Electrocautery in orthodontics

Electrocaute~y Laurance

Jerrold*

Massapequa,

N.

in orthodontics Dr. Jerrold

Y.

Electrocautery has all but disappeared from the clinical dental setting. Through technical advances, there have been developed new instruments which must now challenge the profession to re-examine the use of electrocautery as a valuable adjunct, particularly in the field of orthodontics. This article will describe a simple yet effective battery-operated electrocautery unit. Indications and examples of its use will also be presented.

Key words: Electrocautery,

electrosurgery,

periodonticiorthodontic

considerations

Q

uite often during the course of orthodontic treatment one is faced with oral conditions that impair, delay, and/or extend treatment. For example, during a bonding procedure one or more teeth may be suffering from delayed passive eruption or lack sufficient clinical crown for a bracket to be placed properly. In another instance the clinician may be forced to wait for a canine or other tooth to erupt past those last few layers of tissue before it can enter the oral cavity. These instances extend treatment time much longer than was originally anticipated. Another example might involve hyperplastic interdental gingiva which, regardless of the reason for its occurrence, now hinders further orthodontic progress. The three examples cited above are common occurrences in most practices and can be handled effectively with a minimum of chair time, patient discomfort, and cost by means of an electrocautery instrument to achieve the desired results. REVIEW

Fig.

1. Dental

cautery

unit.

OF THE LITERATURE

Oringer’ defines electrocautery as tissue that is contacted and burned via convection so that coagulation necrosis occurs in the range of third-degree bums. The danger is not so much to the tissue being treated as to the adjacent tissue through radiant heat as well as the sequela resulting from scar contraction. Other authors,“-” including Oringer, have stated that electrocautery has absolutely no place in dentistry today. With recent technical advances in instrumentation, as well as proper clinical technique, the clinician will find electrocautery to have a very definite although limited role in the present-day clinical practice setting. The author has no financial interest in any of the units described herein. *Assistant Clinical Professor of Orthodontics, New York University College of Dentistry.

Fig.

MATERIALS

2. Interchangeable

electrocautery

tips.

AND METHODS

As with conventional electrosurgical procedures, adequate anesthesia is vitally important. This is accomplished by local infiltration of the area with the appropriate anesthetic solution, taking into account the medical and dental history of the patient. Regional or block anesthesia has not been found to be necessary. As a matter of fact, adequate anesthesia is obtained with less than one fourth of a Carpule per tooth. The instrument used (Fig. 1) is a battery-powered electrocautery unit.‘j It is a small, light, compact unit approximately 130 mm long and 16 mm in diameter. It is powered by 2 AA alkaline batteries. It is reusable for the life of the batteries. The interchangeable tips are 189

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Am. J. Orthod. September 1984

Fig. 3. A, Upper left canine and second premolar not erupted placement. B, Teeth immediately after exposure by electrocautery.

Fig. 4. A, Lower left canine removal of adequate tissue. normal tissues.

sufficiently to permit proper C, Brackets in place.

and first premolar which require extensive crown lengthening. C, One month later, tissues were no more edematous than

disposable and are constructed of 28-gauge resistant wire. The operating temperature is in the 1,800” to 2,000” F range. The tip designs (Fig. 2), patterned after conventional electrosurgical unit tips, are interchangeable through the coaptation of the heat-resistant plastic bases with the unit body.

bracket

B, After untreated

The technique used is quite simple. After proper case selection, the patient’s consent is obtained and an anesthetic is administered. The proper tip is selected, depending on the procedure being performed. A 2 x 2 inch gauze square impregnated with alcohol is ready to clean tissue debris from the unit tip during the proce-

Electrocautery

Volume 86 Number 3

Fig. 5. A, Mesially rotated upper nicely 1 month after electrocautery.

right canine.

B, Following

dure. If the gauze is held in the non-working hand, the smell of the alcohol will help mask the odor that is emitted during the procedure if high-speed suction tips are not available. Depression of the “on” button completes an electrical circuit and the tip turns cherry red. If the button is released, the circuit is broken and the tip cools almost immediately. While removing the tissue, the operator must keep the unit in constant motion so that an area of tissue is not subjected to elevated temperatures for a prolonged period. One will actually be cutting through the tissue in layers. When the desired amount of tissue has been transsected, an explorer may help to lift the tissue off the tooth and dispose of it into the gauze. One must not keep the unit on and in prolonged contact with the tooth itself or allow it to touch bone; it must touch only soft tissue. Fig. 3, A shows a case in which the upper left canine and second premolar were not sufficiently erupted for proper bracket placement. Since both teeth required brackets, a crown-lengthening procedure was indicated. Both teeth had adequate zones of attached gingiva, and the oral hygiene was within normal limits. Immediately after electrocautery there was still adequate attached gingiva (Fig. 3, B). Hemostasis had been controlled and the teeth could be bonded immediately. Fig. 3, C shows the brackets in place. In the case depicted in Fig. 4 the lower left canine and first premolar required extensive crown lengthening. Since this case met the requirements of adequate periodontal support both before and after the elec-

removal

of tissue.

