ALL Metrics
-
Views
-
Downloads
Get PDF
Get XML
Cite
Export
Track
Clinical Practice Article
Revised

Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone

[version 3; peer review: 2 approved]
PUBLISHED 01 Mar 2021
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Crown lengthening is a surgical procedure aimed at exposure of a larger tooth surface by gingivectomy alone or with cortical bone remodelling for aesthetic purposes in the anterior zone of the maxilla or for reconstruction of teeth affected by subgingival caries. We report two cases of crown lengthening in the anterior maxilla for aesthetic purposes by gingival and bone re-contouring performed by erbium-doped yttrium aluminium garnet (erbium:YAG) laser. As highlighted in this report, the erbium:YAG laser-assisted crown lengthening is less invasive and also leads to faster clinical outcomes in contrast to the conventional surgical technique by scalpel incision, flap elevation and osteoplastic.

Keywords

flap-less crown lengthening, Erbium:YAG laser; smile line

Revised Amendments from Version 2

Minimal changes have been introduced accordingly to the last reviewer report.

See the authors' detailed response to the review by Nasim Chiniforush

Introduction

Several clinical situations may require dental crown lengthening (CL) such as irregular smile line, gummy smile, decayed or fractured teeth, worn out teeth by parafunction habits (e.g. bruxism)1,2. Regardless of aesthetic or functional purpose, the conventional technique of CL involves scalpel incision, flap elevation and bone remodeling by burns, with or without adjunctive gingivectomy, the latter essentially related to the gingival biotype3,4. Despite the excellent clinical outcome, the conventional surgical technique may be more invasive depending on the severity of the clinical situation as well patient’s general health condition (e.g. medically compromised patients or in therapy with anticoagulant drugs). Many alternatives techniques for CL have been reported in literature but it is generally accepted that the least invasive are the laser-assisted techniques5,6. Of these, the erbium:YAG laser has the advantage to work on both hard (bone) and soft tissues (gingiva)7. We report on 2 cases treated by a mini-invasive erbium:YAG laser-assisted procedure (including gingiva and bone re-contouring) for CL in the anterior maxilla.

Cases presentation

Case 1

The patient was a 53 y.o. Caucasian woman with an no relevant medical history who was unemployed at the time of presentation (March, 2015). She presented an abundant gingiva covering tooth 1.2 which she wished to remove for aesthetical purposes (Figure 1a,b). Gingival remodeling and bone re-contouring by erbium:YAG laser was suggested. A small amount of anesthesia was injected locally (0.9 ml of mepivacaine cloridrate 2%, 1:100,000 epinephrine) after which the gingiva was remodeled by laser (Key Laser 3-Kavo s.r.l.-Italy) in de-focalized modality (not in contact free beam tip, 180 mJ/10 Hz, poor water emission) until the dental crown was sufficiently exposed according to the patient smile line (Figure 1c,d). After one week (Figure 2a), a second procedure was performed to re-contour the marginal bone by the same laser, using a surgical tip (optical prism scalpel-like tip of 01×10mm, 120 mJ/10 Hz, abundant water emission) in contact modality and through the gingival sulcus (flap-less); a light bleeding occurred during the procedure (Figure 2b). The gingival margin was completely healed, and the smile line appeared significantly improved 12 days after surgery (Figure 2c).

f587fd76-a3a7-411d-82b8-9bb7fb05ec17_figure1.gif

Figure 1.

Alteration of the smile line related to the abundant gingiva of tooth 1.2 (a,b); gingival remodelling by erbium-doped yttrium aluminium garnet (erbium:YAG) laser and its immediate clinical appearance (c,d).

f587fd76-a3a7-411d-82b8-9bb7fb05ec17_figure2.gif

Figure 2.

Second step after seven days (a); flapless (through the gingival sulcus) bone re-contouring by erbium-doped yttrium aluminium garnet (erbium:YAG) laser (b) and its clinical appearance after 12 days (c).

