Forums › Nd:YAG lasers › General Nd:YAG Forum › Cosmetic Gingival Recontouring
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May 26, 2003 at 6:37 pm #2746
BenchwmerSpectator50 year old female patient presents w/ no caries, no sensitivity, no perio, no restorations on anterior teeth.
2-3mm of clinical crowns #7,8 covered w/ gingiva.
Probe readings show Psuedo-pockets 3mm on facial #7,8.
Treatment: to remove excess gingival tissue and excise frenulum using PerioLase FR variable pulse width Nd:YAG laser using 320-micron contact fiber to address esthetic concerns.
With laser surgery, no scalpel, no sutures, little bleeding or post-op pain. Probing show the marginal and interdental gingiva can be excised without interfering w/ biologic width.
Laser excision 3.0W 50 Hz 150sec
Laser tissue ablation 3.0W 20 Hz 150 usec
Immediate post-op, no bleeding
One week
Three weeks, shows little inflamation and return of gingival contours, patient happy with cosmetic results
One year
I have complete case presentation notes, if any other questions. I do not take questions on biologic width.
JeffMay 27, 2003 at 12:19 am #5681
AnonymousInactiveJeff,
Great pictures and great case. It’s fun when you have the follow-up to show how stable it is over time. It is good that the patient is happy – they SHOULD be. You didn’t create any “black triangles” and the tissue has remained stable – no need to worry about biologic width.
May 27, 2003 at 2:48 am #5683
Glenn van AsSpectatorWhat about the biologic width??
Glenn
JUST KIDDING JEFF…………great case and one point I always find is that if you take a probe , even if you arent sounding, and take a photo……..NOBODY ever questions you about the depth of the pocket. They might not even argue about the darn procedure…..silly but true.
Nice case and nice result…….hey looking back , do you think that you could have gotten it perfect with some osseous work with the Opusdent??
Glenn
May 27, 2003 at 12:14 pm #5671
BenchwmerSpectatorGlenn,
This procedure was a simple 1/2 hour procedure to expose the clinical crowns of #7,8. Patient had this look for over 40 years. Adding a crown lengthening procedure to the facial #8, would also add a restoration to cover exposed root structure. With #9 being labially tilted, there would still be discrepensies w/o Ortho.
Patient was happy with simple.
JeffMay 28, 2003 at 3:24 am #5686
SwpmnSpectatorJeff:
Nice case and thanks for sharing. I’m sure your patient is very pleased.
Please explain the difference in repitition rate setting of 50 Hz for the frenum excision vs. 20 Hz for the gingivectomy.
Also, remind me what is the range of repitition rate on the Periolase? I have the spec sheet somewhere but not in front of me.
Al
May 29, 2003 at 3:07 am #5672
BenchwmerSpectatorPerioLase has variable pulse settings 10, 15, 20, 30, 50 Hz.
Using 50 Hz in excising thick, fibrous tissue, I don’t need tissue recovery time, gives me some “hot tip” affect on fiber tip for quick cutting.
Used 20Hz for fine tuning, ablating tissue at margins, removing tissue tags, not wanting char or damage to remaining gingival tissue. Here I want tissue recovery. Want margins to heal at this level without recession.
JeffMay 29, 2003 at 10:26 pm #5687
SwpmnSpectatorThank you,
Al
June 25, 2004 at 6:23 pm #5673
BenchwmerSpectatorTwo-year follow-up photo
Jeff
June 25, 2004 at 11:09 pm #5685
Kenneth LukSpectatorHi jeff,
Nice case!
For frenectomy, could you choose a longer pulse width instead of higher Hz to achieve the same outcome you want to achieve?
Ken(Edited by Kenneth Luk at 7:10 pm on June 25, 2004)
June 26, 2004 at 1:23 am #5677
Dan MelkerSpectatorJeff,
I am not against the use LASER at all for this procedure. I am very clear on this point. We are here to evaluate each others cases as friends wanting the best for our patients.
Jeff, this is a case of ALTERED ACTIVE ERUPTION. Your 2 yr. follow-up shows almost 100% relapse. That is not me speaking, this is the pictures of your 2 yr. follow-up.
With AAE. you must do osseous to create a space for the tissue. I am simply being honest. Everyone pats you on the back, Glenn side steps the BW, but the reality is that the procedure could have been far more successful doing the proper biologic correction.
The tissue was on the enamel because there was no space for the BW. It must be made-if not relapse will occurr which certainly is visible in your 2 yr. follow-up.
FORGET the laser, that is not the issue. The issue is the end result. Relapse has occurred.
AAE. must have osseous recontouring to be successful. Your pictures are evidence of that.
Do not get mad at me for stating a fact. No one should jump on me for discussing BIOLOGY! The pictures speak for themselves!
Let’s discuss this case as friends. I can show a dozen cases Monday of trt. of AAE. 10yrs. with absolutely no relapse. None.
Let’s learn from this and not pat each other on the back.
The 2 yr. picture speaks for itself.
In August DT magazine there will be the main feature on AAE. and APE.
To be honest I wrote an article in Contemporary Esthetics on this topic and any one that wishes I can give them the year etc.
IT IS NOT THR LASER!
Sorry,
Danny(Edited by Dan Melker at 7:29 am on June 26, 2004)
June 26, 2004 at 1:17 pm #5674
BenchwmerSpectatorKen,
The 100-150 microsecond pulse width is needed to achieve the peak power needed for tissue ablation while allowing tissue recovery without surrounding thermal necrosis. My laser will not even allow me to use the wide pulse width of 635usec above 20 Hertz over 3 Watts. It would lead to increased tissue temperatures with resulting carbonization.
