Download Closed-Flap Laser-Assisted Esthetic Dentistry

Closed-Flap Laser-Assisted
Esthetic Dentistry Using
Er:YSGG Technology
C
reating ideal esthetic, biologic, and functional results has always been challenging in the esthetic zone. This is often true
when biologic width violations have occurred
iatrogenically. Many differential factors contribute to such failures, mainly intracrevicular
margin location and overcontoured restorations.
Plaque accumulation is problematic, and the
supracrestal fibers become interrupted, causing
the tissues to be further inflamed and esthetically unmanageable.
Kois’ landmark study defined the total
dentogingival complex (DGC) as clinically
predictable at 3 mm on the direct facial aspect
and at 3 mm to 5 mm interproximally when
measured from the free gingival margin to the
osseous crest. It is anteriorally critical that the
gingival margin mimic the osseous scallop
while maintaining the DGC.1 Further, the
degree of inflammation in the soft tissue affects
the clinical development of health and esthetic symmetry.
Often the patient will become frustrated
by poor esthetic results and must be referred to
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Compendium / August 2004
another dentist to improve the periodontal
framework. Even more challenging is the
extended healing time created by reflective
mucoperiosteal surgery, affecting the chronology of final restorative care for a minimum of 2
to 3 months.
Dental lasers have evolved considerably as
an adjunctive and alternative treatment for
safely, conservatively, and reliably decreasing
bacterial levels and improving the hard- and
soft-tissue contours. A historical study of
erbium: yttrium, scandium, gallium, garnet
(Er:YSGG) lasers by Rizoiu and colleagues has
shown that thermal coagulative results, as well
as bony ablation characteristics, are similar to
those of a dental bur.2 From a patient perspective, less need for suturing and shorter healing
times increase case acceptance. In selected
cases, such as the 2 presented in this article,
minimally invasive laser procedures, with precise restorative planning and technique, can
satisfy esthetic and functional parameters.
Title photographs and dentistry by Douglas Terry, DDS, and
Newton Fahl, Jr, DDS, MS.
Author
Hugh D Flax, DDS
Co-Author
Gary M Radz, DDS
Private Practice
Atlanta, Georgia
Private Practice
Chief Executive Officer
Snow Mountain Seminars
Denver, Colorado
Vol. 25, No. 8
Figure 1A—Gummy smile greatly detracts from this patient’s
appearance and perception of health.
Figure 1B—Inflamed tissues surrounding the central incisors are
a priority in this restoration.
Figure 1C—Blueprinting the final result is critical to restorativegingival success and patient communication.
Figure 1D—The free marginal architecture is outlined before
anesthesia.
Figure 1E—The inflamed tissue at teeth Nos. 8 and 9 is sculpted
using the T-4 tip.
Furthermore, patients can enjoy optimal
results more comfortably and efficiently.
Case 1
A 63-year-old woman desired esthetic
enhancement before her son’s wedding, which
was scheduled in 3 months. She wanted
whiter, better shaped teeth and a less gummy
smile (Figure 1A).
Clinical examination revealed an excessive gingival display, although her lip length
was 17 mm. Closer examination of teeth Nos.
8 and 9 revealed exposed crown lengths of 6.5
mm and 7 mm, respectively (at least 30% to
40% esthetically deficient). Tooth color began
at an A3 hue and C3 value. The patient’s goal
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Compendium / August 2004
was a naturally appearing B1/A1 blend. With a
full smile, she displayed 10 to 12 teeth with a
dental midline position and incisal edge curve
that was appropriate. Her lips were symmetrical vertically and horizontally. Her class I
occlusion demonstrated adequate canine rise
and anterior guidance, but a hit and slide
began at tooth No. 14 in centric relation to
maximum intercuspation (verified by the TScan IIa). According to auscultation, her right
temporomandibular joint (TMJ) made a slight
pop on late opening with no history of trauma or
pain. Minor fremitus created slight mobility laterally and protrusively. Periodontally, although
the patient was very diligent with home care,
restorative breakdowns around teeth Nos. 3, 8, 9,
and 15 led to areas of plaque accumulation and
gingival irritation (Figure 1B).
The treatment plan was to balance her
occlusion with orthotic/coronoplasty care, raise
the gingival heights of teeth Nos. 4 through 13,
and eventually restore the upper front 12 teeth
with Authenticb veneers, onlays, and all-ceramic
crowns. A diagnostic wax-up by our laboratory
technician would help create ideal proportions
and contours for the final restorations on a
a
Tekscan, Inc, South Boston, MA 02127; (800) 248-3669
Microstar Corporation, Lawrenceville, GA 30043; (800) 313-6427
b
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Figure 1F—Excellent healing response is observed 3 weeks after
closed-flap laser treatment.
