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The Official Journal of the Vol. 23 No. 2 Pt. I | 2015Academy of Laser Dentistry9900 W. Sample Rd. Suite 400 | Coral Springs FL 33065 www.laserdentistry.org

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Vol. 23 No. 2 Pt. I | 2015 CTAOBNLTEEoNfTS| 201565 Part I 82 CLINICAL CASE EDITOR’S VIEWAchieving Esthetic Smiles with a Variety of Lasers Soft Tissue Gingivoplasty, Osseous Recontouring / CrownStuart Coleton, DDS Lengthening, and FrenectomyGUIDELINES FOR AUTHORS 66 Using an Er:YAG Laser70 CLINICAL CASE Charles R. Hoopingarner, DDS Er:YAG Laser-Assisted Flapless Esthetic How does the use of an Er:YAG laser affect Crown Lengthening the predictability of final gingival position in a case involving gingivoplasty, osseous Walid Altayeb, DDS, MDS, PhD recontouring and crown lengthening, and How does one correct an asymmetric smile line with excessive frenectomy? Dr. Hoopingarner assesses gingival display? Dr. Altayeb’s treatment plan includes guides the clinical outcome. for performing a buccal gingivectomy along with a flapless osteotomy and bone recontouring. The Academy of Laser Dentistry is a not-for-profit organization qualifying under Section 501(c)(3) of the Internal Revenue Code. The Academy of Laser Dentistry is an international professional membership association of dental practitioners and supporting organizations dedicated to improving the health and well-being of patients through the proper use of laser technology. The Academy is dedicated to the advancement of knowledge, research and education and to the exchange of information relative to the art and science of the use of lasers in dentistry. The Academy endorses the Curriculum Guidelines and Standards for Dental Laser Education. © Copyright 2015 Academy of Laser DentistryThis paper meets the requirements of ANSI/NISO Z39.48-1992(Permanence of Paper).

90 CLINICAL CASE The Use of an Er:YAG Laser Editor-in-Chief100 Stuart Coleton, DDS | Chappaqua, NY (2940 nm) in Soft and Hard Tissue Surgery for [email protected] Esthetic Enhancements Managing Editor Raminta Mastis, DDS Gail S. Siminovsky, CAE, Executive Director What are the clinical considerations for using an Er:YAG laser to Coral Springs, FL perform a labial frenctomyand full gingivectomy, assist in raising [email protected] a full thickness flap, and contouring the crestal bone in the upper anterior segment? Dr. Mastis describes her experience. Consulting Editor John G. Sulewski, MA | Huntington Hills, MI SCIENTIFIC RESEARCH Comparison of [email protected] Er:YAG Laser Flapless Crown Lengthening vs. Publisher Open-Flap Bur Approach in Animal Studies Max G. Moses | Member Media Chicago, IL Tosun Tosun, Doç. Dr. med. dent.; Giuseppe Iaria, Prof. Dr. med dent.; 312-296-7864 • Fax: 312-896-9119 Stefano Benedicenti, DDS [email protected] How does a laser-assisted, flapless approach to osseous crown lengthening affect crestal bone topography? The authors use a Editorial Advisory Board rasterization technique to analyze and compare techniques. Sebastiano Andreana, DDS, Buffalo, NY Praveen B. Arany, BDS, MDS, MMSc, PhD,114 Part II Cambridge, MA William Gianni, DDS, Twain Harte, CA CASE REPORTS Advantages of 980-nm Douglas A. Gilio, DMD, Visalia, CA Charles Hoopingarner, DDS, Houston, TX Diode Laser Treatment in the Management of Arthur H. Jeske, DDS, Houston, TX Gingival Pigmentation Gabi Kesler, DMD, Tel Aviv, Israel Mitchell A. Lomke, DDS, Olney, MD Mihir Khakhar, BDS, MDS; Richa Kapoor, BDS; N.D. Jayakumar, BDS, Gloria E. Monzon, RDH, Milpitas, CA MDS; O. Padmalatha BDS, MDS; Sheeja S. Varghese, BDS, MDS; Angela S. Mott, RDH, Tulsa, OK M. Sankari, BDS, MDS Shigeyuki Nagai, DDS, Tokyo, Japan How do patients rate postoperative pain when a diode laser, Giovanni Olivi, DDS, MD, Rome, Italy scalpel, and electrosurgery are used for gingival hyperpigmentation Peter Rechmann, DMD, PhD, treatment? The authors evaluate scores immediately postoperatively San Francisco, CA and at 1 week. Joel M. White, DDS, MS, San Francisco, CA120 CLINICAL CASE Melanin Pigmentation Mission Statement The mission of the Journal of Laser Dentistry Removal Assisted with an Nd:YAG Laser is to provide a professional journal that helps to fulfill the goal of information Hiroshi Umemoto, DDS dissemination by the Academy of Laser What characteristics of a free-running pulsed Nd:YAG laser come into Dentistry. The purpose of the Journal of Laser Dentistry is to present information play for removal of melanin pigmentation in the anterior maxillary about the use of lasers in dentistry. All articles are peer-reviewed. Issues include and mandibular areas? Dr. Umemote relates his clinical experience. manuscripts on current indications for uses of lasers for dental applications, clinical126 CLINICAL CASE Esthetic Treatment of case studies, reviews of topics relevant to laser dentistry, research articles, clinical Gingival Melanin Depigmentation with Er:YAG Laser studies, research abstracts detailing the scientific basis for the safety and Shigeyuki Nagai, DDS efficacy of the devices, and articles about What are the advantages and limitations of using an Er:YAG laser future and experimental procedures. In for removal of superficial pigmentation affecting the anterior labial addition, featured columnists offer clinical gingiva? Dr. Nagai provides a step-by-step description of the clinical insights, and editorials describe personal considerations. viewpoints.132 SCIENTIFIC RESEARCH Pain Assessment Editorial Office 9900 West Sample Road, Suite 400 Using a Visual Analog Scale in Patients Undergoing Coral Springs, FL 33065 954-346-3776 | Fax 954-757-2598 Gingival Depigmentation by Scalpel and 970-nm www.laserdentistry.org Diode Laser Surgery Advertising Integrity Media Group Gurumoorthy Kaarthikeyan, MDS; Nadathur D. Jayakumar, MDS; Kimberly Price 813-390-4003 Ogoti Padmalatha, MDS; Sheeja Varghese, MDS; Richa Kapoor, BDS [email protected] Do patients prefer laser or scalpel instrumentation for gingival depigmentation? Use of a method that measures perceived discomfort levels at different time intervals provides some answers.138 RESEARCH ABSTRACTS Laser Use in Esthetic Smile Enhancement What types of lasers are useful in transforming the esthetics of a patient’s smile? A review of the literature over the past two decades gives an indication of the scope of applications and range of devices.www.laserdentistry.org

SCIENTIFEIDCIRTOESRE’SARVCIEHWAchieving Esthetic Smiles with a Variety of LasersStuart Coleton, DDS, New York Medical College, Valhalla, New York,and Westchester University Medical Center, Valhalla, New YorkJ Laser Dent 2015;23(2 Pt 1):65 Every so often I find it advantageous while examining a new clinical case to look back AUTHOR Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 at similarly themed articles in previous issues of the Journal, especially when we receive BIOGRAPHY requests from readers regarding certain subjects. Much of the clinical interest has centered on the use of lasers in cosmetic dentistry and has ranged from the surgical Dr. Stuart Coleton is a recontouring of both soft and hard tissues to the removal of pigmentation. In this Diplomate of the American two-part issue, we explore these topics in greater detail. Board of Periodontology and the American Board of Dr. Walid Altayeb’s clinical case, published here for the first time and presented as the lead Oral Medicine. He is chief article, provides inspiration for such reflection and historical perspective. attending periodontist atStuart Coleton, DDS Considerable esthetic challenges are posed by a high smile line, excessive asymmetrical Westchester Medical Center gingival display, and short anterior maxillary teeth with excess spacing. Dr. Altayeb University Hospital, holds thepresents a multi-faceted case involving correction of cervico-incisal tooth dimensions, gingival zenith rank of assistant professor incorrections, and gingival symmetry. Er:YAG laser-assisted steps included flapless osteotomy and bone dental medicine at New Yorkcontouring and buccal gingivectomy with papillae preservation. Medical College, and is the chief attending in periodonticsNext, we re-examine a case by Dr. Charles Hoopingarner who presents how the Er:YAG laser can be used in both at the Metropolitan Medicalsoft and hard tissue crown lengthening. Precise operating parameters are discussed. This article stresses the Center in New York City. He is aplanning stage of cosmetic procedures before the surgery is started. past president of the Academy of Laser Dentistry and is aDr. Raminta Mastis discusses the use of the Er:YAG laser for esthetic crown lengthening by removing and Recognized Course Provider.recontouring both the gingiva and the underlying bone to achieve the desired new tooth proportions prior to He has been certified as havingrestoration. Advanced Proficiency, Educator, and Mastership status in lasersDr. Tosun Tosun et al. present the flapless surgical approach to crown lengthening with an Er:YAG laser and by the Academy of Lasercompare it to the open-flap bur approach. Their results and conclusion have the potential of creating a faster Dentistry. His areas of specialand more comfortable surgery for the patient. expertise are periodontal diagnosis and treatment asContinuing in the esthetic realm, in Part II of this issue Dr. Mihir Khakhar and associates discuss the advantages well as oral medicine. He hasof using a 980-nm diode laser in the management of gingival pigmentation. Surgery was performed using taught didactic and clinicala topical anesthetic. Included is a comparison of healing, pain levels, and patient satisfaction when surgery is laser therapy to both dentalperformed using a laser, scalpel, and electrocautery. and medical general practice residents. Dr. Coleton mayDr. Hiroshi Umemoto describes the use of a free-running pulsed Nd:YAG laser in contact mode for the removal be contacted by e-mail atof melanin pigmentation without the need for local anesthetic. [email protected]. Shigeyuki Nagai presents a similar procedure using an Er:YAG laser in contact mode. As part of his treatment Disclosure:plan, he found it necessary to use local anesthetic and utilized a water spray to help minimize shrinkage of the Dr. Coleton has no laser-relatedtissue surface during irradiation. commercial affiiations or personal conflicts of interest.Further comparisons of depigmentation procedures using a scalpel and a 970-nm diode laser are presented byDr. Gurumoorthy Kaarthikeyan and colleagues. Their goal was to compare pain levels using a visual analog scaleboth intraoperatively and at different postoperative intervals. They expand upon some of the findings initiallypresented by Dr. Khakhar’s group from the same university.These reports provide just a sampling of the possibilities for adjunctive use of lasers in cosmetic dentistry. As theResearch Abstracts point out, practitioners and researchers have used multiple laser wavelengths – includingargon, various diodes, Nd:YAG, Ho:YAG, erbiums, and CO2 – to successfully accomplish a variety of estheticprocedures, all aimed at enhancing a patient’s smile.I trust that this review of a new clinical case combined with past articles on the subject of cosmetic dentistry willbe useful in your continued efforts to provide your patients with the highest degree of quality dentistry possible.Yours for the future of lasers in dentistry,Stuart Coleton, DDSEditor-in-Chief, Journal of Laser Dentistry Coleton 65