I use the wide pulse width only for hemostatis.
JeffJune 26, 2004 at 1:26 pm #5678
Dan MelkerSpectatorAn opinion,
I would suggest that the relapse in this case is do to bone being to close to the cej, not allowing a space for the BW.
Under the Erbium section-topic-visibilty of bone-the first case is exactly the problem that Jeff was dealing with in his case.
Reflection of the tissue shows the bone approximating the cej-no room for the BW. The final picture shows the space necessary for the tissue(BW) so relapse does not occur.
We are all in this to learn. Jeff, thanks for posting this case!
DannyJune 26, 2004 at 2:31 pm #5675
BenchwmerSpectatorDanny,
This case was done in 1999, my first attemps at gingival recontouring. The case was done conservatively and documented with power, repetition, pulse width, time and photos.
My dental education at an old Eastern dental school thirty years ago didn’t include the terms biologic width or lasers.
I saw the rebound of tissue on tooth #8, I have discussed the case at the ALD meeting in Tuscon and on DT.
My future cases have included sounding to the bone, measuring height to gingival crest, pocket probing. I have tried to always leave at 2.5mm between bone and my new gingival margin for BW.
You are correct that you never can be sure of where the height of bone is without reflecting the tissue is surely correct. This patient had this look for 35 years, she wasn’t interested in the surgery or Orthodonics. However, when the patient was offered a 30 minute procedure, without pain, scalpels, sutures and at a reasonable cost she was interested. She is still happy with the results despite the amount of relapse. The cases I have presented are of cosmetic nature without restorations or with a single crown. I utilize Periodontists for traditional crown lengthening procedures when tackling restorative cases or when I can’t expect 2.5-3 mm of BW after laser treatment.
The other two cosmetic recontouring cases I posted on this Forum, are only 3-4 months post-op. I will follow over time.
JeffJune 26, 2004 at 5:27 pm #5679
Dan MelkerSpectatorJeff,
Again I really appreciate your case presentation and the fact that it was done in 1999. I have cases I did in the 70’s where I tryed to fake out the BW and lost everytime. A great case to learn from.
Thanks for sharing the case. These are the types of cases we can all learn from.
DannyJune 27, 2004 at 5:32 pm #5682
Glenn van AsSpectatorDanny: Just a note, I didnt really sidestep the BW issue, and I am responding here to your PM and your post. I realize responding to a PM in another post isnt great etiquette but the topic of my sidestepping BW was mentioned in both and I am tired from travelling and have no time to make two separate answers.
I for one want to see cases with photos posted here. For instance I was just looking at the excellent photos that Robert posted on his lingual tongue tie and the relapse. To be honest with you I was surprised by the relapse and I copied the photos and sent them to my friend Larry Kotlow to ask him about the placement of a suture in this case. I thought that Robert resected alot of the frenum (I thought it was perfect treatment in my opinion) and I thought he did a beautiful job, and yet there was so much relapse. I immediately thought of the suture that my good friend Larry Kotlow always talks about to prevent this sort of relapse. I emailed him to ask him for suggestions.
I learned alot from both that case and this one here that Jeff has kindly shown us.
I WANT PEOPLE TO POST PICTURES. I want to see these cases and to continually blast someone for showing their cases if they have warts and all discourages people from posting.
I will not get into details of your PM but will say that I kindly asked if looking back if Jeff would change anything about the case and do osseous in addition to soft tissue work.
Jeff is a good friend, and someone who knows alot about lasers. No need for me to blast him for posting a case we can all learn things about.
Jeff has professionally come on and explained this early attempt to fool mother nature (BW) and I think it is a great teaching case.
There is a way to kindly ask someone if they would change something from a case. I dont think I skirted the BW issue, I asked about it and wanted Jeffs opinion on the matter.
To me it was perfectly obvious, and Jeff when asked kindly pointed out this early attempt.
In closing the frenectomy healed beautifully in this case, without relapse so the laser did have some benefits.
Its a glass half full or half empty and for me when I post a response to someone who has exposed their work to all of us and many who are lurkers, I feel like they need to be acknowledged for that……..
That is the way I post, and if I am a “guru” or a “leader”, that is how I do it.
In closing, I taught at my university 1-2 days a week from 1989-1999 and still teach when lecturing today. Its a win win position where I learn and hopefully the students learn. I discovered a long time ago the best method for approaching a constructive criticism for any case (because I wasnt there in the operatory when he did the treatment) was to do the “sandwhich ” technique where you start with something good……(ie the nice photos) then constructively criticize the case where you need to (ie BW) and then finish with something good (like the frenectomy, or the nice pics).
THat is the best way to approach a post, and I respect people who take the time to approach my cases like that. I think this is something that many people could learn alot in doing before they blurt out something in a PM or a email post that may come back to haunt them.
I just returned from Salt Lake City, am beat and read this so I am off to sleep for a while.
Thanks for sharing and even when a case doesnt turn out 100% perfect it can be a great teaching case, and this certainly was.
“The road to success is paved on failure”……..and I know that I am learning alot from posts that stretch the envelope even if they dont always succeed……..
In time it allows us to figure out what does work and what doesnt……..I for one applaud the pioneers like Jeff, willing to try things, and even more willing to share their attempts at change.
Kudos to the out of box thinking……
Glenn
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