Figure 1G—Final biologic widths are established after provisionalization.
Figure 1H—A bright healthy smile with balanced gingival architecture greatly enhances this patient’s smile and outlook.
Figure 1I—Healthy gingival tissues are noted 2 months after
cementation.
Stratos 200c articulator (Figure 1C). The lower
teeth would be home bleached with the possibility of restorative enhancement after the wedding.
Surveying the preoperative model, many
areas in the esthetic zone needed gingival- and
hard-tissue sculpting to improve the periodontal framework esthetically and biologically
(Figure 1D). Coordinating this with the
restorative and functional aspects would help
us reach our clinical goals and help the patient
meet her deadline.
case, however, the high smile line called for
more time to fine-tune gingival placement at
the day of final tooth preparation, measurements, and provisionalization. Because we
were simultaneously improving the occlusion
and whitening the lower teeth, this multitasking approach was efficient.
At the first phase, the “gum lift” was best
planned before anesthesia using a fine-tip
marker to sketch the gingival levels (Figure
1D). This allowed the patient and restorative
team to assess the proposed positions of the tissues. Any changes could be easily modified and
gave the patient a sense of control.
After the crowns were removed from teeth
Nos. 8 and 9, new posts were placed in root canal
spaces and built up with Luxacore Duald. The
gingival tissues were shaped to the preexisting
black line with an Er:YSGG hard-/soft-tissue
laser, Waterlasee, using a tapered T-4 tip at 1.5 W,
30% air, and 30% water (Figure 1E). This created a precise, controlled cut that provided a proper framework for well-designed ceramic crown
preparations and contoured provisional restorations with Luxatemp Automix Plusd.
After cementation, the gingival margins of
teeth Nos. 4 through 13 were sculpted to the
ental lasers have evolved considerably as an adjunctive and
alternative treatment for safely, conservatively, and reliably decreasing
bacterial levels and improving the
hard- and soft-tissue contours.
D
A reliable method when dealing with
inflamed tissues is to perform a 2-phased
sculpting before the final restorative phase,3
although many laser restorative-gingival treatments (see Case 2 on page 630) can proceed
with impression taking the same day. In this
d
c
Ivoclar Vivadent, Inc, Amherst, NY 14228; (800) 533-6825
Vol. 25, No. 8
Zenith/DMG, Englewood, NJ 07631; (800) 662-6383
Biolase Technology, Inc, San Clemente, CA 92673; (888) 424-6527
e
Compendium / August 2004
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Figure 2A—Removal of the temporary crown shows gingival
overgrowth.
Figure 2C—An occlusal view demonstrates the laser’s ability to provide visualization and access to allow for restoration of the root.
outline created with the patient. We had
invaded the biologic width on many teeth, but
with the laser, osseous recontouring was easily
achieved using the T-4 tip (at a higher setting
of 2.5 W, 30% air, and 30% water). The tip was
measured and marked to 3 mm using digital
calipers. Then it was placed intrasulcularly using
a “sewing machine stitching” motion, which
created a controlled ablation of the bony crest
without leaving a thick ledge. The resection was
smoothed using a Gracey 7/8 curet.
Lastly, a “laser bandage” was placed along
the area of treatment to decrease the release of
histamine postoperatively and decrease patient
discomfort (G-6 tip at 0.25 W, 11% air, and
0% water in a defocused rapid wave motion).
This entire technique allowed for meticulously
creating an osseous scallop that followed the gingival margin and maintained a 3-mm DGC.
Furthermore, Lowe and Politis4 have observed
this phenomenon with a postprocedural surgical
flap. They noted that the osseous crest closely
paralleled the restorative–gingival margin.4
The patient was placed on mild nonsteroidal anti-inflammatory medications and a
strict home-care regimen of Oxygelf, 0.12%
f
Oxyfresh Worldwide, Inc, Spokane, WA 99216; (800) 333-7374
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Compendium / August 2004
Figure 2B—A closed-flap, crown-lengthening procedure with the
hard-/soft-tissue laser is used to expose the healthy remaining
tooth structure.
chlorhexidine gluconate, and gingival massage. She was monitored closely on a weekly
basis. At 3 weeks (Figure 1F), her tissues had
healed well and had stabilized (albeit not fully
matured) to proceed.
