Diode Use in Orthodontic-Related Procedures by Ron Kaminer, DDS

Laser's emergence
It was just 10 years ago that dentists had minimal interest in attending a laser lecture.

Having used lasers for more than 20 years and having lectured on the topic almost as long, I found it somewhat disconcerting that dentists couldn't see past the major stumbling block of “cost” in order to incorporate this incredible technology into their practice. Now, however, more than half of all of the dentists in the U.S. have one.

Diode laser energy is preferentially absorbed by pigment and hemoglobin. That characteristic allows us to cut soft tissue effectively with little to no bleeding, and little to no thermal damage. Difficult procedures become much easier when bleeding isn't an issue. Esthetic soft-tissue recontouring becomes very predictable when there isn't recession. Soft-tissue periodontal procedures are enhanced with the use of the diode, and virtually every specialty can find use for a soft-tissue laser.

The general practitioner will find many uses for the diode laser in the area of orthodontics. Orthodontists have embraced the technology. While we could discuss many procedures, we will focus on a few common ortho procedures that anyone can incorporate into his or her practice.

Below are my five favorite ortho procedures:

• Laser tissue removal for placement of brackets. Lasers cut and coagulate, granting time and cost savings, and improved patient comfort.
• Laser tissue recontouring. As teeth move, so does tissue. It's a breeze with a laser.
• Excess tissue covering brackets. Lasers are safe around and on metal (unlike electrosurge). This is huge advantage for me and my patient.
• Canker sores. Just 60 seconds of bathing the sore with laser energy stops the hurting and promotes healing.
• Frenectomies. These used to be scary, bloody surgeries, but now in just a few minutes I can remove the frenum with a laser to help the stubborn diastema disappear. Lasers cut and coagulate in one simple step.

Here's how.

Maxillary frenums and their location have been shown to contribute to diastemas between the maxillary central incisors. Furthermore, a tight frenum can cause the lip to roll when someone smiles and can contribute to a strong vertical lip pull, which may lead to showing excessive gingiva.

Traditionally performed frenectomies involve using either a scissor or scalpel to cut the frenum. Bleeding very often distorts the surgical field and the inexperienced practitioner may struggle without a clear operating field.

When done with a diode, the procedure typically involves anesthetizing the frenum and removing the band of tissue and its extensions between the maxillary central incisors, midway to the palatal tissue.

A groove director (available through most dental distributors) can help in isolating and retracting the frenum, making surgery even easier (Fig. 1).

Ideally, dissecting the tissue to the level of the periosteum ensures proper healing with little chance of relapse. As the frenum is a fairly large and wide piece of soft tissue, the area when cut typically looks like a diamond-type incision following the anatomy of the band of tissue (Fig. 2).

A suture or PeriaCryl prevents rapid healing, which may lead to early reattachment of the fibers (Fig. 3). Healing is rapid, as evidenced by substantial wound closure after only five days (Fig. 4).

A common issue we see among our ortho patients is overgrowth of tissue due to poor oral hygiene. Regardless of what we suggest to our patients in regard to improving their oral hygiene, tissue health rarely resolves without some surgical intervention. As this tissue is very inflamed, traditional surgical modalities always cause substantial bleeding. It is here that the diode shines with its exceptional ability to coagulate hemorrhagic tissue.

In order to properly perform this procedure, one must first have a good knowledge of the lay of the land. Probing the overgrown and inflamed soft tissue is necessary to know how aggressive a gingivectomy to perform (Figs. 5 & 6).

Once that is done, the doctor can remove the excessive soft tissue. This tissue is very inflamed, but with the attraction of diode to inflamed tissue, little energy is needed to get the job done (Fig. 7). Using minimal energy ensures rapid healing with little to no post-op pain.

The diode is safe to use around metal. Overgrown tissue around orthodontic brackets does not present a problem as it would if using an electrocautery device. If overgrown tissue is left alone, aside from creating a typical unhealthy soft tissue environment, plaque can also accumulate under the tissue and cause enamel decalcification. When tissue growth around brackets is excessive (Fig. 9), some bleeding may still occur despite the diode's ability to coagulate. Once the tissue is sculpted around the bracket, a sharp scaler may assist in removing the excised soft tissue (Fig. 10). Once contouring is completed, hydrogen peroxide in a syringe with a brush tip can help remove any sloughed tissue and clean up the surgical field. Healing is rapid, as evidenced by the five-day post-op (Fig. 12).

As teeth are moved orthodontically, soft-tissue discrepancies can occur. These discrepancies, easily corrected with a diode, can lead to dramatic differences in someone's smile. A little goes a long way in these corrections, and sometimes the difficulty lies in freehanding the gingival sculpting.

While the experienced diode user may find this an easy task, doctors who are less experienced may find freehand gingival sculpting one of the most challenging aspects of the procedure. I simplified this procedure.

As with other gingival procedures, periodontal probing or sounding of the bone must be done prior to removing any soft tissue in order not to encroach on biologic width. After recording the periodontal probing, upper and lower alginate impressions are taken and stone models are poured.

The probings and models are sent to the dental laboratory with specific instructions to recontour the soft tissue on the model following the enclosed probings (Fig. 13).

Care must be taken not to exceed the probings when recontouring the model, even if it means a slight esthetic compromise (unless the patient is willing to go through a true crown-lengthening procedure). Once the stone is recontoured, a soft-tissue stent is fabricated to replicate the change in the soft tissue (Fig. 14).

The stent is then tried in the mouth before anesthetizing the patient to make sure there is positive seat (Fig 15).

After confirming the fit of the stent and anesthetizing the patient, the diode is used to follow the outline of the stent to create pleasing gingival contours. In this particular case, the patient disliked the knife-edge appearance of the gingival tissue around tooth #7 (Fig. 16). The tissue was recontoured (Fig. 17) and typically, what you see is what you get. Note the lack of bleeding in the previous photo. Healing is rapid and despite some esthetic compromise due to biologic width issues, the patient was thrilled with the final result (Fig. 18).

Conclusion
As evidenced by a few of the highlighted procedures, using the Picasso diode laser can enhance orthodontic-related procedures. Other ortho procedures for which a diode can be used include uncovering of soft-tissue impactions, removing soft tissue for easy bracket placement, and supracrestal fiberotomies.

Since the Picasso diode is relatively inexpensive, the return on investment is tremendous for the doctor. If a doctor performs only three cases a year of overgrown tissue around orthodontic brackets, he or she will be able to pay for the laser, even at reduced reimbursement from insurance companies. Add in a number of frenectomies, soft-tissue smile-recontouring procedures, and the plethora of other procedures that can be performed with a diode in operative dentistry and crown and bridge, and the doctor will find that the Picasso diode is a sound investment in any practice. Because complete training is included, the learning curve is short and the doctor can start using the diode almost immediately.

Lasers have had a huge impact on my practice over the last 20 years. While change can be difficult, I assure you that if you take the leap into laser dentistry, it will change your practice forever in a positive way.



Dr. Ron Kaminer is a 1990 graduate from SUNY Buffalo School of Dental Medicine. He maintains two practices in Hewlett and Oceanside, New York dedicated to minimally invasive and laser dentistry. He consults for many dental manufacturers and lectures nationally and internationally on topics ranging from minimally invasive and laser dentistry to new materials and technology. He is the founder of the Masters of Laser training course and facility in New York, and has trained thousands of dentists on the use of a variety of dental lasers. He is currently the medical director of AMD lasers and is passionate about spreading the word on laser dentistry. He lives in Hewlett, New York with his wife and three children.