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The Clinical Application of Soft Tissue Lasers

Part 3 - Patient treatment with a laser part I

Dr. Michael Miyasaki, DDS
Dr. Miyasaki reviews treatment witha laser for troughing, gingevectomies, frenectomies, implants, fibromas and orthodontics.

So what are some of the clinical challenges that you have? Now here’s a crown prep that we did. It was a Monday morning. We got in there. We took off an old crown off of the second molar on the lower right hand side and you can see that we have a lot of bleeding. So in this case, how might you handle that? You can take a #0 cord and hemostatic agent, pack it down around there, put a #1 cord and #2 cord and then wait for that and then pray that when you took the impression that you didn’t get any bleeding or the tissue didn’t [fought] back on your hard tissue margin. In this case, all we did is we took our laser. We initiate the tip. We circle around the tooth and it created this physical separation between our hard tissue and our soft tissue and gave us good hemostasis. So we’re able to get an accurate impression. You can see this impression reach way down around that tooth but still you can see the margins. So when we do this type of troughing what we do is bring the laser tip in basically parallel to the tooth and what we just scribe that the edge of the laser the fiber can actually touch the tooth. It’s not going to injure the tooth at all. And we’ll just use light brush strokes when we go around that tooth to create the physical separation as if we have packed a cord. So we go in there and in this video you can see it’s basically parallel to the tooth and we create that physical separation as if we had just removed a cord. So when you remove a cord you see the displaced soft tissue. But as soon as you remove a cord that soft tissue begins to creeps back towards your hard tissue margin. When we use a laser we create a physical separation and that physical separation will give us a couple of hours of time to get the impression material around it, to get an accurate impression the very first time. So with this, the recipe that I use is 0.6 watts continuous. And unlike the canker sore when we’re not trying to remove any tissues so we use the uninitiated tip. In this case because we’re trying to get hemostasis and create the separation between our hard tissue-soft tissue margins, we actually do initiate the tip. Now the fee for this is typically going to be zero. I tell doctors unless you charge your patient to pack cord around their teeth when you do your crown prep I wouldn’t be able to charge my patient for this procedure but it’s going to save you a lot of time and money. Gingivectomy. Gingivectomy is when you’re doing especially an anterior case the use of a laser comes in very handy for this because we can even out the symmetry between the patient’s right and left hand sides. We can do this very easily, very effectively. Again often times without having to give them injectable anesthetic. So in this case, we can actually recontour the soft tissue, create more symmetry. We can raise the tissue on the centrals and the cuspid to create a more idealized smile, and within 7 to 10 days that area will be totally healed up. And the patients really don’t experiencing a discomfort during this time. Again because there’s so much tissue expose we might use the vitamin E oil 3 or 4 times for 3 or 4 days and really nothing else. So the power setting on this would be 0.6 watts. If I found that there is an area where the tissue is a little bit more fibrous, I might bump it up, titrate that power up a little bit but we’re using with a continuous power delivery. And because we are removing soft tissue, we do again initiate the tip. Average fee for this could be anywhere from $350 up to $800. So again an example that if you use a laser it can generate revenue for your practice. With the gingivectomy procedure we come in more perpendicular to the tooth because we’re trying to adjust the height of the soft tissue. When we remove that free gingival margin or the edge there we are now left with a thicker piece of tissue. So we come back in with the tip of the laser to thin that area out kind of like [0:03:37][inaudible] around a denture tooth when we set it up in wax. Here’s a procedure where we’re doing gingivectomy on the patient’s front left central. And all we’ve done in this case we took a little topical anesthetic. We apply it to that soft tissue margin, gingival margin. Let it soak in there for 2 or 3 minutes, wipe it off and now we’re getting in there and doing our laser gingivectomy. Two other things I would like you to observe is one the light brush stroke and then the time. Because a lot of clinicians will ask well how long does it take to do a gingivectomy with the soft tissue laser? Well with the blade maybe I can take the blade and just do with one swipe just create that gingival architecture but now I’m going to have managed the bleeding. So the actual cut maybe quicker. Here you could see that the total length of time it took for this single tooth gingivectomy was 14 seconds. And when we’re done with that we no longer have to worry about postop discomfort or even postop bleeding. So we’ve cauterized that we vaporize or remove that soft tissue and basically we’re done. So could I have done it quicker with a blade? Probably but the entire procedure would have taken much longer. I would have then had to get the patient injectable anesthetic, allow that to kick in. Done the surgical procedure with the blade and then have to manage the postop [0:04:51][inaudible] of the bleeding and possible discomfort. So again with troughing we come in more parallel to the tooth. Gingivectomy is we come in more perpendicular. And as we do this type of procedure one of the things that we have to be aware of is the biologic width kind of biologic seal we have around the neck of the tooth. So whenever we do gingivectomy procedure what we try to do is we try to maintain the biologic width, the 3 mm of tissue over the crest of the bone. And that gives us both predictability and better healing. So if there’s ever a question as to how much tissue is there I’ll actually numb the patient up, take a periodontal probe, go through the attachment to the crest of the bone and measure our soft tissue thickness. Again laser come in very handy for small design cases. When I look at the width to height ratio of a front tooth, sometimes our patients have worn their incisal edges away so they have basically square teeth. Well we want the teeth to look longer than they are wide. If I take that square tooth and the only option I have is to make the tooth longer to extend that incisal edge I could create functional issues. With the use of a soft tissue laser in some cases what I can do is I can actually do a gingivectomy and raise the soft tissue up and that again gives the appearance of a longer tooth without having to extent the incisal edge position much at all. The other