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Gingivoplasty Using Diode Laser

Introduction- An excessive display of gingiva resulting from a high lip line and abnormal gingival overgrowth often complicates treatment planning and can compromise the final esthetic result. Gingival morphology is being considered as an important factor in smile designing. One significant feature of gingival morphology is the gingival line, which is defined as the line joining the tangents of the gingival zeniths of the central incisor and canine. The gingival zenith is the most apical aspect of free gingival margin. With the current emphasis on cosmetic concerns and esthetics in dentistry, lasers are increasingly being used to accomplish esthetic treatment goals. Etiology- It may be due to altered passive eruption of teeth, dentoalveolar extrusion, short or hyperactive lip muscles, short clinical crown, extensive subgingival caries, and subgingival tooth fractures at dentogingival junction. Treatment is performed to improve the dental esthetic by increasing the clinical crown height, thus it restores the normal dentogingival relationships. Treatment modality-.Gingivoplasty is a procedure reshaping the gingival tissue around the teeth. It is not a very traumatic or invasive procedure and often results in healthy, natural looking gums. It can be performed by periodontal knife/scalpel/rotary coarse diamond burs/electrosurgery etc. Moreover these techniques are prone to side effects and complications like surgical trauma, postoperative pain, swelling, bleeding after excision, poor patient acceptance and coronal migration of the soft tissue margins is also seen during healing which makes it difficult for recording the finish lines after the tooth preparation. After evolution of LASERS, conventional techniques are replaced by LASER Gingivoplasty. PIOON Laser offers different wavelengths like 450nm/810nm or 980nm. Out of which 450nm can used in non-contact/contact mode whereas 810nm and 980nm are used in contact mode in order to perform gingivoplasty. The most preferred among them is 450nm wavelength. In the present case, the smile analysis revealed irregular gingival contour and midline diastema. Initially, it was observed that the tooth axis and the gingival zenith contours were not satisfactory. Prior to the diastema closure it is important to normalize the gingival zenith. Firstly Assessment of Biological width was done by probing to the bone level (referred to as "sounding to bone") and subtracting the sulcus depth from the resulting measurement. If this distance is <2 mm a diagnosis of biologic width violation can be confirmed. As there was sufficient sulcus depth of 4mm, gingivoplasty procedure could be performed with laser in this case to lengthen the tooth without encroaching the biological width which was followed by midline diastema closure with composite restoration. Thus, the procedure performed with laser is less invasive and its hemostatic property enables the restorative procedures like closure of midline diastema to be performed in one appointment with predictable clinical results. Fornaini C et al. in 2016 carried out the study to compare the effectiveness of the different laser wavelength and they concluded that use of wavelength 450nm gives a proper contouring to the gingiva with less thermal damage to the tissues which accelerates the healing time.

Excision of Mucocele Using Dental DIODE LASER

Introduction- Mucoceles are known as “mucus filled cavities” usually present in the oral cavity, lacrimal sac, and paranasal sinuses. Preoperative View (Courtesy – Dr. Sana Farista) Etiology - Mucus extravasation and mucus retention are the two most frequently occurring primary mechanical obstructive diseases of salivary glands. Formation of mucus extravasation cyst is mainly due to mechanical trauma causing rupture of ductal system of salivary gland and mucin spills into adjacent soft tissues. Mucus retention cyst is formed markedly by obstruction of salivary ductal walls causing dilatation of ducts without spillage of mucin. Treatment - Although mucoceles may occur literally anywhere in the oral cavity, the most common sites of occurrence are the lower lip. These lesions are soft, fluctuant and closer to the surface. They have a slightly bluish tinge as the mucin shine through. Mucoceles are benign lesions and do not necessarily warrant removal unless their size causes hindrance or they look unaesthetic. There are various treatment aspects available for the management of mucocele like scalpel incision, complete surgical excision, marsupialization, micromarsupialization, intralesional injections of corticosteroids, cryosurgery, laser ablation, sclerosing agent, and electrocautery methods. The conventional treatment includes removal by a surgical excision wherein the entire mucoceles is removed in toto along with any accompanying minor salivary glands to minimize recurrence. One of the more popular methods for mucocele excision is via a diode laser. The main advantages of soft tissue laser applications are minimal intraoperative bleeding and swelling, minimum postoperative pain, very less surgical time, without any need of suturing after excision because of natural wound dressing due to denatured proteins. After informed consent, the lesion is infiltrated with local anesthesia, the protective eye wears are worn and then the lesion is excised using soft tissue diode laser with either wavelength of 810nm/980 nm in contact mode or with450nm wavelength in noncontact or slight contact mode. After the procedure, postoperative instructions are given and analgesic is prescribed on SOS basis. Also, care should be taken to get rid off the cause (sharp cusps or fractured tooth if any) along with the excision to make the treatment outcome more predictive. Here low level laser therapy can also be done over the exposed wound area using 660nm (red light) in noncontact mode to assist in faster healing and to manage postoperative pain.
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Gingival Depigmentation with Dental Lasers for Management of Gingival Hyperpigmentation

