Paul Feuerstein, DMD
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As I continue to work with digital impression systems, there is a common denominator. At this time, all are optical systems and can see only what you can see with your eyes. Therefore, in order for the margins to be read, tissue retraction must be impeccable. Unless, of course, the margins are at or above the gingival crest.
I have used single and double cords of all types, as well as cotton, retraction paste and compression caps (cotton and Styrofoam). All of these work reasonably well, as long as I take one impression. If there is too long of a lag time to a second impression (if necessary), there could be some tissue rebound. And, to be honest, not all patients have perfect perio health on teeth where these restorations are necessary.
One of the great features of digital impressions is the ability to see your preparations and occlusal clearances before they are sent to the lab or milling system. The technology allows you to reprep and rescan the preparation without having to do the whole process again as you would with traditional impressions. If you take some time and rescan, there is a chance for the tissue to rebound and require the dentist to re-retract. I am old enough to remember having taken reversible hydrocolloid impressions when we depended on electrosurgery for retraction to avoid this. Although lasers have been around for a while, the cost and bulk of these units has been a deterrent. Until now.
A few companies have spent much energy (no pun intended) in shrinking the size and cost of soft-tissue diode lasers. I am not discussing the larger, more robust units capable of cutting hard tissue, although there have been some advances. These lower powered devices have the ability to not only do retraction, but allow many small soft-tissue procedures to be accomplished quickly, easily — and in some cases — without local anesthesia. There is some confusion about wavelengths and power in watts that I will try to clarify.
Clinical diode laser applications
The most frequent use for these lasers is the preparation of tissue for impressions digitally and traditionally. But there are many other areas that you will find once you have these at your fingertips, again touting the new, smaller, more portable lasers. As most GPs know, if you have only one unit of anything (intraoral camera, digital sensor, headlight, laser, etc.), you inevitably find yourself working in the room without it. You often have to stop a procedure and send an assistant running to get it, plug it in, fire it up, and use it.
Frequently, there are times in simple restorative dentistry when the diode laser would be handy to use for a few seconds. This gingival restoration just peeks subgingivally and bleeds just enough to interfere with bonding.
How about the older patient with root caries on a bridge abutment slightly subgingival, or the patient who has an implant impression and the tissue has overgrown ever so slightly (or one in which you have to uncover an implant; in this case you probably had the laser set up already)? Are you chasing decay on the distal of a lower molar and sitting with a “glob” of lingual tissue that is in the way of a sectional matrix or wedge? (Again, periodontists will say this is a situation for crown lengthening, but you are there in the trenches and just want to get the restoration done; there is time to send them out later.)
Then there are a few procedures that you normally choose not to do. The laser companies say that you can do many frenectomies and add to your bottom line, yet you may have never done one at all. Periodontists shudder at this thought. But often there are times when a patient appears with some gingival recession on a lower anterior tooth.When you tug a little on the lip, you can see the bottom of the defect right near that frenum. Yes, it would be great to have apical repositioning and more attached gingiva in this area. But a quick “slice” to relieve that pull is still a valid service, and simple with any of the diodes mentioned. There is literature to suggest you can treat aphthous ulcers using the pulse mode, essentially waving the laser tip a few millimeters from the lesion to get instant relief and faster healing. Anecdotally, I can confirm this. Happy patients also are great referrers.
Other interesting situations that arise are pericoronitis on erupted or even partially erupted molars. This is one area where you might need a more powerful laser to get through the tissue quickly, but it still can be done slowly at a low wattage or wavelength. I have seen one practitioner take out a deciduous tooth with the laser and just use a topical (the ones that are just hanging there). The list goes on.
Several of the lasers include a bleaching tip. Often, you have to use special peroxide with titanium dioxide in it, but I will defer to the bleach experts on this point.
Emerging laser technology
A few years ago, Zap Lasers produced a pen-sized diode laser that is totally cordless, uses a wireless foot pedal, has disposable tips, and a small LED menu of procedures and settings in a two-watt device. Discus Dental (now part of Philips Corporation) bought this technology and refined the laser to the current NV model. The company also dropped the cost to less than $5,000.
The NV laser is portable, light, and simple to use for basic soft- tissue procedures. Recently, Discus introduced a new, slightly larger version available at a lower cost called the Discus SL3. It has expanded menus, a wireless foot pedal, and more power. These are groundbreaking products, but the industry did not sit by idly.
Alan Miller started AMD LASERS and entered with the philosophy that every office should have a soft-tissue laser. His company’s Picasso Lite has shattered the industry with a price point of less than $2,500! This is also a compact system, although not as tiny as the NV. The Picasso is a bit more robust and still at a lower price point than others.
Miller says that you do not need portability, just buy a few of these for the cost of competitors. These systems also have “dummy proof” settings for basic procedures, yet still have the ability to tweak the settings for personal preference.
Technology4Medicine has an interesting soft-tissue laser that runs at 1,064 watts. It not only has an LED screen with settings, but also has instructional videos. The higher wattage allows for quicker and smoother cutting.
BIOLASE did not sit by idly either. The company introduced the iLase, a portable diode similar in size to the NV but offering slightly more power and a different (higher) wavelength. (On the hard-tissue side, BIOLASE also unveiled a new, more powerful laser called the Waterlase iPlus at a lower cost than the original Waterlase.)
Speaking of hard-tissue lasers, Lares Corporation took a cue from this new cost cutting and introduced a new laser, the LightWalker, at a remarkable price of less than $30,000. I hope to address these hard-tissue lasers, as well as Millennium’s PerioLase and the LANAP procedure in a future column.
There are several other diodes in the marketplace, and I would need an additional page to discuss all of them. KaVo, Sirona, Ivoclar Vivadent, and others have systems with a variety of features. They are in development. I will keep you posted as new models debut.
Dr. Paul Feuerstein installed one of dentistry’s first computers in 1978. For more than 20 years, he has taught technology courses. A general practitioner in North Billerica, Mass., since 1973, Dr. Feuerstein maintains a website (www.computersindentistry.com) and can be reached at [email protected].
