By David Eshom, DDS
If our patients had one wish, it would almost always be to have perfect aesthetic smile lines, contoured healthy gums, and rigorously aligned teeth. Unfortunately, many of them are plagued with excessive gum tissue and minimal biologic width, which has prevented many dentists from attempting to lengthen the crown, contour the gum tissue, and give the patient the smile they’ve always dreamed of.
Thankfully, many of the advances in cosmetic materials, lab techniques, and tools are allowing dentists to fulfill the wishes of their patients. using these new tools and techniques, cosmetic work can be much less invasive, dramatically improving postoperative comfort and recovery time.
One instrument that routinely amazes me is the Er,Cr:YSGG laser (Waterlase, BIOLASE Technology, Inc., San Clemente, California). This laser cuts all types of tissue–soft tissue, hard tissues such as enamel and dentin, and even osseous tissue. But, we’ll focus on the YSGG’s ability to cut soft tissue and subsequently contour bone as part of a “closed-flap crown lengthening” procedure–just the type of procedure that has given many patients their ideal smiles.
The key to achieving this ideal is to optimize gingival height relationships, properly develop the buccal corridor, and make sure the bicuspid gingival margins have proper height. If a cosmetic dentist focuses on the teeth only, the teeth are gorgeous from mid-facial to incisal, but the patient complains because some teeth look “fat” or “crooked.” This complaint is a result of inappropriate gum architecture–too much gingival tissue or improperly positioned gingival margins or zeniths.
In the past, the solution for this complaint has been traumatic at best. To lengthen a crown, a patient had to visit a periodontist and endure six to eight weeks of recovery time. Often, the case was lost as the patient lost enthusiasm, got distracted, or simply gave up. Alternatively, in an effort to keep the patient optimistic, the dentist is forced to compromise treatment results.
With the YSGG laser in my practice, there is no compromise. I’m able to perform a closed crown lengthening and trim gingival tissue and trough before I impress the teeth and subsequently place crowns and veneers. The days of the “perio penalty box” are over.
The procedure is fast and easy. First, check attached gingiva in the area and then numb the area with local anesthetic. Next, measure the sulcus and push the probe past the attachment to measure bone height. It’s always appropriate to probe past the attachment in 3 to 6 areas, noting the average. The average is the patient’s biological width. Then, mark the proposed gingival zenith with the YSGG laser.
Before continuing, check the contour of your marks. Using the appropriate soft tissue settings, cut a slot in the tissue, holding the laser perpendicular to the tissue. use a scaler to remove the trimmed tissue.
After removing the gingiva, adjust the setting son the laser (usually through a pre-set), and trough circumreferential bone to the proper depth using a marked laser tip on the end of the YSGG hand piece.
After troughing bone, sound the area with a perio probe and check for rough or ledged bone architecture. If rough bone remains, use the YSGG laser again to trough and remove additional bone.
Smooth the bone laterally, and then use a scaler to smooth the root.
Finally, use the laser to band-aid the surgical area, coagulate any bleeding, and promote faster healing.
Before I use the YSGG laser, this procedure was lengthy, painful and required a variety of steps that risked losing or compromising the result. Thanks to this “magical” tool, I am able to perform this in-depth procedure quickly and easily with minimal trauma to the patient. I can send the patient home with the smile they’ve always dreamed of.