Nov/Dec 2008 —
Soft-Tissue Management Using an Er, Cr:YSGG Laser During Restorative Procedures
Cynthia Jetter, DMD
Effective management of gingival tissues in
restorative dentistry poses a challenge to practitioners. Many methods and
materials are available to dental professionals
to manage tissue. This article will demonstrate the use of an Er,Cr:YSGG
laser as an effective, minimally invasive technology to manage soft tissue
during restorative procedures.
The term laser is an abbreviation for light amplification by stimulated emission of radiation. The stimulated emission theory
was first postulated by Albert Einstein and
describes the manner in which lasers produce
light energy. The light produced by a laser is
monochromatic, highly focused, and of a specific wavelength. Laser systems are composed of an active medium, which may be a solid or a gas; an external power supply; an optical resonator; a cooling system; a control system; and a
Lasers are named by their active medium. The active
medium of an Er,Cr:YSGG laser is erbium,
chromium, yttrium, scandium, gallium, and
garnet. The active medium of an Er:YAG laser is
erbium, yttrium, aluminum, and garnet. In both of these lasers, the active
medium is a solid. In contrast, the active medium of a CO2 laser is a gas. When the
active medium of a laser is pumped with energy, monochromatic light energy
of a specific wavelength is emitted from the
active medium and transferred to the target tissue via the laser’s
delivery system. Laser energy can be delivered via an articulated arm,
hollow wave guide, or an optic fiber. In the
case of the Er,Cr:YSGG laser, energy is delivered
to the targeted tissue via an optic fiber to a handpiece, is reflected by a mirror, and passes through a sapphire or zirconium tip.
Lasers exhibit specific properties depending on their
position in the electromagnetic spectrum.
Most lasers produce light energy that is found
in the visible and infrared part of the electromagnetic
spectrum. The wavelength of the Er,Cr:YSGG laser is 2,780 nm, which places
this laser in the mid-infrared part of the electromagnetic
spectrum. The energy produced by the Er,Cr:YSGG laser demonstrates good absorption by water and, to a lesser degree, hydroxyapatite.1-3 Because all dental tissues contain water, the Er,Cr:YSGG laser is useful for many dental procedures. Enamel contains approximately 3% water and dentin contains approximately 12% water.4 Bone and cementum have a slightly
higher water content compared with dentin, approximately 15%, and soft tissue has the highest water content, greater
than 70%. The water contained in enamel,
dentin, cementum, bone, and soft tissue absorbs
the energy produced by the Er,Cr:YSGG
laser, and the result is ablation of the target tissue. Less laser energy is required to ablate soft tissue than enamel.
Managing soft tissue during restorative procedures is
a challenge that dental practitioners encounter
on a daily basis. The restoration of class V
lesions and gingival retraction for crown-and-bridge
impressions can be some of the most challenging dental procedures.
Traditionally, with class V lesions gingival-retracting
rubber-dam clamps isolate the cavity preparation and guard against
contamination by saliva and blood during the restorative phase. Gingival flap surgery in conjunction with a gingival-retracting rubber-dam clamp also has been described
in the dental literature as a way to manage soft tissue and minimize or eliminate contamination from crevicular fluid or
the case of impressions for crowns and bridges, the two-cord retraction
technique is widely used.
Managing soft tissue using rubber-dam clamps,
scalpels, or retraction cord is effective, but
each method results in postoperative
discomfort. Discomfort can be a source of anxiety in dental patients, which can cause
adults to avoid regular dental care.6 The use of retraction cord containing epinephrine can
result in high blood levels of epinephrine,
which can cause undesirable cardiovascular
changes.7-9 The use of retraction cord also can result
in permanent gingival recession if connective tissue fibers are torn, causing a less than esthetic result after the
restoration has been placed.10
By contrast, the removal of soft tissue to access
caries or for gingival troughing before impressions can be performed using
laser energy with little or no bleeding, minimal tissue trauma, and reduced postoperative pain.11-12 The dental literature contains
many cases illustrating the use of the Er,Cr:YSGG laser in soft-tissue procedures, such as oral papilloma removal,
fibroma removal, gingival troughing for
impressions, and the elimination of gingival
pigmentation.12-16 Each article reports that patients did not complain of
postoperative pain. One study compared the use
of the Er,Cr:YSGG laser to the CO2 laser in laser-assisted
uvulopalatoplasty for the treatment of snoring.17 This study used the number of
days it took patients to return to a normal
diet and the number of days that patients took pain medication as an indication of recovery from surgery. The patients who had their surgery performed with the Er,Cr:YSGG laser returned to a normal diet after 4.5 days vs patients
in the CO2 laser group, who took 8.6 days. Additionally,
patients in the Er,Cr:YSGG laser-treated group
used pain medication for 4.1 days after surgery
vs patients in the CO2 laser-treated group who used
pain medication for 10.1 days. Patients whose surgery was performed with the Er,Cr:YSGG laser recovered from surgery
sooner than patients treated with the CO2 laser.