GUIDELINES FOR AUTHORS Journal of Laser Dentistry: Guidelines for Authors The Academy of Laser Dentistry Welcomes Your Articles for SubmissionJournal of Laser Dentistry | 2015 Vol. 23, No. 1, Pt. I The Journal of Laser Dentistry publishes Permissions donations, clinical materials, special discounts articles pertaining to the art, science, and Direct quotations of 100 or more words, and or gifts, or other forms of support should be practice of laser dentistry. Articles may be illustrations, figures, tables, or other materials specified. 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GUIDELINES FOR AUTHORS Manuscript Components • For journal citations, include surnames Illustration Captions and Legends Title Page and all initials of all authors, complete title All illustrations must be accompanied by The title page of the manuscript should of article, name of journal (abbreviated individual explanatory captions which should include a concise and informative title of the according to the U.S. National Library of be typed double-spaced on a separate page article; the first name, middle initial(s), and last Medicine (www.nlm.nih.gov/services/ with Arabic numerals corresponding to their name of each author, along with the academic lpabbrev.html), year of publication, volume, respective illustration. degree(s), professional title(s), and the name issue number, and complete inclusive page and location (city, state, zip code) of current numbers. If abstracts are cited, add the Tables institutional affiliation(s) and department(s). abstract number after the page number. Tables must be typewritten double-spaced, Authors who are private practitioners should including column heads, data, and footnotes, identify their location (city, state, and country). • For book citations, specify surnames and and submitted on separate pages. The tables Include all information in the title that will initials of all authors, chapter number are to be cited in the text and numbered make electronic retrieval of the article sensitive and title (if applicable), editors’ surnames consecutively in Arabic numerals in the order and specific. Titles of case studies should and initials, book title, volume number (if of their appearance in the text. Provide a include the laser wavelength(s) and type(s) applicable), edition number (if applicable), concise title for each table that highlights the utilized for treatment (for example, “810-nm city and full name of publisher, year of key result. GaAlAs diode”). publication, and inclusive page numbers of citation. 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The image must be submitted in A self-standing summary of the text of up to • For articles published online but not yet in the size it will be printed, or larger. Illustrations 250 words should precede the introduction. print, cite with the paper’s Digital Object are to augment, not repeat, material in the It should provide an accurate summary of the Identifier (DOI) added to the end of the text. Graphs must not repeat data presented most significant points and be representative reference. in tables. Clinical photographs must comply of the entire article’s content. Provide the with ALD’s Guidelines for Clinical Photography, context or background for the article, basic • For Web citations, list the authors and titles available online. Authors are to certify in a procedures, main findings and conclusions. if known, then the URL and date it was cover letter that digitized illustrations accurately Emphasize new or important aspects. Do not accessed. represent the original data, condition, or image use abbreviations (other than standard units of and are not electronically edited. measurement) or references in the abstract. • For presentations, list the authors, title of presentation, indication that the reference Author(s) Biography is a lecture, name of conference or Provide a brief, current biographical sketch presentation venue, date, and location. of each author that includes professionalJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 education and professional affiliations. For Summary of Illustration Types and Specifications authors who hold teaching positions, include the title, department, and school. For authors Illustration Type Definition and Examples Preferred Required who are in federal service, include rank or title Format Resolution and station. 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GUIDELINES FOR AUTHORSPublisher and Copyright Holder SubmissionsThe Journal of Laser Dentistry is published by Max G. Moses, Member We encourage prospective authors to follow JLD’s “Instructions to Authors”Media, 1844 N. Larrabee, Chicago, IL 60614, Telephone: (312) 296-7864; before submitting manuscripts. To obtain a copy, please go to our Web siteFax: (312) 896-9119. The Journal of Laser Dentistry is copyrighted by www.laserdentistry.org/uploads/files/members/jld/JLD%20Author%20Guidelines.The Academy of Laser Dentistry, 9900 W. Sample Road, Suite 400, pdf. Please send manuscripts by e-mail to the Editor at [email protected] Springs, FL 33065, Telephone: (954) 346-3776; Fax: (954) 757-2598. 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Reprints may be obtained directly from theGail Siminovsky ([email protected]). Academy of Laser Dentistry provided that any appropriate fee is paid.Gail Siminovsky The Journal of Laser Dentistry ISSN# 1935-2557.Academy of Laser Dentistry9900 W. Sample Road, Suite 400 The Journal of Laser Dentistry is published semi-annually and providedCoral Springs, FL 33065 electronically to all ALD members. The Journal is mailed nonprofit standard mailPhone: (954) 346-3776. to ALD members requesting a hard copy. Issues are also mailed to new member prospects and dentists requesting information on lasers in dentistry.Editorial PolicyThe Journal of Laser Dentistry is devoted to providing the Academy and its Copyright 2015 Academy of Laser Dentistry. All rights reserved unlessmembers with comprehensive clinical, didactic, and research information about other ownership is indicated. If any omission or infringement of copyrightthe safe and effective uses of lasers in dentistry. All statements of opinions and/ has occurred through oversight, upon notification amendment will beor fact are published under the authority of the authors, including editorials and made in a future issue. No part of this publication may be reproduced orarticles. The Academy is not responsible for the opinions expressed by the writers, transmitted in any form or by any means, individually or by any means,editors or advertisers. The views are not to be accepted as the views of the without permission from the copyright holder.Academy of Laser Dentistry unless such statements have been expressly adoptedby the organization. Information on any research, clinical procedures or productsmay be obtained from the author. Comments concerning content may bedirected to the Academy’s main office by e-mail to [email protected] Information and Rates Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1Display rates are available at www.laserdentistry.org and/or supplied upon request. Insertion orders and materials should be sent to Integrity Media Group,Kimberly Price at [email protected]. Call 813-390-4003 with any questions.. Companies are encouraged to contact Integrity Media Group forinformation on display advertising specifications and rates. The Academy reserves the right to edit or refuse ads.Editor’s Note on Advertising:The Journal of Laser Dentistry currently accepts advertisements for different dental laser educational programs. Not all dental laser educationalcourses are recognized by the Academy of Laser Dentistry. ALD as an independent professional dental organization is concerned that courses meetthe stringent guidelines following professional standards of education. Readers are advised to verify with ALD whether or not specific courses arerecognized by the Academy of Laser Dentistry in their use of the Curriculum Guidelines and Standards for Dental Laser Education. 69

CLINICAL CASE LITERATURE REVIEW Er:YAG Laser-Assisted Flapless Esthetic Crown Lengthening Walid Altayeb, DDS, MDS, PhD Doha, Qatar J Laser Dent 2015;23(2 Pt I):70-81 PRETREATMENT A. Outline of Case 1. Clinical Description A 29-year-old female patient presented with the chief complaint of a gummy smile and requested esthetic improvement of her smile. She had previously undergone orthodontic treatment followed by gingivectomy. Examination showed increased gingival display on smiling. It was apparent that the golden proportion of the eight upper anterior teeth, size and length on the centrals, axial inclinations, gradation, gingival symmetry, contour, and zenith were not as esthetically pleasing as the patient desired (Figure 1).Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 1: Preoperative anterior view showing excessive display of gingival tissue and tooth asymmetry when smiling The treatment plan involved esthetic crown lengthening around several anterior teeth followed by prosthetic procedures. The patient was informed in detail of the nature and potential risks of the proposed closed- and open-flap procedures, and informed consent was reviewed and signed.70 Altayeb

CLINICAL CASE2. Medical History The patient was in excellent medical health with no medical concerns or history. She had no known allergiesto any medications and was not taking any medication at the time. There was no history of bleeding or clottingdisorders.3. Dental History The patient had undergone orthodontic treatment to correct a deep overbite relationship as well as to correcta midline discrepancy. She had existing composite restorations that were placed in an effort to close the proximalspaces after long orthodontic treatment.4. Occlusion Intraoral examination revealed a Class I deep-bite occlusion. The patient had a 2-mm overjet and a 60%overbite.5. Temporomandibular Joint Examination of both temporomandibular joints, through palpation, revealed normal movements.6. Radiographic Examination The height of the alveolar bone and the outline of the bone crest were examined in the radiographs, and noperiodontal bone loss was noticed. The crown-to-root ratios on the treatment teeth were favorable. No periapicalpathology was detected on the radiographs (Figure 2). Figure 2: Radiographic examination Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.17. Soft Tissue Examination 71 Periodontal examination showed abundant keratinized tissue and there were no changes in color and textureof the soft marginal tissue. Bleeding on probing had been registered on teeth #2, 3, 5, 12, 13, 14, 15, 17, 18, 23,24, 25, 26, 27, 29, 30, and 31. Full-mouth periodontal probing (Figures 3-4) was utilized to determine tissue andbone topography and showed normal sulcus depth around all the examined teeth with no attachment loss. Thepatient was diagnosed as plaque-induced gingivitis that was modified by localized tooth-related factors (dentalrestorations). Bone sounding was done for upper anterior teeth to determine biologic width; the tip of theprobe was forced through the supra-alveolar connective tissue to make contact with the bone, and the distance Altayeb

CLINICAL CASE from the cementoenamel junction to the bone level was assessed in mm. There was no furcation or mobility involvement. Oral hygiene instructions were reviewed with the patient, with emphasis on the importance of effective brushing twice daily and flossing once daily.Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 3: Initial periodontal chart72 Altayeb

CLINICAL CASEFigure 4: Preoperative probing depth at tooth #8 Figure 5: Preoperative intraoral view8. Hard Tissue Examination Clinical examination revealed that 4 first premolarshad been extracted for the orthodontic treatmentgoal. In addition, excess spacing was present followingorthodontic treatment. There were some amalgamsand composite fillings but no sign of any majorcarious lesions. No mobility was noted in any teeth.Radiographic examination showed favorable crown-to-root ratios on all teeth without alveolar bone loss.9. Preoperative Photography Figure 6: The width-to-length ratio of central incisors was 94% A series of intra- and extraoral photographswere taken.10. Other Tests Figure 7: The surgical plan was mapped to measure the Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 planned correction in the cervico-incisal direction to ensure Smile analysis: The dentolabial gingival relationshiphad been registered to analyze the patient smile. There esthetic width-to-length ratios were followedwas excessive display of the maxillary gingiva (onfull smile, the patient presented 5-6 mm of gingival B. Diagnosis and Treatment Plandisplay at the maxillary centrals, and the patient hada crown size discrepancy between the 2 maxillary 1. Provisional Diagnosiscentrals and a mild case of altered passive eruption(Figures 5-7). Tooth size and proportion were found to The patient exhibited a high smile line withbe undesirable with a width-to-length ratio that was excessive asymmetrical gingival display and shortgreater than 90% for the maxillary centrals. Impressions anterior maxillary teeth with excess spacing.for study models were made. The desired symmetricalgingival contour, zenith positions, and ideal tooth 2. Final Diagnosisdimensions were drawn in the buccal aspect of theanterior maxillary teeth on the diagnostic cast. The Altered passive eruption of maxillary teeth.stone cast with diagnostic wax-up was used tomanufacture the soft acetate template. Altayeb 73