C, Tissue

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has responded

trocautery procedure, adequate tissue was removed and the appliances were placed. One month later the cauterized tissues were no more edematous than untreated adjacent tissues. Full healing takes approximately 3 to 5 weeks in such cases, and patients can resume oral hygiene practices the day that the procedure is completed Fig. 5, A shows an upper right canine which was mesially rotated so that a bracket could have been placed only in an incorrect position. When the tissue was removed (Fig. 5, B) proper placement of the bracket was possible. Fig. 5, C demonstrates that 1 month later the tissue had responded nicely. The preceding cases are classic examples of the need for clinical crown-lengthening procedures in orthodontics. Another obstacle faced routinely is the necessity of waiting for teeth to erupt. Usually the culprit is a canine, although premolars have this tendency as well. The case shown in Fig. 6 had been at this stage of treatment for 6 months. Exposure was deemed necessary and, once it was ascertained that this was a softtissue impaction and not one covered with bone, anesthesia was induced and a window was created. It is important to remember not to expose the entire tooth, as this would most likely require removal of unattached mucosa, which is contraindicated. When a path of least resistance is created, the tooth will usually come down into place. Attaching a button or cleat at this point and pulling the tooth down may risk creatioi of too long a clinical crown secondary to periodontal compromise.

Am. J. Orthod. Sqmnher 1984

Fig. 6. A, A case in which a canine has been unerupted trocautery. C, Tooth fully erupted and ready for bonding,

In the case shown in Fig. 6 the tooth was fully erupted and ready for bonding two visits after exposure of the tooth. Periodontal support at this time was excellent. The case shown in Fig. 7 was similar to the preceding case except that the impaction was deeper in nature. With well over 100 cases thus treated to date, only one patient has complained of pain or discomfort relating to the electrocautery. She spoke of feeling as if she had eaten something that was too hot. The discomfort lasted for 1 day. There have been no other complaints. The next case illustrates treatment versus nontreatment. Fig. 8, A shows the upper right canine, which required exposure. Fig. 8, B shows the window created, which came dangerously close to impinging on loose alveolar mucosa, and Fig. 8, C shows the situation 1 month later. Two months postoperatively periodontal status was excellent (Fig. 8, D). In Fig. 8, E the untouched contralateral side is seen to be identical in nature to the treated side. The last type of case to be presented is that which requires a gingivectomy. Quite often we will see varying degrees of hyperplastic interdental gingiva due to Dilantin, poor oral hygiene, too rapid space closure, etc. Miller’ states that space closure frequently produces a bunching of the interproximal tissues and that electrosurgery is used to reshape and recontour these tissues. Fig. 9 shows a typical case involving the lower anterior teeth. The tissue was excised and 5 weeks later the area had healed nicely. If at this point proper oral

for 6 months. with excellent

B, Window periodontal

created support.

by elec-

hygiene is neglected, tissue breakdown will occur (Fig. 9, U), but reinstitution of proper care will elicit a positive response (Fig. 9, E). In the last case to be presented here, there was severe gingival enlargement due to poor oral hygiene and space closure (Fig. 10, A). Coincidentally, if the tissue is too fibrous in nature, a small unit such as the one under discussion is not sufficient, and either a fully rectified electrosurgical unit or a scalpel should be used. The patient shown in Fig. 10 had a poor selfimage and was uncooperative. He would not smile, and he hated the way his mouth looked. The excess tissue was removed (Fig. 10, B), and 3 weeks later healing was progressing nicely (Fig. 10, C). Six weeks after the procedure (Fig. 10, D) all hard and soft tissues were back within normal limits, and the patient was a changed person. Cooperation was no longer a problem, his oral hygiene was good, and he smiled more because of this new self-image. The patient was instructed to rinse the area thoroughly several times daily and to maintain adequate oral hygiene. DISCUSSION

There is no question that the situations presented are valid clinical hurdles which we, as practitioners, must clear in the completion of our daily routine. One method of doing this has been presented. This is not to say that there are no other considerations that must be addressed as well. The question of whether or not we, as orthodontists, should be performing “periodontal”

Volumr Number

Electrocuute~

86 3

Fig. 7, A, Deeply exp osu Ire

Fig con mol ider

impacted

upper

canine.

B, Tooth

. 8. A Upper right canine requiring exposure. close to impinging on loose nes d ingerously postoperatively, with excellent uth 2 months side. itic al in nature to treated

exposed

by electrocautery.

C, Tooth

in orthodontics

9 weeks

after

B, Window created by electrocautery. Note thz It this alveolar mucosa. C, Tooth 1 month later. D, Pal :ient’s side, periodontal status. E, Untouched contralateral

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Am. J. Orthod. Sqmmber 1984

Jerrold

Fig. 9. A, Typical case of gingival hyperplasia involving lower anterior teeth. B, Tissue has been excised. C, Lower anterior region 5 weeks later, showing nicely healed tissues. D, Tissue breakdown due to poor oral hygiene. E, Positive response after reinstitution of proper home care.

treatment such as described can be argued both pro and con. This, of course, must be decided on an individual basis. The question of the fee for this service likewise should be answered in a similar manner. The purpose of this article was to present a new instrument and its use for the orthodontic community to evaluate in the light of safety, effectiveness, ease of use, wound healing, and cost. No problems with safety have been encountered during clinical trials with the dental cautery unit. Certain points must be stressed again. With electrocautery, as with electrosurgery, care must be taken regarding the following: 1. All tissue being treated must be adequately anesthetized.