Introduction - Gingival hyperpigmentation is a common esthetical concern in patients with gummy smile or excessive gingival display. It is an overproduction of melanin, beyond the normal expected degree in the oral mucosa, induced by various causes. Etiology - Several physiologic and/or pathologic factors can cause hyperpigmentation. Gingival hyperpigmentation is mostly caused by the physiologic deposition of a brown pigment, melanin produced by melanocytes in the basal and supra-basal cell layer of the gingival epithelium. The colour of gingiva depends on the intensity of the melanogenesis, degree of epithelial cornification, depth of epithelialization and the arrangement of gingival vascularity. Treatment Modalities – Gingival depigmentation is a treatment to remove melanin hyperpigmentation of the gingiva and various methods have been used for this procedure with different degrees of success including gingivectomy, gingivectomy with free gingival autografting, electrosurgery, cryosurgery, chemotherapy with 90% phenol and 95% alcohol and abrasion with diamond bur. Moreover some of these techniques are prone to side effects and complications. However, Laser therapy is an effective and noninvasive treatment option for Gingival Depigmentation.  In depigmentation process the epithelial tissue exhibiting excessive melanin pigments is ablated using diode lasers. PIOON Laser offers different wavelengths like 450nm, 810nm/980nm which can either be used in contact or non-contact manner to perform this procedure. Most recommended for an effective treatment procedure is the blue light (450nm) which can be backed by a report by Kenneth Luk in 2017 where he studied the comparison between the 810nm and 445nm working in a noncontact mode to perform depigmentation of gingiva. He stated that 445nm is much better absorbed by melanin and haemoglobin than 810 nm and hence, a much lower power density can be used for the treatment. Manaf Agha in 2020 concluded that lesser the power settings used for the procedure, faster would be the healing with much less discomfort to the patient leading to greater acceptance of the procedure. Before laser irradiation, the operating staff, assistant and the patient wears special laser-protective eye glasses corresponding to laser wavelength, highly reflective instruments or instruments with mirrored surfaces are avoided and most of the times only the use of topical anesthesia suffices for a painless laser tissue ablation.

