FROM the ARCHIVES
For Easy, Everyday E-Surgery – Keep It Simple
By Martin B. Goldstein, DMD – Wolcott, CT
Demystifying the Electrosurge
Some authors seem determined to make
electrosurgery complicated. It’s not.
In fact, if you limit its use to the most
common dental applications, e-surgery is
almost ridiculously simple.
Here’s virtually everything you
need to know to incorporate it
into your daily practice.
You may have decided that the ultra
high-tech laser you saw at the last meeting
just wasn’t going to happen anytime soon.
Too many other irons in the fire now to
commit to another lease payment.
Not to worry. Before there were lasers,
the mighty electrosurge roamed the earth.
Fortunately, it is not extinct. In fact, if you
poke around in the closet where you keep
things you don’t currently use, but are not
quite ready to chuck, you might just
spy one.
If so, I’m hoping that after you read this
article, you’ll consider dusting it off. On
the other hand, if you never got around to
purchasing an electrosurge, you can easily
acquire one without ever having to speak
with a finance company. The surges that
grace my operatories currently sell for less
than $700, which is ironic considering
their tremendous functionality. (Yes, there
still are some bargains to be had within
the dental market.)
If you want to perform sophisticated surgical
procedures, e-surgery can get complicated.
Personally, I prefer “simple”. So, I pretty much
limit my use to troughing and anterior tissue
sculpting. For these two simple applications, I
use my surges virtually every day.
© 2011 Parkell, Inc. • Toll Free: 1-800-243-7446 • Visit www.parkell.com • Email: info@parkell.com 1
Monopolar vs. Bipolar.
Electrosurgery vs. Radiosurgery
This article will discuss my use of “mono-
polar electrosurgery”, involving a single
wire tip from which a current emanates
and travels to an indifferent plate posi-
tioned behind the patient’s back.
Contrast that to “bipolar electrosurgery,”
where the surgical tip includes two
electrodes. The current flows from one tip
(the “active” or “cutting” tip), to its twin
tip, which serves as the indifferent plate.
The cost of bipolar units is considerably
greater than that of monopolar units.
While there are certain advantages to the
bipolar system (primarily hemostasis and
the ability to work around metal restora-
tions), precision cutting with a bipolar
device is more challenging due to the
broader dual-tipped electrode. For preci-
sion cutting and troughing procedures,
the monopolar design remains king.1 My
comments in this article will be limited to
monopolar devices.
For the record, “Electrosurgery” and
“Radiosurgery” are one and the same. The
latter term is more of a marketing seman-
tic, but it stems from the fact that dental
E-surge units operate at frequencies rang-
ing from 1.5 to 4.0 megaHertz. For in-
stance, my unit, the Parkell Sensimatic™
600SE operates at 1.7 MHz, while another
popular unit, Ellman’s Dento-surge 90,
operates at 3.8 MHz. These are both
radio frequencies.
I will purposely avoid most of the com-
plexities and all of the bugaboos typical of
an E-surge article, because in my experi-
ence E-surgery is utterly simple. Fur-
thermore, clouding the air with needless
cautions, irrelevant statements and arcane
uses risks scaring away the would-be
beneficiaries of this tried-and-true
dental adjunct.
I will instead advise the purchaser to read
the manual that comes with the unit and
make sure of at least one thing:
Don’t forget to put the indifferent plate
under your patient’s back or shoulder.
This will allow smoother, more predict-
ABOUT the AUTHOR:
Dr. Goldstein is a 1977
graduate of the University of
Connecticut School of Den-
tal Medicine and practices
general dentistry in a group
setting in Wolcott, Conn.
He enjoys promoting the
cosmetic side of his practice
and has found it helpful to incorporate
digital photography into his daily routine as
a practice builder. Recently, Dr. Goldstein
has been appointed to the staff of Contrib-
uting Editors at Dentistry Today. In addition
to writing for Dentistry Today, Dr. Goldstein
also writes for DentalTown, Contemporary
Esthetics and Dentistry, the UK’s version of
Dentistry Today.
