How to use your electrosurge around metal implants

Your patient returns for the first restorative appointment after implant exposure. Though the tissue has healed nicely, there’s now too much of it. It’s overgrown the implant healing abutment. How long will eliminating this hypertrophy delay your restorative treatment?

Correct answer : About 5 minutes.

By Laurence Stein, DDS
Miami FL

Everyone knows that you can’t perform surgery around implants with a common monopolar electrosurge ($700). For that you need a special bipolar surge ($4,000) – or better yet, a laser ($15,000).

For many years, I thought so too. So whenever I discovered excess tissue over a healing cap, I sent the patient back to the surgeon. He’d use his laser or a circular biopsy punch to remove the overgrowth. Of course this meant an extra appointment or two for the patient, and as much as a two-week delay for me, but it was my only alternative. In an effort to save my patient the extra trek to the surgeon, I bought my own set of tissue punches. But I discovered they weren’t an ideal solution. They removed the overgrowth, but they created a new wound. Furthermore, I often had to curette the site to remove the tissue-tags left by the punch.  Use of the punch probably increased the risk to the success of the implant integration.

If only I could use my electrosurge, it would be so easy.

Tissue removal would take just seconds with my surge, and because electrosurgery provides simultaneous hemostasis, I could go immediately to an impression step or place a prep-able abutment.

So I did some experimenting.

I tried isolating the metal implant using cellophane, but the results were not good. Plastic impression caps worked … sometimes. When there was a lot of overgrowth, I couldn’t get the tight-fitting cap past the tissue. Besides not all systems offer a plastic cap. Furthermore, an impression cap is a pretty expensive component for an application that takes just a few seconds.

Then one eventful day, I was pondering the problem (probably in the shower), when I had a Newton-in-the-orchard moment. SODA STRAWS! It was so simple.

Think about it -

1) They insulate.
2) They come in a variety of diameters.
3) They can be cut whatever length or contour needed.
4) They’re available in clear or translucent plastic, which meant that as I made the circumferential cut, I could see the electrode on the opposite side of the tooth.

And if all that weren’t enough …

5) They’re FREE. (I could also pick up some sugar, salt, pepper and a few napkins if I needed them ... What? Like I’m the only person who does this?)

So I collected straws from various fast food restaurants and tried them over different healing caps.  I found the ones that fit, disinfected them and tried them with my electrosurge. They worked! 

The average straw fits the healing cap of a “standard” implant. Slurpy, wide-diameter straws fit over wide-neck, 6 mm healing caps. Some coffee stirrers or cocktail straws are the diameter of mini-implants. 

As I mentioned, use clear or translucent straws because they make it easier to see the operative field. Cut them into 1/2-inch sections and place them in cold disinfection overnight.  Then store in a clean zip bag.

Before surging tissue away from the implant, select a straw that slides snugly over the healing abutment. They stretch slightly, so if the straw is a bit too narrow, it will often slip over if you apply a little pressure, but be careful because you don’t want to damage the pseudo-attachment.   If the straw splits, use a larger one, or make sure there is no tissue to remove in the area of the split. The straw will usually stay by itself, and will retract even heavily overgrown implants.  If necessary you can tissue-contour the straw like a copper band to allow for the bucco-lingual differences in height.

When retracted by the straw, the most central tissue of the overgrowth becomes the most coronal tissue. To remove it, just zip around the implant with a fine wire electrode, holding it at about a 45-degree angle (Diagram A).

Any limitations?

I’ve been using this technique for several years now. The only problem I’ve encountered is with an occasional monumentally overgrown healing abutment.  If there’s no way I can displace the tissue with the straw, I cut the straw on a steep diagonal, hold it in place with a hemostat and remove the tissue in several steps as I move the straw around the tooth. Or I may use several straws. Sometimes I have to split the straw vertically and slip it under the tissue to get started.

I suppose some dentists might complain that the straw is only disinfected rather than sterilized.  I can’t argue with that, though I’d point out that the straw comes in a wrapper and is clean enough to stick in your mouth.  I disinfect it for 24 hours, so short of tuberculosis (and even that should be dead) I don’t know what is left to contaminate the site.

I’ve used this straw/electrosurge technique for the past 6-8 years without a single adverse response.

My opportunity for fortune

I jokingly suggested to Parkell that they create an FDA-approved medical device based on this concept and give me royalties. They responded that by the time they got governmental approval, each cylinder would probably cost $3.00. Besides, they tend to avoid markets where the competitive product costs about a penny at any grocery store - or (worse!) it’s free at any fast-food restaurant. They have a point. Even if Parkell introduced it as a product, I’d probably stick with my soda-straws.

I am now thinking about investing in a laser for my practice - but not for trimming around implants. For this application, my e-surge is so simple and so predictable that the only way I’d resort to a laser would be if my e-surge was temporarily out of order and I had no alternative.

About the author: A graduate of the Emory University School of Dentistry, Dr. Laurence Stein practices General Dentistry in Miami FL. He is heavily involved in both cosmetics and implant restoration. A certified diver as well as an experienced author, Dr. Stein’s articles concerning various dental and health aspects of diving have appeared in several diving publications. He can be reached at SteinDiver@aol.com.

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