Lasers Saved My Bacon

Lasers are like seat belts; you don’t absolutely need them everyday but when you do, you’re very glad you have them.  A patient in his mid-thirties with negative medical history presented with a chief complaint “My front tooth is loose.”  I was able to remove # 8 with gauze and finger pressure.  Here’s the clinical and radiographic appearance:

So we have an exfoliated prefabricated post/core/PFM crown.  Normal probing, asymptomatic, no decay present, and dental history significant for a fracture of # 8 when he was a kid.  He’s had the same crown now for almost thirty years.  Is there a recurrent periapical radiolucency?  Hard to say, more on that later…

So the treatment plan is a new post/core/crown, right?  We can use a fiber post with dentin-shaded core material and a nice all-ceramic crown.  We’ll get rid of that ugly metal margin from the PFM which will be nice, especially since the patient has a slightly high smile line.  I’ll send the patient to Marotta for a custom shade selection to match # 9 as close as possible since he doesn’t want a veneer on # 9.  Are we good to go?

The one thing the pictures don’t relay is the smell.  There was a faint but distinct odor of funk that even the patient noticed.  So there’s that.  The other thing is the hyperplastic gingival tissue growing over the margin on the facial and mesial.  Hmm…

Occlusal view: note the extra tissue growing in on the mesial and facial.

My conclusion after those two factors is that this tooth had been loose for some time.  The patient states he had noticed the looseness for a couple of weeks.  My theory is that the funky odor comes from bacteria leaking underneath the crown and having a party in the endodontic space.  Although there’s no decay or obvious recurrent periapical radiolucency yet, we would be wise to assume that the gutta percha has become contaminated.  The redundant gingival tissue provides greater evidence that there has been a marginal discrepancy for a little while.  The gums grew in to fill the space as if it were an extraction socket.  Oh gums, you so crazy.

Let’s get this tooth ready for a trip to the endodontist.  I don’t just slam some temporary cement in there.  I need to create a seal.  This is for two reasons: (1) when the retreatment is complete, we need a good seal to prevent bacteria from invading again, and (2) a loose crown is going to keep falling off and annoy everybody.

So we’ll add acrylic to the post/core/crown to seal the margins.  But first we have to get rid of that hyperplastic tissue.  This is a great indication for a soft tissue laser since it will cauterize the wound as we cut.  That means no bleeding to mess up my curing acrylic.

I used my Picasso Lite (AMD Lasers) and removed the tissue under local anesthesia.  I prefer a laser to a scalpel because I see little or no bleeding and virtually no post-operative discomfort.  Also because… lasers!

Laser gingivectomy looking bad ass.

Now I can reline the post/core/crown with acrylic and get a nice seal.  We can use some temporary cement and send him to the endodontist.

Post/core/crown before and after relining with acrylic. We’ve got a reliable provisional for the endodontist.

The real hero here was the laser.  Imagine doing the gingivectomy with a scalpel and trying to get a nice seal of acrylic with blood everywhere.  Yeah, not so nice.  But the laser saved us time and got us a better result.