Doctor Goldstein can be contacted at
martyg924@cox.net or at his office at
203-879-4649. He is available for speaking
engagements on both digital imaging in
dentistry and the use of high tech method-
ology to further the cosmetic practice.
able cuts and reduce the chance of the
patient’s experiencing any discomfort.
Three cases where you SHOULDN’T use
an e-surge.
Don’t use an e-surge on patients who have
pacemakers or cochlear implants. Granted,
some authorities may say you can do it
“if you take particular cautions” - but I
want to keep things simple ... so I avoid
situations where I have to “take
particular cautions.”
Also, keep the probe away from metal
implants and restorations and bone.
With those cautionary statements out of
the way, let’s now focus on how I use my
E-surge.
My electrosurge has 10 power settings, 3
cutting modes, and 7 different tips. That’s
210 options. I use one cutting mode (“cut/
coag”), one power setting (“7”), and for
90% of my procedures, one tip (straight
wire). For the other 10% I use a loop tip.
Basic Set Up:
First rule: Your E-surge unit must be
chairside. If it’s not, you simply won’t
use it as frequently as you could
or should.
Consider it another handpiece that just
happens to cut tissue instead of tooth.
While a myriad of settings are possible,
the button I use most is the “on-off”
switch. I keep the waveform set to “cut
with coagulation” and the power set to
“7”. I use a long needle electrode 90% of
the time and a narrow loop about 10% of
the time. The other electrode shapes just
sit in the drawer.
That’s it. One power-setting. One cutting
mode. Two tips.
True, some lecturers love to discuss
the subtleties of various tip and power
selections. Those may matter for exotic
applications - but not for what I use it for.
Despite the many uses of the E-surge in
the literature (everything from frenecto-
mies to pulpotomies), I pretty much limit
my usage to troughing for crown and
bridge impressions and tissue-sculpting
for anterior cosmetic rehabs.
Though this may sound rather restricted,
these two applications keep me using my
E-surge on a daily basis.
To trough or not to trough? That is the
question…
Take a look at (Fig. 1 & 2) to see how #19
and #20 were returned to me post-end-
odontically. The distal margin of #20 was
somewhat buried, but overall the tissue
was attractively pink and reasonably well
attached. Situations such as this (that is,
non-esthetic zone, non-vital teeth) beg for
Esurge exposure.
Fig. 1 Fig. 2
(Fig. 1) #19 and #20 as returned from the
endodontist (Fig. 2) #19 and #20 cleaned up
and ready for E-surge
Why tamper with the attachment trying
to stuff a retraction cord into the tightly
bound sulcus? Instead, I used my needle
electrode (Fig. 3) to expose 19 and 20
for maximum visibility prior to
core placement.
Then I applied Parkell’s Brush&Bond
(Fig. 4) to both teeth, followed by an
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Question: How deep do you trough?
Whenever possible, I use a shoulder or chamfer without going deep
subgingivally, so I’m not looking for huge
fins of PVS extending into the sulcus.
My main purpose in troughing is to create a
visual separation between tissue and tooth.
This usually requires a troughing cut of just
1/2 to 1mm. If I need a more dramatic
exposure, I’ll use string and peel back any
material that remains close to the finish-line
with the e-surge. (In the cases described in
this article, no string was used.)
Fig. 3 Fig. 4
(Fig. 3) Long needle electrode creating trough
around molars (Fig. 4) Brush&Bond applied
to the preps to provide the coronal seal and
bond the core
Fig. 5 Fig. 6
(Fig. 5) Bisacryl core material applied (Fig. 6)
Teeth prepared and E-surge completed
Fig. 7 Fig. 8
(Fig. 7) Crystal clear impression
(Fig. 8) Crowns delivered
automix core material (Fig. 5). I prepped
the cores (Fig. 6) and took an impression
even my mother could read (Fig. 7). (No,
she’s not a dentist.)
(Fig. 8) shows the finished crowns,
tissue healed.
