- Thursday, 09 January 2014 20:55
Images of “normal gums”
Images of “overgrown gums“
Case Study: Photos of a gingivectomy on RitaS. 113012 with her critique (Click here)
Sometimes gums overgrow the crowns of the teeth making them look too short at the end of treatment. We sculpt them to look normal
I am pleased to announce the addition of a new instrument/service in the office called the “Sapphire Diode Soft-tissue laser” and have completed the Advanced Diode online soft tissue laser training course granting an Associate Fellowship Certificate in the WCLI (World Clinical Laser Institute)* See below. This laser instrument will permit my office to offer an array of services to treat conditions that commonly arise at the start of orthodontic treatment or occur during and at the end of orthodontic treatment. One of the most common problems at the start of treatment is to expose the surfaces of teeth that are covered with gums to allow braces to be attached to them, and at the end of treatment is the need to resculpture/reshape the gums of patients whose gums have become bulbous/ overgrown/ uneven or misshapen. The Sapphire can accomplish this in most cases painlessly, without swelling and without surgery/bleeding and without the need for stitches. It has a variety of other useful applications. See Video
Below: list of YouTube videos demonstrating a variety of treatment applications using the soft-tissue diode laser for common problem seen before during and after orthodontic treatment as well as for use in treatment of some common gum diseases
The operations the 810 soft tissue diode laser can perform
- Excision and incision biopsies
- Hemostatic/Hemostasis assistance
- Treatment of apthous ulcers
- Gingival incision and excision
- Gingivoplasty (reshaping)
- Gingival troughing
- Gingival recontouring
- Tissue retractions for impressions
- Oral papillectomy
- Sulcular debridement
- Sulcular tissue removal
- Removal of granulation tissue
- Abscess incision and draining excision
- Removal of fibromas
- Soft tissue crown lengthening
The 810 Diode Soft Tissue Laser
In the CW (continuous wave) mode the power to vaporize gum (soft) tissue varies .1 watts to 3.0 watts. 1.5 watts is typical.
In the P (Pulsed wave) mode the power to vaporize gum (soft) tissue varies .1 watts to 5.0 watts.
Here you see me holding the barrel of the laser which is covered by a protective plastic sac.
Here you see me shining the
Here you see the mock start of the maxillary
Here you can see the laser beam within the aiming beam. The beam is being delivered from a 4mm long quartz/glass tip 400 microns wide.
The assistant, the operator and the patient are required to wear the laser 810nm wave length light-specific glasses.
Case Study: Photos of a gingivectomy on RitaS. 113012 with her critique
Critique: The procedure was very good. At first I was nervous I would feel the entire procedure but I didn’t feel a thing. Dr. Ted & Bryan were so catering. Dr. Ted put a numbing cream on the gum of which needed to be removed , and within 3-5 minutes my mouth starting becoming numb then he put the injection in and I didn’t feel a thing. Once my left side of my mouth was completely numb they went in and removed my gum with a laser. The procedure was calming, quick and painless. Out of a scale from 0-10 the procedure was a 0.
Thanks Dr. Ted & Bryan. RitaS.
The Problem: Overgrown Gum preventing placement of a bracket. Solution: Remove overgrown gum by laser evaporation.
Procedure: Place gum-numb paste on gums above tooth; Give injection of local anethesia. Test that patient's gum is deeply anesthetized. Vaporize excess gum away.
Bond a bracket to the tooth.
Replace the arch wire and add an open coil spring to push teeth apart to help make space for the tooth that is stuck.
Tie the bracketed tooth to the arch wire so that as the space is widening the tooth is being pulled forward
Photo of healed surgical site 7 days later.
Literature References (*Articles Available to Read)
- Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):262-4.
HERE AT AAO
* Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems.
Sarver DM, Yanosky M.
PMID: 15750548 [PubMed - indexed for MEDLINE]
- Dent Clin North Am. 2007 Apr;51(2):525-45, xi.
HERE AT AAO
* Laser use for esthetic soft tissue modification.
Magid KS, Strauss RA.