Treatment of Gingival Melanin Hyperpigmentation using Dental Diode Laser

A beautiful smile surely enhances the individual’s self-confidence. The esthetics of smile though majorly influenced by the color, shape, and position of the teeth, is also influenced by the color of the gingival tissues. The color of gingiva is influenced by the vascular supply, thickness and degree of keratinization of the epithelium, and presence of various pigments. Among these, the major factor contributing to the color of gingiva is melanin. Gingival hyperpigmentation does not pose any medical problem, but many patients may consider this an esthetic problem, particularly patients who have excessive gingival display or gummy smile. The most common cause is physiologic pigmentation i.e. melanin production, although some adverse habits such as smoking can further stimulate melanin pigmentation, and so intensity of pigmentation is also related to the duration of smoking and number of cigarettes consumed. Treatment Modalities Gingival depigmentation is a treatment to remove melanin hyperpigmentation of the gingiva and various methods have been used for this procedure with different degrees of success including gingivectomy, gingivectomy with free gingival autografting, acellular dermal matrix allograft, electrosurgery, cryosurgery and abrasion with diamond bur. The drawbacks of these techniques are intraoperative and post-operative bleeding, need for anaesthesia, need of periodontal pack/dressing, risk of post-operative infection, edema etc. Laser with different wavelengths have been used easily with well-tolerated and good esthetic outcomes. In depigmentation process the epithelial tissue exhibiting excessive melanin pigments is ablated using diode lasers. PIOON Laser offers various wavelengths that can either be used in contact or non-contact manner to perform this procedure. In the present case only topical anesthesia was applied, wavelength of 980nm was used in contact mode in scrapping motion at ablative settings for removal of the pigmented epithelium and a part of connective tissue, leaving behind the rest of connective tissue intact. After the procedure, laser bandage was done, postoperative instructions were given and patient was kept on follow up. Hanaa M. El Shenawy et al in 2015 used 980nm wavelength and concluded that the use of diode laser is a safe and effective treatment modality that provides optimal aesthetics with minimal discomfort in patients with gingival hyperpigmentation. Eser Elemek in 2018 also suggested that the use of 810nm diode laser for gingival depigmentation resulted in complete healing with maximum esthetic outcome and minimum patient discomfort. Rationale behind Use of Lasers Laser is absorbed by pigments (melanin and haemoglobin) in the soft tissue, thus making it an excellent modality for depigmentation procedure with minimal amount of bleeding. It also offers easy handling of tissues, less chairside time, potential decontamination and sterilization.  It also forms protein coagulum on the wound surface which act as a biological wound dressing, sealing the ends of sensory nerve endings hence obsoleting the need of periodontal packs/dressings, thereby making the aesthetic laser treatment more acceptable for the patients. Conclusion The use of a diode laser is a safe, effective, quick, and minimally invasive. They provide optimal aesthetics with reduced discomfort to the patients during and after procedure.
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Vestibuloplasty Procedure using Dental Diode Lasers

Introduction-The shallow vestibule was one of the mucogingival problems cited by Friedman in the late 1950s that required apicocoronal dimension of gingiva. Problems with shallow vestibule includes, - Unable to perform intra-sulcular cleaning or modified Bass method, as it requires placement of tooth brush bristle into the gingival sulcus. In patients with reduced vestibular depth this couldn’t be possible. Thus it interferes with oral hygiene procedures causing ineffective plaque control.  It compromises the denture retention and stability, predisposes the gingiva to recession which compromises the esthetics and often leads to dentinal hypersensitivity and root caries on exposed root surface. Vestibuloplasty is a mucogingival procedure that aims at the surgical modification of the gingiva-mucous membrane relationships including deepening of the vestibular trough, altering the position of the frenulum or muscle attachments, and widening of the zone of attached gingiva. It is indicated to halt the progression of gingival recession, to regain the width of attached gingiva, for effective plaque control procedures, better esthetics, to improve denture retention and stability, and to prevent inflammatory alterations and tissue recession around implants. It is contraindicated in areas showing bone loss due to chronic periodontitis or traumatic extraction and in cases with ridge resorption around implants. Treatment Modalities- A variety of vestibuloplasty techniques have been advocated in literature such as Clark’s vestibuloplasty, Edlanplasty, Kazanjian vestibuloplasty, etc. Most of these techniques have been used as pre-prosthetic procedure to enhance the vestibular depth related to edentulous denture bearing areas. Major drawbacks of these conventional vestibuloplasty procedures were the severe pain and discomfort and the delayed healing with the high chances of relapse making them less acceptable. Laser vestibuloplasty with the Diode laser represents a contemporary non-invasive alternative to conventional scalpel method. PIOON Laser offers different wavelengths like 450nm, 810nm/980nm which can either be used in contact or non-contact manner to perform this procedure. In this case wavelength of 450nm was selected and 400 micron initiated tip was used in non-contact/slightly contact mode, starting at the mucogingival junction with a horizontal stoke directing the laser parallel to the bone slowly relieving the muscle fibers till the desired depth. Laser safety glasses were worn by the clinician, assistant and the patient and proper precautions were taken. According to a study by Carlo Fornaini et al 2016, blue light lasers provide minimal discomfort to patients with little traces of carbonization in the histopathological investigation. Again an interesting study by C. Fornaini et al 2017 suggested decreased excision time with a blue diode laser (wavelength 450nm) with much lesser rise in temperature. Rationale behind Use of Lasers  Lasers offer an array of advantages over the traditional scalpel in providing a clean sterile field with excellent hemostasis for the clinician and by providing less pain and swelling postoperatively for the patient.