thing that we try to do is we try to get the midlines of the anterior teeth to appear as they have a mesial inclination. So many times what I’ll do is I’ll take the soft tissue diode laser and I’ll move the gingival zenith which is the high point the curvature at the gingival margin of that soft tissue area. I’ll move the high point slightly distal to the midline of the tooth to create a more mesially inclined appearance. Now the other thing again that we use the soft tissue laser for is to create symmetry. Because in a lot of our patient’s mouth there’s something that’s asymmetrical a cuspid, central, it could be the soft tissue height could be lower on those two teeth on the patient’s right side than the right side. So again with the soft tissue laser because it’s so quick and easy we can put a little topical anesthetic there and even that out. So whenever we do a gingivectomy we try to be aware of the biologic width of the tissue. If I’ve got 4 mm and I want 3 mm to remain after the procedure I can take a millimeter away. Again what I try to do is position the gingival zenith slightly distal to the midline of the tooth help create a mesially inclined appearance. So here’s a case. It’s a veneer case where we’ve done soft tissue re-contouring with the diode laser through the anterior segment of our patient’s mouth. We’ve gone in there and we’ve done prepared veneers. So we have a defined margin. We did that the same appointment where we did the laser gingivectomy. In the past when I’ve used things like a blade or electrosurge unit I’d actually do the gingivectomy, allow the tissues to heal up and then get the patients back maybe two or three months later once that soft tissue is healed up and I knew where to place my soft tissue or my hard tissue margins around my soft tissue. In this case what we’re doing is we are adjusting our soft tissue positions and then placing our hard tissue margins during the very same visit. Just to show you that it can be very predictable. We’re not going to get a lot of recession. In this case the [0:08:04][inaudible] are placed. And the soft tissue position in relationship to our veneers which had prepared margins you can see it’s very predictable and healthy. Things like frenectomy. Frenectomies in the past were very bloody. We had to cut away the tissue with a blade. We had the suture. The patient had the discomfort of feeling the sutures underneath their lip or maybe underneath their tongue. Today, what it can do is we can take the laser and we do laser frenectomy. When remove that soft tissue attachment, we actually get cauterization so we don’t have typically place any sutures which then again improves the patient’s healing and postop comfort. The recipe in this case would be 0.6 watts. There are areas like you can see in the anterior segment in this frenulum where the tissue is more fibrous and not as pigmented so it’s not going to absorb as much of our laser energy. So as we get into those areas we may need to bump our laser power up from 0.6 maybe we’ll move up to 0.8 maybe 1 watt of power. Again the key point is we need to initiate the tip. Because we’re again cutting tissue we have to initiate the tip. An average fee for a procedure like this might be $200 to $350. Implant recovery is something we can do. Often times after we placed an implant, loaded the bone, the soft tissue will overgrow that implant and we need to find a way to uncover that. If I use a blade, I could uncover that implant but I’ll have to deal with the bleeding. In this case what we do is we use laser. Again 0.6 watts as we work our way down to the bone. Sometimes I need to bump the power up because the tissue becomes a little bit more fibrous. And because we’re removing soft tissue, we initiate the tip. Again works out very well. If our laser hits the implant we’re not going to transfer any heat to that as long as we’re moving that tip quickly, we’re blowing air, suctioning the heat off, it’s going to be really safe and we won’t see sparking. When we do a biopsy what we can do is we can actually elevate the fibroma in this case and take the tip of the laser and go under the fibroma with the fiber being stiff and glass as it is we can feel those attachments. I’ll try to get underneath the attachment to that fibroma as far down as I can. When we send that in for a biopsy we want to write down on the script that it was removed with a soft tissue diode laser because there will be some artifacts that the lab will see histologically. And as long as they understand why those artifacts are there we’ll be okay. Now you can see that as we remove this fibroma, we got coagulation. So we don’t have to place sutures in this case. And because we don’t have to place sutures this is going to heal up through secondary intention. There’s no tension on that tissue so we’re going to have little or not scarring which is actually a postop advantage. Again 0.6 watts is my go to power setting in a continuous mode. Because we’re cutting away tissue we initiate the tip. And again you should charge a fee for this. It is a surgical procedure. So an average fee might be $250. If you were using a blade what you have to do is you have to numb the patient up, cut the fibroma off. You probably have to stitch up, manage the bleeding the post op discomfort. In this case, we made all that much easier for both ourselves and our patients. This is more of an esthetic case where we have an instance where we’re missing a right lateral. And what we’re going to do is we’re going to actually just recontour the soft tissue so that we can have an ovate pontic. So what we do in this case is we scribe out where we want the new free gingival margin to appear to be in that upper right central area. And then lingual to that we create almost, well we do create a ball. That ball is going to be the receptor site for our pontic so that when the patient smiles it’s going to look more as if that tooth is interrupting from the tissue. And when they do cleanse that area and run floss underneath there because we have a convex surface the patient will be able to clean that area much more effectively and efficiently. Lasers and orthodontics almost are very hand in hand. If you have cuspid that is staying up high, you know the orthodontist for those of you providing orthodontic treatment can wait for that cuspid to descend or we can actually go up there uncover the cuspid and because we get coagulation as we uncover that cuspid, we can bond the bracket to the cuspid and then bring it down. If we have performed operculectomy type of procedure, remove the tissue flap around the distal molar, we can do that again with the soft tissue diode laser. We got good hemostasis so we can bond the bracket on to that tooth immediately. If the patient’s hygiene has been lacking and we have a lot of hyperplastic tissue, we can go back in there, lay some topical over that tissue and just vaporize it away. And then if we have diastema or tissue attachments, frenectomy could be done effectively.