6

Lasers in Fixed Prosthetic and

Cosmetic Reconstruction
JAMES C. DOWNS, ROBERT A. CONVISSAR, EUGENIA ANAGNOSTAKI,
GRACE SUN, AND CHARLES R. HOOPINGARNER

This chapter describes the clinical applications of laser den- they are used on soft tissue. Soft tissue excision or incision is
tistry with respect to soft tissue and hard tissue alterations accomplished at 100° C, at which vaporization of intracellu-
for fixed prosthetic and cosmetic reconstruction. The clin- lar and extracellular water causes ablation of biologic tissue.1
ical advantages of laser use, for both the patient and the The mode of operation for 10,600 nm CO2 lasers his-
dentist, are well recognized: Major benefits associated with torically has been as a continuous wave: Energy is emitted
laser surgery include reduced bleeding, less postoperative constantly for as long as the laser is activated. Mechanical
discomfort, and remarkably less edema compared with con- and electrical controls can produce chopped, gated, “super-
ventional techniques or electrosurgery. In addition, a clear fast,” or ultrafast bursts of energy with relatively long relax-
field of vision resulting from excellent hemostasis and mois- ation intervals. This controlled delivery minimizes the heat
ture control allows much greater precision in performance transferred to the collateral tissue, which in turn reduces
of the reconstructive procedure. unwanted thermal damage to the surrounding tissue.
Many procedural techniques are routinely incorporated
into fixed prosthetic and cosmetic reconstruction, such as Erbium Lasers
• Exposure of clear margins for impression taking
• Hard and soft tissue crown lengthening Two erbium wavelengths are currently available: the erbium-
• Creation of a physiologic emergence profile doped yttrium-aluminum-garnet (Er:YAG) wavelength at
• Cleansable ovate pontic site creation 2940 nm and the erbium-chromium–doped yttrium-scan-
• Melanin depigmentation dium-gallium-garnet (Er,Cr:YSGG) wavelength at 2780
• Laser bleaching nm. Erbium laser wavelengths are transmitted through
Before any of these procedures is considered for use, the role semiflexible hollow waveguides, low-OH− fiberoptic cables,
of various laser wavelengths and biologic width consider- or articulated arms. All of the delivery methods terminate
ations should be fully understood. in a handpiece that may use sapphire, quartz, or hollow
metal tip to transmit the energy to the target tissue. These
wavelengths are highly absorbed by the water molecules in
Laser Wavelengths for Cosmetic/Prosthetic both soft and hard tissues.2 Erbium lasers cut soft tissue, but
with much less hemostatic ability than for other soft tissue
Procedures lasers.2 With newer technology providing for longer pulse
Carbon Dioxide Lasers durations and wave configurations, however, the hemostatic
ability has improved.
The carbon dioxide (CO2) laser wavelengths of 10,600 Erbium and 9300 nm CO2 lasers are safe for ablating
nm and 9300 nm are delivered using an articulated arm or diseased tooth structure. Patients may not need traditional
waveguide that terminates at a handpiece. Most CO2 laser injectable anesthetic; however, this requirement is driven as
manufacturers offer multiple handpieces with different much by the patient’s perception of dental treatment as by the
angles (straight and contra-angle) and different focal points procedure itself. Laser cavity preparation is less traumatic to
to perform procedures such as vaporization, coagulation, or the tooth’s pulpal tissues than techniques that involve tra-
tissue modification (see Chapter 2). ditional rotary instrumentation. The vibration and heat pro-
Oral soft tissue is 90% to 97% water. The CO2 laser wave- duced by rotary instruments, which are the main reasons for
length is highly absorbed by water, as are the erbium laser discomfort during procedures, do not occur as much with the
wavelengths. CO2 lasers are therefore highly efficient when erbium wavelengths as with traditional rotary instruments.3

89
90 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

To obtain increased bond strengths over conventional

techniques, the finished preparation should be etched in the
traditional manner. Techniques that involve adhesion to the Enamel

smear layer should be avoided, because these lasers remove

smear layers.4 Sulcus

One disadvantage is that these wavelengths similar to all

Sulcular
lasers cannot remove gold or metal crowns, vitreous porce- (crevicular)
lain, or amalgam restorations (see Chapter 10). epithelium

Junctional
Diode Lasers epithelium

Diode lasers deliver wavelengths ranging from 810 to 1064 nm.

Gingival fibers
Diode lasers are compact and portable solid-state units. They
are used strictly for soft tissue procedures and penetrate 2 to 3 Cementum
mm or more into soft tissue, depending on the wavelength and
tissue biotype. Diode laser wavelengths are absorbed by pig-
mented structures, making them ideal for cutting melanotic Periodental
or highly vascularized soft tissues and providing hemostasis.5 ligament fibers

The usefulness of the diode laser can be greatly expanded

by proper carbonization of the fiber tip. This preparation
allows for vaporization with limited peripheral damage to
nonpigmented tissue.6
Bone