Department of Cariology and Comprehensive Care, New York University College of Dentistry, 345 East 24th Street, New York, NY 10010, USA. firstname.lastname@example.org In esthetic dentistry, expanding the evaluation beyond the teeth is necessary to achieve a truly desirable result. The lips, attached and unattached mucosa, free gingival margin, and osseous position and contours must be considered and changed if necessary. Although many treatment modalities are available to accomplish these modifications, the use of lasers of varying wavelengths provides advantages not possible by other means. Lasers are often thought of as generic instruments, but different laser wavelengths function differently, and each has its place in the esthetic continuum. Diode, neodymium:YAG, CO(2) and erbium lasers each have advantages that can be exploited to maximum effect and disadvantages that must be taken into consideration. A thorough understanding of their mechanism of action, their tissue effects, and laser safety is vital to obtaining excellent results.
PMID: 17532926 [PubMed - indexed for MEDLINE]
- Dent Clin North Am. 2004 Oct;48(4):833-60, vi.
HERE AT AAO
* Lasers in aesthetic dentistry.
Adams TC, Pang PK.
Las Vegas Institute, 9501 Hillwood Drive, Las Vegas, NV 89134, USA. This article focuses on lasers and aesthetic dentistry and their unique parallel in history from their early development to their present day usage and application. The demand for aesthetic dentistry has had a major impact not only on treatment planning but also on the choice of materials, techniques, and equipment. It is this demand that has married the use of lasers with aesthetic dentistry. A short literature review on the five basic laser types precedes the basic premise of smile design and its critical importance in attaining the desirable aesthetic end result. A short review on biologic width and biologic zone reinforces their importance when manipulating gingival tissue. Four case reports highlight the use of diode, erbium, and carbon dioxide lasers. The end results show the power of proper treatment planning and the use of a smile design guide when using these instruments and confirm a conservative, aesthetic treatment without compromising the health and function of the patients.
PMID: 15464555 [PubMed - indexed for MEDLINE]
- Dent Today. 2008 Feb;27(2):156-9.
HERE AT AAO
Soft-tissue surgery: use of the Er,Cr:YSGG laser.
PMID: 18330202 [PubMed - indexed for MEDLINE]
- Gen Dent. 2008 Nov-Dec;56(7):663-70; quiz 671-2, 767.
HERE AT AAO
* Lasers in cosmetic dentistry.
Academy of Laser Dentistry.
Lasers have become a necessary instrument in the esthetic restorative armamentarium. This article presents smile design guidelines for soft tissue lasers, as well as an overview of hard tissue procedures that may be performed using all-tissue lasers. The goal is to help dentists determine the appropriate laser for a given clinical situations.
PMID: 19014026 [PubMed - indexed for MEDLINE]
- Gen Dent. 1996 Jan-Feb;44(1):47-51.
HERE AT AAO
* Laser treatment of orthodontically induced gingival hyperplasia.
Convissar RA, Diamond LB, Fazekas CD.
New York Hospital Medical Center of Queens, USA.
Several studies have shown that gingivitis is common in children and adolescents.
Introduction of orthodontic devices may exacerbate the gingival inflammation.
Orthodontically induced gingival hyperplasia in adolescents, its etiology, and treatment alternatives are discussed. Three instances in which laser therapy was used are described.
PMID: 8940569 [PubMed - indexed for MEDLINE]
- J Am Dent Assoc. 1998 Jan;129(1):78-83.
HERE AT AAO
* Case report. Use of an argon laser to treat drug-induced gingival overgrowth.
Mattson JS, Blankenau R, Keene JJ.
Department of Periodontics, Creighton University School of Dentistry, Omaha, Neb.
This article explores the use of an argon laser to treat severe drug-induced gingival overgrowth. The patient was being treated with phenytoin (Dilantin, Parke-Davis), cyclosporine and a calcium channel blocker. He had undergone a kidney transplantation and had insulin-dependent diabetes mellitus. He had severe gingival overgrowth, which prevented him from wearing his removable prostheses, and a superimposed Candida albicans infection. An argon laser was used to excise the gingival overgrowth so new maxillary and mandibular prostheses could be fabricated.
PMID: 9448349 [PubMed - indexed for MEDLINE]
- J Clin Pediatr Dent. 2003 Winter;27(2):123-6.
HERE AT AAO
Cyclosporin-induced gingival overgrowth in a child treated with CO2 laser surgery: a case report.
Guelmann M, Britto LR, Katz J.
