Name: Tsuneo Kawai D.D.S

Address: 4F-6-6-19, Chuo-ku, Ginza, Tokyo, JAPAN

Phone: 81-3-3573-9330

Fax: 81-3-3573-9330

E-mail: kawai@maronie-dental.com

Title:

Management of Soft and Hard tissue of Medically Compromised

Patient using LiteTouch Er:YAG Laser

April 3, 2019

Academy of Laser Dentistry

Advanced Proficiency Clinical Case Studies

Pre- treatment

a) Outline of case

1. Full clinical description

37-year-old Japanese female presented with the chief complain of bleeding from the upper anterior gums. There was

a significant selling and bleeding with probing on#5~#11. Interdental separation has been recognized between # 9 and

#10. The crown margin of #5 is exposed. Pt. wanted to be replaced the restorations of this anterior section because of

the aesthetic reason. The X-ray showed that there was a prosthetic incompatibility and the translucency at the apex

of the root on#5 and #7. The inappropriate buccal margin is set deep and root canal treatment is necessary on #5 and

#7. Pt. agreed to remove the old restorations and change to the provisional restoration for the treatment. The

anterior fixed restorations were removed to enhance the heeling of the gingiva and for the root canal treatment on #5

and #7. Dental hygienist initiated treatment through plaque removal, scaling and root plaining. The patient was

educated and instructed to aggressively improve oral hygiene. No significant clinical improvement in pocket depth

and gum swelling after 4 weeks.

Medical history: The patient has been taking medications for high blood pressure (nifedipine) and antidepressant for

her mental care from 2 year ago. Patient has been smoking for over 10 years.

Dental history: The patient presented with porcelain-fused-to-metal(PFM) restorations and bridge on #5-11,

#12-14.The patient had gone through orthodontic treatment. Patient lost tooth #1, #6, #13, #15, #16, #17, #30, #32.

Tooth #5, #7, #8, #9,#10, #11, #12, #14 were PFM crowns and bridge. Root canal Treatment has been done for teeth

#5,#7,#8,#9,#10,#11,#12,#14,#19,#31 followed by build up and crown. Composite restoration has been on #3(O).,

#4(O)., #20(O).

Pre-treatment: periodontal charting

Periodontal pocket depth charting revealed pockets to be between 3-9 mm at the upper front teeth.

Figure 1: Preoperative periodontal charting (Initial)

Occlusion: This patient was class III of the Angle classification.Occlusal height is normal.

TMJ: TMJ Examination revealed no abnormality.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 333 323 334 446 X 989 655 656 655 554 433 X 333 X

Bleeding on Probing

Upper Lingual 323 323 324 436 X 979 545 556 555 544 433 X 323 X

Bleeding on Probing

Lower Lingual 322 X 322 223 222 222 222 222 222 222 223 323 223 322

Bleeding on Probing

Lower Facial 322 X 322 222 222 222 222 222 222 222 222 223 222 322

Bleeding on Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 2: Preoperative Full anterior view Figure 3: Bleeding on probing

Figure 4: Radiographic examination

2. Radiographic exam

Deantal X-rayradiographs revealed that Horizontal bone resorption was present at tooth#5,#7,#8,#9,#10,#11. There

were apical lesion on tooth #5 and #7. prosthetic incompatibility at crown margin area. #5-#7, #8-#9 and #10-#11

were connected with the fixed restoration.

3. Soft tissue status

There was a significant selling and bleeding with probing on#5~#11. Interdental separation has been recognized

between # 9 and #10. The crown margin of #5 is exposed. Deep pockets depth from 7-9 mm on #7 was measured

with periodontal probing. The other teeth are normal limit of pocket depth with probing.

The gingival swelling with hyper collagen fiber was remained caused by medications for high blood pressure and

antidepressant.

4. Hard tissue status, tooth vitality

Tooth #6, #13, #15 and #30 were missing and prosthodontically rehabilitated with fixed PFM. Vertical bone loss was

present in tooth #7.

5. Other tests

Impressions for study models were made.