CLINICAL CASEJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 3. Treatment Plan b. Specific The ability of the Er:YAG laser to cut both hard and Flapless esthetic crown lengthening procedure soft tissues creates the opportunity for a minimally utilizing an Er:YAG laser followed by esthetic restorative invasive flapless crown lengthening approach that: procedures to improve the overall esthetics of the patient’s smile. This crown lengthening procedure • Allows for faster uneventful wound healing and was planned to be done completely by Er:YAG laser in eliminates irregular tissue positioning due to accordance with the following clinical needs: tension in the tissue that occurs when a flap is reflected and sutured a. Buccal gingivectomy with a papillae preservation approach from tooth #4 to #13 to achieve these goals: • Prevents collateral tissue damage that could occur with conventional methods, as the erbium • 2 mm gingival display at full smiling laser is end-cutting • Gingival zenith located distal to the long axis of • Minimizes necrosis of surrounding tissues caused the tooth on the labial surface of the maxillary by collateral thermal damage. central incisors and canines • Gingival height of contour to ideally follow the 5. Indications and Contraindications contour of the upper lip • Height of contour of the central incisors a. Indications symmetrical and at a level coincident with the Treatment: Esthetic crown lengthening that maxillary canines includes gingivectomy and osseous recontouring • An 80% length-to-width ratio of the maxillary is indicated to resolve altered passive eruption central incisors where repositioning the gingival margin will result in exposure of the osseous crest or the violation of b. Flapless osteotomy and bone contouring of biologic width. teeth #4 to #13 where there was adequate attached gingiva and less than 3 mm of tissue coronal to the Laser: For minor biologic width and esthetic bone crest to establish a healthy biologic dimension of gingival corrections, a flapless osteotomy procedure the dentogingival complex (biologic width) that may is performed through the gingival sulcus using an prevent postoperative recession or open embrasure Er:YAG laser without the longer healing time required spaces. for open crown lengthening surgeries. To do this, it is imperative to meet the precise indications: to have 4. Treatment Plan Outline an adequate width of keratinized tissue and a bone crest not considered thick (thin and intermediate tissue a. General biotypes). One-stage flapless crown lengthening is The treatment plan involved an esthetic crown less traumatic for gingival tissues and shortens the total lengthening procedure that allowed for the surgical treatment time. repositioning of the gingival margin in order to obtain an esthetic smile and create a symmetrical The Er:YAG laser’s 2940-nm wavelength is well and harmonious relationship between the gingival absorbed by water, a chromophore of soft and hard architecture and the positions of the maxillary teeth. tissues. In this case, a pulsed Er:YAG laser can cut and The second phase of treatment addressed the ablate tissue with excellent surgical precision and fabrication of provisional restorations to reestablish the minimal collateral effects resulting in decreased tissue correct incisal edge position that harmonized with the damage, causing less inflammation, less postoperative esthetic needs of the patient. discomfort, and thus enhanced healing. The concept of minimally invasive dentistry can be achieved by choosing laser treatment.74 Altayeb

CLINICAL CASE b. Contraindications 8. Informed Consent Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Treatment: The absolute contraindication wouldbe present if the patient were suffering from serious The relative risks/benefits and treatment alternativesillnesses of the hematogenic system. Ostectomy were discussed with the patient. She preferred thebecomes a liability when the stability of the treated flapless laser treatment option and provided verbaldentition may be affected. informed consent which was documented. Laser: Lasers are safe to use if the user adheres to TREATMENTprotocols, so there was no contraindication for thechosen wavelength on this patient. A. Treatment Objectives6. Precautions Improve the overall esthetics of the patient’s smile through: • The specific absorption of this wavelength is in water which is present in both hard and soft • Minimizing the excessive display of gingival tissue tissue. The clinician must be careful to avoid on smiling possible damage to adjacent root surface tissue by moving the laser tip carefully and positioning • Establishing a healthy biologic dimension of it almost parallel to the root surface. the dentogingival complex (biologic width) as an adjunct to esthetic restorative procedures to • It is appropriate to use minimal power and correct the width-to-length ratio of the maxillary proper technique, minimizing the risk of collateral anterior teeth. tissue damage. • Minimal extension porcelain veneers were • Laser energy leaving the fiber vaporizes planned as a restorative option to correct the biological tissue and amalgam restorations; dental esthetic parameters. therefore the clinician must be aware of this potential danger. B. Laser Operating Parameters • Since the primary laser-tissue interaction is The laser chosen was an Er:YAG laser (K.E.Y. Laser, thermal, care must be taken to avoid excessive KaVo Dental GmbH, Biberach, Germany) with the heat build-up in the sulcus, especially when using following operating features: higher energy for osseous contouring. Proper irrigation and water cooling must be carefully • Wavelength: 2940 nm managed. • Pulse energy: 80 to 600 mJ • Pulse frequency: 2 to 30 Hz • The “blind” approach to bone surgery may • Pulse Width: 250 µs cause bone craters which may become a risk for • Average Power: 0.16 to 7.8 W developing an area of chronic inflammation or • Emission mode: Free-running pulse even periodontal disease. • Delivery system: Flexible quartz-silica optical7. Treatment Alternatives fiber with an additional rigid quartz or sapphire tip The possible alternative treatment for this patient • Tip diameter: Disposable 400- micron width,could be: lengths either 6 mm or 18 mm a. Mucoperiosteal flap with ostectomy using Specific laser operating parameters for this conventional instruments, i.e., scalpel and high- treatment were: speed rotary instruments 1. Marking the gingival contour: 80 mJ/pulse, 10 b. Osseous crown lengthening by Er:YAG laser and Hz, with air, no water. Laser handpiece 2062 with open-flap technique fiber insert size 50/10 (0.47 mm diameter and 10 mm length) in contact mode. Total estimated c. Two-stage procedure, which requires flaps, exposure duration for each tooth was 5 seconds. ostectomy, and repositioning 4 to 6 weeks after gingivectomy. 2. Gingivectomy: 100 mJ/pulse, 20 Hz, with air, no water. Laser handpiece 2062 with fiber insert size 50/10 (0.47 mm diameter and 10 mm length) Altayeb 75

CLINICAL CASEJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 in contact mode. Total estimated exposure determined, the fabricated soft acetate template duration for each tooth was 30 seconds. was used as a guide to mark the planned 3. Intrasulcular soft tissue ablation and osteotomy gingival contour of the area to be treated by of bone crest: 300 mJ/pulse, 6 Hz, with using the Er:YAG laser at low power (0.8 W) maximum water and air. Laser handpiece P2061 perpendicular to the gingival tissue following with quartz prism (exit surface 0.4 × 1.65 mm) in the margins of the surgical template (Figure 8). near-contact mode. Total estimated exposure • With the laser tip almost parallel to the root duration for each tooth was 1 minute. surface, the soft tissue was cut in a sweeping 4. Bone recontouring and smoothening: 180 mJ/ motion from the mesial to distal level just pulse, 10 Hz, with maximum water and air. Laser coronal to the desired points using 2 W average handpiece P2061 with cylindrical fiber (1.1 mm power. Then the soft tissue was beveled to the diameter, circular flat) in contact mode. This tip marked points. Lasing began with the central was chosen because of the shallow depth of incisors after the ideal symmetry, contour, and penetration. Total estimated exposure duration zenith were established; the right side was for each tooth was 30 seconds. completed, followed by the left side (Figures 9 and 11). C. Preliminary to Patient Treatment • After contouring of the free gingival margin, a periodontal probe was placed into the sulcus Prior to the treatment, the following safety to the level of the bone around each tooth. precautions were utilized: Bone sounding measured the biological zone (Figure 10). All 8 front teeth had compromised • Infection control guidelines were respected for biological width and needed osteotomy. environment, patient, and dental staff. • The intrasulcular soft tissue was ablated down to the bone crest to form a pouch using the • A safe environment was maintained by prism tip that was applied parallel with the long restricting operating room access to persons axis of the tooth and the long exit surface of involved in the treatment, posting warning signs, the tip in a mesiodistal direction. The laser was and minimizing highly reflective surfaces. then used to remove bone, with the tip held adjacent to the tooth and “walked” across the • All instruments were pre-dispensed prior affected area; the tip was advanced apically to to treatment commencing. High-volume its full 3-mm marked length to satisfy biologic evacuation was used. width requirements. The average power was 1.8 W and air and water irrigation were applied. • The patient and all staff members working in the The papillae were left intact. During bone above-mentioned safety-controlled area wore ablation, superimposing several pulse rows protective glasses specific for the laser. was applied rather than working down to the desired depth. This method has the advantage • The laser was first test-fired outside of the that unintentional cutting can be avoided and patient’s mouth. The patient was then seated it helps to create a more even osseous margin and appropriate safety equipment was utilized. (Figures 12-13). • Following the osteotomy, the crestal portion D. Treatment Delivery Sequence of the labial cortical plate was recontoured and smoothed. The laser was set at 10 pulses After cleaning of the preparation site and per second, 1.8 W average power with air and disinfection with chlorhexidine, a topical anesthetic water irrigation. The 1.1-mm cylindrical tip (benzocaine) was placed from tooth areas #5 to #12, was moved laterally from mesial to distal in a followed by local anesthesia (articaine HCl 4% and adrenaline 1:200 000, Ubistesin™, 3M™ ESPE™, Seefeld, Germany). • The level of the alveolar crest was determined by bone sounding prior to any considerations regarding esthetic crown lengthening. • Since the gingival margin levels were already76 Altayeb

CLINICAL CASE sweeping motion, following the cementoenamel Figure 10: Following laser-mediated gingivectomy, bone junction contours through the sulcus to a depth sounding revealed the osseous crest at the newly positioned of 3 mm from the new free gingival margin. It gingival margin. Osseous resection was therefore required to is important to note that with both of these movements, the tip of the laser was in contact create space for the biologic width with the bony crest and care was taken to insert the laser tip parallel to the root surface to avoid cementum ablation (Figure 14).• After the bone had been resected, the possible roughing and irregularities created on the bone surface by the erbium laser were smoothed with a hand bone file and Gracey curettes (Figures 15- 16). Figure 11: View after completion of the gingivectomy Figure 8: With the surgical guide in place, the proposedgingival margin was transferred to the patient’s tissues by using the Er:YAG laser at low power Figure 12: The Er:YAG laser’s quartz tip was calibrated at 3 mm Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 9: A periodontal probe was used to measure theplanned correction in the cervico-incisal direction to ensure the esthetic width-to-length aspect was followed. An acceptable starting point for the central incisors was 11 mm in length Figure 13: Er:YAG laser quartz laser tip was 3 mm in length advanced apically Altayeb 77

