Cosmetic Gingivectomy - Laser Dentistry Forum

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May 22, 2004 at 3:31 pm #2735 Reply

Benchwmer
Spectator

The following forty something female patient presents with gingival height discrepency on her anterior Maxillary central incisors.
Peroidontal evaluation and probing shows no signs of periodontal disease. Probing shows 3mm to attachment on the facial of #9, another 2mm to sound bone. This should allow me to remove 2mm of gingiva on the facial of #9 without violating biologic width.
Photos before:

Treatment will consist of Laser Gingivectomy of only tissue covering the clinical crown of #9.
The PerioLase free running, pulsed Nd:YAG, with a contact fiber will be used. LA 4% Citanest infiltrated.
Laser Parameters were 3.0W 20 Hz 150 usec to ablate, bevel and contour the gingival tissues. Duration less than a minute.
Photo immediately after:

Note precise removal of tissue to expose underlying tooth enamel. The Nd:YAG was chosed for this procedure over the Erb:YAG because of increased hemostatis and not having to protect the root surface during treatment. The laser tip can be directed at a 90 degree angle to the tooth to facilitate tissue removal and final contours without any fear of damage to the underlying tooth or root surfaces.
Photo at post-op evaluation at 12 days:

Treatment is complete. Patient is happy.
Before/After:

(Edited by Benchwmer at 11:36 am on May 22, 2004)

(Edited by Benchwmer at 11:39 am on May 22, 2004

(Edited by Benchwmer at 11:46 am on May 22, 2004)

May 22, 2004 at 8:40 pm #5598 Reply

ASI
Spectator

Hi Jeff,

Well handled and documented case. A simple procedure can make a world of difference on an asymmetrical gingival contour even though her smile line barely displays it.

Cheers.

Andrew

May 22, 2004 at 9:10 pm #5614 Reply

Glenn van As
Spectator

HI Jeff: I like this one alot for alot of reasons, the fact that you got great photos. The fact that the case was beautifully handled and subtle things like the lack of char are all wonderful.

In addition, I think it is neat to see how there was slight rebound in this case.

I wonder if we did erbium osseous (open or in this case a mm of closed flap) if we could get the rebound to not occur.

I would estimate that 75% of the original amount of removal stayed in place.

I think from your case and ones I have done as to whether I will tell patients its a 2 phase treatment with soft tissue first and if needed hard tissue after wards.

Perhaps it can be combined if we are adequate in our probing depths…….

Neat case Jeff, and a big big service to your patient.

CLAP CLAP CLAP……..love to see various lasers for different treatments I learn each time I see em.

Cya

Glenn

May 22, 2004 at 10:13 pm #5600 Reply

Benchwmer
Spectator

Glenn,
25% rebound? May be camera angles.
Notice how I didn’t touch the mid-line papilla. I you laid a flap you would be able to see the height of bone, use the Erbium to crown lengthen, but you are adding the variable of healing after a flap, added expense, post-op complications.
In this case the worse case scenario is the tissue doesn’t heal to the height after laze. If, the patient doesn’t like the results, it is a 10 minute procedure to remove more tissue if probing and bone sounding merit the attempt or if not, then flap/remove bone.
Case selection determines the “How to”.
I’ll post a soft tissue Erbium use later.

Jeff

May 22, 2004 at 10:34 pm #5593 Reply

Anonymous
Guest

Can anyone tell me why this extra tissue is there to begin with? Jeff, did you probe the sulcus after removing the tissue? How did you decide you could remove 2mm, i.e. how did you determine the 3mm BW after Tx would be enough?
Also, if you did flap and didn’t touch the bone interproximally, couldn’t you expect the papilla to return to normal position?
Sorry for all the questions, just trying to understand this BW and anterior cosmetic procedures better.

May 22, 2004 at 11:14 pm #5604 Reply

Benchwmer
Spectator

Ron,
These are my thoughts on biologic width. “Studies” (I don’t footnote quickly like you, I learned fron my DentalTown posting, you can reference the responses to my laser cases on DT case studies) show you need 2.6mm of biologic width. I measured 3mm from crest of the gingiva to the base of the pocket, under LA I sounded bone at 5mm from the gingival crest. That gives me 5.0mm minus 2.6mm or 2.4mm of free gingiva I can excise without violating BW. I measured 2mm and used a perioprobe to create bleeding points in 5 or 6 right (where you placed the line). This lets me connect the dots and remove a finite measured amount of tissue.
I’ll try to get you a couple of good articles to read.
I won’t probe the area for 6 months. Will expext less than 2mm of probe depth.
Jeff

May 23, 2004 at 3:38 am #5622 Reply

Andrew Satlin
Spectator

Ron,

To answer part of your question, In my experience (12 years of perio sx) if you completely reflect the papilla you will lose soft tissue height even if you do not remove interproximal bone.