When used to remove soft tissue, laser energy is more
precise than a clamp or a scalpel because laser
energy can be delivered to the tissue in a more
controlled manner. The reduction in tissue
trauma results in decreased postoperative pain.
CASE REPORT: SUBGINGIVAL CARIES
A 28-year-old woman presented with an existing
composite restoration in tooth No. 22, which
also exhibited recurrent caries and a midfacial
sulcular depth of 3 mm. A dark area showing
through the marginal gingiva suggested subgingival caries (Figure 1A View Figure). Wavelength-specific laser protective
eyewear was placed on the patient as well
as everyone present in the treatment room. An
Er,Cr:YSGG laser (Waterlase MD, Biolase Technology Inc, Irvine, CA) was used to remove the failing composite resin at
a setting of 4.0 W, 25 Hz, 30% water 70% air, H mode with a G4 tip. The composite was removed without injected anesthesia (Figure 1B View Figure). The gingival tissue was dried with gauze
and a 20% lidocaine, 4% tetracaine, and 2%
phenylephrine topical anesthetic (Tac 20%
Alternative, Professional Arts Pharmacy, Lafayette,
LA) was applied to the tissue. Adequate anesthesia was determined by touching the tissue with an explorer.
Removal of gingival tissue to expose
the subgingival caries was accomplished using a T4 tip at a setting of 1.0
W, 50 Hz, 7% water 11% air, S mode. The
gingivectomy did not cause the tissue to bleed (Figure 1C View Figure).
The remaining caries was removed using the Er,Cr:YSGG laser at a setting of 3.5 W, 25 Hz, 30% water 70% air, H
mode using a G4 tip. After caries removal
(Figure 1D View Figure), the tooth was restored using the
total-etch technique with Etch ‘N’ Seal® (Den-Mat Corp, Santa Maria, CA), Tenure® Quik (Den-Mat), and Herculite® XRV (Kerr Corp, Orange, CA) in
Vita shade A2 (Figure 1E View Figure). To the author, the
gingival trauma from finishing and polishing the restoration with ET® burs (Brasseler USA, Savannah, GA) in a high-speed handpiece appeared greater than during the removal of the gingival tissue with the
laser. Although the tissue trauma from
finishing and polishing was not significant, it demonstrates that the laser
can be more precise than rotary instruments.
Fourteen months after treatment, the tissue
surrounding tooth No. 22 was healthy, with a
midfacial sulcular depth of 2 mm and an attachment level of 1 mm (Figure 1F View Figure). If the
postoperative sulcular depth was <
2 mm, an osseous crown lengthening would be indicated to restore biologic width. This procedure
also could be performed with the Er,Cr:YSGG
laser but would require injected local anesthetic.
CASE REPORT: GINGIVAL TROUGHING
A 46-year-old man presented with tooth No. 4 requiring
full coverage after endodontic therapy.
Wavelength-specific laser protective eyewear
was placed on the patient and everyone present in the treatment room. Tooth No. 4 was prepared for full coverage
using a diamond bur in a high-speed handpiece without injected anesthetic. Instead of
placing gingival retraction cord, the Er,Cr:
YSGG laser was used to perform gingival troughing with a T4 tip at a setting of 1.0 W, 50 Hz, 7% water 11% air, S mode.
For comparison, the T4 tip has a
diameter of 400 µm; size 1 retraction cord is approximately 1 mm in
diameter. Tac 20% Alternative was applied
to the gingival tissues before gingival troughing for maximum patient comfort. After preparation and gingival
the Er,Cr:YSGG laser (Figure 2A View Figure), an impression was made for the final porcelain restoration (Figure 2B View Figure). When the Er,Cr:YSGG laser is used for gingival troughing, the laser
energy is delivered parallel to the tooth with
a lower power setting than would be used to
remove enamel, dentin, or bone.
At a follow-up visit 17 months after treatment, tooth
No. 3 exhibited subgingival recurrent caries on
the lingual that caused the tissue around it to
have a less than optimum appearance (Figure
2C View Figure). After caries removal was completed, a provisional crown was placed on the tooth. Three months after
treatment, the appearance
of the gingival tissue around tooth No. 3 improved because the caries had been removed.
However, the lingual papillae of
tooth No. 4 developed slightly hyperplastic keratinized tissue from wound healing (Figure 2D View Figure). This redundant
tissue was removed,
thinned, and reshaped to a more optimum architecture using the Er,Cr:
YSGG laser. Tac 20% Alternative was applied to
the gingival tissue for optimum patient comfort. A T4 tip at a setting of 1.0 W, 50 Hz, 7% water 11% air, H mode was used
to reshape the gingival tissue (Figure 2E View Figure and
Figure 2F View Figure).