Department of Pediatric Dentistry, University of Florida, Gainesville, FL 32610-0426, USA. email@example.com
A case of a 10 year-old boy with gingival overgrowth due to cyclosporin therapy after heart transplantation is described. Different treatment approaches are discussed and the surgical effect of CO2 laser is illustrated. The critical role of routine professional cleaning and good oral health maintenance for the healthy status of the gingival tissue is also emphasized in this paper. Replacement of cyclosporin by tacrolimus, another immunosuppressive agent associated with minimal to none gingival overgrowth, might be considered in cases with reported recurrences.
PMID: 12597682 [PubMed - indexed for MEDLINE]
- N Y State Dent J. 2009 Jun-Jul;75(4):26-9.
HERE AT AAO
* Laser gingivectomy for pediatrics. A case report.
Kelman MM, Poiman DJ, Jacobson BL.
Cedars-Sinai Medical Center, Los Angeles, CA, USA. firstname.lastname@example.org
Todays FDA. 2010 Jan-Feb;22(1):41-5.
Traditional gingivectomy procedures have been a challenge for pediatric dentists who confront issues of patient cooperation and discomfort. Treatment of pediatric patients must involve minimal operative and postoperative discomfort. Laser soft-tissue surgery has been shown to be well accepted by children. For the pediatric patient, the greatest advantage of the laser is the lack of local anesthesia injection and the associated pre- and postoperative discomfort. The following case report describes a gingivectomy procedure performed on a 14-year-old female.
PMID: 19722478 [PubMed - indexed for MEDLINE]
- Pediatr Dent. 2009 Jan-Feb;31(1):8-13.
HERE AT AAO
Gingival overgrowth in a child with arthrogryposis treated with a Er,Cr:YSGG
laser: a case report.
Soares FM, Tarver EJ, Bimstein E, Shaddox LM, Bhattacharyya I.
Department of Pediatric Dentistry, University of Florida College of Dentistry, Gainesville, Fla, USA.
The present manuscript reports a case of a 21/2 year old girl, diagnosed with
arthrogryposis, presenting increasing gingival hyperplasia which was treated with Er,Cr:YSGG Laser. The patient was treated under general anesthesia by the Pediatric Dentistry and Periodontics departments. Er,Cr:YSGG laser G6 tip was used at 1.50 watts, 20 pps, 8% water and 11% air, which is recommended by the manufacturer. Scalpel and periodontal curettes were used to complement the laser. Tissue samples from the anterior maxilla, anterior mandible and palatal sites were formalin-fixed and submitted for evaluation. The samples biopsied revealed prominent hyperplasia of the fibrous connective tissue with areas of theepithelium exhibiting pseudoepitheliomatous hyperplasia. At 1 week and 3 months follow up, oral examination showed appropriate healing of gingival tissue. The use of Er,Cr:YSGG laser in the present case proved to be effective in the removal of large amounts of hyperplasic gingival tissue and resulted in fast heeling and mild discomfort.
PMID: 19320254 [PubMed - indexed for MEDLINE]
- Quintessence Int. 2007 Jan;38(1):e54-9.
HERE AT AAO
Combined treatment approach of gingivectomy and CO2 laser for cyclosporine-induced gingival overgrowth.
Haytac CM, Ustun Y, Essen E, Ozcelik O.
Department of Periodontology, Cukurova University, Faculty of Dentistry, Balcali/Adana, Turkey. email@example.com
The aim of this report is to present a combined treatment approach with gingivectomy and CO2 laser for the management of cyclosporine-induced gingival overgrowth in 4 cases. Four renal transplant patients were surgically treated for marked gingival overgrowth by means of gingivectomy and CO2 laser. Postoperatively, all patients were followed for bleeding, pain, infection during the early healing period, and recurrence of gingival overgrowth for 12 months. The healing was uneventful, and no signs of bleeding, postoperative pain, or infection were observed in any patient during the early healing period. In the 12th postoperative month, there was evidence of mild recurrence in 1 patient, while no sign of recurrence was observed in the other patients during the follow-up period. The advantages of this combined technique include satisfactory bleeding control and clear visibility during the procedure, as well as reduced postoperative pain and swelling.