Neodymium:Yttrium-Aluminum-Garnet Laser
The neodymium-doped yttrium-aluminum-garnet (Nd:YAG)
wavelength of 1064 nm delivered in a free-running mode
can be used for numerous soft tissue procedures. As with
diode and CO2 lasers, the advantages of the Nd:YAG laser
• Figure 6-1  The tooth is attached to the surrounding gingival tissue
include a relatively bloodless surgical field, minimal swell- and alveolar bone by fibrous attachments. The gingival fibers run from
ing, reduced surgical time, excellent coagulation, and in the cementum into the gingiva immediately apical to the junctional epi-
most cases, reduced or no postoperative pain.7 thelium attachment, and the periodontal ligament fibers run from the
The main disadvantage of the Nd:YAG laser is the greater cementum into the adjacent cortex of the alveolar bone. (Modified from
Rose LF, Mealey BL: Periodontics: medicine, surgery, and implants,
depth of penetration into the target tissue. The Nd:YAG
St Louis, 2004, Mosby.)
wavelength penetrates deeply into tissue because it is poorly
absorbed by water, the main component of gingival tissue.
The clinician must be alert to the risk of unnecessary col- and the connective tissue attachment was 1.07 mm. This
lateral tissue damage, particularly to underlying bone or 2-mm functional unit has been described as the biologic
pulpal tissues. Tissue vaporization is slower than with other, width of the attachment. Biologic width is defined, in a
better-absorbed laser wavelengths (e.g., CO2). Application restorative context, as the combined height of connective
of a topical photoabsorbing dye can shorten the lag time for tissue and epithelial attachment plus 1 mm. This should be
absorption of the laser energy.8 Nd:YAG laser light directed the most apical extension of dental restoration toward the
at the clinical crown or root surface of the tooth for any osseous cress necessary to maintain periodontal health. The
length of time is a concern. Consequent heating of the pulp 1-mm added depth of sulcus establishes a good margin of
may be of sufficient magnitude to cause inflammation and safety to avoid unnatural inflammatory response to the res-
possibly irreversible tissue damage.9 Such damage would toration (Figure 6-1). This distance is important to consider
occur only if incorrect laser parameters were used. This risk when fabricating dental restorations because the dentist must
highlights the critical role of proper training for performing respect the natural architecture of the gingival attachment to
laser-enhanced dentistry (see Chapter 16). avoid an inflammatory response to the restoration. The prob-
lem is not the restoration but rather the bacteria that will
Biologic Width always find shelter in the interface between the restorative
margin and the tooth structure. When restorative procedures
Gargiulo first described the biologic protection of the dento- fail to take these considerations into account, with conse-
gingival junction as being a combined function of the con- quent violation of biologic width parameters, three possible
nective tissue, fibrous attachment, and epithelial attachment issues may arise: (1) pocketing develops, with progression of
of the gingival tissues to the dentition.10 It was determined periodontal soft tissue loss; (2) gingival recession and local-
that the length of the epithelial attachment was 0.97 mm ized bone loss occur; most dramatically in cases with thin
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 91

2. Create a blood-free environment and achieve hemostasis

if necessary
3. Control moisture content of the field
4. Ensure bacterial decontamination of the field, leading to
superior gingival health around the margins
5. Control the soft tissue contours for a harmonious
esthetic and functional relationship between the soft tis-
sues of the periodontium and the restored hard tissues of
the teeth and underlying bone
A
These steps are essential for the fabrication of precise impres-
sions, for digital scanning, or for direct placement of restorative
materials. Whenever the restorative interface is subgingival, the
displacement of gingival tissue is critical for finalizing tooth
preparation and impression taking or restorative material place-
ment.12 With older restorative materials, a common challenge
to the dentist was placement of the preparation “finish line”
at or below the crest of the gingiva so that the margin did not
show. Retraction of the gingival tissues usually was performed
B mechanically, with retraction cord impregnated with medica-
• Figure 6-2 Laser correction of biologic width. A, Biologic width
ments for hemostasis. Packing of retraction cord around the
impingement in the anterior segment. Note localized gingival hyper- circumference of the tooth to reflect the gingiva away from
plasia, redness, and inflammation surrounding the porcelain veneers. the tooth and to absorb crevicular fluids was the conventional
B, Photograph of site 2 weeks after correction of biologic width using technique used for recording the finished preparation margin
an erbium laser in a closed-flap procedure to establish new bone level. or to complete placement of the direct restorative material.

labial bone; or (3) localized gingival hyperplasia develops, Conventional Techniques

with possible bone loss as well (Figure 6-2). This standard
remained for many years until Vasek suggested that the con- A technique widely used for gingival retraction is a double-
nective tissue attachment had a more variable width with cord technique for subgingival reflection of tissue. Removing
a more narrow distribution and range than the epithelial the second (top) retraction cord before injecting the impres-
attachment. Although the mean attachment measurements sion material or creating an optical impression allows for
for both epithelial attachment and connective tissue attach- complete capture of the finish line. This time-consuming
ment remained remarkably similar to those as described by technique has its disadvantages, including potential injury to
Gargiulo, a range was given of 0.32 to 3.27 mm for epi- the periodontal ligament if excessive force is used; difficulty
thelial attachment and 0.29 to 1.84 mm for connective tis- in removing the retraction cord without creating shredding
sue attachment. These findings suggest the need for more of the cord or bleeding, and postoperative discomfort.13
thorough analysis of each patient’s individual biologic width Another conventional gingival troughing technique, use
before a determination of restoration placement is made. As of electrosurgery or radiosurgery, allows for contouring of gin-
described further on, these attachment levels may be altered gival tissues and hemorrhage control. The electrosurgery pro-
with crown-lengthening procedures, using dental lasers. cedure may be associated with delayed wound healing, with
asymmetric gingival heights, crestal bony recession, and mod-
erate postoperative discomfort.14 In a study of electrosurgi-
Soft Tissue Troughing with and cal gingival troughing with a fully rectified current on rhesus
without Gingivoplasty monkeys, Wilhelmsen et al.15 showed statistically significant
recession of the gingival margin along with apical migration
The gingival trough is defined as the narrow space between of the junctional epithelium. Deep soft tissue resections close
the free margin of the gingival epithelium and the adja- to bone typically produced gingival recession, bone sequestra-
cent enamel of a tooth.11 At times, permanent alteration tion and necrosis, loss of bone height, furcation involvement,
of the gingival contours around a tooth or teeth is neces- and tooth mobility. Electrosurgery (or radiosurgery) is con-
sary to ensure a superior, long-lasting cosmetic restoration. traindicated around dental implants16 and must not be used
The successful outcome of a direct or indirect restoration in patients with any of the following:
is related to the dentist’s ability to control the surgical site. • Pacemakers
In controlling the site for delivery of a superior restoration, • A history of radiation to the jaws
lasers provide the following functions: • Poorly controlled (or uncontrolled) diabetes
1. Enable the dentist to access and visualize the operative • Blood dyscrasias
site and all of the margins clearly, especially when the • Immunodeficiencies
margins are subgingival • Other diseases that cause delayed or poor healing17
92 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