Despite the tissue’s sometimes charred
appearance after electrosurgery, I’ve
come to believe that the E-surge should
be thought of as a kinder, gentler way to
separate tissue from tooth before taking
crown impressions. Though use of retrac-
tion cord is almost universal,2 my experi-
ence has been that soft-tissue response
after e-surge troughing is generally more
predictable than after packing cord.
If the sulcus height is preserved during
prep exposure, tissue will almost always
regenerate to its original level. Even
when tissue height is modestly reduced
during surgery, it seems to return to the
height you originally found it at so long
as a poorly-fitting provisional doesn’t
block its re-growth (more on this later).
Contrast this to the mechanical trauma
that often accompanies the dentist’s
least-favorite task of packing retraction
cord... a scenario well-known to encour-
age tissue recession.3
More than meets the eye
By the way, when I increased the
magnification of my loupes, there was
a corresponding jump in my confidence
as an e-surgeon, so I wound up using my
surges even more.
This makes sense. A thin wire electrode
permits a precision, blood-free cut, dif-
ficult to achieve with a scalpel. But you
can’t take maximum advantage of that
enhanced control without magnification.
When I stepped up from 2.5X magnifica-
tion to 4.8X, I saw an improvement in
my results. Being better able to visualize
the exact location of the needle electrode
at all times prevents unwanted tissue
removal from errant strokes.
Some readers may already know that I
employ Orascoptic’s EyeMax 4.8 TTL
loupes during all operative procedures.
How can seeing better NOT elevate one’s
level of performance? Is there such a thing
as seeing “too well”?
So you touched the tooth. Big deal!
Some articles suggest that accidentally
touching the tooth with the electrode is a
disaster that kills the pulp, creates a black
hole that threatens to swallow the solar
system, and causes immediate revocation
of your license.
Relax.
Enamel and dentin are fairly poor conduc-
tors of electricity. While I try to avoid
electrode/tooth contact with vital teeth, I
don’t panic if the tip momentarily brushes
against a tooth surface.
My observation after accidentally touch-
ing more teeth over the years than I like
to admit, is that as long as the contact is
brief, the pulps survive just fine.4, 5 (By the
way, I hear exactly the same thing from
every other surgeon I talk to.)
Needless to say, non-vital preps relieve
any apprehension about the anesthetized
pulp, as it has already gone missing.
Much to be said about strokes
Well ... not really. Again, another area
over-complicated.
You simply move the electrode where
you want the tissue to be gone. My usual
routine is to plant a solid finger rest with
my fourth finger and hold the handpiece
like a pencil.
I then make short oscillating strokes back
and forth in the area I wish to remove.
Such strokes travel two to three mm’s.
I then inspect the cut and return to areas
where small tissue tags remain. With my
loupes I can easily track the electrode as it
clears its path. This back-and-forth stroke
keeps me from tarrying in any one spot -
which might cause the tissue to overheat.
When I’ve finished, there will often be
a little charred residue adhering to the
margin of the prep. Using a fine diamond
or a carbide finishing bur, I’ll quickly
clean that up. In today’s world of shoul-
der-based, equigingival crown prepara-
tions, you don’t need much of a trough to
expose the finish line. (See sidebar, How
Deep Do You Trough?)
I should also mention that there are still
times when I desire the hemostatic ben-
efits of an epi-soaked cord (we’ve all been
there). Here I simply augment the retrac-
tion by using the needle electrode to open
areas where the cord has not adequately
retracted the tissue. This might be just a
3mm zone of tissue on the mesio-buccal
margin of a crown preparation.
Time out for an observation:
Touching up the tissue after packing cord
takes only a couple of seconds, and that’s
precisely why I keep a chairside e-surge
in each operatory. If I had to lug the de-
vice from another room and then set it up,
© 2011 Parkell, Inc. • Toll Free: 1-800-243-7446 • Visit www.parkell.com • Email: info@parkell.com 3
I’d probably forgo minor modifications
like this. Yet the touch-up could be the
difference between a pristine impression
and one where the technician has to fudge
a bit during die-trimming.
