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The Advantage: Laser Techniques and Orthodontics Robert E. Ford, DMD

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by Robert E. Ford, DMD

You have finally opened up space for the canine that was blocked out, or another tooth elsewhere that is stuck in the soft tissue. Now you are waiting for the tooth to come through, but it doesn't want to erupt. Treatment time has surpassed the original expected removal date, and the patient keeps asking how much longer he will be in braces. You realize the tissue is either too thick or too fibrous, which is preventing eruption.

Have you ever run into this situation? We, of course, are describing a soft tissue condition not a bony impaction issue. We still refer bony impactions to an oral surgeon for exposure and bonding.

You have waited and waited and finally you refer the patient to a peridontist or oral surgeon to get the tissue removed. The patient comes back several weeks later and informs you he can't get an appointment with the periodontist or the oral surgeon for another two or three months, or worse yet, maybe he doesn't have the finances to get the appropriate procedure. This leaves both you and the patient somewhat frustrated knowing all you have left to do is get one tooth into place.

There is a simple solution to this dilemma – laser surgery. The word "surgery" might turn several of you off, but in my experience, it really is a very simple and easy-to-do procedure. With the advent of lasers, these procedures can be performed with a minimal amount of anesthesia. In fact, most cases only require an easily applied topical anesthetic, which is available at most pharmacies. There is no need to have needles, syringes or carpules on hand, which quickly expire.

Prior to the surgery, we have the patient or parent (if a patient is a minor) sign a risks and limitations informed consent form for laser exposure of a tooth. The chart is reviewed for any allergies. We also double check with the patient or parent to make sure there is no prior reaction to any type of anesthetic. We go over the entire procedure and explain how simple it is and assure them they will not experience any major discomfort. Of course, we give them a chance to ask questions and address any concerns.

The surgery itself takes a minimal amount of doctor and staff time. When using these lasers, you often find the tissue is extremely thick, but the procedure still goes quickly. Most patients don't feel any discomfort at all. In almost all cases we have completed to date, there hasn't been a need for post-surgical analgesics.

Immediately after the surgery, a button or bracket can be bonded using your normal bonding procedure because there aren't any blood or tissue fluids to interfere. A wire can also be placed at the exposure visit. Then put the patient back into the normal appointment rotation which is about six to eight weeks.

Their next visit will either be an archwire change or a bonding appointment if a button was bonded previously. This procedure significantly reduces the number of appointments and treatment time required to bring the tooth into place. Overhead is reduced, and patients and parents are happy to be on the road to the end of treatment.

We use our records room, a room that is closed off from the treatment area, to perform the surgery. This way, we can ensure unprotected eyes aren't looking at the laser. The assistant applies quadcaine, a topical anesthetic formulation, onto the tissue for two minutes and then wipes it off with a cotton roll. This step is repeated two additional times for a total of six minutes of application time. A test for sensation is performed with an explorer to make sure the patient is numb and doesn't feel anything sharp. Once numb, we begin the procedure by using the laser to remove the tissue over the tooth. After the tissue is removed, we irrigate the site with hydrogen peroxide using a special sponge-tip applicator. Next, we bond a bracket or button to the tooth. Normal bonding procedures are used. Total doctor time for both the laser and the bonding is only a few minutes. Instructions to take some analgesics are given in case the patient has any discomfort later. In more than 100 patients, to our knowledge, we only have had one person take an Advil. He said he probably didn't even need it, but he took it to be on the safe side. We have not experienced any problems with this procedure, nor have we had any negative side effects.

Another situation where we have found lasers to be useful is when a tooth is lingually inclined, such as a lateral incisor, and we want to bring it forward with a removable type appliance such as Invisalign. During one of our CE courses, we learned if we first remove the tissue over the tooth, we will have an adequate amount of tooth surface area which will allow the aligner to grip it more readily. Laser surgery is done at the same appointment prior to taking the impressions, which are sent to Invisalign. We find this greatly reduces the amount of refinement in these areas. Again, there is a considerable reduction in chair time and total treatment time.