Scalpel techniques are used primarily to resect tissue to Erbium lasers use thin tips made of sapphire, quartz, or hol-
provide access and visualization of the target site. Scalpel low metal for troughing. For use of erbium lasers on soft tis-
incision surgery may result in gingival attachment loss with sue, the water spray usually is turned off. This precaution aids
apical repositioning, exposure of sensitive root surface to in hemostasis. CO2 lasers have thin hollow metal or ceramic
the oral environment, asymmetric gingival margins, and the tips for troughing. The Nd:YAG and diode lasers use optical
postoperative pain and discomfort typically associated with fibers of various diameters to perform gingival troughing.
periodontal surgery.18
Procedure
Laser Troughing The laser troughing procedure is simple to perform. With
CO2, erbium, and Nd:YAG lasers, the laser tip is placed
In contrast with conventional techniques, laser troughing parallel to the long axis of the tooth, barely into the peri-
allows for clear, clean visualization of gingival margins. odontal sulcus. The tip should glide circumferentially
Most lasers are excellent coagulation devices, with minimal around the margin of the tooth, with slight to no resistance.
to no bleeding. Unlike blade or electrosurgical techniques, Watch for any yellowing of the gingival tissue, which will
laser gingival troughing with a laser gingivectomy can be indicate thermal collateral damage. With diode lasers, the
performed at the same appointment as impression taking. fiber may be directed from the gingival crest toward the
The patient saves a trip to the office, greatly reducing valu- tooth just apical to the margin, removing a thin layer of tis-
able chair time. The ease with which necrotic tissue debris sue and opening more of a wedge-shaped trough for easier
is removed from around the preparation finish line sim- flow of the impression material.
plifies impression taking. Retraction cord is not necessary To maximize its efficiency, the tip must be kept free of
for reflection around the tooth or teeth; no placement or debris. With CO2 lasers, a stream of air blown through the
removal of cord from multiple pockets is required for tak- hollow tip keeps it patent. Debris may accumulate on the
ing impressions of multiple teeth or a full arch. Laser treat- outside of the tip, however, in which case the tip should be
ment causes no recession or repositioning of the gingival wiped down with gauze or replaced. Nd:YAG and diode
margin.19 Laser troughing promotes an ideal environment lasers use glass or quartz fibers, which become dulled and
for use of current impression scanning devices. scratched after multiple uses. A dull tip may cut tissue poorly,
Dentists who practice laser surgery and laser gingival much like a broken piece of glass, leaving tissue tags.7 The
troughing have reported high patient acceptance and com- tip must therefore be cleaved periodically to ensure optimal
fort. Neill’s survey20 on self-reported patient comfort after results. Some diode lasers are supplied with disposable tips,
laser gingival troughing revealed that 3 h after treatment, but the cost of tips is much greater than that incurred with
patients were comfortable, with half “extremely” comfortable. simple recleaving of a standard 3-m optical fiber. The tip
The overall pain rating was 1.9 (on a scale of 0.0 to 10.0), also must be “initiated” so that the depth of penetration of
indicating that patients experienced minimal to no pain. the wavelength is minimized, with no deep thermal damage.
Laser vaporization of fibrotic tissue around crown mar- During troughing to establish gingival proportions
gins is extremely fast, with no bleeding, swelling, or post- with the diode and Nd:YAG lasers, the clinician may note
operative pain. Predictable stability of the gingival tissue on carbonization on the tissues.8,23 This layer can be quickly
healing is the rule, with the additional benefit of elimina- removed using a 3% hydrogen peroxide solution in a mini-
tion of pathogens from the periodontal pocket.21,22 brush tip syringe (Figures 6-3 and 6-4).
Slightly different techniques are used for each wave-
length. The laser dentist must learn the specific procedure
and follow the specific protocols for the particular device
employed. Once again, it must be emphasized that training CLINICAL TIP
is critical in using this technology. An important point of technique is that the laser tip should
“glide” through the tissue, with minimal to no resistance. If the
Nd:YAG or diode fiber meets resistance or moves irregularly
CLINICAL TIP through the sulcus, the tip needs to be cleaved or replaced.
When using the laser for hemostasis of previously inflamed
The novice laser dentist should never start with procedures
tissue, remember to treat the area that is bleeding, which may
in the esthetic zone. Gingival troughing should start with
be coronal to the depth of the trough itself.
molars, where the tissue is slightly thicker. Once proficiency
with molars has been attained, development of laser surgery
skills can be furthered with procedures in more anterior areas,
until the confidence and technical expertise necessary for
successful surgery in the esthetic zone have been acquired. Crown-Lengthening Procedures
Beginner-level laser users should always start with power
settings at the lower end of suggested parameters until The performance of crown-lengthening procedures has
they become experienced with the modality of treatment. become progressively more driven both by esthetics, reflect-
Thermal tissue damage in the anterior region associated with ing the increasing popularity of “smile enhancement” pro-
inappropriate use of higher-power settings could potentially cedures, and by practitioners’ better understanding of the
result in undesirable gingival contours.
principles of biologic width preservation in the restoration
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 93

A B

C D
• Figure 6-3  Gingival troughing of soft tissue with a CO2 laser. A, Treatment of deep distal decay in tooth
#28 involves use of CO2 laser to create gingival trough around entire tooth and minor gingivoplasty of tis-
sue on distal surface of tooth. Note dry field and excellent visualization of gingival margin. B, Soft tissue
troughing and soft tissue crown lengthening to expose tooth structure without violating biologic width
dimensions in an 83-year-old man with traumatic mouth injury. C, Anterior facial view of final splinted
prosthesis 1 month after delivery. D, Lingual-incisal view of final restoration 1 month after delivery. Gingival
tissues responded well to treatment.

A B

C
• Figure 6-4  Gingival troughing of soft tissue with a diode laser. A, In this procedure, the diode laser fiber
tip glides along the axial surface of the tooth for precision. Technique uses slow, continuous strokes, with
care taken not to blunt interproximal papillae. B, During gingival troughing to establish gingival proportions
with diode laser, carbonization may be seen on the tissues. This layer can be quickly removed using 3%
hydrogen peroxide solution in a diffusing-brush syringe. Keep the laser tip parallel to the tooth surface or
slightly angled away from the surface, to avoid absorption of the wavelength by hard tissue. C, Final post-
operative facial view of healthy tissue after gingival troughing and placement of restorations.
94 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

