Introduction        

An operculum is a flap of gingival tissue typically distal to a molar that remains as a sequela of the eruption1, see Figure 1.



In some cases, operculum can lead either to pain due to the occlusion of the opposing maxillary molar (in this instance the pericoronal gingiva becomes inflamed and often ulcerated due to trauma) or to local inflammation/infection due to food debris and plaque accumulation between the tooth surface and the gingival flap.1 The inflammation in the soft tissues surrounding the crown of the partially erupted tooth is called pericoronitis.2,3 It typically arise in teeth that erupt very slowly or become impacted. When the follicle of the tooth communicates with the oral cavity, bacterial penetration into the follicular space instigates the infection. 2 It is generally agreed that this process is potentiated by food debris entrapped in the proximity to the operculum and occlusal trauma of the pericoronal tissues by the opposing tooth.2,4 Pericoronitis may be acute or chronic. The acute pericoronitis is characterized by severe radiating pain, localized swelling of the pericoronal tissues, purulence or drainage (hence unpleasant taste), trismus, regional lymphadenopathy, painful swallowing, pyrexia, sometimes spreading of the infection to adjacent tissue spaces.2,3,4 Chronic form may be characterized by dull pain or discomfort, often accompanied by bad taste, lasting a couple of days with remission lasting several weeks of months.2,4  Stress, pregnancy or fatigue are often associated with an increased occurrence of pericoronitis. Diagnosis of pericoronitis is done on the basis of the symptoms and clinical presentation.
 

Treatment

The painful and/or inflamed/infected operculum can be removed by operculectomy - the surgical excision or ablation of the operculum via a wide variety of techniques: scalpel, caustic agents, radiofrequency surgery, electrosurgery, cautery, CO2 laser or via hot tip diode surgery.1,2,4,5,6,7 Operculectomy, however, is also advocated as a precaution to prevent pericoronitis. In orthodontics, operculectomy is performed to aid molar eruption (even in the absence of pain) and/or gain access to the tooth for banding or bonding purposes.1,8,22 Convissar et al.22 and Chmura8  state that removing gingiva with the laser allows for an immediate banding or bonding due to its hemostatic effect.
One of the potential disadvantage of operculectomy is that it may prove to be a temporary measure, because operculum can regrow, which may lead to new trauma and inflammation.3 In such cases the removal of the offending molar may be indicated.2,3



Tip-retainer laser handpieces utilize disposable hollow focusing tips (made of high-temperature resistant aluminum oxide ceramic – see Figure 4) with 250 µm spot size allow for intra-sulcular periodontal applications.
Disposable-free “tipless” CO2 handpieces are designed to closely simulate the scalpel-like experience without making any contact with the tissue. Maintaining 1-3 mm distance between the distal-end of the handpiece and the tissue (see Figure 4) is required to achieve the designated spot size for cutting.
 

Operculectomy by CO2 Laser Ablation – Case Study

Initial Findings

The patient presented with a raised, inflamed, painful operculum distal to the left mandibular second molar (Figure 1). The lesion was red, edematous, and bled easily. Periodontal pocket on the distal of the second molar was greater than 6 mm deep. There was no evidence of abscessation.

Diagnosis and Treatment Plan

Patient had been previously treated with a scalpel. He returned 24 hours later with severe pain and a granulomatous lesion present. The lesion was clinically diagnosed as chronic pericoronitis. It was decided to surgically remove the inflamed pericoronal tissue via CO2 laser ablation technique.
 

Surgical Laser Equipment and Settings

Flexible fiber dental CO2 laser (LightScalpel LS-1005) with two different autoclavable dental handpieces was used: (1) dental angled tipless handpiece with the 0.25 mm spot diameter; and (2) dental angled tip-retainer handpiece with sterile disposable tapered ceramic 0.25 mm spot diameter perio tip.

For ablation of the inflamed tissue, the laser was set to 4 watts in the SuperPulse mode (SP) with repeat pulsing at 25 msec pulse-width and 29 Hz repetition rate – see Figure 7. The tipless dental handpiece (LightScalpel – see Figure 4-6) was used at 3-5 mm nozzle-to-tissue distance.
For sulcus decontamination, the laser was set to 2 watts in the SuperPulse mode (SP) with repeat pulsing at 15 msec pulse-width and 20 Hz repetition rate. The tip-retainer dental handpiece (LightScalpel – see Figure 4) was used with perio tip’s distal end at approx. 1 mm from the base of the pocket and parallel to the surface of the tooth; air purge was constantly supplied through the tip and was set to the highest flow.
 

CO2 Laser Surgery

1.    Anesthesia was administered by local infiltration technique (2% lidocaine with 1:100,000 epinephrine; 30 gauge needle was used) (Figure 8).
2. The angled handpiece of the CO2 laser was held perpendicular to the target lesion (Figure 9) and the ablation of the inflamed tissue began (Figure 10). The dental surgeon was careful to avoid contact between the laser beam and the tooth enamel. Note: In this case, the inflamed tissue was located distally from the involved molar. There was no direct contact of the beam with the tooth as the surgeon was careful to not hit the enamel. However, if operculum covers part of the tooth, an adaptive tool (for example, a wax spatula) needs to be inserted between the tissue and the tooth to prevent possible damage. For an inexperienced CO2 laser surgeon, it is important and highly recommended to always shield the tooth during the procedure.6
3. After the initial pass with the laser, the inflamed gingiva bled slightly and the surgeon defocused the beam by increasing the nozzle-to-tissue distance to quickly obtain hemostasis (Figures 10-11). Note excellent visualization and clear operatory field.
4. Additional tissue around the primary surgical site was superficially ablated to “feather out” the wound and make the treated area blend with the healthy gingiva better (Figure 12).
5. After the removal of lesion, a perio tip was placed approx. 1 mm from base of pocket to decontaminate the sulcus area. Laser energy was administered using horizontal movements along the entire distal sulcular aspect.
6. Finally, laser was defocused by moving the handpiece farther away from the surgical area and additional hemostasis was created. No suturing or dressing was needed and the wound was left to heal by secondary intention (Figure 12).
 




 

Post-Operative Instructions:

The patient was dismissed with the instructions do warm salt water rinses and mild stimulation of site with a rubber tip twice a day; he was also instructed to apply topical antibiotic and vitamin “E” gel twice daily directly to the area. The patient was advised to avoid spicy, acidic or harsh foods or caustic mouth rinses. Although the patient was prescribed Vicodin 7.5, he did not need pain medications and was happy with the result. He reported to be completely pain-free in 24 hours.