Figure 5: Preoperative Full anterior view Figure 6: after removal of the prostheses

#11 post core was detached internally at the time of removal of the old restoration

Figure 7: 4 weeks after the initial treatment

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 333 323 333 435 X 989 654 655 555 544 333 X 333 X

Bleeding on Probing

Upper Lingual 323 323 323 435 X 969 544 555 554 534 333 X 323 X

Bleeding on Probing

Lower Lingual 322 X 322 223 222 222 222 222 222 222 223 323 223 322

Bleeding on Probing

Lower Facial 322 X 322 222 222 222 222 222 222 222 222 223 222 322

Bleeding on Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 8: Periodontal charting(4 weeks)

b) Diagnosis

1. Provisional diagnosis

Localized Periodontitis at #5 ~ #11.

2. Final diagnosis

Localized Periodontitis and Hyperplasia caused by medication at #5 ~ #11 .

3. Treatment plan outline

Phase I Gingivoplasty and Crownlengthing on#5,#8,#9,#10,#11 and bone shaping for the ovate pontic on #7 after the

extraction with the Er:YAG laser

Phase II The final restoration will be placed after the evaluation of surgical success.

4. Indications and contraindications

a.Indications

The Er:YAG laser is well absorbed by water, a constituent of all soft tissue. This laser is an excellent scalpel providing a

wet surgical site that collaborates to promote gingival healing. It also helps eliminate the smear layer. Changing tips

allows different spot sizes to be easily achieved.

b.Contraindications

The contraindication for laser treatment is the risk of damage to any tooth structure during the periodontal incision,

which could be reduced by using the angled handpiece with a thin tip inside the sulcus and parallel to the tooth

structure.

5. Precautions

The Er:YAG laser wavelength easily interacts with both hard and soft tissue, so care must be taken to avoid

interaction with any associated healthy tissue, especially hard dental tissue. It is important that adequate water spray

be used during soft tissue ablation to avoid thermal damage through charring.

6. Treatment alternatives

Treatment alternatives included conventional scaling and root plaining treatment for a long period of time,

conventional surgical techniques.

7. Informed consent

Written and verbal consent was obtained.

Treatment

A. Treatment objectives strategy

The treatment objective was the selective removal of soft and hard tissue using an Er:YAG laser.

B. Laser operating parameters

An Er:YAG laser (Lite Touch, Light INSTRUMENTS LTD, Israel ) was used for the soft and hard tissue surgery. The

operating features are as follows:

1. Wavelength: 2,940 nm

2. Delivery system: Direct Drive Delivery System

3. Beam diameter: 800 micron sapphire tip

4. Average Power: From 3.5 to 7.5 Watts

5. Energy Level: 150 to 180 mJ

6. Pulse Rate: 20 to 50 Hz

7. Total time taken: 15 minutes

C. Treatment delivery sequence

After cleaning of the preparation site and disinfection with acrinol. This treatment was provided under surface

anesthesia. (20% ethyl aminobenzoic acid) It was placed from tooth areas #6 to #11, followed by local anesthesia (2%

Lidocaine with 1/100,000 epinephrine, 1.8ml).The laser warning sign was posted before the operation.

All people present in the operating room wore protection goggles to protect their eyes.A test fire of the laser was

performed to establish correct working and patency of light delivery. A safety area check (only required personnel

present, safety warning signs posted, reflective surfaces minimized) was carried out. The patient and all personnel

within the above-mentioned safety area were issued protective glasses. High-volume evacuation was used for tissue

cooling and suction of removed tissue

Modified Widman incision with internal bevel with the blade and made fullthickness flap at buccal and palatal

side.(Figure 9)

* A periosteal elevator was used to separate the tissues. After the flap was lifted the granulated tissue was removed.

* Bone shaping for clownlengthning 180mJ/20Hz(=3.6W) with water spray. The tip of choice is 800-micron sapphire

tip applied in near-contact mode.

* removing the remained soft tissue 80mJ/50Hz(=4W) with water spray, 800-micron sapphire tip with water spray in

near-contact mode.

* For bone smoothing the energy applied is 120mJ/50Hz(=6W) with water spray, 800-micron sapphire tip in

near-contact mode.

* For cleaning of the bone surface of the apical lesion 80mJ/30Hz(=2.4W) with water spray, 800-micron sapphire tip in

near-contact mode.