of the broken-down dentition. Crown lengthening is a sur- Erbium lasers have end-cutting tips with a water spray
gical procedure performed to expose a greater gingivoin- that prevents the surgical site from overheating, in con-
cisal length of tooth structure, before restoring the tooth trast with the rotary friction heat released by conventional
prosthetically. Such exposure involves predictably excising a burs. Collateral thermal tissue damage when using erbium
small amount of only gingival tissue around the tooth (soft lasers is less than with conventional techniques.4 The use of
tissue crown lengthening), or of both gingival tissue and rotary diamond or carbide burs for osseous tissue removal
alveolar bone (osseous crown lengthening). Although many risks possible damage to adjacent tooth structure. Healing
general dentists perform this procedure, many others refer after conventional osseous surgery is associated with swell-
patients requiring crown lengthening to a periodontist or ing and postoperative pain.26 Bleeding from a conventional
oral surgeon. Conventional techniques of osseous crown (blade) incision typically will compromise visualization of
lengthening generally involve a full-thickness flap procedure the surgical site, in contrast with a laser incision, and visu-
to establish the new gingival level.17 alization is critical in working on osseous structure. The risk
of bony damage caused by dissipated heat from rotary burs
Soft Tissue outweighs the risk of trauma from a water-cooled erbium
laser when correct parameters are used.
The crown-lengthening procedure is basically an excision of The procedure starts by measuring the amount of needed
gingival soft tissue. Conventional methods of executing this reduction of the bony crest. End-cutting then commences.
technique involve the use of surgical scalpels or periodontal While maintained in parallel orientation with the root sur-
knives or electrosurgery. Recommended placement of the face, the laser tip is advanced to penetrate the crestal bone
excision is at least 2 mm coronal to the bottom of the gin- to the desired depth. Miniature osteotomies are produced
gival attachment, to reduce the risk of root exposure and with the laser tip. Once at the desired depth, the laser tip
violation of biologic width principles.24 is withdrawn and moved 1 to 2 mm laterally, and the next
osteotomy is performed to the desired depth. This sequence
Hard Tissue continues across the facial or buccal, mesial, distal, and
lingual walls until the entire circumference is treated, if
Surgical crown-lengthening procedures may involve the necessary.25
hard tissue as well. To provide adequate biologic width Once the cut is completed, the laser tip is inserted into
from the margin of the restoration, a minimum of 3 mm of the osteotomy site. A swiping motion in the mesial or distal
attached gingiva must remain over the underlying bone to direction is performed to remove any osseous tags between
create a healthy periodontal environment. osteotomy sites. Soft smoothing of the underlying bone
Use of flap surgery with osseous resection is the tradi- removes troughs or craters and creates a scalloped topogra-
tional method of choice when crown margins will impinge phy from the facial surface to interproximal surface.25 The
on the biologic width. Rotary instruments have long been gingival tissue is essentially a marker of underlying bone,
used to recontour the alveolar structure. Bone recontouring and preservation of the interproximal bone height will pre-
can be achieved conventionally with fissure or diamond burs, vent loss of the interproximal papillae. A literature review
using copious amounts of water, or with bone chisels. Thin- revealed that the contact area between teeth should be posi-
ning of the bone around the tooth or teeth reduces craters tioned 5 mm incisal to the height of the interproximal bone
or ridges that create sharp, uneven soft tissue topography. to maintain the papillae.27 Provisionalize the area, and allow
Sufficient bone is removed to create a 3-mm space between 3 to 4 weeks for healing before taking the final impression.
the crest of the bone and the new restoration’s finishing-line Once again, it must be pointed out that a closed-flap osseous
margin. However, poor esthetics may result from enlarged procedure is a “blind” procedure and is not recommended
gingival embrasures, root sensitivity, transient mobility, or for laser dentists to perform until they have extensive experi-
root resorption.24 ence and training with their units.
In some cases, the need for osseous recontouring may If conventional (rotary or bone chisel) open-flap osse-
be localized to one specific area because of the presence of ous recontouring is performed, any laser wavelength (or a
a subgingival restoration, carious lesion, or fractured cusp. scalpel) may be used to open and reflect the flap. With a
Erbium lasers may be useful in localized osseous tissue laser incision for full-thickness flap reflection rather than
removal for establishing a new biologic width without rais- conventional techniques, visualization of the bony crest is
ing a gingival flap. In allowing for careful removal of osse- enhanced because bleeding is minimal. The surgical site is
ous tissue in a closed-flap technique, along with soft tissue cleaner, free of blood, and more “sterile,” because the laser
removal, the clinician can create the biologic width for the destroys bacteria as it incises the soft tissue.
final restoration and complete the impressions for the indi- The bone should be contoured so that the bone structure
rect restoration in the same appointment.25 The closed-flap, has no craters or ledges. If any of these defects are present,
hard tissue crown-lengthening procedure is very technique- the overlying soft tissue will become thick, hindering good
sensitive and is not recommended for the novice laser den- impression taking, in addition to resulting in deep probing
tist; advanced training in open-flap periodontal surgery is depth after the restoration is cemented. Before suturing, it
highly recommended. is essential to ensure that the flaps are without tension and
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 95

A B

C D

E
• Figure 6-5 Hard tissue crown-lengthening procedure. A, Miniature osteotomies are produced with
the laser tip. Once at desired depth, laser tip is withdrawn and moved 1 to 2 mm laterally, and the next
osteotomy is performed. Osseous tissue is dropped to desired depth to create a biologic width zone.
Osseous troughing is done circumferentially with Er,Cr:YSGG laser, followed by soft tissue contouring with
diode laser to expose tooth structure. B, Incisal view after hard tissue and soft tissue crown lengthening
on tooth #11. C, Dry field has been established for post-and-core buildup, and the site is ready for taking
impressions. D, Provisional restoration with opened interproximal papilla development. E, Final restoration
5 years postoperatively.

preferably covering where the eventual crown margin will ovate pontic site formation, implant placement), pres-
be placed. Flaps will not lie correctly if the bone is not con- ence of interproximal tissue that has no papilla point is
toured properly.11 typical. This characteristically fibrotic tissue can present an
Sutures should be removed within 7 to 10 days. If crown esthetic challenge in treatment plans incorporating crowns
lengthening is performed correctly, the impression can be and veneers. The clinician needs to measure the periodon-
made 3 to 6 weeks after the open-flap surgery for posterior tal pocket to establish a biologic width requirement. The
teeth and a few weeks later for anterior teeth, for which soft general rule for creating the ideal emergence profile of
tissue esthetics is critical (Figure 6-5) (see also Chapter 4). the restoration is that for every millimeter of additional
width added to each tooth to close a diastema, the margin
Emergence Profile of the restoration must be prepared an additional 1 mm
subgingivally.29
Emergence profile is defined as the axial contour of a tooth Emergence profile is critical for gingival health and
or crown as it relates to the adjacent soft tissue.28 In devel- esthetic contours. Axial contours of the prepared tooth
oping an optimal emergence profile during procedures structure will be reflected in the final restoration contours
that close spaces between teeth (e.g., diastema closure, as well. The contact point of the restoration(s) will influence
96 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

