A laser gingivectomy can perfect the beautiful smile you’ve worked so hard to create—here’s how to proceed
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).
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
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).
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
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.
- 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.
- 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.
- 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
- When the patient arrives, new
photographs are taken to prepare for
the appointment, then loaded and
displayed at the clinical chair.
- 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.
- 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.
- 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
- 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.
- 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
- 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
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.
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.
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).
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
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.
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.
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.
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.
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!