At the second phase, definitive preparations were made on the teeth remaining in our
plan. Any gingival fine-tuning was conducted
before this. All preparations were designed for
margins to match the gingival height.
Regarding previous subgingival restorations,
retraction was avoided by gently creating gingival “troughs” with the laser using a 9-mm Z6 tip at 0.75 W, 15% air, and 10% water settings. Final impressions were accurately made
using Honigumd. New registrations were created. Provisional restorations driven by the waxup were placed. All gingival sulci were sounded to bone. Any biologic width discrepancies
were adjusted using the T-4 as previously noted
(Figure 1G).
The patient was sent home with the same
home-care regimen to test her new smile for
esthetics and function. She returned in a week
to perfect the prototypes and give the laboratory
a final blueprint for the porcelain restorations.
After 4 weeks, the provisional restorations
and cement were carefully removed from the
teeth. All restorations were tried in individually and as a group to verify fit and esthetics.
After the patient’s approval, the porcelain was
bonded using the 2-by-2 technique and isolation. Margins were smoothed and polished and
occlusion balanced with the T-scan. A protective nighttime appliance was created to add
longevity to the rehabilitation.
The patient returned 4 weeks after treatment (Figures 1H and 1I) very excited about
having a beautiful smile for her son’s wedding.
She especially was impressed that we could
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Figure 2D—A tooth-colored fiber-reinforced post is used to
restore tooth structure.
Figure 2E—An occlusal view of the final preparation after
closed-flap crown extension surgery.
Figure 2F—A putty-like material is used for hemostatic control
and tissue retraction.
Figure 2G—The extent of the defect can be seen in the final
impression.
accomplish this without major surgical intervention.
arch wire was approved. After removing the
arch wire and the provisional crown, it was
observed that the separation of the provisional
acrylic crown and the root had left a significant gap, which had been overgrown with gingival tissue (Figure 2A).
Case 2
A 15-year-old boy was referred by a local
pediatric dentist for an emergency evaluation
regarding the appearance and mobility of tooth
No. 9. From the pediatric dentist, we learned the
history of the tooth and the patient. When the
patient was 12 years old, tooth No. 9 was severely traumatized. A root canal was completed on
the tooth, and a provisional crown was placed.
The patient and parent were informed that a
more definitive restoration (post and core with a
crown) would be required in the near future.
The pediatric dentist had not seen the patient
again until that day.
According to clinical evaluation, a provisional acrylic crown was located on the rootcanal–treated tooth No. 9. From the lingual
view, the distal portion of the margin was missing. A periapical radiograph showed that the
provisional crown had been moved distally
from the root of tooth No. 9 because of the
orthodontic appliances.
The treating orthodontic office was contacted, the situation was explained, and a
request to remove the patient’s orthodontic
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rom a patient perspective, less need
for suturing and shorter healing
times increase case acceptance.
F
The risks and benefits of different treatment options were explained to the parent. He
chose the use of the hard-/soft-tissue laser in
the office that day and placement of an esthetic post and temporary crown (to be followed up
in the near future with an esthetic crown).
Because of the amount of soft tissue to be
removed and the tenderness caused by inflammation, a local anesthetic was used. With a
tapered tip and a setting of 2.5 W, 30% air, and
30% water, the laser was used to remove the
excessive soft tissue, exposing the remaining
tooth structure (Figures 2B and 2C). Surgical
exposure revealed a significant fracture on the
facial aspect of the tooth. To find the termination
Compendium / August 2004
626
Figure 2H—The final, long-term provisional indirect composite
is ready for delivery.
Figure 2I—The patient visits 1 month after surgery for evaluation.
of the facial fracture, soft tissue was removed to a
depth of 5 mm below the gingival height of tissue. At the point where the fracture terminated,
the unaffected facial tooth structure was 1 mm to
2 mm below the height of the bone.
The treatment was stopped and the parent
and orthodontist were informed that the prognosis of this tooth was poor. Any attempt to
correct the problem with conventional crown
extension surgery had a high potential for leaving an unesthetic soft-tissue result. We suggested instead of immediately extracting the
tooth, using the laser to create the needed biologic width, placing a post and core, and creating a long-term temporary restoration with an
indirect composite crown (Belleglassg). This
would keep the tooth during the course of
orthodontic treatment, and as the end of the
treatment drew near, the tooth could be orthodontically extruded, then extracted, and
replaced with an immediate implant. The
orthodontist could use the correct width of the
restored tooth to complete positioning of the
teeth, and the chances of maintaining the
patient’s interdental papilla would increase significantly. After explanation of this treatment
rationale, the parent and the orthodontist agreed
to proceed.