CLINICAL CASE Figure 14: Er:YAG laser performing an osteotomy on the alveolar crest through the incision sulcus in a minimally invasive fashion Figure 17: View after completion of the osteotomy. Periodontal probe showed that 3 mm from gingival margin to alveolar crest was achieved Figure 18: Immediate postoperative view with sealing of tissuesJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figures 15-16: Bone troughs and irregularities were minimized E. Postoperative Instructions with a bone file and Gracey curettes Verbal and written postoperative instructions were Sutures were not necessary because the papillae were given to the patient. These included warm salt water still attached. Wet gauze was used to apply pressure rinses, 400 mg ibuprofen as needed, chlorhexidine over the surgical site for 3 to 5 minutes until a thin clot gluconate 0.12% rinses twice daily. The patient was formed under the tissue. The tissue was then sealed instructed to use a soft cotton applicator and 3% with oral tissue adhesive (PeriAcryl®90, GluStitch, Delta, hydrogen peroxide twice daily to gently cleanse the British Columbia, Canada) (Figures 17-18). areas. She was cautioned to avoid crunchy and hard foods in the first week and resume normal hygiene Altayeb practices in 4 to 7 days. The patient was scheduled to return after 1 week, 1 month, and 3 months. Esthetic restorative treatment was scheduled after 3 months from the surgery date.78

CLINICAL CASEF. Complications The patient had no significant complications duringthe procedure. The gingival margins were swollenfor about 1 week. The patient complained of mildspontaneous pain during the first 3 days which wasresolved by ibuprofen (400 mg / three times daily). Noother complications were reported.G. Prognosis Figure 21: Six-month postoperative view. Note the correction of cervico-incisal tooth dimensions, gingival zenith corrections, The prognosis was very good during thepostoperative period. and gingival symmetryH. Treatment Records All procedural details were entered in the patient’streatment notes, along with the consent forms,radiographs, and chartings.FOLLOW-UP CAREA. Assessment of Treatment The patient was first assessed at one week post-operation (Figure 19), then at 3 months (Figure 20), 6months (Figures 21-24), and 9 months (Figure 25-26).All through the follow-up care, there was no sign ofany complication related to the laser treatments. Therecovery was relatively uneventful.Figure 19: One-week postoperative view Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1Figure 20: Three-month postoperative view showing porcelain Figure 22: View of 1-mm probing depth of tooth #8 afterveneers and apical repositioning of the gingival tissues. Note 6 monthsthe decrease in excessive gingival display compared to Figure 1 Altayeb 79

CLINICAL CASE Figure 25: Nine-month postoperative view Figure 23: Clinical crown height of tooth #8 is 11 mm Figure 26: Patient smile after 9 months after 6 months Gingival swelling and redness were noticed at theJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 1-week recall without bleeding or infection. The gingiva was completely healthy at the 1-month recall. The healing at the crown lengthening site was satisfactory, in that there was no swelling or bleeding. The porcelain laminate veneers were placed after three months. Healing assessment photographs of the area after 3, 6, and 9 months showed complete healing without complications, well-attached gingival tissue, and stable gingival margins. The cone-beam computed tomography after 9 months did not reveal any bony defect over the surgical area (Figures 27-29). Figure 24: Patient smile after 6 months Figure 27: Cone-beam computed tomographic (CT) image after 9 months80 Altayeb

CLINICAL CASE C. Long-Term Results The long-term results were felt to be good with continued six-month recall visits. The soft tissue remained healthy and no gum or bone recession was observed. The tissue healing remained relatively the same through the postoperative period. The patient, who was having esthetic problems for years, found herself in a much better position after a relatively short laser treatment.Figure 28: CT shows 2.57 mm distance from restoration margin D. Long-Term Prognosis to bone crest at tooth #11 With the patient having a better understanding of dental conditions and improved home care, the long-term prognosis for laser-assisted crown lengthening was excellent. Laser-assisted flapless crown lengthening was more predictable than other methods, less traumatic with a shortened healing time, and overall a positive experience for the patient who achieved her desired results. AUTHOR BIOGRAPHYFigure 29: CT shows 2.43 mm distance from restoration margin Dr. Walid Altayeb received his Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 to bone crest at tooth #8 dental degree from Faculty of Dentistry, Damascus UniversityB. Complications in 1998, and completed his Master of Science in Periodontics No long-term complications were observed. The in 2004 and Doctorate of Philosophy in Periodontics inpatient will be seen annually for recalls to monitor any 2007. He is a Fellow and Master of the Academy of Laser Dentistry. He has served ashygiene issues. lecturer in the Department of Periodontics, Damascus University. He has participated in many conferences in the Middle East, Spain, and USA as speaker in the fields of periodontal medicine and laser dentistry. Dr. Altayeb has achieved an advanced level of knowledge about the application of lasers in dental science and patient treatment (Advanced Proficiency certificates from the Academy of Laser Dentistry in 980-nm diode and 2940-nm Er:YAG lasers). He is currently Chair of the ALD affiliate study club in Qatar and is working in private as a periodontist and implantologist in Madina Dental Center, Doha. Dr. Altayeb may be contacted by e-mail at [email protected]. Disclosure: Dr. Walid Altayeb has no financial arrangements with any corporate organization related to this article. Altayeb 81

CLINICAL CASE LITERATURE REVIEW Soft Tissue Gingivoplasty, Osseous Recontouring / Crown Lengthening, and Frenectomy Using an Er:YAG Laser Charles R. Hoopingarner, DDS Houston, Texas J Laser Dent 2015;23(2 Pt I):82-89 SYNOPSIS This article describes soft and hard tissue crown lengthening and a maxillary frenectomy that were all performed with an Er:YAG laser. PRETREATMENT four first bicuspids. Probing depths were 2-3 mm in all areas, as shown in the periodontal chart, Figure 1. A. Outline of Case Her chief complaint was an unaesthetic gingival 1. Full Clinical Description presentation in the maxillary anterior region. She A 24-year-old white female was referred for stated she “had a gummy smile and her lip comes up too far.” Figures 2 and 3 depict the full smile and a evaluation and treatment of excessive maxillary close-up of the anterior region of her smile. gingival display with no medical limitations to treatment. She had vital signs within normal limits 2. Radiographic Examination (blood pressure 110/78, pulse 70). She was allergic to codeine and was taking Lexapro® 10 mg once daily, A panoramic radiograph and decay-detecting Topamax® 10 mg at bedtime, and Estrostep®. The radiographs were evaluated, revealing a normal bone patient had completed an endodontic obturation and contour, and no caries or osseous defects (Figure 4). crown on tooth #14. Teeth #3, 29, and 30 had occlusal There was no interproximal decay present. resin restorations. She had a Class I occlusion which had been orthodontically treated and was missingJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 1: Preoperative periodontal chart82 Hoopingarner

Figure 2: Preoperative full smile CLINICAL CASE Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 3: Preoperative full anterior viewFigure 4: Preoperative panoramic radiograph 3. Soft Tissue Status Oral cancer screening was negative. There was a high frenum attachment in the maxillary midline. There was also slight blunting of the papillae, and generalized marginal gingivitis in the posterior segments. Oral hygiene was fair at best. The anterior segment was characterized by excessive gingival display. The upper lip was highly active, traveling 15 mm from rest to full smile. 4. Hard Tissue Status There was no caries detected and no indication for vitality testing. 5. Other Tests There was modest physiologic tooth wear and faceting present. No mobility or fremitis was observed. There was no muscle or joint tenderness, joint sounds, or limitations in range of motion present. Smile evaluation revealed excessive gingival display and a width-to- length ratio of 92%. The gingival extension on the maxillary centrals was at the same level as that of the canines. B. Diagnosis and Treatment Plan 1. Provisional Diagnosis Mild generalized chronic gingivitis, excessive gingival display, incisally positioned maxillary midline frenum (relative to the desired tissue level). It was believed this would allow tension to be expressed in the area of the gingival margin after completing the gingival and osseous recontouring. Final individual biologic width was determined at the time of surgery. 2. Final Diagnosis Mild generalized chronic gingivitis, excessive gingival display, incisally positioned maxillary midline frenum placing tension on the gingival apparatus, lack of sustainable biologic width or attachment subsequent to soft tissue recontour. Hoopingarner 83

CLINICAL CASE 3. Treatment Plan Outline 6. Precautions for Wavelength Because a soft tissue revision alone would have Standard safety precautions for laser operation left an inadequate periodontal attachment apparatus, should be strictly adhered to. As this wavelength gingival and osseous recontouring with the Er:YAG readily interacts with both hard and soft tissue, care laser would allow for ideal aesthetic width-to-length must be taken to avoid excessive tissue removal and ratio for the incisors and preservation of the biologic in particular premature osseous ablation when using width. Revision of maxillary frenum attachment with the laser without cooling water spray. Care must also the Er:YAG laser is indicated to prevent excessive be taken to avoid interaction with the tooth itself tension at the gingival margin. Oral hygiene review by properly angling the tip or leaving a thin tissue and motivation, along with scheduled dental layer over the tooth prior to removal with a hand prophylaxis were part of the treatment plan. instrument. Adequate water spray must be used during the osseous phase. Care must be taken to 4. Indications for Treatment avoid tissue emphysema by turning the cooling air off or down to an appropriate level and using digital Indications for gingival recontouring are largely pressure to compress the tissue at the mucogingival aesthetic. However it was felt that over the life of border. Care in treatment planning must be exercised the dentition that the hyperplastic tissue would be a to leave an adequate dimensional band of gingival contributing factor to diminished periodontal health tissue to prevent mucogingival dehiscence, to leave in the anterior segment. Osseous recontouring was the cementoenamel junction subgingival, and to necessary to maintain the patient’s individual biologic maintain a healthy, adequate biologic width. width. Frenum revision was indicated to prevent apical migration of the gingival margin. For this 7. Treatment Alternatives procedure, the Er:YAG laser’s 2940-nm wavelength allowed the advantage of decreased healing time with Conventional periodontal surgical procedures with minimal patient discomfort. The Er:YAG also has the subsequent increase in healing time and maxillary advantage of being able to be utilized for both soft impaction as a Le Fort osteotomy are treatment tissue ablation and osseous recontouring for biologic alternatives. No treatment was another alternative. width maintenance and scoring the periosteum.. With a complete understanding of biologic width/gingival 8. Informed Consent attachment mechanics, final gingival position is very predictable using the Er:YAG laser. Scoring of the After a full explanation and question answering, periosteum is easily accomplished during the frenum a written informed consent was obtained for both revision. surgical procedures.Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 5. Contraindications TREATMENT There were no contraindications for treatment. A. Treatment Objectives Strategy However there are many precautions which must be observed. The gingival tissue will be contoured with an Er:YAG laser to allow for ideal width-to-length ratio (77.5%) of Hoopingarner the central incisors, establish proper soft tissue heights from canine to canine, establish proper tissue scallop/ zenith on each individual tooth from #6 to #11 while establishing an attachment distance consistent with the patient’s individual biologic width. This will require osseous recontouring to support the attachment at the desired levels. The frenum attachment will be shortened, eliminating tension on the gingival margin, and the periosteum will be scored to prevent reattachment. The Er:YAG laser has the advantage84

