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

Categories: Orthodontics;
Soft-Tissue Contouring 

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


As orthodontists, we’re always looking for ways to improve our finishes. We spend an average of 14–33 months aligning teeth, widening arches, dialing in smile arc and correcting malocclusion, but many times we’re left disappointed because our beautiful work is hidden by thick, erythematous, unhealthy tissue.1 In some cases, this tissue will heal on its own over time, although with most it remains imperfect, hiding or distorting our amazing result (Figs. 1a–1c).

Soft-Tissue Contouring
Fig. 1a
Soft-Tissue Contouring
Fig. 1b
Soft-Tissue Contouring
Fig. 1c


We’re in the smile-making business—not just straightening teeth, correcting bites and making retainers. The smiles we provide are our product; they’re what we sell, what sells for us and the legacy we leave with patients and within the community. We want to create the best smiles we can, and that includes a result that’s free from distractions such as asymmetric gum tissues or smiles where the true beauty of the teeth is hidden.

A simple and quick contour of the gums can dramatically improve your finishes. Yes, it takes time—and we’ll discuss the flow of how we manage this in a busy practice—but the value is tremendous. It will increase your following and your brand and, most importantly, it will help you provide your patients with the confidence of an incredible smile.

Taking some measurements

The best way to describe how this process is accomplished is to begin with the end in mind. Just like a sculptor imagines what’s under the clay, we too must have an artistic vision of what we want to create.

For this, we can lean on many great orthodontists who have provided us a model of these principles. (For example, Dr. David Sarver discusses macro-, mini- and microaesthetic models and how these principles can produce superior outcomes. Figs. 2 and 3 show miniaesthetics and microaesthetics, respectively, as presented by Sarver.2)

Soft-Tissue Contouring
Fig. 2
Soft-Tissue Contouring
Fig. 3

From this, we can take a close-up smiling photograph of the patient to plan our procedure using the principles of both mini- and microaesthetics. We encourage doctors who are just beginning this process to print out the close-up smiling photograph of the patient and draw the appropriate gingival margins to practice the clinical procedure.

If clinicians are looking for additional guides on gingival recontouring and how tissue should be managed, it can also be evaluated through measurement of the clinical crown. Fig. 4 demonstrates studies performed by Sterrett, et al.,3 that show average clinical crown length and height as well as relation between width and height of central and lateral incisors.

The gingival contour with the lateral incisor should be 1 millimeter below the apical limit of the central incisor and the canine4 (Fig. 5).

The gingival zenith is the highest, or tallest, point of the gingival margin curvature. Sarver4 suggests that the ideal position of the apex of the contour of the lateral is the center of the crown, and distally displaced on the central and the canine (Fig. 6).

Soft-Tissue Contouring
Fig. 4
Soft-Tissue Contouring
Fig. 5
Soft-Tissue Contouring
Fig. 6


Finally, it’s important to know the depths of the pockets to determine how much tissue can be removed, and if crown lengthening might be necessary. We will normally attempt a gingivectomy even in cases where crown lengthening might be necessary: We inform the patient that if the tissues rebound, we will send him or her to a periodontist or oral surgeon for a crown-lengthening procedure.

Research tells us that the minimum pocket depth is approximately 2mm for biological width and that 5mm is needed between the alveolar bone crest and the contact point.5 Therefore, if a pocket depth is 5mm, one can predict that 3mm of tissue can be removed with predictable healing.

The initial steps

The best way to start is just to start: Pick a case and go for it! Err on the side of removing less tissue and take excellent photographs, study them, improve and keep going. For those who have taken advantage of this great opportunity, keep improving.

Now that we have the vision in mind, it’s time to discuss the process and the recipe for success. These steps provide a “cookbook” approach to gingival recontouring.

  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.
Soft-Tissue Contouring
Fig. 7a
Soft-Tissue Contouring
Fig. 7b


Appointment details

  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.

Soft-Tissue Contouring Fig. 8
Soft-Tissue Contouring
Fig. 9
Soft-Tissue Contouring
Fig. 10

Figs. 11a and 11b show photographs directly after the procedure.

The patient is recalled about 3 weeks later to update records and to check healing and retention. In most cases, the healing process is completed by this time; Figs. 12a and 12b show the patient 3 weeks after the procedure; Figs. 13a and 13b compare before and after the soft-tissue contour.

Soft-Tissue Contouring
Fig. 11a
Soft-Tissue Contouring
Fig. 11b
Soft-Tissue Contouring
Fig. 12a
Soft-Tissue Contouring
Fig. 12b
Soft-Tissue Contouring
Fig. 13a
Soft-Tissue Contouring
Fig. 13b


Additional details and suggestions

Having a stellar finish includes several key characteristics. Of these, it is important to show 100% of the upper incisor with 1–2mm of gum tissue; showing more gum tissue can be distracting to the smile and leads people to have insecurities with their full smile.

Gummy-smile treatment with TADs or surgery should be distinguished from those in need of gingivectomy. There are many references to judge this from measurement of tooth size, incisor display at rest and more.

Many patients who have gummy-smile treatment are also in need of a gingivectomy. Figs. 14a–c show a gummy-smile case treated with TADs and a gingivectomy.

Soft-Tissue Contouring
Fig. 14a
Soft-Tissue Contouring
Fig. 14b
Soft-Tissue Contouring
Fig. 14c


We have found in our practice that providing this service to patients has helped to grow our brand and our reputation in the community. We have been sent several cases by local dentists and even periodontists for orthodontic treatment and gingival recontouring. Much of what we do in orthodontics is so slow, and this is a simple and quick procedure that leads to better outcomes and happier patients (Figs. 15a and 15b).

Soft-Tissue Contouring
Fig. 15a
Soft-Tissue Contouring
Fig. 15b


For predictable healing, some cases do require the frenum be reduced (Figs. 16a–c) in order for the gums to heal properly. The combination of orthodontics and gingival recontouring can truly change lives (Figs. 17a-c)!

Soft-Tissue Contouring
Fig. 16a
Soft-Tissue Contouring
Fig. 16b
Soft-Tissue Contouring
Fig. 16c
Soft-Tissue Contouring
Fig. 17a
Soft-Tissue Contouring
Fig. 17b
Soft-Tissue Contouring
Fig. 17c


When we consider all that goes into making a case beautiful and the amazing opportunity we have as providers to increase confidence and allow patients to do things that they otherwise might not do, we must push our limits and expand our knowledge and skill. Like anything, this comes with education and repetition.

We encourage those who have yet to explore the wonderful world of lasers to do so! This will add great value to your practice and to your patients. We have truly come to love our lunch laser hour, because we see these great transformations. By doing these procedures, we feel more fulfilled as providers and our reputation has grown and expanded beyond what we thought possible.

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

Author Bio
Dr Trevor Nichols 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 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!

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