A post hole was created to within 4 mm of
the apex of the tooth. An esthetic bondable post
(Twin Luscent anchorsh; Figure 2D) was bonded
into place using a dual-cure resin material
(Luxacore Dual) as the post cement and buildup
material (Figure 2E). The tooth was then prepared with a fine chamfer diamond. Before the
impression was taken, the laser was used in the
manner described in Case 1, reducing the bone
height to create the desired biologic width.
After the bone removal, a putty-like material (Expa-sylg) was used for hemostasis and tissue
retraction (Figure 2F). A full-arch impression
was taken using a polyvinylsiloxane impression
material (Aquasil Ultrai; Figure 2G). The depth
that the impression material traveled subgingivally to record the preparation margin demonstrates the extent of the fracture.
M
g
The impression was sent to the laboratory for
fabrication of the indirect composite crown. An
indirect composite was chosen because, unlike
porcelain, it can be successfully bonded to resin
cements, which is important for the orthodontist
when placing brackets. Regarding the final
restoration, the laboratory technician not only
recreated the crown of the tooth but also accurately recreated the root form (Figure 2H).
Before the patient left, a temporary crown
(Luxatemp Automix Plus) was fabricated and
cemented to place with a clear temporary cement
(Tempbond Clearg). When the patient returned
after 2 weeks, the indirect composite crown was
cemented to place using a dual-cure composite
resin cement (Nexus 2g).
One month after surgery (Figure 2I), the
crown had been orthodontically bracketed.
Although the soft tissue did not look perfect,
bleeding on probing was minimal, and the probing depths had not changed (at the 6-month
recall, this periodontal condition remained
stable and unchanged).
h
i
Kerr Corporation, Orange, CA 92867; (800) 537-7123
Dentatus USA Ltd, New York, NY 10016; (212) 481-1010
627
inimally invasive laser procedures, with precise restorative
planning and technique, can satisfy
esthetic and functional parameters.
Compendium / August 2004
Dentsply Caulk, Milford, DE 19963; (800) 532-2855, x794
Vol. 25, No. 8
The patient has 10 to 14 months of orthodontic treatment remaining. The crown will provide an esthetic and functional purpose during
orthodontic treatment until it is time to slowly
extrude the tooth and place the long-term
restorative prosthetic, a single-tooth implant.
Without the hard-/soft-tissue laser, it
would have been impossible to provide this
treatment. Moreover, use of the laser allowed
for the opportunity to make a long-term plan
that would provide an esthetic long-term
result.
their laboratory technicians, Wayne Payne
(Payne Dental Lab, San Clemente, CA) and
Americus Dental Labs (Jamaica, NY), respectively, for their help in creating such beautiful
results for each case. Furthermore, the assistance of their staffs in patient care was invaluable. Lastly, the support of their wives and families makes it possible to learn and share these
techniques.
Disclosure
The authors have no personal or financial
interest in any dental product company.
Summary
Use of a hard-/soft-tissue laser is a wonderful
adjunctive tool for esthetic and restorative dentistry. The cases described here demonstrate some
of the many ways in which this laser technology
allows clinicians to make significant soft- and
hard-tissue changes. These changes not only
improve the final esthetic outcome of the case
but also provide the biologic functional parameters required for successful dentistry.
Acknowledgments
Dr. Flax and Dr. Radz would like to thank
Vol. 25, No. 8
References
1.
2.
3.
4.
Kois JC. Altering gingival levels: the restorative connection.
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Rizoiu I, Eversole LR, Kimmel A. Osseous repair subsequent
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Antypas G, ed. International Laser Congress: Athens, Greece,
September 25-28, 1996. Bologna, Italy: Inter-national
Proceedings Division; 1997:213-221.
Flax H. Maximizing aesthetics and health using a closed-flap
Er:YSGG laser technique. Pract Proced Aesthet Dent.
2004;16:201-205.
Lowe RA, Politis D. Surgical Tissue Management for the
Esthetic Dental Practice. Lecture and hands-on, live-patient
demonstration presented at: Nash Institute for Dental
Learning; November 14-15, 2003; Charlotte, NC.
Compendium / August 2004
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