Case 2

This 47 y.o. Caucasian housewife who presented in April 2016 with severe abrasion of the anterior teeth related to bruxism over a long duration (Figure 3a). Her medical history was un-remarkable. No pain and/or teeth hyper-sensibility were indicated by the patient, however, she was unhappy with her smile. A laser-assisted CL of the lateral and central incisors was planned to re-define a new marginal gingiva profile. After local injection of anesthesia, (1,8 ml of mepivacaine cloridrate 2%, 1:100,000 epinephrine), the marginal gingiva was careful recontoured by erbium:YAG laser (Key Laser 3-Kavo s.r.l.-Italy) (not in contact free beam tip, 180 mJ/10 Hz, poor water emission) till an adequate teeth exposure (Figure 3b,c); subsequently, the cortical bone was-remodeled by a surgical tip (optical prism scalpel-like tip of 01×10mm, 160 mJ/10 Hz, abundant water emission) on both aspects of the maxilla through the gingival sulcus without flap elevation (Figure 3d). After 14 days, gingival tissues appeared healed and teeth prepared for the following prosthetic restoration by cemented metal-ceramic crowns. (Figure 3e,f).

f587fd76-a3a7-411d-82b8-9bb7fb05ec17_figure3.gif

Figure 3.

Severe abrasion of incisors due to bruxism (a); erbium-doped yttrium aluminium garnet (erbium:YAG) laser-assisted gingivectomy (b) and contextual flapless bone remodelling (c); the clinical appearance after 14 days (d), the teeth preparation as appearing on computer-aided design and the following prosthetic rehabilitation (e,f).

Discussion

Several medical devices have been proposed to make CL less invasive, including piezosurgery4,8. Several lasers such as diode, neodymium-doped yttrium aluminum garnet (Nd:YAG), potassium titanyl phosphate (KTP), CO2, Erbium, chromium-doped yttrium, scandium, gallium and garnet (Er,Cr:YSGG) and erbium:YAG are widely used for CL1,2,6,9. However, the main difference between these is their capability to work exclusively on soft or hard or both tissues3,9,10. Diode, Nd:YAG, KTP and CO2 lasers may be useful when only gingival remodeling alone is necessary and this is essentially related to their surgical capabilities, especially contextual cuts and coagulation2,9,11,12. In fact, they are generally suggested for many surgical and non-surgical procedures in the oral cavity (frenectomy/frenulotomy, vestibuloplasty, mucosal biopsy, treatment of tooth hyper-sensibility, benign, potentially malignant and malignant lesions removal, surgical and not-surgical periodontal treatments including drug-related gingival overgrowth, photocoagulation of venous malformations, etc), but not for bone treatments1219. When both gingival and bone remodelling is required, instead, the choice necessarily must fall on Er;Cr:YSGG or erbium:YAG lasers thanks to their selectivity for water, resulting in the capability to work by ablation on hard tissues as tooth and bone10,11,20,21. Therefore, such lasers can be used for dental cavity preparation, periodontal treatments, dentinal hypersensitivity, benign lesion removal, treatment of viral lesion of the oral mucosa and lip, gingival and/or bone remodelling or cutting7,9,10,20. In the reported cases, authors used an erbium:YAG laser both for soft and hard tissue treatment but with different tips and output energy parameters. The excellent clinical outcomes we described in terms of minimal invasiveness, lack of intra- and post-operative complications and pain, fast and predictable healing, are essentially related to the intrinsic proprieties of the erbium:YAG laser light and to the generally recognized gentle laser-oral tissues interaction10,11,2023.

Conclusion

The overall clinical benefits of the erbium:YAG laser allows flapless CL to be simplified, even in difficult cases. The total absence of laser-related thermal injuries to the oral hard and soft tissues leads to highly predictable clinical results, and this is important in the treatment of the anterior teeth for aesthetic purposes. However, a good knowledge of laser-tissue interaction principles, sufficient experience on laser use and, obviously, familiarity with the general and basic guidelines of oral/periodontal surgery are mandatory to achieve desirable clinical results.