the overall appearance of the gingival tissue and restoration. with regard to axial inclination is the creation of a bulge
Proximal contacts between the posterior teeth are located in or excessive convexity, especially at the gingival third of the
the occlusal to middle third of the crowns. The contact must restoration. Dental technicians frequently overemphasize
be more than just a point occlusogingivally; it also must this feature. Overcontouring promotes the accumulation
not extend too far gingivally to encroach on the gingival of food debris and plaque, and gingival inflammation is
embrasure. The axial surface of the restoration cervical to encouraged rather than prevented.30
the proximal contact point should be flat or slightly concave Provisional restorations should be used to create and
to prevent encroachment on the interdental papilla.27 preview the acceptable gingival contours of the final resto-
Overcontouring of the proximal surfaces apical to the rations. The provisional restorations may be used to guide
contact area creates convex surfaces, which in turn vio- the healing contours of the gingival tissue and to fabricate
lates the space of the interproximal papilla, creating bio- a similar emergence profile in the definitive prosthesis24
logic width encroachment issues. The most common error (Figure 6-6).

A B C

D E F

G H I
• Figure 6-6  Laser-assisted closure of diastema. A, Preoperative view showing the patient with old por-
celain veneers removed. Diastema between teeth #8 and #9 is 2.5 mm wide. Periodontal probing reveals
gingival pocket depth of 3 mm. Each tooth will be widened by 1.25 mm to close the diastema. B, Gingival
trough 1.25 mm deep is created on tooth #8 for lowering preparation margin to establish new emergence
profile of restoration. Laser tip is guided along the axial tooth surface for precise control, using slow, con-
tinuous strokes from facial-mesial-lingual. Soft tissue wall is tapered toward new papilla point. C, Continue
creating gingival trough on #9 with same 1.25-mm depth as on #8. Slope tissue trough toward new inter-
dental papilla, and always leave 1 mm of tissue island. Apically position preparation margin on mesial side
of #8 and #9 for new emergence profile. Impressions can be taken at this appointment and provisional
restorations placed. Allow space for papilla to develop while the patient is wearing provisional restorations.
D, Facial-incisal view after removal of provisional restorations. Note well-developed, healthy stippled inter-
proximal papilla. E, Incisolingual view of developed interproximal tissue before final placement of restora-
tions. F, Anteromesial view of interproximal papillae with stippled tissue. G, Try-in of final restorations. Note
slight blanching of interproximal tissue between #8 and #9. On final cementation, firm pressure is applied
to seat the restorations fully before tack curing. H, Diastema 3 mm in width in a similar case. Emergence
profile will begin 1.5 mm subgingivally on mesial aspect of both #8 and #9. I, Postoperative facial view of
diastema closure in patient in H. Gingival tissue framing is proportionate to the teeth, and restorations have
been fabricated with long contact points incisogingivally.
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 97

Advanced Emergence Profile Dilemma The conventional ovate soft tissue design was classically
created by means of gingivoplasty using either a round
The goal of reconstructing an alveolar ridge is to restore the carbide bur or a football-shaped diamond bur. Major dis-
health of the periodontal apparatus so that the patient can advantages with this technique are the potential for tissue
continue to function normally. Success is based on not only mutilation, bleeding, inability to take the final impression
the final state of health of the gingival tissues but also the immediately after the procedure, and delayed tissue devel-
stability and esthetics of the case. Some restorative cases may opment and healing.32
feature irregular bone loss. As bone loss progresses, the ante- To prevent development of a poor pontic site, immedi-
rior ridges become knife-edged, with loss of papillae and the ately after removal of a tooth, a socket preservation proce-
normally scalloped gingival contour.31 dure (the socket is filled with bone material) is performed to
The absence of the interproximal papilla has adverse maintain the tissue height.33
effects on esthetic and phonetic results. Restoring the An ovate pontic site requires a significant facial-lingual
papilla requires surgical precision and soft tissue manipu- width (depending on location in the dental arch) and apical-
lation to create the desired outcome. Any mistake may be coronal thickness to surround the ovate pontic within the
catastrophic because of the small size and meager blood edentulous space. A thin, knife-edge ridge often is a contrain-
supply of the papilla. Even the use of vasoconstrictors in dication to an ovate-type pontic; however, if the dimensions
anesthetics and in conventional retraction cords may lead mentioned are inadequate, a surgical augmentation proce-
to necrosis. A laser procedure reduces the risk of gingival dure can be considered. Various soft tissue augmentation
migration while not affecting the blood supply necessary to
support the interdental papilla.22

PROCEDURE
1) Probe the gingival sulcus to determine the biologic
width. Treatment is the same as for a small diastema
closure at the gingival embrasure.
2) Measure the embrasure from root surface to adjacent A
root surface (e.g., 2 mm). Use the rule of thumb that for
every millimeter of space closure needed, the margin
of the restoration is lowered by a similar distance. If the
gingival embrasure is a 2-mm gap, divide 2 mm in half
to have proper proportions, and drop each restoration
margin 1 mm subgingivally to create the emergence
B
profile mesially and distally. The trough created is only
interproximal to the lingual aspect. Any zenith correction
can be done at this time, if necessary (Figure 6-7).

CLINICAL TIP
Ask the dental laboratory technician to fabricate the C
restorations with a long contact area, and to be sure that
the axial walls gingival to the contact area are concave.