PMID: 17508077 [PubMed - indexed for MEDLINE]
Diode Soft Tissue Suggested Settings for a Variety of Common Procedures: Advanced Laser Training.com; 877-Laser66
- Setting Number One: 1.5-2.0 Watts continuous initiated
Soft Tissue with anasthesia, Gingivectomy, frenectomy, gingival troughing around crown preps instead of using retraction cord, uncovering implants, fibroma removal, operculectomy
- Setting Number Two: 3.0 Watts pulsed initiated
Soft Tissue without anasthesia, Gingivectomy, frenectomy, gingival troughing around crown preps instead of using retraction cord, uncovering implants, fibroma removal, operculectomy
- Setting Number Three: 1.0 Watt continuous initiated
Sulcular Debridement-eliminates granulation tissue in periodontal pockets
- Setting Number Four: 1.5 Watts pulsed 30/30 uninitiated
Sulcular decontamination, and tip initiation
With uninitiated tip at 1.5 Watts pulsed 30/30 you can do the following,
- Tooth desensitization, (Start 5 mm away and paint the area BUT DO NOT TOUCH THE AREA) with the tip, keep about 1-2 mm away from tooth contact at all times, if patient reports warmth or discomfort move fiber further away from tooth until comfort returns, paint 60 seconds then repeat for more profound effect
- Hemostasis- paint the area until bleeding stops, 1-2 mm from touching tissue, tissue will turn bluish grey color
- Ulcer treatment, herpetic lesions- 90 seconds of painting the area from 1-5 mm away from the lesion
The above settings are a good place to set your 4 preset buttons on your diode laser system. As operators learn more about the system and it’s capabilities, they can adjust the wattage up or down to fit individual preferences. Please note that these settings are suggestions only and are not a replacement for clinical judgment or training.
Brooklyn Orthodontist Ted Rothstein demonstrates laser gum reshaping Gingivectomy
This film is intended to be shown as a 28 minute film on BCAT, and as a 15-minute (or a two-part: 10-minutes each part) YouTube Video
Preparatory notes for videographer regarding filming the gum reshaping (“Gingivectomy”) procedure.
(Suggested subject of film Clip in red)
(Head shot: DrTed introduces subject)
Overgrown gums can substantially detract from an otherwise beautiful orthodontic treatment correction of a patient’s smile, and at times even impede the progress of orthodontic treatment dramatically. Consequently, one of the most common problems at the completion of orthodontic treatment is the need to resculpture/reshape the gums of patients whose gums have become bulbous/ overgrown/ uneven or misshapen. The soft tissue diode Laser can accomplish this in most cases painlessly, without swelling and without surgery/bleeding and without the need for stitches. It has a variety of other useful applications.
(Here is normal gums look like) Images of “normal gums”
Images of “overgrown gums”
(shot revealing Kal-El’s overgrown- -BUT NOT INFLAMED–gums)
(Shot back to normal gums)
(Shots of the Diode Laser)
Soft Tissue Laser Gum Reshaping Using the Diode 810 Laser: Kal-El Johnson– age 15y/o
The expected time to complete the reshaping is 45-60 minutes.
Family and patient have visited the drted.com laser gum reshaping page and previewed the pertinent videos. The INFORMED CONSENT is an especially useful document for it provides important and helpful information to both the Parent-Patient and the Doctor. It should be included as part of the video. http://drted.com/LaserGumTrimmingGingivectomy.htm
(Film Clip showing the informed Consent)
Parent must read and sign the Inform Consent which is located on the same page as the videos.
Kar-El is seated where Dr. Rothstein usually treats him.
Just in back of the patent’s dental chair is placed the Diode Laser in the top of the portable suction machine (which may or may not be used- usually not).
We will briefly acquaint Kal-El with the procedure and what he will experience.
(Medium Shot of Dr. Ted and Kal-El in the chair listening to DrTed describe the procedure and asking question as may be the case. Dr. Ted will show Kal-El the finger-up method to indicate he want DrTed to stop)
All members of the team will be wearing Laser safety-glasses including the videographer, Kal-El, Brian and myself. (Shot of Sign)
The Laser Safety Officer staff member will have posted a sign outside the treatment room warning that a laser procedure is being performed and “Please do not enter” during Laser Reshaping Gum Reshaping procedure.
(Close up of gums being painted)
We will begin by paint his gums high up with a gum numbing ointment and then wait for 5 minutes.
This will numb the area where I am going to give him an injection of local anesthetic “Novacaine”. He will be given one injection to the right of his midline and one to the left of his midline.
The gum-numbing ointment greatly reduces the discomfort typically felt when an injection is given.
(Dr. Ted is shown administering the anesthetic)
We will then wait 10-15 minutes for the anesthesia to take effect on the gums that we are aiming to reshape.
During this wait we will test his gums with a semi-blunt instrument to be certain that he has achieved TOTAL /PROFOUND anesthesia.