CLINICAL CASEof being able to be utilized for soft tissue ablation, Laser settings:osseous recontouring for biologic width maintenance, • Soft tissue ablation: 30 Hz and 50 mJ, air coolingand scoring of the periosteum. The central incisors and no waterwere 8.5 mm wide. This condition would support a • Osseous recontouring and scoring of periosteum:length of 11.3 mm and would mean removal of 2.1 mm 30 Hz and 50 mJ with air and water spray andof soft tissue. This procedure would not expose the decreased air volumecementoenamel junction (CEJ) but would leave only1.9 mm for attachment and sulcus. As this violates the C. Treatment Delivery Sequenceconcept of individual biologic width, the osseous crestneeds to be recontoured to a level 1.1 mm apical to the Pretreatment: The operatory was secured andpresenting position to satisfy the patient’s individual the laser warning sign was posted. The laser unitbiologic width needs. was properly placed and connected to the air supply. Safety glasses with 4+ optical density for the 2940-nmB. Laser Operating Parameters laser wavelength that met ANSI standards Z136.1 andLaser: Er:YAG (DELight, HOYA ConBio, Z136.3 were used. All shiny reflective objects wereFremont, Calif.): removed from the operative area. The operatory was set up and supplied according to the standard for a • Delivery system: Fiber-optic system with surgical procedure. Charting and radiographs were varying quartz tips: 600-micron for initial tissue visible to the operator. The procedure was reviewed ablation, 400-micron for osseous recontouring, in the morning report meeting. Prior to administration a 400-micron straight soft tissue tip, and 1200 of anesthesia, the treatment was reviewed with the x 300-micron chisel tip for tissue and osseous patient and informed consent was confirmed. The beveling and smoothing patient was properly draped and 3.8 cc Septocaine™ 4% 1:200,000 epinephrine was distributed by infiltration • Wavelength: 2940 nm in the maxillary anterior segment. Eye protection • Mode: Free-running pulsed was placed on the patient as well as the operator and • Pulse width: 300 microseconds assistant. The laser was test-fired in a safe direction. • Power: 1.5 Watts (30 Hz and 50 mJ) A width-to-length measurement was confirmed and • Beam Diameter: Varied, 400 to 600 microns used the ideal length was established, as shown in Figures 5 and 6. as focused and defocused patterns • Repetition rate: 30 Hz • Continuous air (reduced pressure) and water spray for osseous procedures and air only for soft tissueFigure 5: Preoperative width Figure 6: Preoperative target length Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Hoopingarner 85

CLINICAL CASE Since there was more than 2 mm of attached gingival tissue apical to the intended finish Figure 7: Preoperative crestal bone level line, the limiting factor became the position of the CEJ. This was assessed by probing Figure 8: Initial laser ablation of tissue and marked with stab punctures. Crestal bone was identified by probing and marked,Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 9: Tissue beveling under way as shown in Figure 7. The refined intended gingival finish line was appreciated and indicated with tissue-marking ink. The laser was set with a straight soft tissue quartz tip at an energy setting of 50 mJ and repetition rate of 30 Hz. The gingival tissues were ablated to the desired level without the use of water spray (Figure 8). This was done using longitudinally directed noncontact strokes until the desired amount of tissue was ablated; care was taken not to score the tooth itself and not to approach the osseous crest too closely. As shown in Figure 9, the tissue was beveled with a chisel tip while establishing the proper alignment and zenith placement at the same time. All teeth in the segment were treated in this manner. The frenum was revised with longitudinal noncontact strokes that were directed around larger vessels until all fibrous bands had been ablated, as shown in Figure 10. This was accomplished with a straight soft tissue tip at 30 Hz and 50 mJ of energy with no water spray and decreased cooling air. The effectiveness of the revision was checked by confirming there was no tension on the gingival tissue when elevating the upper lip. With the addition of water spray, the periosteum was scored to the level of the bone using horizontal light contact strokes and a chisel tip (Figure 11). To avoid tissue emphysema, the cooling air was decreased appropriately and digital pressure was applied around the operated area. The immediate postoperative view of the soft tissue surgery is shown in Figure 12. The biologic width was reassessed by projecting the patient’s individual biologic width onto the tissue (Figure 13).86 Hoopingarner

CLINICAL CASEFigure 10: Initial frenum revision Figure 11: Scoring the periosteum Figure 12: Immediate postoperative view of soft tissue surgeryFigure 13: Crestal bone depth prior to Figure 14: Tip extended to 3 mm marking Figure 15: Crest of bone confirmed at 3 mm osseous recontouring Figure 16: Immediate postoperative view with osseous contouring finished.The osseous tissue was contoured using a 400-micron surface; moreover, the distance between the contact Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1tip at 30 Hz and 50 mJ with adequate water spray and area and the osseous papilla crest did not exceed 4.5decreased air flow. The protective sleeve on the tip mm. The periodontal probe was then used to confirmwas marked at 3 mm and used as a depth guide during the new biologic width (Figure 15) and an immediatethe procedure (Figure 14). Care was taken to avoid postoperative view of the completed laser surgery istissue emphysema by compressing the tissue with shown in Figure 16.digital manipulation. The bone was then beveled withthe chisel tip in a noncontact defocused mode with The biologic width measurement was confirmed at 3water spray and decreased cooling air. Recontouring mm from the osseous crest to the intended final freewas extended interproximally through to the palatal gingival margin. Hoopingarner 87

CLINICAL CASEJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 D. Postoperative Instructions At one month the tissue still appeared inflamed (Figure 18). There were significant plaque and accretions The patient was told to avoid foods warmer than present. Hygiene was again stressed and a mild room temperature for 48 hours and then begin hot cleaning of the area was done. saline mouth rinses. The area was to be cleaned with hydrogen peroxide on cotton tip applicators for the At two months the tissues were within normal limits first 48 hours. After the first postoperative visit, the and appeared to have stabilized. patient was cleared for normal hygiene procedures which included nonsulcular brushing with an ultrasoft Figure 19 shows a close-up of the frenum and some of brush dipped in hot water and gentle flossing. the anterior tissue, and Figure 20 is the smile view. Emergency care contact numbers were given. Over- the-counter ibuprofen was suggested if necessary. The patient was seen at 6 months and again at 1 year. As hygiene had improved, the tissues looked healthy, E. Complications the tissue length was being maintained, and the frenum attachment was taut and showed no signs of No complications arose during the procedure or migration. Figure 21 shows a one-year postoperative during the recovery stage. close-up view of the tissue, and Figure 22 shows a one- year postoperative view of the smile. F. Prognosis B. Complications Because of the exact planning, there is an excellent prognosis for the tissue to remain at the expected No complications were appreciated during the level. The scoring of the periosteum raises the procedure. The inadequate oral hygiene compliance prognosis for frenum stability to excellent. led to a prolonged inflammation and final healing was delayed. The marginal gingival tissue at the zenith of G. Treatment Records teeth #6 and 12 at first appeared to be below the CEJ. By accurately placing the bone level relative to the CEJ The treatment record reflects the treatment described and because the patient’s individual biologic width including estimated exposure times totaling 26 had been properly assessed, the final tissue height was minutes. coronal to the CEJ. FOLLOW-UP CARE C. Long-Term Results A. Assessment of Treatment Outcome The patient has maintained a healthy aesthetic gingival display. While there continues to be plaque- The patient was assessed at 4 days, 2 weeks, 6 induced inflammation, the periodontal attachment weeks, and 10 weeks and has returned to a semiannual mechanism is healthy. recare program in our office. At 48 hours there was some edema around the frenectomy site. Lip D. Long-Term Prognosis manipulation produced discomfort but there were no static tissue pain reports. The tissues, while In order for this state of health to be maintained, the erythematous, showed no sign of infection and patient’s oral hygiene must continue to improve and healing appeared to be progressing nicely. At 2 she must maintain periodic recare evaluations. If these weeks there were no complications and the tissues improvements are maintained there is a very good were healing uneventfully (Figure 17). Oral hygiene, long-term prognosis. however, was inadequate. General oral hygiene protocol was reinforced and a polish and flossing was performed.88 Hoopingarner

CLINICAL CASEFigure 17: Two-week postoperative view Figure 18: One-month postoperative view Figure 19: Two-month postoperative view of the frenum of frenumFigure 20: Two-month postoperative view Figure 21: One-year postoperative Figure 22: One-year postoperative view of of the full smile close-up view of soft tissue the full smileAUTHOR BIOGRAPHY Dr. Charles Hoopingarner attended the University of Texas Health Science Center at Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Houston (UTHSCH) Dental Branch, graduating with a DDS in 1973. He has maintained a private practice in Houston, Texas since 1973. He was an adjunct associate professor in anatomical sciences at UTHSCH Dental Branch for 12 years. Currently he is a clinical associate professor in the Department of General Practice and Dental Public Health at the UTHSCH School of Dentistry and has been a clinical instructor at the Las Vegas Institute for reconstruction and laser dentistry. Dr. Hoopingarner is the Vice President of the Academy of Laser Dentistry (ALD), has served on the ALD Board of Directors, and has held chairman positions for Regulatory Affairs, Education, and General Sessions for the 2013Conference. He has used dental lasers of various wavelengths as integral parts of his patient care delivery systemfor the last 20 years. He holds Advanced and Standard Proficiency certifications from the ALD in the Er:YAG laserwavelength and has lectured internationally on the safety and use of laser technology in the dental practice. Dr.Hoopingarner is the 2016 ALD President-Elect and 2017 Conference Chairman. He may be contacted by e-mail [email protected]: Dr. Hoopingarner has no direct financial or ownership positions with commercial companies relative to this case presentation. He hasreceived honoraria and expenses from HOYA ConBio, Great Plains Technology, and Biolase to present material on laser dentistry.Editor’s Note: This article first appeared in J Laser Dent 2008;16(2):81-86. Hoopingarner 89

