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ePaper created 2016-06-17, 09:51:15 | version 1.38.0
May-June 2016 | No. 3, Vol. 6 Published in Dubai www.dental-tribune.me Implant uncovery with the Picasso diode laser By Gregori M. Kurtzman, DDS, MAGD,DICOI,DADIA Introduction Dental implants are placed either utilizing a 1-stage approach (healing abutment placed at implant place- ment)ora2-stageapproach(implant is covered by soft tissue at time of placement) and modification of the soft tissue to expose the implant ful- ly may be required. When the pros- theticphaseisinitiated,softtissueto either removed to uncover the im- plants or reshape the gingival mar- gin for better esthetics which can be accomplished by several methods. A cutting instrument, (ie. Scalpel or tis- sue punch1) has been the traditional approach to incise through the soft tissue to the underlying implant. The result is a bleeding edge that can interfere with impressions if they are to be taken at the same appoint- ment. Additionally, post-operative sensitivity has been reported and can result from the fresh cut edge. Typicallyadelayof2weeksorlonger is required before impressions can be taken so that bleeding doesn’t hamper the accuracy of how the soft tissueiscaptured. An alternative to the blade, electro surgery has been offered as it can cauterize the cut edges and decrease post-operative bleeding. Yet, this presents with two negatives out- comes to their use in and around dental implants. Electro surgery re- quires a circuit be formed between the monopolar tip intraorally and the surgical unit with a grounding plateplacedonthepatientadistance from the oral cavity. When the cur- rent is activated it flows between the electro surgery tip through the soft tissue to the grounding plate, completing the circuit with the me- tallic implant conducting the cur- rent along the path.2 Temperature increases have been reported that whenexceedingathresholdof10de- grees C at the osseous interface with the implant may lead to bone loss and possible de-integration of the implant. A general recommendation is to avoid electro surgery units in andarounddentalimplants. As electro surgery affects cell layers deeptothesurface(deeperpenetrat- ing), combined with the tempera- ture increase tissue shrinkage is of- ten reported. 3 Necessitating a delay between uncovery and impressions to allow the cut edge of gingival tis- suetostabilizeisrequiredsothatthe gingival margin captured is stable when the prosthetics is returned for insertion. Increasing diode lasers are being uti- lized in dental practices both due to lower costs to implement this tech- nology then the more expensive CO2andND:YAGlasersandthewide rangeofeffectivetreatmentafforded bythesedevices.Diodelasers,suchas the Picasso (AMD Lasers, Indianapo- lis, IN, www.amdlasers.com) (Figure 1)provideadequatepowertomodify soft tissue in and around the dental implant for uncovery or alteration of the gingival margin to improve the esthetics. Additionally, these op- erate within the temperature range recommended so that the negative effects associated with electro sur- gerydonotoccurtothebonearound theimplant.4 Coagulationcanalsobe controlledcombinedwiththelackof tissue shrinkage following use of the diode laser allowing impressions to be taken at the time of uncovery. As the diode laser affects fewer cell lay- ers, tissue response does not involve an inflammatory response that can lead to tissue shrinkage during the healing period the first few weeks af- tertreatment.5-9 (Figure2) Utilizationofthediodelaser Diode lasers are primarily used in a contact application when cutting or coagulation is required.10 The diode laser tip is used in either an initiated stateoranuninitiatedstate.Initiated refers to the tip of the diode laser which has been coated with a block- ingmaterial.Thisallowsenergyfrom thediodewhenactivated,toheatthe tip causing cell ablation (vaporiza- tion) at the contact point with cut- ting resulting.11 The light energy in the coated tip is converted into heat by refraction of the blocking mate- rial on the diodes tip creating a “hot tip”. This secondary thermal effect of the heated tip allows cutting or incising of the soft tissue. An area of carbonization at the border of the vaporization results. Coagulation oc- cursinthetissueborderingthiszone ofcarbonizationasaresultofcontact with the overheated tip rather than by the laser energy itself. (Figure 3) Bacterial decontamination can be accomplished with an initiated di- ode tip which is useful in treatment of peri-implantitis on the implants surface or within the periodontal sulcus/pocket around implants and naturalteeth. Initiation of the tip is accomplished with the diode set at 0.5 watts and touched to a piece of blue articulat- ing paper (Bausch Ref BK05) and the laser is activated for 1 second. This is repeated 6-8 times contacting differ- ent areas of the tip so that when fin- ishedtheentiretipand3-4mmofthe sides has been marked with the ar- ticulating paper. It is recommended to avoid articulating ribbon as it will ignite and is ineffective in initiating the tip. A properly initiated tip will glow orange when the foot pedal is depressed.12 The tip should be wiped with a piece of dry gauze to remove debris periodically as it is being uti- lized to maintain efficiency. When cutting fibrous tissue it may be nec- essary to reinitiate the tip during the procedure when the tip appears to notbecuttingwell. Cutting efficiency is related to watt- age. The higher the wattage, the faster the soft tissue is vaporized. But a greater zone of unwanted lat- eral thermal damage may result. It is advised to use the lowest wattage to accomplish the task to avoid the risk of thermal damage within the adjacent tissue. The assistant during usageofthediodelaserusestheHVE near the site to remove any odors and periodically can spray water on the site to aid in cooling the tissue. This also minimizes thermal issues which improves initial healing. To remove the soft tissue covering the implants cover screw or reshape the tissueforestheticsasettingof0.8-1.0 watts in a continuous mode is usual- ly sufficient. A 400 micron diode tip (orange) is utilized for oral and peri- odontal surgical applications. The 300 micron tip (purple) is designed for periodontal applications such as Laser Assisted Periodontal Treat- ment(LAPT). Beyond the carbonization zone, an area of hemostasis (coagulation) occurs. Typically sites treated with the diode laser will demonstrate lit- tle to no bleeding depending on the condition of the tissue prior to treat- ment. Tissue that is hemorrhagic will require longer contact with the diode laser to achieve coagulation and may ooze due to the inflamma- tion present prior to laser treatment. The coagulation affects and lack of post treatment tissue shrinkage al- lowimmediateimplantimpressions shouldthatbedesired The laser also creates an area of bi- ostimulation adjacent to the coagu- lationarea. Tissues and cells following irra- diation with a diode laser, have a Figure1:PicassoDiodeLaser(AMDLasers) Figure 2: Comparison of the depth of affected cells with an electrosurgery unit andadiodelaser Figure 5:When minimal keratinized gingiva is present, the diode laser is utilized to make an incision distal-mesially and the tissue is spread conservingallof theattachedgingivapresent. Figure 6. Buccal view of the anterior maxilla demonstrating preservation of the papilla due to theprovisionalbridge. Figure 7. Occlusal view of the anterior maxilla demonstrating preservation of the papilla due to theprovisionalbridge. Figure 8. Picasso diode laser removing soft tis- sue touncover theimplantscoverscrews. Figure 3: Tissue reaction upon con- tact with an initiated diode laser tip demonstrating the effect as one movesawayfrom the tip Figure 4: Implant to be uncovered (A) presents with two options depending on width of attached gingiva available. Wide band of attached gingiva will remain after removal of tissue over cover screw, the diode is utilized in a spiral pat- ternstartingatcenteruntilfullyexposed(B).Narrowbandofattachedgingivapresent,anellipticalcutismadewiththe diodeand tissueispushedbuccallyandlingually topreserve theattachedgingiva(C). ÿPage2