Cuts Like a Knife

Sept. 1, 2009
In the old days, if a patient needed a gingival buccal restoration, the tooth was prepared, tissue dried with cotton or retraction cord, and (after good old Copalite) an amalgam was plastered in place.

by Paul Feuerstein, DMD

For more on this topic, go to and search using the following key words: troughing, implant exposure, restoration, gingivectomy, laser, Dr. Paul Feuerstein.

In the old days, if a patient needed a gingival buccal restoration, the tooth was prepared, tissue dried with cotton or retraction cord, and (after good old Copalite) an amalgam was plastered in place. Sometimes there was bleeding but the amalgam was burnished in under the fluids. Lo and behold, many are still there.

With more complex subgingival restorations, dentists set up electrosurgery. Dentists needed the clinical sense to understand biological width to avoid “frying” the bone. Of course, the unit had to be brought into the operatory, and a pad placed under the patient's back for a 30–second sweep of the tip. Some offices that use electrosurgery on a regular basis have the pad built in or preset in the chair.

Then along came bipolar units and, at a cost, the pad was not an issue. There are many great trainers in the industry. With proper coursework, this unit is a great tool for soft tissue removal, as well as retraction/troughing for crown and bridge and many other applications.

With composites today, isolation and dry field are critical. You will not get a good marginal seal if there is any moisture. For the patient who comes in with the lingual cusp fractured to the gingival level, even with electrosurge and dropping in a piece of retraction cord during the process, there are problems.

With an etch technique, the cord will get wet and have to be replaced. With current one–step bonds, the cord becomes saturated with the bonding agent and can cure to the point it has to be peeled away from the restoration. This can affect the marginal seal. Those of you who try to restore these teeth with heroic measures to avoid crowns or hold elderly restorations together, face this regularly.

In these economic times, this is the reality of a family general practice in which every patient is not a candidate for crowns or more complex dentistry. I see older patients with a tooth that is compromised, resulting in root caries that often becomes a restorative nightmare. I try to “salvage” old crowns and bridges on a more frequent basis. This requires some tissue removal around failing margins.

Medication, dry mouth, and often physical factors seem to increase this dilemma. My practice does its best to get these patients on fluorides, more frequent recalls, and products like GC America's MI Paste Plus.

In the past few years, many new diode lasers have been introduced that address this issue. Recently, with the advancement of electronics, these units have become more portable and their costs have decreased.

Let me preface my discussion by stating that I am not about to discuss all of the various laser types and cause an industry debate. I merely want to show a segment of the units that I have found clinically useful for a specific application. I hope to open some eyes to the laser world.

With one notable exception (the Zap Styla), current diode lasers are small tabletop units that weigh just a few pounds, and can easily be moved from room to room in seconds. A few are the size of an iPhone and have screens that look similar. Some have long fibers built in that you clip (cleave) after each use until you deplete the fiber. Others, meanwhile, use unidose, disposable tips.

The settings have been “dumbed down.” Most have touch screens identifying various procedures that set up at the touch of a finger. Terms like “troughing,” “gingivectomy,” and “implant exposure” appear on screens, even though an operator can alter any setting he or she chooses. You have to do some homework regarding wavelengths and wattage. Each manufacturer recommends “best settings” for its laser.

Brands such as Ivoclar Vivadent, KaVo, Sirona, Biolase, and Zap are familiar names, while Lasers4Dentistry and AMD may be less known.

AMD entered the marketplace with a diode laser for less than $5,000. Zap's Styla captured my attention with a portable diode that is about the size of a fat pen. It weighs about two ounces, and it is wireless. This includes the footpedal. The tips are “one use” and the cost of the unit is just under $10,000, but the convenience of grabbing this small unit and being able to work with it in seconds makes it a device I use daily. Zap also makes a tabletop model for less than $6,000.

If nothing else, please take a good look at the diodes available as a first step, and do a little homework on other types of lasers, applications, and limitations. There are dozens of procedures for hard– and soft–tissue, including some therapeutic processes that might amaze you.

Dr. Paul Feuerstein installed one of dentistry's first computers in 1978. For more than 20 years, he has taught technology courses. A mainstay at technology sessions, Dr. Feuerstein is an ADA seminar series speaker. A general practitioner in North Billerica, Mass., since 1973, Dr. Feuerstein maintains a Web site ( and can be reached by e–mail at [email protected].

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