Written by Scott D. Benjamin, DDS
Figure 1 Pretreatment natural smile.
Figure 2 Pretreatment; note the gingival contours and coronal coverage.
Figure 3 Immediate posttreatment; note the gingival height and absence of bleeding.
Figure 4 One week posttreatment with provisional restorations; note the consistency of the gingival height with the immediate postoperative image and the healthy, stippled consistency of the gingival tissue. Photos courtesy of Dr. Michael Swick.
Figure 5 The movement of the laser fiber in a back-and-forth motion similar to that of a pencil eraser, with the fiber parallel to the long axis of the tooth with the laser energy directed away from the tooth structure.
Confusing and often misleading technology is used by both clinicians and salespeople to describe laser dentistry; the term “soft-tissue crown lengthening” is one of the most common. According to the ADA’s Current Dental Terminology 2009-2010 (CDT 2009-10), the procedure does not exist.1 However, this does not negate the need to perform a procedure to correct soft-tissue asymmetry, or to establish the proper clinical crown length, or crown-to-root ratio, or a healthier and more esthetic gingival contour.
The CDT 2009-10 does list the procedure “D4249 clinical crown lengthening—hard tissue.”1 This is a periodontal procedure in which gingival and osseous tissue is removed in order to expose more clinical tooth structure. As the terminology implies, for appropriate reimbursement, some osseous recontouring or removal must be performed as part of the treatment. It requires reflection of a flap and is performed in a healthy periodontal environment.2 This code is appropriate where the preparation of a restoration violates the biologic width of the periodontal attachment apparatus, or where there is less than 3 mm of tooth structure remaining between the alveolar crest and the restorative margin as noted by radiographic review or bone sounding.3 Because of this code’s requirement of an osteotomy or an osteoplasty, it would be inappropriate to use it for a strictly soft-tissue procedure.
Code “D4211—Gingivectomy or gingivoplasty—one to three contiguous teeth or bounded teeth spaces per quadrant”4 is a soft-tissue procedure. By definition it involves the excision of the soft-tissue wall of the periodontal pocket and is performed to eliminate suprabony pockets after adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargements or asymmetrical or unesthetic topography is evident with normal bony configuration.5 Gingivectomy may be the appropriate code to use for the “soft-tissue crown-lengthening” procedure, as it is strictly a soft-tissue procedure.
However, there may be specific plan restrictions that exclude coverage in some situations. These exclusions vary and may include but are not limited to: other procedures performed on the same tooth on the same date, optional treatment performed for cosmetic (esthetic) purposes, or to correct congenital or developmental defects and gingival pocketing of less than 5 mm.
When submitting any periodontal procedure for third party (insurance) reimbursement, all practices need to follow the ANSI/ADA Specification No. 1047—Standard Content of an Electronic Periodontal Attachment, which was adopted by the ADA in 2006. It was developed to standardize the uniform content requirements for the documentation to be included in a periodontal attachment to the original claim form to enable claims adjudication for various periodontal procedures.
A clinician should never determine a patient’s treatment needs based on their third-party coverage. However, both the patient and the clinician need to set realistic goals, treatment objectives, and expectations that are financially realistic and acceptable to the patient.
With all that being said on procedural terminology, clinicians should always consider the benefits and techniques of a laser-assisted, soft-tissue crown-lengthening procedure. The goal of this procedure is to create gingival contours and anatomy that is healthy, maintainable, and esthetically pleasing. This enables the creation of the proper symmetry, clinical crown-to-root ratio, and incisal–cervical to mesial–distal ratios in the dentition.
The proper use of a dental laser can simplify the procedure for both the patient and the clinician with very predictable outcomes. Almost any wavelength of surgical lasers can be used for this procedure with slightly differing degrees of ease and success. The precise control over the tissue interaction that lasers provide minimizes, if not eliminates, any postoperative discomfort and enables a very predicable outcome, with minimal to no bleeding both during and after the treatment.
This ability to manage the soft-tissue interactions with a laser is very desirable for both the patient and clinician and enables multiple procedures of both periodontal and restorative nature to be performed in the same appointment. However, this can also cause some patient management and reimbursement issues at the same time. Often, when any soft tissue treatment is performed on the same day as a restorative procedure it will be perceived, by the patient and especially insurance carriers, as an incidental process that is part of the restorative care. An example of this is the use of a laser for soft-tissue troughing around a crown preparation instead of using retraction cord for tissue management. The troughing should be considered an incidental process and part of the methodology of the crown procedure.
However, soft-tissue crown lengthening or a gingivectomy/gingivoplasty is often perceived as an incidental procedure, which it is not. One of the best ways to manage these perceptions is with proper documentation as mentioned above. A strictly soft-tissue procedure such as this will not show any radiographic changes between the pre- and post-treatment images. Nevertheless, diagnostic radiographs are required to assist in determining the osseous architecture and ruling out any other pathology. Additionally, the use of photo-documentation with both pre- and posttreatment images can demonstrate what was needed and what has been accomplished.