Ovate Pontic Design

Ovate pontic design enhances esthetics to make the pon-
tic appear to be emerging from the gingival crest, as would
a natural tooth, unlike a ridge lap design. The cosmetic D
advantage of the ovate pontic is its ability to replicate natu- • Figure 6-7  A, After periodontal surgery, wide gingival embrasures
ral contours, maximizing esthetics. The clinical advantages are evident. Absence of interproximal papilla has adverse esthetic and
of the ovate pontic include excellent emergence profile for phonetic results. B, Final restorations in place with long incisogingi-
natural contours, ease of cleaning, its function as an effec- val contacts. Serrated interproximal papilla creates esthetic soft tissue
framing of restorations. C, Lateral incisor–central incisor embrasure.
tive seal to prevent food entrapment under the prosthesis, Treatment technique is the same as for diastema closure between
and elimination or minimization of the “black triangle” gin- teeth #8 and #9 (see Figure 6-6). D, Lateral view of interproximal papil-
gival embrasures.32 lae with healthy stippled tissue.
98 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

A Thick Thin Very thin

B C

D E
D
• Figure 6-8  A, From left: posterior ovate site placement in center of ridge; bicuspid ovate site placement
toward midbuccal area of ridge; anterior ovate site placement to facial area of ridge. B, Provisional restora-
tion removed to expose ovate site for try-in of fixed bridge. Note development of interdental papilla mesial
and distal to pontic site. C, Note ovate pontic fabricated by dental laboratory technician to sit into ovate
site. D, Occlusobuccal view of interdental papilla development. The ovate site is red and inflamed as a
consequence of no plaque control while the patient was wearing the provisional restoration. E, Prosthesis
try-in. Note slight blanching of ovate site at teeth #5 and #3. These sites may need to be modified at this
visit by deepening the ovate site with a laser before cementing the prosthesis.

techniques can be used for this purpose, depending on the tissue mesially and distally, the interproximal papillae can
complexity of the ridge defect (Figure 6-8). be developed33 (Figures 6-9 and 6-10). The procedural
A molar pontic requires the ovate site to be designed steps are as follows:
in the middle of the ridge. With more anterior sites, the
ovate site design should be closer to the buccal-facial aspect.
PROCEDURE
Aligning the adjacent gingival heights can be accomplished
so that the pontic tooth does not appear to be a short 1. Locate the center of the desired pontic site, and mark it
clinical crown. Alteration of the gingival edentulous site is with the laser tip.
2. Create an ovate outline on the ridge with the laser.
started in the middle of the ridge. Sounding the bony ridge
3. Start from the center with small-diameter movements,
to determine gingival thickness allows for evaluation of the and swirl outward to the peripheral boundary of the
biologic width. The center of the convex ovate will be the ovate pontic.
deepest segment.
The formation of an ovate pontic site using a laser starts
with the removal of tissue from the center of the site. In
a circular manner, the diameter of the ovate site is then The sculpting of gingival tissue is exceptionally precise
slowly increased, ending it 2 mm from the adjacent abut- with the laser. Use of controlled laser energy for these proce-
ment tooth in its mesial and distal aspects. The gingival dures minimizes postoperative swelling, decreases postoper-
tissue of the ovate site should now begin to slope so that ative pain, and reduces healing time.18,21 These procedures
the deepest portion is the center; for this component of the all are performed at initial treatment, whereas using con-
procedure, it is helpful to visualize an egg and how it will ventional methods would mean completing these soft tissue
be able to sit into that divot. By leaving 2 mm of gingival alterations several weeks before preparation/impression day.
A B C
• Figure 6-9  A, Posterior ovate site between teeth #18 and #20. The ovate pontic should be placed
in center of the ridge for a molar site. B, First, mark the site by outlining planned ovate area. C, Start by
applying laser energy in center of ovate site and then swirl outward to peripheral boundary of ovate pontic
site. Slope the deepest part of ovate (center) up to interproximal area of adjacent teeth. Leave the slope 2
mm from adjacent teeth to create interproximal papillae.

A B

C D

E F

G H
• Figure 6-10  A, Anterior intraoral view in a patient with lateral #7 and #10 teeth missing. Ovate pontic
designed to facial aspect of gingival ridge and to match adjacent apical gingival heights. Leave 1 to 2 mm
of interproximal tissue to create papillae mesial and distal to the pontic. B, Seated three-unit bridges #6 to
#8 and #9 to #11. Note gingival heights and interproximal papillae on ovate pontics #7 and #10. C, Ante-
rior lower ridge site for ovate pontic development with diode laser. D, Mark ridge with diode laser for ovate
pontic site. Stay to facial side of ridge. Deepen center portion of pontic and slope up to interproximal papil-
lae. E, Deepen ovate sites for pontics to sit within gingival ridge, as opposed to overlapping it. Check for
overheating of gingival tissue. If tissues acquire a yellowish tint during the procedure, correct by reducing
the wattage. F, Ovate pontic site on lower anterior ridge at 5 years. G, Ovate pontic site developed around
implants in anterior lower segment. Site is deepened for the ovate pontic. H, Final restoration in place at 6
months shows excellent interproximal papillae.
100 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