CLINICAL CASE LITERATURE REVIEW The Use of an Er:YAG Laser (2940 nm) in Soft and Hard Tissue Surgery for Esthetic Enhancements Raminta Mastis, DDS St. Clair Shores, Michigan J Laser Dent 2015;23(2 Pt I):90-98 SYNOPSIS The use of an Er:YAG laser for esthetic crown lengthening is reported. This wavelength can be used for removing and recontouring both the gingiva and the underlying osseous structures to achieve the desired new tooth proportions prior to restoration. PRETREATMENT Figure 1: Preoperative close-up view of patient’s smile A. Outline of Case 1. Full Clinical Description A 44-year-old male patient presented for a cosmetic consultation for improving his smile. He was seeking a third opinion because his own dentist and a second opinion offered him very differing treatment plans and he was confused. The patient stated that he was recently divorced and also quit smoking and now wants to do something about his teeth. He did not like the appearance of his teeth because they were “short and stained.” He also had spaces between his teeth that he did not like.Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 The consultation addressed esthetic principles. Figure 2: Preoperative view of fibrous labial frenum with Clinical examination revealed severe incisal insertion just above teeth. Note also the wide band of attrition of both maxillary and mandibular anterior teeth. The patient had at least a 1.0-mm diastema attached gingival which is pink and stippled between the maxillary central incisors (with evidence of bonding attempts to minimize space), with a low labial frenum insertion just above the teeth (Figures 1-3). There was no evidence of caries or of additional fracture; however, several posterior teeth exhibited some evidence of cervical abfractions. Additionally, the patient had occlusal wear facets on posterior teeth, which confirmed parafunction such as bruxism. Both TMJs appeared normal to palpation and movement. Figure 3: Preoperative view of patient in centric occlusion90 Mastis

CLINICAL CASEThe patient’s medical history included recently quitting smoking. The patient was taking Lipitor® for hischolesterol levels and had an allergy to codeine. The patient had no medical concerns or contraindications fortreatment.Dental history included multiple posterior teeth restored with moderate-size fillings. Several molars (#1, 14, 18,and 30) were removed in the military more than 20 years ago. The patient had a natural dentition with a Class Iocclusion and had maintained regular recall appointments.2. Radiographic Examination Both periapical and panoramic radiographs of the maxillary teeth showed no evidence of osseous or periapicalpathologies (Figures 4-5). There was no significant bone loss surrounding any of the maxillary anterior teeth,which would be typically associated with periodontal disease. Teeth #1, 14, 18, and 30 were missing, resulting insome mesial tipping of remaining molars. There were moderate-size restorations on posterior teeth as well as alarge composite on tooth #9, with no evidence of uncontrolled caries.Figure 4: Preoperative panoramic radiograph Figure 5: Preoperative periapical radiographs3. Soft Tissue Status Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 The patient had generalized healthy peridontium. The periodontal probings were 1-3 mm throughout themaxillary anterior region with no bleeding. The anterior teeth were surrounded with a broad band (9-14 mmwidth) of attached gingiva with stippling. The tissue was pink, firm, and healthy. Periodontal probings of theposteriors ranged from 2-5 mm. Some of the deeper probings were associated with the mesial tipping of molarsafter neighboring tooth loss. The tongue, floor of mouth, palate, cheeks, and lips were all within normal limits. 91Mastis

CLINICAL CASE 4. Hard Tissue Status B. Diagnosis and Treatment Plan 1. Provisional Diagnosis Examination of dental hard tissue revealed the following of note: Tooth #9 had a large bonded Healthy periodontium with shortened teeth due to restoration, and was slightly shorter than #8 (resulting excessive incisal wear. from trauma to tooth #9 more than 20 years ago). Several posterior teeth had moderate-size restorations 2. Final Diagnosis which appeared in satisfactory condition. The maxillary laterals exhibited rotation. Spacing was A final diagnosis was made of healthy periodontal evident in the posterior region from drifting into areas tissues with esthetically compromised maxillary of molar extraction sites (Figure 6). The patient had anterior teeth, where the gingiva had encroached evidence of bruxism (or similar parafunction) due to onto the enamel in the cervical areas. In addition, a the wear patterns on occlusal surfaces. Despite this, his low attachment of the maxillary labial frenum with temporomandibular joints were asymptomatic. an insertion point just above the central incisors contributed to the diastema as well as to limiting lip retraction and was at a height which compromised a full smile.Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 6: Preoperative maxillary occlusal view 3. Treatment Plan Outline 5. Other Tests It was decided to perform a full gingivectomy at the upper anterior segment, employing an associated A diagnostic cosmetic mock-up was made as a flap procedure and labial frenectomy. In this way, the guide for visualizing the restorative plan as well as mobility of the upper lip would be improved and a for measurement purposes for the proposed crown more pleasing esthetic appearance of the anterior lengthening procedures. Additionally, bone sounding teeth obtained. The objective was to reduce the (with local anesthetic) was performed prior to surgery gingiva by 2 to 3 mm, with osseous recontouring to to evaluate bone levels for maintaining biologic width. maintain the biologic width. All treatment would involve the use of an erbium:YAG laser. Following a healing phase, the final restorative plan would include the provision of esthetic porcelain restorations. 4. Treatment Plan Alternatives Alternatives to laser use: • The use of traditional surgical procedures including scalpel for the incision and raising the flap, followed by rotary instrument for osseous recontouring. The use of scalpel or electrosurgery for the labial frenectomy and gingivectomy. • Since the proposed treatment was elective to aid in improving the esthetic result, an alternative included refraining from surgery altogether and accepting compromises in restorative attempts.92 Mastis

CLINICAL CASE5. Indications for Laser TREATMENT The use of an Er:YAG laser is considered ideal for this A. Treatment Objectives Strategytype of hard and soft tissue surgical procedure becausethe same instrument can be used to perform the The Er:YAG (2940 nm) laser would be used to carryvarious stages of treatment. Laser osseous contouring out the following stages of treatment:offers improved visualization of the surgical sitebecause of the small laser operating tip, as opposed • Ablate the fibrous tissue of the maxillary frenumto restrictions of visualization with the head of a • First probe pocket depths (Figure 7), mark androtary handpiece. Additionally, the laser is an asset forefficient osseous ablation due to minimal trauma to outline the proposed gingivectomy (Figure 8),vital tissue, as opposed to rotary instrumentation, and then incise the soft tissue, following this outlinehas an advantage for clearing debris from the surgical to remove gingival tissue for the gingivectomysite rather than creating a smear layer on freshly cut procedurebone by a rotary handpiece. Anecdotally, the laser may • Assist in raising a full thickness flap for access toresult in less postoperative discomfort. the surgical site • Contour the crestal bone adjacent to the anterior6. Contraindications for Laser teeth to a minimum measurement of 3.0 mm below the height of the gingiva for establishment There were no absolute contraindications for the of a healthy dentogingival complex.use of the laser on this patient. Proper energy controlneeds to be adjusted for the tissues treated both to Following surgical correction, the flap would be suturedavoid tissue overheating and also to prevent collateral and allowed to heal.thermal damage to adjacent tissue structures. Caremust be taken to avoid an air embolism in a flappedsurgical site by directing the air away from theattachment.7. Precautions Figure 7: All anterior teeth were probed for pocket depths The Er:YAG laser wavelength easily interacts with Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1both hard and soft tissue, so care must be taken toavoid interaction with any associated healthy tissue,especially hard dental tissue. It is important thatadequate water spray be used during soft tissueablation to avoid thermal damage through charring.8. Informed Consent The patient was well informed about the treatmentproposal and the benefits and risks involved. Thepatient was also given the option to have the surgicalprocedures performed by a periodontist. Written andverbal consent were obtained from the patient for thesurgical procedures as well as use of the photographs. Figure 8: Proposed levels for tissue reduction were marked with a Sharpie marking pen, measured, and recorded 93Mastis

CLINICAL CASE B. Laser Operating Parameters C. Treatment Delivery Sequence A 2940-nm wavelength free-running pulsed Er:YAG All safety precautions, which included laser laser (HOYA ConBio, Fremont, Calif.) was used. The protective eyewear for the patient, doctor and energy was delivered through an optical zirconium assistant, were verified by the laser safety officer. aluminum fluoride fiber to a 600-micron quartz tip The laser was test-fired into water, using minimum with an 80-degree curve. operating parameters, to establish correct function and patency of the delivery system. Local anesthetic The frenectomy was performed with settings of 20 was administered with buccal infiltration and allowed Hz repetition rate and 70 mJ per pulse, with water, to take effect. The laser was set to the soft tissue for approximately 30 seconds total. For the gingival settings and test-fired outside the mouth. The outlining, a setting of 10 Hz repetition rate and 35 upper lip was retracted to maintain tension on the mJ per pulse, without water, was used. For the frenum. The laser was fired (with water) at the fibrous gingivectomy, water was added and the surgical attachment in order to facilitate release and then settings were increased to 20 Hz repetition rate used to ablate fibrous connective tissue at the site of and 70 mJ per pulse, for a total of 30 seconds per frenum insertion on the alveolus. The laser was used tooth. The tip was kept in noncontact mode (about in noncontact and light-contact mode. No sign of 0.5 mm away from the tissue surface). The incision charring was observed (Figure 9). No sutures were for the flap was continued at the same settings as required. for the gingivectomy, with water. For the osseous recontouring, the same setting of 20 Hz and 70 mJ was used with water for a total of about 40 seconds per tooth in a combination of noncontact and light- contact mode. The average power for the soft and hard tissue procedures was 1.4 Watts.Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 Figure 9: Laser being used to ablate the dense fibers of the Figure 11: Laser being used for gingivectomy procedure frenum to facilitate release Figure 10: Laser being used without water at low settings Figure 12: Immediate postoperative view of gingivectomy to outline proposed tissue reduction prior to surgery, and94 verified. Note outline on left side as well Mastis