As demonstrated in the cases presented, the use of an
Er,Cr:YSGG laser is an effective, minimally
invasive method to accomplish the goal of
soft-tissue management for various restorative procedures. In this
author’s experience, patients reported
little to no postoperative discomfort compared with conventional tissue-management techniques, such as
retraction clamps, retraction cord, or gingival
flap reflection with a scalpel. Patients may be
more motivated to have regular dental visits if
a source of dental anxiety, postoperative pain, can be reduced or eliminated.
The author has no financial interest in any companies
or products mentioned in the article.
The author wishes to thank Dr. Gail Gerard Childers, a
periodontist who maintains a
private practice in Marlton, New Jersey, for
1. Eversole LR, Rizoiu
IM. Preliminary investigations on the utility of an erbium, chromium YSGG laser. J Calif
Dent Assoc. 1995;23(12):41-47.
2. Eversole LR, Rizoiu IM, Kimmel AI. Pulpal response
to cavity preparation by an erbium, chromium:
YSGG laser-powered hydrokinetic system. J Am Dent Assoc. 1997;128(8):
3. Hadley J, Young DA, Eversole LR, et al. A
laser-powered hydrokinetic system for
caries removal and cavity preparation. J Am
Dent Assoc. 2000;131(6):777-785.
4. Arends, J, Ruben JL,
Inaba D. Major topics in quantitative microradiography of enamel and dentin: R parameter, mineral
distribution visualization, and hyper-remineralization. Adv
Dent Res. 1997;11(4):403-414.
5. Meraner M. Soft tissue management for difficult
cervical restorations. Gen Dent. 2006;54(2):117-120.
6. Sohn W, Ismail AI. Regular dental visits and
dental anxiety in an adult dentate population.
J Am Dent Assoc. 2005;136(1):58-66.
7. Kellam SA, Smith JR, Scheffel SJ. Epinephrine
absorption from commercial gingival retraction
cords in clinical patients. J Prosthet Dent. 1992;68(5):761-765.
8. Forsyth RP, Stark MM, Nicholson RJ, et al. Blood
pressure responses to epinephrine-treated
gingival retraction strings in the rhesus monkey. J Am Dent Assoc. 1969;78(6):
9. Hatch CL, Chernow B, Terezamy BT, et al. Plasma
catecholamine and hemodynamic
responses to the placement of epinephrine-impregnated
gingival retraction cord. Oral Surg Oral Med
Oral Pathol. 1984;58(5):540-544.
10. Chiche G, Pinault A. Esthetics of
Anterior Fixed Prosthodontics. Chicago,
Ill: Quintessence Publishing; 1994:204.
11. Rizoiu IM, Eversole LR, Kimmel AI. Effects of an
erbium, chromium: yttrium, scandium, gallium,
garnet laser on mucocutaneous soft tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;82(4):386-395.
12. Scott A. Use of an erbium laser in lieu of
retraction cord: a modern technique. Gen Dent. 2005;53(2):
13. Boj JR, Hernandez M, Espasa E, et al. Laser
treatment of an oral papilloma in the pediatric
dental office: a case report. Quintessence Int. 2007;38(4):307-312.
14. Boj JR, Poirier C,
Espasa E, et al. Eruption cyst treated with a laser powered hydrokinetic system. J Clin Pediatr Dent. 2006;30(3):
15. Walinski CJ. Irritation fibroma removal: a
comparison of two laser wavelengths. Gen Dent. 2004;52(3):
16. Azzeh MM. Treatment of
gingival hyperpigmentation by erbium-doped:yttrium,
aluminum, and garnet laser for esthetic purposes. J Periodontol. 2007;78(1):177-184.
17. Pavelec V, Polenik P. Use of Er,Cr:YSGG versus
standard lasers in laser assisted
uvulopalatoplasty for treatment of snoring. Laryngoscope. 2006;116(8):1512-1516.
|Figure 1A Preoperative view of tooth
No. 22 with a failing composite restoration
and a midfacial sulcular depth of 3 mm.
||Figure 1B The composite resin was
removed from tooth No. 22 with an
|Figure 1C After gingivectomy, the subgingival
caries were accessible.
||Figure 1D Tooth No. 22 after caries removal.
|Figure 1E Completed restoration on
tooth No. 22.
||Figure 1F Fourteen-month postoperative
view of tooth No. 22.
|Figure 2A Tooth No. 4 prepared for full
coverage and gingival troughing.
||Figure 2B Impression of the prepared
|Figure 2C Seventeen-month postoperative
view of the final crown on tooth No. 4.
Note the less than optimal gingival tissue
surrounding tooth No. 3.
||Figure 2D Twenty-month postoperative
view. Note the improved tissue surrounding
tooth No. 3 and the redundant tissue
surrounding tooth No. 4.
|Figure 2E Immediate postoperative view
after the removal of the redundant tissue.
||Figure 2F Healed gingival tissue, 11 days
after tissue removal.