A two-stage soft tissue treatment would be likely with laser gingival depigmentation usually is performed with use
conventional techniques because of the swelling associated of only topical anesthetic.
with electrosurgery, rotary instrumentation, or soft tissue
scalpel surgery. Soft tissue results would be unpredictable
if these methods were used at the preparation/impression CLINICAL TIP
appointment.14,21 Diode and Nd:YAG lasers usually come with just one size
of fiber, usually a 300- or 400-μm diameter fiber; however,
manufacturers make many different sizes of fibers, ranging
Hard Tissue Ovate Pontic Site Formation from 100 μm to 1000 μm in diameter. For dental use, the
100-μm and 200-μm fibers are too thin and fragile to be useful for
If less than 2 mm of gingival tissue is present between the many procedures. Attempts to use these fibers in periodontal
bony crest and the pontic site, other treatment modalities pockets led to breakage of fibers within the pocket. A 300- to
must be considered. Using an erbium laser to remove bone 400-μm fiber is an “all-purpose” fiber, capable of performing
from the pontic site would be the solution. Sufficient bone most routine dental tasks. For melanin depigmentation when
the goal is to cover a large surface area quickly, availability of
must be removed so that there is no violation of the bio-
a 600-, 800-, or even 1000-μm fiber will make this procedure
logic width. A provisional restoration is placed in the area, much more efficient.
and at least 2 mm of space is left between the tissue side of
the pontic and the crestal bone, to allow the gingival tis-
sue to granulate inward before proceeding with the final
impression.25 Carbon dioxide lasers may be used to perform a deepi-
thelialization procedure. Again, the goal is not to cut the
Laser Depigmentation tissue but to remove the epithelial layer that contains the
melanocytes. Low power is used with a large spot size; this
Deeply melanotic gingiva can be a social stigma in many combination minimizes the power density and enables the
cultures; accordingly, laser melanin depigmentation of a dentist to cover a large area more quickly. In like manner,
patient’s gingiva is becoming more common. All of the erbium lasers can be used in contact with the tissue, gently
current dental lasers can accomplish gingival depigmen- removing the tissue layer by layer until the epithelial layer
tation, and as with most procedures, dentists have their containing the melanocytes is removed (Figure 6-11).
preferences regarding which wavelength is “best.” Some
clinicians prefer Nd:YAG and diode laser wavelengths Laser Bleaching
because of their affinity for pigment such as melanin. Oth-
ers prefer the erbium and CO2 laser wavelengths because The pursuit of whiter teeth and use of bleaching techniques
these are easily attracted to the water in the gingival tis- have been documented since the nineteenth century. Chem-
sue. Most dentists who perform gingival depigmentation icals used for bleaching vital teeth have included oxalic acid,
believe that laser treatment is the most reliable and satisfac- ether peroxide, hydrogen dioxide, and hydrogen peroxide
tory method.34–38 (H2O2). In the early twentieth century, 35% H2O2 was
Diode and Nd:YAG lasers use the same basic technique: recognized as the most effective bleaching agent. In 1918,
Because the aim is not to cut the tissue but rather to deliver Abbot used high-intensity light, raising the temperature of
the laser energy deep to the epithelium, to be absorbed by H2O2 rapidly to accelerate the bleaching process. In the
the pigment, a low power is used. Nd:YAG and diode lasers late 1960s, Klusmier noted that a 10% carbamide perox-
may be used out of contact with a noninitiated tip; the ide solution placed in a nightguard to improve the gingival
energy will then not be absorbed by the superficial layers health of his patients also resulted in bleaching. In 1989,
of tissue but will penetrate the tissue until it is absorbed by Haywood and Heymann39 introduced and published this
the melanin. As the laser energy is absorbed by the mela- technique. By the 1990s, this procedure had become com-
nin, the tissue lightens in color. Alternatively, the diode and monplace in dentistry.
Nd:YAG lasers can be used in light contact with very light, Some patients cannot complete the home bleaching pro-
brushstroke-like movements of the beam through the tissue. cess because of the lengthy time investment, discomfort or
If this technique is used, care must be taken that the tip does irritation from the trays, or discomfort from the bleaching
not accumulate tissue debris. Once debris accumulates on agents associated with gingival recession. For these patients,
the tip, the laser becomes “activated” and will work super- a single-visit in-office procedure produces good results
ficially, rather than penetrating into the melanin. Erbium quickly without these problems.
and CO2 lasers interact with surface tissue, so it is neces- “Power bleaching,” which originated with Abbot in
sary to “peel” the tissue down to the level containing the 1918 and progressed to use of heat lamps and heated spatu-
pigmentation.37 Care should be taken to preserve the mar- las in the 1980s, has been effective, but with many side
ginal gingiva. Because most pigmentation is in the basal and effects, including pulpal necrosis related to the inability to
suprabasal areas relatively close to the surface, both tech- control the highly reactive and caustic 35% H2O2 solu-
niques can be effective.36 Regardless of the wavelength used, tion. The goal of a single-visit power-bleaching procedure
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 101

B C

D E
• Figure 6-11  Laserdepigmentation of deep melanotic gingiva. A, Preoperative view. B, Erbium laser
performing melanin depigmentation. C, Immediate postoperative view. D, Two-week postoperative view.
E, Six-week postoperative view with new anterior crowns in place.

is to whiten efficiently using controlled temperature eleva- The best overall results were obtained with laser activa-
tion of the H2O2 on the tooth to prevent pulpal necrosis. tion of the bleaching agent. Zhang et al.41 reported similar
The development of bleaching agents that combine H2O2 results in comparing a potassium titanyl phosphate (KTP)
or its analogs with thickening agents, buffers, catalysts, or laser, a diode laser, and an LED. The selection of laser
coloring agents has made power bleaching safer and more wavelength is not important; any laser wavelength will
reliable. successfully bleach tooth structure so long as the emission
The objective of laser power bleaching is to excite the spectrum of the laser matches the absorption spectrum of
bleaching agents using a very efficient source of light the bleaching material.
energy—a laser. Many studies have shown a relationship Torres et  al.42 evaluated the amount of coloring agent
between exposure time and adverse pulpal responses: the placed in bleaching agents. Their results showed that bleach-
greater the exposure time of the bleaching agent to the ing was more intense when double and triple the amount of
tooth, the greater the risk of pulpal necrosis. With use of coloring agent was placed in the gels. The light energy from
photons of one specific wavelength that approximates the the laser excites the highly reactive H2O2 molecules, and as
absorption spectrum of the bleaching agent, rather than the molecules absorb the laser energy, the peroxide decom-
using a light source that emits multiple wavelengths, the poses, with ionization into the following compounds:
  
chemical reaction proceeds at a faster rate, thereby decreas-
ing exposure time of the bleaching agent to the tooth. Hydroxyl ions (OH−)
Wetter et al.40 evaluated bleaching performed using no Perhydroxyl ions (HOO−)
light source, a light-emitting diode (LED), and a diode laser. Water (H2O)
102 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