2. Proper pacing is a must; lingering for any prolonged period of time may raise serious problems regarding healing due to compromise of the hard and soft supporting structures. Constant movement of the unit also distributes the heat better and maximizes cutting potential and efficiency. 3. Hard tissue must be respected, as bony response and healing as well as other negative sequelae are a direct result of improper clinical technique. Although no negative pulpal effects have been directly attributable to electrosurgery, this has not been totally proved regarding electrocautery; therefore ~11 prolonged contact with hard tissue is to be avoided. If all of these precautions are followed there is no safety problem. The effectiveness of the unit is directly related to

Electrocautery

Fig. 10. A, Severe after hard

gingival removal of hyperplastic and soft tissues back

enlargement due to poor oral hygiene tissue. C, Healing progressing nicely to normal 6 weeks after electrocautery

case selection. If used properly, it can handle minor periodontic-orthodontic problems quite well with a minimum of time and effort. The periodontic community has reviewed the unit and results and has voiced a favorable response, provided proper technique and case selection are used. In addition to the types of cases presented here (increasing clinical crown length, softtissue exposures, and minor gingivectomies), operculectomies have also been performed. With the increased interest in lingual orthodontics and its periodontal sequelae, the unit described takes on an added positive dimension. One of the most important considerations not even discussed yet involves the great increase in the number of adult patients we now see. As we receive more requests to aid in prosthetic rehabilitation of an older population, the possibility of treating patients with pacemakers becomes more real. Naturally, fully rectified electrosurgery units are contraindicated in this type of patient, and an electrocautery instrument takes on added significance. Even though the unit has various contra-angled tips, it is still slightly unwieldly from certain angles. The farther back in the oral cavity one is working, the more difficult it becomes to use. Since the unit uses batteries, it is also mildly cumbersome compared to a conventional electrosurgery handle. With practice, however, these slight drawbacks can be easily overcome. Conversely, the patient does not have to be grounded, as with a conventional unit, and no postoperative dressings have been required, as would be the case with the use of conventional scalpels. The unit can easily be

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and space closure. 6, Immediately 3 weeks after electrocautery. D, All procedure.

taken from the refrigerator and used immediately as opposed to setting up a large machine which, because of its infrequency of use, can become objectionable. Once again, high-speed suction via a plastic tip is extremely beneficial in masking any obnoxious odors resulting from either conventional electrosurgery or electrocautery procedures. All things being equal, regardless of the type of wound or the means by which it is inflicted, the soft tissues will heal comparatively, be it by primary or secondary intention. This has been demonstrated by the cases presented here. The same is not true of hard tissues. Conventional rectified electrosurgery units have a peizoelectric influence on the crystalline structure of bone as well as other effects,’ whereas heat injury via electrocautery has a different effect. Research into the medicolegal ramifications of using the dental cautery unit reveals no obstacles. From a cost-effectiveness standpoint, one must weigh the amount of use that an instrument will undergo against the cost of that particular unit. The ease of operation, as discussed, must also be considered. Although a market price has not been set, the price of the unit and the four different tips is targeted to be most reasonable. The unit itself is disposable when the battery stores are depleted. However, a batteryreplaceable one is being developed.* Clinical use has shown that the tips wear out well before the power handle. Both items, of course, can be repurchased separately. Refrigeration will extend the life of the power handle. and if the unit is not kept on

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injudiciously the tips will not anneal and soften as readily. This differs dramatically from conventional units, where only an occasional tip replacement is necessary. CONCLUSION

It is hoped that the information presented will generate an appreciation of electrocautery in orthodontics. It was not the intention of this article to promote any particular product but, rather, to address certain periodontal considerations that affect the practice of orthodontics and to describe a product and treatment technique to better aid us all in the services that we render to our patients. REFERENCES 1. Oringer M: Electrosurgery W. B. Saunders Company.

in dentistry,

Philadelphia,

1962,

2. Schon F: Electrosurgery in dental practice, Chicago, 1974, Quintessence International. 3. Harris HS: Electrosurgery in dental practice, Philadelphia, 1976, J. B. Lippincott Company. 4. Malone W: Electrosurgery in dentistry, Springfield, Ill., 1974, Charles C Thomas Publisher. 5. Symposium on Electrosurgery. Dent Clin North Am. October, 1982. 6. Ector L (product design engineer, Concept, Inc., Clearwater, Fla.): Personal communication. 7. Miller CJ: Minor tooth movement in orthodontics. Alpha Omegan 75: 23-29, Spring, 1982. 8. Young AT: Healing of mucoperiosteal incisions made by electrosurgery, Chicago, 1983, Quintessence International. Reprint requests to: Dr. Laurance Jerrold 100 Clark Ave. Massapequa, NY 11758