CLINICAL CASEFigure 13: Laser tip is angled parallel to root Figure 14: Immediate postoperative view Figure 15: Procedure repeated on left side surfaces when contouring crestal bone showing recontoured crestal bone with the laser to recontour crestal boneFigure 16: Full thickness gingival flaps passively Figure 17: Immediate postoperative view with sutured repositioned over teeth postoperatively surgical site. Note also the frenum release siteThe laser settings were reduced, the tip was examined was used in contact mode to aid in the release of the Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1and the laser was test-fired outside the mouth. The attached gingiva by directing the tip (with water andlaser was then used without water to mark reference soft tissue settings) in the pocket parallel to the surfacespots (Figure 10) and to outline the gingival contours of the tooth. A periosteal elevator was used to reflectof the proposed gingivectomy as an aid to determine the full thickness flap on the right side from tooth #6how much tissue would be removed or contoured to #8. The osseous tissue was contoured with thefor the desired cosmetic result (using the diagnostic laser in short intervals, utilizing noncontact mode withmock-up as a guide). The laser settings were reset to water. Care was taken to keep the tip parallel to thethe soft tissue surgical settings and test-fired again root surface (Figure 13) to avoid removing cementumoutside the mouth. The gingivectomy excision was or ablating the root surfaces of the vital teeth. Alsoperformed (Figure 11) using a noncontact mode first on care was taken to aim the water/air spray away from thethe right side on teeth #6, 7, and 8, then repeated on soft tissue flap to avoid an air embolism. High-speedthe left side on teeth #9, 10, and 11. Water was used to suction was used throughout the procedure for theaid in cooling neighboring tissue and underlying bone purpose of cooling, removing plume, and evacuatingand thus reduce collateral thermal injury. No sign of debris and water to allow proper visualization of thecharring was observed (Figure 12). postoperative surgical site (Figure 14). The procedure was repeated on the left side (Figure 15) with theThe level of the alveolar crest on the facial surface vertical releasing incision on the distal aspect of theof each of the anterior teeth was again verified with interdental papilla between teeth #11 and 12, and abone sounding and confirmed to be deficient for full thickness flap raised from tooth #11 to the midlinemaintaining a healthy dentogingival complex. The for osseous recontouring. The same settings andlaser tip was examined, cleaned, and test-fired outside procedure used on the right side were repeated onthe mouth. A vertical releasing incision was made (with the left. The flap was repositioned over the maxillarywater, noncontact mode) on the distal aspect of the anteriors (Figure 16), sutured into place (Figure 17), andinterdental papilla between teeth #5 and 6. The laser allowed to heal. Mastis 95

CLINICAL CASEJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 D. Postoperative Instructions G. Treatment Records The patient was instructed to minimize disturbance All treatment data, including the type of laser used, of the sutured area, but to begin gentle warm salt operating parameters, materials used, intraoral photos water rinses the following day. The patient was also and radiographs, were recorded along with the written instructed to pull up on his upper lip once per hour documentation. during waking hours for several days and to keep site clean. He was instructed to maintain oral hygiene of FOLLOW-UP CARE the rest of his teeth. A prescription for Motrin® 800 mg was written to relieve pain, if any. The patient was A. Assessment of Treatment Outcome advised to call the office immediately if he noted any adverse reactions or problems. The patient was asked to return at two-day (Figures 18-19), one-week, two-week, and at one-month and E. Complications – Types, Events, three-month intervals. He was contacted the next Management day after surgery. He reported no discomfort and was not taking any analgesics. At the one-week After the completion of the surgical procedures, a follow-up, the sutures were removed, the tissue hematoma was noted in the maxillary right vestibule looked pink, the incisions were healing satisfactorily near the sight of the frenectomy. This was associated (Figures 20-21), and the patient had no complaints. with the manipulation of the lips for retraction during At the second-week follow-up, the tissue continued the appointment. Management included watching the to heal satisfactorily with no evidence of swelling or area at postoperative appointments, with no specific inflammation (Figure 22). At the one-month follow-up, intervention at this time. The patient was contacted the frenum had healed in a more superior position. the following day and he reported no discomfort and The tissue surrounding the teeth looked pink and had no need to use any analgesics. The patient was firm, and the tissue height remained stable (Figure seen two days later for evaluation, and the area was 23). The patient was happy with his longer teeth, but healing uneventfully with no postoperative discomfort. was now concerned about the color and staining One week after the surgery, the sutures were removed. from years of smoking. Impressions were made for The hematoma in the maxillary labial vestibule was take-home bleaching trays and delivered together resolving uneventfully. The healing of the surgical with a 30% carbamide peroxide gel (Life-Like Cosmetic sites was progressing satisfactorily and the patient Solutions, Harbor Dental Bleaching Group, Inc., Santa was comfortable throughout the period. The patient Barbara, Calif.) and instructions. Periodontal probings was instructed to resume normal oral hygiene home were performed at the three-month follow-up and care. At the two-week postoperative visit, the gingival confirmed good gingival health and reestablishment tissue was pink and adhering to underlying bone of a healthy dentogingival complex; sufficient biologic with no evidence of inflammation. The patient had width to proceed with esthetic restorative procedures no complaints of discomfort and was happy with the was noted (Figures 24-27). An average of 2.0 to 3.0 elongation of his teeth. mm of crown length was gained through the surgical procedures, and thus the treatment objectives were F. Prognosis met. There were no significant complications arising from the procedures, and the long-term prognosis for the gingival healing from the crown lengthening procedure as well as the frenectomy was excellent.96 Mastis

CLINICAL CASEFigure 18: Two-day follow-up view of gingival Figure 19: Two-day follow-up view of Figure 20: One-week follow-up after healing with minimal inflammation frenectomy. Healing is uneventful suture removalFigure 21: One-week follow-up of frenectomy Figure 22: Two-week follow-up showing Figure 23: One-month follow-up. Note healthy healing well healthy gingival healing with no inflammation tissues with broad band of attached gingiva and healthy appearance of released frenumFigure 24: Three-month postoperative Figure 25: Periodontal charting at three months Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 radiographsFigure 26: Three-month follow-up after patient’s use of home whitening trays Figure 27: Three-month follow-up view showing fuller smile Mastis 97

Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1CLINICAL CASE B. Complications Aside from the self-resolving hematoma in the labial vestibule, no complications were noted and the patient was comfortable throughout the healing period. C. Long-Term Results and Prognosis The long-term outlook for the frenectomy and crown lengthening procedures is considered excellent. The patient now has good bony support for the crown-lengthened teeth, and has good gingival architecture with adequate attached keratinized gingiva. A healthy dentogingival complex had been established and prepared for the esthetic restorative procedures. The area is healthy, stable, and maintainable for the patient with normal oral hygiene home care. The patient is happy with the results and is motivated to refocus his financial concerns to proceed with the proposed esthetic restorative phase of the treatment plan. AUTHOR BIOGRAPHY Dr. Raminta Mastis received her dental degree from the University of Illinois College of Dentistry in 1987. She maintains a private practice in St. Clair Shores, Michigan, focusing on integrating cutting-edge technology in general dentistry. She is a member of the Academy of Laser Dentistry and has Standard Proficiency certification in Er:YAG, Er,Cr:YSGG, diode, and CO2 laser wavelengths. In 2006 she achieved Advanced Proficiency in the Er:YAG laser wavelength. She served as the ALD Laser Safety Committee Chair for 5 years and has received recognition at the Mastership level through the ALD. Dr. Mastis currently serves as co-chair of ALD's Education and Certification Committees as well as the Treasurer of the ALD Executive Board. Dr. Mastis may be reached via e-mail: [email protected]. Disclosure: Dr. Mastis has no commercial relationships relative to this case study. Editor’s Note: This article first appeared in J Laser Dent 2007;15(1):28-33.98 Mastis

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SCIENTIFIC RESEARCH Comparison of Er:YAG Laser Flapless Crown Lengthening vs. Open-Flap Bur Approach in Animal Studies Tosun Tosun, Doç. Dr. med. dent.; Giuseppe Iaria, Prof. Dr. med dent.; Stefano Benedicenti, DDS Department of Biophysical, Medical and Odontostomatological Sciences and Technologies, Medical School, University of Genova, Italy J Laser Dent 2015;23(2 Pt I):100-106Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 INTRODUCTION ABSTRACT Crown lengthening (CL) has been used as Background: Conventionally, crown lengthening surgery is achieved a preprosthetic surgical method to increase through an “open” mucoperiosteal flap access procedure and the use of crown retention in fixed partial prosthesis rotary instruments. The introduction of mid-infrared laser wavelengths, e.g., treatment;1 it was further adopted through erbium:YAG (2940 nm), has made possible a “flapless” approach to crown the development of esthetic dentistry to lengthening surgery, which has several advantages such as uneventful become a common procedure in achieving healing, less edema, and no sutures. Flapless surgery is a blind approach and “smile design.”2-4 The aim of CL in esthetic the outcome of crevicular bony modeling in such a method is uncertain. dentistry is to avoid or correct the excessive visible parts of gum tissue below the Aim: The aim of this study is to compare the topographic results of both patient’s upper lip line while smiling.5 Before surgical methods in a sheep model. and during such corrective surgery, care must be taken to preserve the “biologic Material and Methods: Ten fresh sheep mandibles were used. Bilateral width” and to measure the distance from crown lengthening was obtained on four molar teeth. Randomly, one side the free gingival margin to the bony crest was used as test and the other as control. An Er:YAG laser (15 Hz frequency, by “sounding” under anesthesia.6 Sounding 400 mJ energy, 200 µsec pulse duration, 6 W average power) was used on is a critical presurgical measurement and the test sides without raising a mucoperiosteal flap, and buccal crestal bone must absolutely be performed prior to of 2 mm height was removed around each tooth. After laser application, the surgery, because once incisions are each alveolar bone site was smoothed with Gracey curettes, and root made it is not possible to measure the planing was performed. Control sides underwent conventional open-flap distance from the free-gingival margin surgery: 2 mm of buccal crestal bone was removed by a round diamond to the crestal bone.5 With respect to the bur, at 800 rpm under saline irrigation, and root planing was performed mucosal tissue band width to be removed, with Gracey curettes. At the end of the operation, flaps were raised at the excluding teeth with pockets deeper than test sites. Impressions were taken by high-durometer silicone die material. 3 mm which are pathologic and need Impression blocks were rendered uniform in size (10 x 28 mm surface). Stone to be eliminated, in healthy periodontal models were cast and refined to uniform size and then scanned at 15,500 conditions the proportional distance resolution. The data was analyzed using computer software. Macroscopic from the new free gingival margin to the surface texture was compared by inspection of standardized digital images. bone must be retained.7 Thus, in many Microscopic surface properties were analyzed by “current triangles” and cases, collar bone adjacent to the teeth “current vertices.” involved must be removed. Conventionally, CL surgery is achieved through an open Results: Both groups revealed similar macroscopic features, but (raised mucoperiosteal) flap procedure and microscopically there were no significant correlations between current bone is removed through the use of rotary triangles and current vertices values of both groups (rcurrent triangles = 0.0207; instruments. Postoperative soft tissue healing rcurrent vertices = 0.0289). and gingival border line stabilization time of such a technique varies from 4 to 6 weeks.8-9 Conclusion: Macroscopically, both methods have similar effects on bone surface topography. The Er:YAG laser microscopically creates more rough Tosun et al. surface on bone tissue. The results of this study confirm that flapless surgery performed by an Er:YAG laser is as effective in contouring crestal bone as conventional surgery and, taking into consideration the advantages of the flapless surgery, it is suggested as preferable to the conventional crown- lengthening procedure. KEYWORDS Laser, erbium, Er:YAG, bur, crown lengthening, gummy smile, smile design, flapless surgery, animal study100 110000