Oxygen ions (O2−) • Bibs

Hydrogen ions (H+) • Cotton rolls
Oxygen (O2) • Cheek retractors
  
• Preparation kit
The perhydroxyl ions are considered to be the strongest free • Pumice and a prophylaxis angle
radicals formed during the breakage of the H2O2 bonds. • Floss
Using a laser maximizes the perhydroxyl concentration with- • Interproximal strips
out increasing exposure time (i.e., increased concentration • Fluoride gel and/or potassium nitrate gel
of bleaching free radical without increased contact time). • Rubber dam (conventional or paint-on)
Free radicals are unstable and immediately seek an available • Bleaching kit
target with which to react. These free radicals react with • Bleaching agent
the chromophilic structures of the larger, longer-chained, • Brushes, mixing pad, spatula
darker organic compounds in the tooth. As a result, the
compounds dissociate into smaller, shorter-chained mol-
ecules with different optical properties. The cosmetic result
is a visually whitened tooth structure. PROCEDURE
1. Make certain that all personnel are wearing
wavelength-appropriate safety glasses.
General Protocol 2. Pumice all surfaces to be bleached. Do not use
conventional prophy paste; such pastes usually
After a general review of the medical history, the patient’s
contain fluoride and oils, which will interfere with the
oral habits, diet, and lifestyle must be ascertained, along bleaching process.
with expectations regarding the outcome of treatment. 3. Isolate teeth with rubber dam or light-cured dam.
A patient who drinks four cups of black coffee daily and one 4. Prepare the bleaching agent and carefully place on the
or two glasses of red wine with dinner every night will have enamel.
5. Activate the laser and follow manufacturer’s
different results from those for a patient who drinks neither
instructions for exposure time. Be sure to use the
coffee nor red wine. recommended wavelength for the bleaching material.
Patients with severe tetracycline staining must be Many power-bleaching materials change color when
informed that their treatment may take multiple applica- the oxidation process is complete. Do not continue to
tions and appointments; treatment alternatives should be expose the bleaching agent to any more laser energy
once the color change of the bleaching agent has
discussed. Evaluate the teeth for presence of fluorosis and
been completed.
white-spot lesions, and review the kinds of results that can 6. Wipe off the used bleaching agent with wet gauze/
be expected with these lesions. cotton and reapply fresh material. Do not rinse with
Confirm the starting shade of the patient’s dentition by water between applications. Use just enough
arranging the Vitapan Classical Shade Guide values in the water on the gauze/cotton to remove the used
agent.
following order (Figure 6-12):
7. Reapply fresh agent and reactivate the laser.
B1 − A1 − B2 − D2 − A2 − C1 − C2 − D4 − A3 − 8. Wipe off the used agent, and reapply fresh agent for
D3 − B3 − A3.5 − B4 − C3 − A4 − C4 the third time, or apply according to manufacturer’s
instructions.
Document this aspect of the evaluation with photographs. 9. When the third application is complete, wipe off all
of the used agent, irrigate with water, remove the
A detailed discussion with the patient is recommended.
isolation material, and rinse thoroughly for 1 min
Identify the existing restorations and clarify the necessity with a fluoride rinse. Apply a nonstaining fluoride
to replace composite restorations after the bleaching pro- solution.
cess, because these restorations will not change color during 10. Confirm new shade with the shade guide, and
bleaching. Point out any posterior stains, such as amal- photograph the result.
11. Provide a home bleaching kit, or schedule a follow-up
gam “shining through” on the buccal surfaces of posterior
appointment if necessary.
teeth, that will not change without replacing the restora-
tion. Discuss possible treatment problems, such as sensitiv-
ity during and after the procedure, associated with gingival
recession and exposed root surfaces. The use of take-home
trays to complement the in-office treatment may be offered
if appropriate. CLINICAL TIP
For the bleaching procedure, assemble the following: As an objective method for validating the color changes
• First-aid kit, including vitamin E ointment or aloe vera achieved with bleaching processes, a fully calibrated
gel for accidental exposure of soft tissue to the bleaching spectrophotometer can used to determine all tooth shade
agent values preoperatively and postoperatively, as in the cases
shown in Figures 6-12 to 6-15.
• Laser safety glasses
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 103

A B

C D

E F

G H
• Figure 6-12  Laser-assisted bleaching versus home bleaching. A, B, Appearance of teeth before and
after home bleaching procedure. A, The initial shade of upper teeth was A3 on the Vitapan Classical Shade
Guide on gingival and middle thirds and A4 on the incisal third. Lower teeth were graded as C4. B, Lower
arch after 10 days of home tooth whitening (upper arch before bleaching) with cheek retractors in place.
Lower teeth improved from C4 to D3, a six-step change on the value-oriented Vitapan shade guide. C to H,
Laser-assisted bleaching procedure and result. C, Laser-assisted bleaching of upper arch. Paint-on dental
dam is in place, and bleaching material has been applied to teeth. Note cotton protecting lower arch and
safety glasses protecting the patient’s eyes. D, Diode laser handpiece applying laser energy to bleaching
material. E, Completed laser bleaching of upper arch. F, Postoperative view of laser bleaching results at 48 h.
Upper teeth were graded as A1 on the gingival and middle thirds (seven-step change) and as B2 on the
incisal third (10-step change). G, Immediate postoperative view of second laser bleaching on upper arch
and first laser bleaching on lower arch. Upper arch teeth improved from A1 for the gingival and middle thirds
and B2 for the incisal third to A2 for the gingival third and A1 for the middle and incisal thirds. Ten days after
laser bleaching, lower teeth shade improved from D3 to D2, a six-step change. These results show that one
laser-assisted bleaching session of the lower arch produced the same degree of change (six steps) as 10
days of home bleaching. H, Six-month postoperative view of laser bleaching result.
104 CHA P T E R 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction

A B

D
C
• Figure 6-13  A, Preoperative view of laser-assisted bleaching of upper arch (shade A4) and LED bleach-
ing of lower arch. B, Paint-on dental dam in place and bleaching material on teeth. Note mouth prop in
place and laser safety glasses protecting the patient’s eyes. Bleaching material for upper arch is wave-
length specific for the diode laser to be used, and bleaching material for lower arch is wavelength specific
for the LED unit. C, Immediate postoperative view of laser bleaching of upper arch and LED bleaching of
lower arch. Upper arch shade was B2, representing a change of 12 steps on the Vitapan value-oriented
scale. D, Six-month postoperative view shows two-step rebound to A2.

A B

C D
• Figure 6-14  A male patient elected to undergo 810-nm laser bleaching on the right side of the mouth
and 940-nm laser bleaching on the left side. A, Preoperative view. Preoperative shade of upper arch
was A4. B, Immediate postoperative view. C, Postoperative view at 48 h. Final shade was A2, a 10-step
difference. D, Postoperative view at 3 weeks. The upper arch was completed in two sessions. The
lower arch was completed in one session. The maximum results were visible at 48 h, although a slight
relapse was noted after 3 weeks.
 CHAPTER 6  Lasers in Fixed Prosthetic and Cosmetic Reconstruction 105

Soft tissue lasers are especially increasing in popular-

ity because of their potential value in prosthetic and cos-
metic gingival procedures. The ability to control moisture
and facilitate hemostasis for both soft tissue and hard tissue
lasers appears particularly promising for dentists excising or
recontouring gingival tissues. The ability to address biologic
width issues and maintain same-day impression capabilities
enhances the effectiveness and efficiency with which esthetic
procedures can be performed.
A
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