Two final cautionary statements: the first,
a repeat: DON’T FORGET THE INDIF-
FERENT PLATE. The second, keep the
high speed suction close to the operative
site to control odor. Oh ... you don’t need
plastic mirrors (old myth) and slightly
moist tissue cuts better than dry tissue.
That’s all you need to cloud your mind
with. Let’s talk tissue-sculpting now.
Setting the Stage…
A patient presented wanting her smile im-
proved (Fig. 9). Upon examination it was
noted that previous treatment had included
a two unit cantilevered bridge, #6-#7, and
four direct composite veneers #8-#11.
One doesn’t need to be very far along in
their dental education to realize that hopes
of improving this smile depended on
creation of more pleasing tissue contours.
Gingival probing revealed a fair amount
of “extra” gingiva. If removed, this
would open the door to an attractive
smile (Fig. 10).
Fig. 9 Fig. 10
(Fig. 9) Smile exhibiting considerable redun-
dant tissue (Fig. 10) Periodontal Probe assess-
ing gingival tissue available for removal
After gathering all the diagnostic data,
including a complete set of digital photos,
the case was planned, beginning with the
electro-surgery. #8’s tissue height plus 1
mm would serve as the guide for tissue-
sculpting #8, 9 and 10. Additionally, an
ovate pontic form would be created at the
#7 site.
As is typical of such cases, I first obtain
a digital smile simulation based upon a
portrait of the patient. These simulations
are created for me by Smile Vision (www.
smilevision.net). In this instance, the
planned tissue modification was included
in the simulation prescription uploaded to
Smile Vision. (Figs. 11 and 12)
Following patient approval, a closed-
mouth impression was taken using a
Premier Alfa Triple Tray® and vinyl
impression material. This approach is fast,
Fig. 11 Fig. 12
(Fig. 11 & 12) Pre-op portrait as submitted to
Smile Vision (Left) and simulation as presented
to patient (Right)
Fig. 13 Fig. 14
(Fig. 13) Resin Replica mock up (Fig. 14)
Reduction template used to gauge both tissue
and tooth removal
well-tolerated and accurate. The impres-
sion was sent to Smile Vision who in turn
provided a mock up (Fig. 13) as well as
the corresponding templates for provision-
al fabrication and preparation guidance.
Built into the prep guide are the planned
tissue heights following E-surge (Fig. 14).
The provisional templates (called “hard/
soft” templates) will allow temporary
fabrication in accordance with the newly-
created tissue contours.
Showtime….
Following local anesthesia, tissue was
removed using the Sensimatic needle
electrode to a height that left behind 1 to
1.5 mm of sulcus depth. This is critical.
E-surge gingivectomies that encroach on
the biologic width are prone to long-term
inflammation.
It was scalloped with the goal of creat-
ing a pleasing curve that reached its apex
slightly distal to the midline. This typi-
cally requires ten minutes to complete
(Fig. 15).
Following tooth preparation, I squeezed
a new loop electrode slightly to make it
oval, and used it to create an ovate pontic
site in the #7 region (Fig. 16). (New elec-
trodes can easily be bent before use. Once
they’ve been used, however, they harden
and cannot be bent without breaking. So
if you feel you’ve excessively deformed
the electrode, and won’t need that shape
again, just toss it after use. Fortunately,
electrodes are cheap.)
 Fig. 15 Fig. 16
(Fig. 15) Needle electrode used to create
more pleasing tissue (Fig. 16) Loop electrode
used to create ovate pontic site
Fig. 17 Fig. 18
(Fig. 17) Dental Floss used to compare contra-
lateral tissue heights (Fig. 18) Provisional at
one month
Fig. 19 Fig. 20
(Fig. 19) Ceramic
restoration and
revamped tissue
contours at three
months (Fig. 20) The
transformed smile
Following surgery, I used dental floss to
compare the relative tissue heights
(Fig. 17). Note the tame look to the
sculpted tissue.
I routinely sculpt the gingiva with my e-
surge, prep the tooth, and take the impres-
sion all at the same appointment.
