Gingival Retraction and Bacterial Reduction Therapy

A 65-year-old female patient presented to the practice for a crown preparation on tooth No. 5 (Figure 1). As the preoperative radiograph shows, this maxillary bicuspid is in an area of the mouth that can be challenging to restore (Figure 2). For this reason, the decision was made to use a soft-tissue diode laser (NV^® PRO3, DenMat) to achieve gingival retraction once the tooth was prepared.

Many of today's dental preparations are slightly subgingival, and this case was no different. The ultimate goal of this appointment was to capture a clean, detailed impression with clear margins so that the dental laboratory would have ample information to create an esthetic, fitted restoration.

A soft-tissue diode laser can be an excellent tool for achieving gingival retraction around a prepared tooth. This is because it enables oral healthcare professionals to obtain blood-free gingival retraction, predictable margins, and a clean final impression. The use of a diode laser replaces the traditional cord-packing technique and, in most cases, eliminates the need for topical anesthetic. In addition, using a soft-tissue diode laser in lieu of retraction cord saves valuable time for both clinicians and patients.

The soft-tissue diode laser was used to achieve the desired margins around the crown preparation. It was set to produce 1.4 W at a continuous wave with an initiated tip. Once the tip was fully initiated, it was placed approximately 1 mm subgingivally between the tissue and the bone. The laser's tip is placed into the gingival sulcus in a manner that is parallel to the long axis of the tooth. Light brush strokes dispose heat and allow the laser to vaporize the tissue. As it troughs around the margins of the tooth, the laser achieves complete and effective retraction in a quick yet safe manner (Figure 3).

If charring of the tissue occurs, it is likely because the laser setting is too high. The soft-tissue diode laser used in this case comes preset to eliminate the guesswork in determining the power needed to achieve the desired results. In the event that charring of the gingival tissue occurs, a cotton swab doused in hydrogen peroxide may be used to wipe the area clean to improve visualization of the margins.

With the desired gingival retraction achieved, high-quality light body and heavy body vinyl polysiloxane impression materials (Splash Max^®, DenMat) were used inside stock impression trays to capture the necessary intraoral details. The final impression demonstrates the clean margins that were captured using this technique (Figure 4).

Thanks to the effectiveness of the diode laser, the task of capturing an impression is simplified without sacrificing the crucial details that are needed in order for the laboratory to fabricate a precision-fit zirconia crown (BruxZir^® Solid Zirconia, Glidewell Laboratories) (Figure 5). As this case demonstrates, the use of the diode laser for troughing results in predictable margins, no recession of the gingival tissue, limited bleeding and patient discomfort, improved productivity, detailed dental impressions, and a beautiful final restoration (Figure 6).

A 54-year-old female patient who presented for a routine prophylaxis was given the recommendation to undergo laser bacterial reduction because she experienced significant bleeding on probing and exhibited marginally deep pocket depths during the pretreatment examination (Figure 7). Her periodontal pockets needed to be cleaned to prevent permanent bone damage; therefore, the dental hygienist opted to recommend use of the soft-tissue diode laser as part of her ongoing treatment.

In many states, a certified dental hygienist is permitted to perform bacterial reduction using a laser. However, dental practice regulations vary by state, so it is the responsibility of the dental professional to remain up-to-date on the laws pertaining to laser use.⁴ For this case, the dental hygienist was authorized to use the soft-tissue laser for the treatment of periodontitis.

To perform the periodontal therapy with the diode laser, the dental hygienist set the laser to 0.7 W at a continuous wave and did not initiate the tip. Soft-tissue laser energy is effective in reducing bacterial counts in the pocket, which reduces the risk of bacteria entering the patient's bloodstream and can also encourage healthy reattachment of the gingiva, reducing pocket depth in some cases.

With the tip placed subgingivally, it was moved in a sweeping motion to perform 15 to 20 strokes on the mesial side, followed by the facial side, and then finally, the distal side of each pocket that required treatment (Figure 8). Care was taken to keep the tip aimed at the gingiva and not the root. No anesthetic was required during this procedure, which is a relief for many patients.

A 2-week postoperative follow-up evaluation indicated reduced pocket depth, improved color of the gingiva, and decreased bleeding on probing, providing evidence that the soft-tissue laser can be a safe and effective means of treating periodontitis (Figure 9).

Oral healthcare professionals who wish to deliver minimally invasive treatment to their patients would be wise to learn more about soft-tissue diode lasers. This treatment modality is a modern-day marvel that offers many practical applications in dentistry. From restorative to periodontal care and more, the implementation of lasers in dentistry offers myriad benefits, including maximized workflow and production, limited patient discomfort, and the ability to uphold minimally invasive treatment standards.

Timothy Kosinski, DDS
Adjunct Associate Clinical Professor
University of Detroit Mercy
School of Dentistry
Detroit, Michigan

Master
Academy of General Dentistry
Private Practice
Bingham Farms, Michigan

Stephanie Pajot, RDH
Private Practice
Bingham Farms, Michigan