* For bone shaping of the ovete pontic on #7 180mJ/20Hz(=3.6W) with water spray, 800-micron sapphire tip in

near-contact mode.

* After these procedures were completed, the flap was replaced back against the teeth and anchored with the

suture(Figure 12).

Figure 9: Incision with the blade for the Modified Widman flap Figure 10: Bone shaping for a scallop shaped bone

Figure 11: After bone surface cleaning on apical of #7 Figure 12: Light after the treatment with suture

and shaping for ovate pontic

D. Post-operative instructions

Verbal and written postoperative instructions were given to the patient. The patient was instructed to take

antibiotics if needed for any discomfort, rinse with chlorhexidine, and a special soft tooth- brush was given.

Postoperative checks were done every week for the first month and once a month for the next 6 months. No

complications were reported during surgery.

E. Complications

There were no complications. The patient reported no discomfort at all.

F. Prognosis

Prognosis is very good. The final soft tissue health was excellent during the post- operative.

G. Treatment records

Completed. Use of the laser was noted at the operating parameters specified above.

Follow-up

A. Assessment of treatment outcome

The healing process was clinically observed. The patient reported no postoperative pain or discomfort.

Figure 13: Removal of suture ,1 week after the treatment Figure 14: at 4 weeks after surgery

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111 X X 212 212 212 212 212 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 111 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 223 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure15: Periodontal charting after 4 weeks

After 4 weeks probing showed no bleeding, but some recurrent swelling of the gum is observed.

Therefore, it was decided to observe a little more. 3 months later, gingivoplasty was performed before taking an

impression.

* For second gingivoplasty 60mJ/30Hz(=1.8W) with water spray, 800-micron sapphire tip in near-contact mode

without anesthesia.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111 X X 212 212 212 212 212 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 111 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 222 212 212 212 212 212 212 221 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure16: Periodontal charting before the gingivoplasty

Figure17:3 month after the surgery Figure 18: during Gingivoplasty

Figure19:right after the second gingivoplasty

One week later, impression was made because the form of the gum got better.

Figure20: One week after the gingivoplasty

Figure 21 : Final Figure 22: Palate view

Figure 23:Final restoration

1. Post-treatment perio charting

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111 X X 112 211 211 211 111 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 111 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 223 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 24: Periodontal charting at final restoration

2. Specify treatment assessment intervals

The patient returned for a one-week follow- up. The soft tissue had healed beautifully without incidents. At the

six-week check- up, the hygienist resumed treatment. At the 3,6,12month checkup, periodontal pockets are nomal

limit and dental X-ray was taken.

Figure25 : Three-month Postoperative view Figure26: Three-month Postoperative view

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111

X X 112 211 111 111 222 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 222 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 223 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure27: Periodontal charting at three-month

B. Complications

No complications occurred during treatment. The patient could not believe how frightened she was before, and how

much she appreciates the new technology now.

C. Long term results

The soft and hard tissues appeared healthy at the 6-month and 1-year postoperative examinations.

We re-evaluated three months, six months, one year later. Mild gingival swelling is considered to be a drug effect. In

some cases, it may be necessary to perform gingivoplasty again with Er: YAG Laser, so it is necessary to continue

careful observation.

D. Long term prognosis

Long-term maintenance is necessary in future .

Figure 28: six-month postoperative view Figure 29 six-month close-up view of patient’s smile

Figure 30: six-month Figure 31 :Alveolar junction is good

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111 X X 112 211 111 111 222 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 222 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 223 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 32: Periodontal charting at Six-month

Figure33: one-year postoperative view Figure34: one-year close-up view of patient’s smile

Figure 35: one-year palate view Figure 36: Dental X ray comparison

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Upper Facial 222 222 222 111 X X 111 112 111 111 222 X 322 X

Bleeding on Probing

Upper Lingual 222 222 222 111 X X 111 111 111 111 222 X 322 X

Bleeding on

Probing

Lower Lingual 223 X 223 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

Lower Facial 223 X 222 222 222 222 222 222 222 222 222 222 222 223

Bleeding on

Probing

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 37: Periodontal charting at One-year