: maximizing esthetics, function of fixed partial bridges. Dent Prod Report. June 2002;68-71.
7. Vitale W. Using lasers to increase revenues. Dent Econ. July 2001;34-38.
8. Jameson J. How to profit from lasers: an interview with Dr. Gerald Bittner, Jr. Dent Econ. July 2001;40-42.

Dr. Radz’s practice, the Colorado Center for Aesthetic Dentistry, is located in downtown Denver, Colo. Dr. Radz has completed both AEGD and GPR residency programs. He has been an instructor of several postgraduate teaching institutes. Dr. Radz lectures and publishes extensively on aesthetic-related materials and techniques. Aside from his private practice Dr. Radz is president of Snow Mountain Seminars and is currently the program cochairmain for the American Academy of Cosmetic Dentistry’s 2003 annual meeting. Dr. Radz may be contacted at radzdds@aol.com.