(DrTed is shown pressing blunt instrument in to Kal-El’s gums to test that patient is profoundly anesthetized)
When anesthesia is completed and the patient assures us it is profound we can begin.
First we will photograph the gums to be reshaped the “BEFORE”
(Close-up of patient’s gums needing to be reshaped.)
We will then measure the depth and shape of the gums using a probing instrument with a small ruler and those measurements will be noted on the pre-operative sheet.
(Film showing how depth of overgrown tissue is measured with ruler-instrument, and gums marked to remove the correct amount of tissue.)
Typically Brian sits on the other side of the patient chair and assists in use of the laser reshaping since he has a perspective of the gums that reinforces our notion of the tissue that has to be reshaped (we use the term “vaporizing the tissue”
Upon marking out the tissue to be removed we set the laser machine to the watts of power we want to begin vaporizing the tissue at. Typically we choose 1.7 watts to 2.0 watts of “continuous” power. Sometimes we switch to the “pulsed” power setting and raise the wattage for more effective vaporizing.
(Shot of laser instrument control panel monitor).
Brian will “INITIATE” the tip of the laser’s electrode with carbon paper thereby effectuating a sufficient efficient energy level to effectuate the vaporizing action.
(DrTed introduce assistant Brian Millard)
(Shot of Brian “initiating” the laser vaporizing tip with carbon paper)
I will begin reshaping the gums on the patient’s right side. The power is activated and stopped by stepping on a foot-pedal.
When the laser is actively vaporizing/removing the overgrown gum tissue the laser cutting tip glows brightly and an audible beep will be heard every 3 seconds and a slight wisp haze can be noticed rising from the patient’s gums.
Where the gum tissue has been vaporized it turns color which will be visualized as being “caramel” color
(Various clips showing reshaping in action; cleaning tip of instrument and bathing surgical wound with peroxide)
We stop momentarily to take measurements to see how close we are getting to the target amount of tissue we planned on removing /reshaping.
We also stop momentarily to clean/remove the vaporizing tip of the tissue that was removed and is sticking to the tip.
We also stop momentarily to clean away tissue that has been cut but still adheres to the gums.
We frequently bathe the surgical wound with peroxide to keep it clean from tissue debris; it also disinfects and removes any tissue that shows charring.
(Various clips showing reshaping in action; cleaning tip of instrument and bathing surgical wound with peroxide)
The goal of setting the proper power level is to avoid charring and rather leave a caramel colored surgical wound.
Rarely is bleeding encountered; when bleeding is encountered it is minor and soon stops: this non-bleeding is because as the laser tip vaporizes it also cauterizes/seals the blood vessels and nerve endings.
During the procedure we constantly monitor the patient’s welfare. Indeed the patient has been previously advised to raise a finger if they want us to stop and they need to take some “timeout”
When we have completed the gums reshaping the diode laser is turned off and we can remove our glasses.
The surgical wound is thoroughly cleaned again with peroxide and covered over with a Vitamin E coating to soothe the tissue and promote healing.
(Final shot of gums reshaped to normal and back to shot of his gums at the start)
No “bandage”/covering of any kind is placed over the gums since there is no bleeding and the gums have been desensitized.
The anesthesia will wear off in 1-2 hours.
(DrTed addresses Kal-El re use of Listerine; wearing-off of anesthesia, avoidance of crunchy food and gentle use of soft toothbrush.)
Patient discomfort is generally mild when the anesthesia wears off.
Discomfort the following day, if any, is well tolerated by the patient.
We will provide 6 Advil in case discomfort exceeds patient’s tolerance which is rare in our experience.
Healing is typically uneventful over the next few days and by the 7th day the gums are back to normal.
We suggest that the patients begin brushing with a soft brush as soon as possible and to avoid foods that are crispy, crunchy and crusty so as to avoid aggravating the healing tissue.
We encourage Kal-El write about his experience with special attention to what he experienced in the days following the Laser Gum Trimming.
DrTed is shown speaking to Kal-El suggesting he write a narrative about his experience with special reference to the next seven days during which healing will take place.
Following 7-10 days of healing Kal-El returns to office.
(Shot of how gums looked BEFORE laser reshaping and how they look healed–AFTER)
(Some footage of DrTed offering a very short summary of what we have seen)
Dr. Ted Rothstein
September 28, 2012