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 30 Sep 2020
Comment
Author details Author details
Competing interests
Grant information
Copyright
Download
 
Export To
metrics
Views Downloads
F1000Research - -
PubMed Central
Data from PMC are received and updated monthly.
- -
Citations
CITE
how to cite this article
Capodiferro S, Tempesta A, Limongelli L et al. Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone [version 3; peer review: 2 approved]. F1000Research 2021, 9:1185 (https://doi.org/10.12688/f1000research.26008.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.

Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 3
VERSION 3
PUBLISHED 01 Mar 2021
Revised
Views
6
Cite
Reviewer Report 02 Mar 2021
Nasim Chiniforush, Dental Implant Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran 
Approved
VIEWS 6
The article in this ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Chiniforush N. Reviewer Report For: Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone [version 3; peer review: 2 approved]. F1000Research 2021, 9:1185 (https://doi.org/10.5256/f1000research.54289.r80423)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 2
VERSION 2
PUBLISHED 22 Jan 2021
Revised
Views
16
Cite
Reviewer Report 26 Jan 2021
Nasim Chiniforush, Dental Implant Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran 
Approved with Reservations
VIEWS 16
  • The unit for energy should be mJ not MJ. 
     
  • What does poor emission mean? Give exact amount of water irrigation.
     
  • The country of laser device should be
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Chiniforush N. Reviewer Report For: Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone [version 3; peer review: 2 approved]. F1000Research 2021, 9:1185 (https://doi.org/10.5256/f1000research.54007.r77858)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 02 Feb 2021
    saverio capodiferro, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
    02 Feb 2021
    Author Response
    Dear Reviewer, thank you for your suggestions. Changes (MJ with mJ, adding of references and Country of laser device as suggested) will be performed accordingly in the next version. With ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 02 Feb 2021
    saverio capodiferro, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
    02 Feb 2021
    Author Response
    Dear Reviewer, thank you for your suggestions. Changes (MJ with mJ, adding of references and Country of laser device as suggested) will be performed accordingly in the next version. With ... Continue reading
Version 1
VERSION 1
PUBLISHED 30 Sep 2020
Views
5
Cite
Reviewer Report 03 Dec 2020
Nasim Chiniforush, Dental Implant Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran 
Approved with Reservations
VIEWS 5
  • In two cases please add pulse duration of laser device you used for each purpose and laser tip diameter and length.
     
  • You can add some more information about the advantages of erbium
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Chiniforush N. Reviewer Report For: Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone [version 3; peer review: 2 approved]. F1000Research 2021, 9:1185 (https://doi.org/10.5256/f1000research.28703.r72300)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 22 Jan 2021
    saverio capodiferro, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
    22 Jan 2021
    Author Response
    Thank you very much. Changes have been made accordingly.
    Competing Interests: No competing interests were disclosed.
COMMENTS ON THIS REPORT
  • Author Response 22 Jan 2021
    saverio capodiferro, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
    22 Jan 2021
    Author Response
    Thank you very much. Changes have been made accordingly.
    Competing Interests: No competing interests were disclosed.
Views
14
Cite
Reviewer Report 17 Nov 2020
Rada T. Kazakova, Department of Prosthetic Dentistry, Faculty of Dental Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria 
Approved
VIEWS 14
Dr. Saverio Capodiferro et al.’s article reports two cases of a crown lengthening procedure with an Er:YAG laser. This procedure aims at exposure of a larger tooth surface usually on the anterior maxillary region by gingivectomy alone (soft tissue crown ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Kazakova RT. Reviewer Report For: Minimally invasive (flapless) crown lengthening by erbium:YAG laser in aesthetic zone [version 3; peer review: 2 approved]. F1000Research 2021, 9:1185 (https://doi.org/10.5256/f1000research.28703.r72302)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 30 Sep 2020
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
Sign In
If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password.

The email address should be the one you originally registered with F1000.

Email address not valid, please try again

You registered with F1000 via Google, so we cannot reset your password.

To sign in, please click here.

If you still need help with your Google account password, please click here.

You registered with F1000 via Facebook, so we cannot reset your password.

To sign in, please click here.

If you still need help with your Facebook account password, please click here.

Code not correct, please try again
Email us for further assistance.
Server error, please try again.