Soft-Tissue Contouring by Drs. Trevor Nichols and Stuart Frost

A laser gingivectomy can perfect the beautiful smile you’ve worked so hard to create—here’s how to proceed

by Drs. Trevor Nichols and Stuart Frost

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1. Discuss with the patient and/or parent to provide expectations. For us, this is typically done in the initial consultation, then repeated toward the end of treatment. In our practice, there is no additional fee for this procedure; it is included in the comprehensive fee.
2. Take excellent photographs at the debond appointment. For patients with less-than-optimal hygiene, give at minimum 6–8 weeks to allow the gums to heal on their own before the gingivectomy is performed. For those with healthy tissue, the soft-tissue recontour can be done at any time, and is sometimes done directly after the debond if time allows. Figs. 7a and 7b show the beginning of a patient case we’ll follow from debond to final outcome.
3. Schedule time for the procedure. With busy practices and many patients in need of soft-tissue contouring, finding time in the schedule can be difficult, especially considering how much doctor time is involved in the appointment. For us, the best time to schedule these procedures is during our lunch hour. We use one back-office assistant and offset their lunch. The procedure normally takes 15–20 minutes of doctor time.

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1. When the patient arrives, new photographs are taken to prepare for the appointment, then loaded and displayed at the clinical chair.
2. We use a compound topical anesthetic (Fig. 8). Application involves placing the patient in cheek retractors with slow suction to prevent swallowing of the topical. The numbing gel is administered using a small syringe (Fig. 9) along the gingival margin, left on for 5 minutes, then suctioned off. The patient then sits for 5 more minutes.
3. Prepare the laser! We use the Spectralase 980, an ultrapulse diode laser, which requires the patient, assistants and doctor to all wear protective eyewear. We prepare a cup of water with microbrushes and a cup with a diluted solution of hydrogen peroxide and a toothbrush, and use a high speed to cut a surgical suction.
4. Begin the procedure. We typically perform the contour from second bicuspid to second bicuspid on the upper arch, starting with a test spot in the posterior, then scalloping the gingival margins. Contact with the tissue is not necessary; the longer the laser is held active in a location, the more tissue that will be removed, so many times, slow passes accomplish the most.
5. In many cases, it is helpful to debulk the tissue to aid in proper margin creation. This is done simply by thinning the tissues and papilla. Normally this procedure is done at the 12 o’clock position. Once the initial pass is complete, it can be helpful to take a photograph for evaluation or to approach the patient from the front to detail the margins of the incisors.
6. During the procedure, the clinical assistant uses a slow surgical suction to eliminate odor and to catch pieces of tissue (Fig. 10). The microbrushes are used to wipe away excess tissue to allow for better visibility, while the toothbrush dipped in diluted hydrogen peroxide does a wonderful job of cleaning tissue at the end of the procedure.
7. After the procedure is completed, patient instructions are provided: The patient should brush aggressively, can take Tylenol as needed and should avoid hot, spicy and sour foods. Vitamin E oil can also be used to aid in tissue healing. New photographs are taken and scans for new clear retainers.

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References
1. Tsichlaki A, Chin SY, Pandis N, Fleming PS. How long does treatment with fixed orthodontic appliances last A systematic review. Am J Orthod Dentofacial Orthop. 2016;149(3):308–318
2. Sarver, D. Dentofacial Esthetics From Macro to Micro. Batavia, IL. Quintessence Publishing Co, Inc, 2020.
3. Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell CM. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J Clin Periodontol. 1999;26(3):153-57.
4. Sarver DM. Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop. 2004;126(6):749-53
5. Tarnow DP, Magner AW, Fletcher P. The effect of distance from the contact point to the crest bone of the presence or absence of the interproximal dental papilla. J Periodontol. 1992;68:995-6

Dr. Trevor Nichols attended Arizona State University, where he completed a bachelor’s degree in science and fitness and graduated as valedictorian. He then attended the Arizona School of Dentistry and Oral Health for his doctoral training, where he served as class president. While there, he also completed a certificate in dental public health. After obtaining his DMD, Nichols completed his specialty training in orthodontics at ASDOH and earned a master’s degree while completing research on TMD. He has also received inaugural awards in clinical excellence and leadership. Nichols is involved in organized orthodontics and as a lecturer educates other orthodontists and residents in the creation of beautiful, healthy, life-lasting smiles.

Dr. Stuart Frost graduated from the University of Rochester Orthodontics and Dental Facial Orthopedics program in 2000 and is a key expert for the Damon System, iCat and Propel Orthodontics. Frost, an associate professor at the University of the Pacific School of Orthodontics, has had the opportunity to lecture in 29 countries and has been a featured speaker annually at the National Damon Forum since 2000. He has been awarded as one of the top orthodontists in Phoenix magazine’s Top Dentists issue consecutively from 2004 to 2019, and recently published the book The Artist Orthodontist: Creating an Artistic Smile Is More Than Just Straightening Teeth!