When used after surgery, a carefully-
fabricated provisional restoration not only
protects the tooth and allows function, but
also acts as a guide during tissue healing.
Modest convexity in the cervical aspect
of your provisional teeth will allow the
gingival margin to cozy up to it in a
harmonious fashion.
Using the soft-hard template I received
from Smile-Vision, I created a shrinkwrap
provisional, which I meticulously trimmed
to ensure that it didn’t encroach on soft
tissue. Once again, higher magnification
enhances this entire process.
A bottle of Oxyfresh® oral rinse was given
to the patient, and she was told to use it
daily in the effort to optimize tissue tone
and color.
(Fig. 19) demonstrates very happy tissue
adorned by a three-unit cantilevered
4 Enjoy this article? Visit our article archive to download other free technique articles.
bridge #5-#7 (porcelain fused to metal) as plied and rinsed over five second intervals
well as a series of porcelain veneers from will do the trick. The whitish residue left
# 8-#12 courtesy of Aesthetic Porcelain behind will quickly fade.
Studio in Los Angeles.
And in conclusion…
The final reward, of course, is the trans-
To those of you who already enjoy the
formed patient, two months after case
benefits of an e-surge, I hope you’ve
delivery (Fig. 20).
picked up a few extra pointers that will
There is no doubt in my mind that the enhance your experience.
success of this case was due largely to the
For those who have abandoned their units
extra fifteen minutes I invested in tissue-
or who have not been drawn to this tried-
plasty prior to impression taking.
and-true practice adjunct, there’s still time
When the e-surge is not enough to get on board.
If all gummy cases lent themselves to The learning curve is short and the re-
such E-surge miracles, the cosmetic dental wards are long. And as mentioned before,
world would be a better place for all. Alas, the cost is laughable when compared to
sometimes ugly tissue can’t be easily cor- the myriad of high-tech gadgets dangled
rected with an electrosurge. When sulcus in front of us every day. What are you
depth is 1mm or less, more complex mea- waiting for?
sures must be taken that involve removal
This article is an expansion of one that ap-
of bone.
peared in Dentistry Today (Nov. 05). It is
In these cases I frequently show with the kind permission of that publica-
patients simulations of smile rehabs tion that it appears here.
done two ways:
• One with simulated tissue changes
• And the other without.
References:
This lets patient preview the effects
1 Livaditis GJ. Comparison of monopolar and
and decide whether or not the cosmetic bipolar electrosurgical modes for restorative
result of periodontal surgery is worth the dentistry: a review of the literature. J Prosthet
expense and effort. Dent.86(4):390-9, Oct 2001 Oct
If the patient elects the more complex 2 Hansen PA, Tira DE, Barlow J. Current
methods of finish-line exposure by practicing
treatment, both the simulation and the prosthodontists. J Prosthodont.;8(3):163-70,
mock-up based templates can be supplied Sep1999
to the periodontist, enabling him to create
the desired tissue contours.
3 Scott A. Use of an erbium laser in lieu of re-
traction cord: a modern technique. Gen Dent.
.53(2):116-9 Links Mar-Apr2005
Odds and Ends...
4 Krejci RF, et al Effects of electrosurgery on
Again in an effort to demystify the dog pulps under cervical metallic restorations.
e-surge, I should mention that it was not Oral Surg Oral Med Oral Pathol.;54(5):575-
82.,Nov 1982
necessary to dress the minor wounds cre-
ated by the procedures discussed in 5 Robertson PB, et al. Pulpal and periodontal
effects of electrosurgery involving cervical
this article.
metallic restorations. Oral Surg Oral Med Oral
In fact, patient complaints regarding post-
Patho..;46(5):702-10. Nov 1978
surgical pain related to tissueplasty are,
for the most part, non-existent.
Use of OTC analgesics can be suggested
if the need arises, but they rarely will
be needed.
One other helpful tip … If, during the
course of a procedure, spot bleeding
occurs that you’d like to quickly control
with other means than the e-surge itself,
33% hydrogen peroxide (Superoxal®) ap-