There are alot of factors involved particularly tissue thickness but when osseous recontouring is required on cases like this, I split the papillae and leave as much interprox tissue as possible.

This gives you good acces to the buccal bone and you can delicately ramp it interproximally if you need to.

Vertical matress suture to minimize pressure on the papillary height.

Try it sometime (or refer your patient to me!!!)–just joking

See you all

Andy

May 23, 2004 at 1:15 pm #5608 Reply

Dan Melker
Spectator

Answer to Ron’s question,
Cause of tissue position-
1. traumatic injury when this patient was young(#9 intruded)
2. tooth in lingual version
These 2 factors may effect the outcome of this beautifully done procedure.
I think why Glenn thought there was rebound of tissue was because #9 is intruded. Just a thought.
Thanks,
Danny

(Edited by Dan Melker at 9:16 am on May 23, 2004)

May 26, 2004 at 3:32 am #5595 Reply

whitertth
Spectator

Jeff,
Very nicely done…..
Questions….I want to make sure I understand u …You probed the sulcus and got a measurement, then went thru the attachment under local got another measurment(Bone_) and subtracted first from second to know how much tissue u could remove…Is that correct?
Now a quick comment … Mind u a great result…But I beleive that u could have achieved as nice a result with the Waterlase with minimal bleeding and done it without local especially with my DRKLIQUID topical…. Just a thought but still outstanding case…

May 26, 2004 at 4:54 am #5615 Reply

Glenn van As
Spectator

That brings me to a question I have………

Ron I want to know what topical I can get here in Canada that I can order and it will get through the border.

I have a frenum to cut soon on a child and mom wants no local.

ANy ideas Norman, Andrew or my Canadian compadres.

Glenn

May 26, 2004 at 7:45 am #5599 Reply

ASI
Spectator

Hi Glenn,

I have used EMLA mostly along with Hurricaine topical spray and adequate water irrigation with the 980nm diode. With all of the above going on, and if greater comfort is still required to complete the treatment, I will have no hesitation to place judicious drops of local as needed.

As you know, some parents are the greatest cause of discomfort in terms of anxiety that they induce, as much if not more so than the procedure itself….

Cheers,

Andrew

May 26, 2004 at 1:16 pm #5602 Reply

Benchwmer
Spectator

The same results could be achieved using different tools.
If I’m going to soung to bone with a perio probe, patients prefer LA, a few drops of 4% Citanest infiltrated into the tissues is all that is needed. I place a topical before injecting. I have purchased the DrKLiquid.
I just find very limited uses for it as a replacement for LA.
The biggest advantage of using the Nd:YAG in this type of case is you don’t have to protect the root surface from the laser tip, the procedure can be done with the fiber directly pointed at the tissue, the tissue can be ablated, the margins beveled, tissue tags removed without harming the root surface, with an Erbium I would have to use the tip parrallel to the tooth. Plus better hemostatis w/ Nd:YAG.
I have the choice of lasers.
Why is it such a big deal for Waterlase users not to use LA?
I was at a Preview session last month, and saw the Waterlase user, firing the fiber into the sulcus surrounding a Mandibular molar, 4 different points, took about 3 minutes, all for a buccal pit that would not have been painful if the Erbium would have been used on the tooth directly.
What effect does the laser energy have on attachment?
Jeff

May 26, 2004 at 2:22 pm #5612 Reply

Glenn van As
Spectator

Hi Andrew……..where can I get EMLA topical.

Glenn

May 26, 2004 at 3:25 pm #5597 Reply

ASI
Spectator

Hi Glenn,

Any pharmacy. No Rx required.

Andrew

May 26, 2004 at 5:13 pm #5596 Reply

whitertth
Spectator

Glen,
contact me offlist and lets seeif we can come up with [email=”something…whitertth@aol.com”]something…whitertth@aol.com[/email]
516 521 0394 cell
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