SCIENTIFIC RESEARCH To reduce healing time of CL surgery, attempts In such cases, after the chosen level of Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1have been made to introduce new devices such as excess mucosal tissue has been removed either“piezosurgery,” a methodology which uses ultrasonic conventionally by scalpel and/or curettes or by use ofvibrations with frequencies up to 25,000 Hz to the laser with soft tissue power settings, the laser tipmechanically remove hard tissues by sharp-cutting is inserted perpendicularly to the underlying alveolartips.10 Piezosurgery is less traumatic compared to rotary crest and parallel to the tooth long axis. Bone isinstruments; postoperative healing time is also less removed to the desired depth, initially point by pointthan with rotary instruments, but is still approximately 4 and then with circular movements around the root.weeks.11-12 Thus, mucoperiosteal flaps are not raised and the mucosa remains intact. Critics of this technique cite Mid-infrared laser wavelengths (2940-nm Er:YAG the “blind” approach to bone surgery and possibleand 2790-nm Er,Cr:YSGG), with a high absorption rate damage to adjacent root surface tissue.22 Thus a studyinto water molecules of mucosa and bone, remove model was designed to investigate bone topographysuch target tissues by a thermo-mechanical ablation after laser application in CL surgery.mechanism.13-14 Free-running pulsed emission of suchwavelengths and debris dispersal by air and water spray The aim of the present study was to compareenable cooling of the operating field.15 Such properties topographic results of conventional and laser-assistedof the erbium family of lasers help ensure atraumatic surgical methods in a sheep model.soft and hard tissue ablation when compared to tissueremoval via rotary instruments.16-17 During the last MATERIALS AND METHODSdecade, published reports show how erbium lasershave been used to treat “gummy smile” cases without Ten freshly harvested sheep mandibles were used.raising flaps through a closed surgical technique.18-20 A Bilateral crown lengthening was obtained on foursignificant aspect of such techniques is to shorten the molar teeth. Randomly, one side was used as a test andhealing time period to about 2 weeks.21 the other as control. Test side procedures were carried out using an Er:YAG (2940 nm) laser (VersaWave, Hoya Figure 1: Sample of test group bone topography ConBio, Fremont, Calif., USA). Operating parameters after flap reflection employed were as follows: 200-µsec pulse duration, 400 mJ energy per pulse, 15-Hz frequency, 6 W average Figure 2: Sample of control group bone topography power output. No soft tissue flap was raised, as the aim of the study was to investigate collar bone sites. An 80-degree, 600-micron curved laser tip (312-9069, Hoya ConBio), marked to 2 mm and 4 mm depths, was inserted intrasulcularly and buccal collar bone amounting to 2 mm in height was then removed around each tooth. After laser application (an average of 44 seconds duration per tooth), each bone site was smoothed with Gracey curettes and root planing was performed. At the end of the procedure, flaps were raised in the test sides to detect surface alterations (Figure 1). Control sides underwent a modified conventional open-flap surgery (without establishing a new free gingival margin by a mucoperiosteal incision): 2 mm of buccal crestal bone was removed by a 2-mm diameter round diamond bur. The operator used a 20:1 reduction contra-angle handpiece under saline irrigation at 800 rpm. Subsequent bone smoothing and root planing was carried out using Gracey curettes on about 1 to 2 mm of the beveled collar bone and along the exposed root surface (Figure 2). Tosun et al. 110011

SCIENTIFIC RESEARCH Figure 3: Test and control group mandibles. Impression Figure 5: Scanned sample of test group pastes on operated areas are secured by plastic bases Figure 4: Impressions of control group (left side) and test group (right side) Figure 6: Scanned sample of control groupJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 In the authors’ experience, crown lengthening collar osteotomy band of about 2 mm in width was procedure failure is caused by improper maintenance evaluated on the photographs. of the original biological distances of the epithelium- connective tissue to the crestal bone, and the soft Impressions were taken of the exposed operating tissues tend to revert to their original locations. fields with high-density silicone die material Connective tissue attaches faster and bonds more (Quick-Die™, Bisco, Inc., Schaumburg, Ill., USA) (Figure strongly to the rough surfaces on bone or root surface, 3). Impression blocks were rendered uniform in size (10 because of the fibrin network attachments to the x 28-mm surface) (Figure 4). Stone models were cast rough floor within the coagulum and subsequent and refined in uniform size and then were scanned inflammatory healing process. Thus, to avoid coronal (Maestro 3D Easy Dental Scanner, AGE Solutions S.r.l., migration of the connective tissue, it is better to Pisa, Italy) at 15,500 resolution. The data was analyzed smooth collar surfaces both on bone and root surfaces. by computer software (Maestro Easy Dental Scan, AGE Solutions). Macroscopic surface textures were The macroscopic surface texture of each sample compared by inspecting standardized digital images was photographed with standard settings (Nikon D100 (Figures 5-6). Microscopic surface properties were camera, f/22 diaphragm, 1/125 sec exposure, 105-mm expressed in “current triangles” and “current vertices” macro lens). The presence or absence of a and were compared statistically by the Pearson correlation test. Tosun et al.102

SCIENTIFIC RESEARCH Scanners work by a process called “rasterization” corresponding 2-dimensional points on the viewer’swhich is “the task of taking an image described in monitor, and fill in the transformed 2-dimensionala vector graphics format (shapes) and converting it triangles as appropriate.”23into a raster image (pixels or dots) for output on avideo display or printer, or for storage in a bitmap RESULTSfile format…The most basic rasterization algorithmtakes a 3-D scene, described as polygons, and Macroscopic evaluation of crestal bone topographyrenders it onto a 2-D surface, usually a computer by evaluation of standard photographs revealed themonitor. Polygons are themselves represented as presence of about a 2-mm width of collar osteotomycollections of triangles. Triangles are represented by 3 band buccally to each tooth in both groups (Table 1).vertices in 3-D space. At a very basic level, rasterizers Macroscopically, both methods have similar effectssimply take a stream of vertices, transform them into on bone surface topography.Table 1: Collar Osteotomy Presence Current triangles and vertices for groups are summarized in Table 2.sample # test control Microscopically, there were no significant1++ correlations between current triangles and current vertices values of both groups (rcurrent triangles = 0.0207;2++ rcurrent vertices = 0.0289). There was a positive correlation between current triangle and current vertex values of3++ each group as the verification of the rasterization (rtest = 0.9999; rcontrol = 0.9999).4++ The current triangle and vertex values of the5++ test group are at least three times greater than the6++7++8++9++10 + + Table 2: Triangles and Vertices in Test and Control Groups Test Group – Er:YAG Laser Control Group – Bursample # current triangleslaser current verticeslaser current trianglesrotary current verticesrotary Journal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 237817 119268 88321 44442 1 357844 179509 99327 49954 2 360003 180600 92324 46556 3 365576 183417 105184 52938 4 256177 128619 104786 52676 5 356506 178801 99866 50246 6 331478 166277 90831 45753 7 331606 166454 109813 55266 8 374712 188024 103997 52364 9 377480 189329 81639 41204 10 Table 3: Surface Roughness Values in Test and Control Groups Test Group – Er:YAG Laser Control Group – Burminimum current triangleslaser current verticeslaser current trianglesrotary current verticesrotarymaximum 237817 119268 81639 41204 median 377480 189329 109813 55266 average 357175 179155 99596.5 50100 334919.9 168029.8 97608.8 49139.9 Tosun et al. 103

SCIENTIFIC RESEARCHJournal of Laser Dentistry | 2015 Vol. 23, No. 2, Pt.1 control group which show that the Er:YAG laser by the erbium laser can be smoothed by using hand microscopically creates rougher surfaces on bone instruments such as Gracey curettes. tissue (Table 3). Clinically, osseous roughness does not affect the outcome of crown lengthening, because It should be noted that rasterization was performed the essential factors are contouring the crevicular after surgical intervention. As the sensitivity (resolution) bone level and maintenance of the biologic width. of the rasterization procedure is high, microporosities created by ablation of the hard tissue remained after DISCUSSION use of the curette. Gracey curettes mostly served to ensure removal of bony irregularities created Although predictable esthetic results of crown during intrasulcular ablation. When the diamond lengthening-related “gummy smile” correction can bur was used to remove collar bone, attention was be achieved, the extended healing time associated paid to minimizing interaction with the root surface; with conventional surgical techniques can prove undesirable grooving on the root surfaces caused by disadvantageous. Thus attempts were made to the bur was removed or reduced by subsequent root shorten the healing time by using different surgical planing. Irregularities can be seen on macroscopic devices such as piezosurgery instruments and images (Figures 1-2), but there were no deep grooves erbium lasers. Piezosurgery is a less traumatic device or sharp chips. compared to rotary instruments.24-25 However, with such instrumentation, there remains a need to apply CONCLUSION open-flap surgery to perform CL. Flap raising lengthens healing time. Once the periosteum is separated from The results of this study, using in vitro animal tissue, the underlying cortical bone, host inflammatory provide support to the suggestion that flapless response pathways are stimulated and initiated.26 surgery performed by Er:YAG lasers can enable crestal Cortical bone blood supply is interrupted, predisposing bone recontouring to be as effective as conventional to resorption of the outer bony cortex.27-32 Pain, edema, surgery. The experimental model of this study and inflammation accompany flap surgery.33-35 Thus, considers only the real-time changes on the bone a method to avoid flap raising would avoid these tissue but not the possible clinical consequences disadvantages.36-37 Dental hard-tissue lasers have been of the laser energy on soft and hard tissues. Thus found to be less traumatic when compared to other the experiment could be criticized for not including surgical devices.17, 38-40 Dental lasers have been used the long-term results of such an approach. For this for crown lengthening procedures during the last purpose the research group of the present study two decades.4, 18-20, 22, 41-42 Techniques to perform closed- would extend the test model on living animals. On flap crown lengthening to promote postoperative the other hand, flapless osseous crown lengthening comfort and uneventful healing are proposed.18-19, 22 has been used successfully since the last decade, Appropriate quartz or sapphire delivery tips of erbium as published in case reports which are testimonials lasers can be inserted via the periodontal sulcus to of the clinical outcomes.18-20 When one examines reach cortical bone; by measuring along the laser tip, the advantages of flapless surgery, the laser-assisted bone can be decorticated to the desired level. Care procedure is considered a more advisable technique, must be taken to insert laser tips parallel to the root compared to a conventional crown lengthening surface to avoid cementum ablation. The laser tip is operation. placed into the sulcus and the connective tissue at the104 depth of the sulcus is sectioned vertically. By further ablation in an apical direction, the tip reaches the bony hard tissue level which can be felt through the laser handpiece via tactile feedback. This perpendicular insertion operation is repeated around the entire tooth circumference to enable soft and hard tissue removal through a laser-assisted thermo-mechanical ablation mechanism, without the need to open mucosal flaps. The possible irregularities created on the bone surface Tosun et al.

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