Prior to the insertion of mini screws or temporary anchorage devices (TADs), I use the laser to make a pinhole in the tissue. This allows me to go through the tissue without any bleeding. I can also measure the depth of the tissue in order to determine what size collar is needed on the TAD. Lastly, it enables me to feel around with a periodontal probe for bony contours to ensure the placement of the TADs in the proper position. I can't even begin to tell you how much easier it is to insert the TAD with the help of a laser. Prior to using the laser, I had to use local anesthetic to control bleeding with almost every case. Quite often I had to remove some of the thick tissue with a soft tissue punch, which could result in a considerable amount of bleeding and soreness. With the laser, there is little or no bleeding. This is a significant improvement over the previous technique which greatly increases patient comfort and acceptance.

When I first saw the advantages of using laser techniques at the American Association of Orthodontists (AAO) Annual Session a few years ago, I decided I wanted to give it a try. A referring family dentist kindly allowed me to borrow his laser. I began practicing on a tomato because of its similarity to gum tissue. By doing this, I got a feel for the laser before actually using it on patients. Since the device was useful, my practice purchased the Picasso from AMD LASERS located in Indianapolis, Indiana.

We've been using the Picasso now for more than a year, and have been extremely happy with what it has allowed us to do. We now have more access to the tooth, speedier eruption of the teeth, and the ability to bond brackets or attachments on the tooth quicker than we ever would have before.

The laser is easy to transport between our main office and our satellite office. It is very compact, and it comes with its own carrying case. We now use it routinely to facilitate our patients' treatment. Patients and parents are certainly appreciative of the fact that we can speed up their treatment. The general dentists are very supportive of us because most of them still do not own lasers. They actually encourage us to perform the exposures.

While these are the main procedures for which we use lasers, there have been occasions where we have used it for other purposes. Namely, it can be used to make a fine cut in the tissue to release the tension of the supercrestal fibers, better known as a fiberotomy. Another indication for use of a laser in the office would be hypertrophy of the gingival tissue due to poor oral hygiene or a reaction to the materials used in the appliances. Contouring of the soft tissue can be performed to facilitate proper oral hygiene and to provide access for the orthodontist to apply brackets, springs or other auxiliaries onto the teeth. Frenectomies due to a problematic frenum can be performed with the laser. Generally, we refer patients out for these procedures, but there have been occasions where we have done them in-house because of patient finances or time constraints.

Post orthodontic gingival contouring is a great adjunct to both orthodontic and restorative procedures. Reduction of the traditional "gummy smile" can often be accomplished without resorting to osseous recontouring, much to the patient's relief.

Many soft tissue ulcerative lesions such as apthous ulcers are also very amendable to the use of a laser. These procedures give immediate relief to our patients and are noninvasive. Just think how often an apthous ulcer appears in our patients. We now have an easy method to relieve their discomfort and accelerate the healing of such conditions.

The cost of lasers has come down significantly. Therefore, for our procedures, we do not charge an additional fee. We look at it as a side benefit to reduce treatment time and reduce overhead. Ultimately, you will have to decide what procedures you are most comfortable performing in your office, and whether the laser is a good investment for your practice.
Author’s Bio
Dr. Robert Ford is a graduate of Marquette University where he received a Bachelor of Science in Mechanical Engineering. After completing the U.S. Naval Nuclear Power training program, he served as an officer in the U.S. Naval Submarine Service for six years. He graduated from the University Of Florida College Of Dentistry in 1981 and completed the postgraduate program in Orthodontics at the University of California, San Francisco, in 1984. Dr. Ford has been in the exclusive practice of orthodontics since 1984. Ford is a member of The American Association of Orthodontists (AAO) as well as all local, state, and national dental and orthodontic associations. In addition to his dental license, Ford is a Licensed Professional Engineer in Quality Assurance and Reliability Engineering.
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