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• Technology Review: Dental Optical Coherence Tomography
• Case Reports: Venous Lake Elimination, Caries Removal,Esthetic Enhancement, Periapical Surgery, TuberosityReduction
The Official Journal of the Academy of Laser Dentistry 2007 • Vol. 15 No. 1The Official Journal of the Academy of Laser Dentistry 2007 • Vol. 15 No. 1
Ablation of bone by an Er:YAG laser. See the scientific / clinicalreview article on the use of lasers in bone surgery on page 9
American Academy of Laser Dentistry3300 University Drive, Suite 704
Coral Springs, FL 33065
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TA B L E O F C O N T E N T SThe official journal of the
Academy of Laser Dentistry
Editor in ChiefJohn D.B. Featherstone, MSc, PhDSan Francisco, CA [email protected]
Managing EditorGail S. Siminovsky, CAE, Executive DirectorCoral Springs, FL [email protected]
Consulting EditorJohn G. Sulewski, MA Huntington Woods, MI [email protected]
Associate Editors Donald J. Coluzzi, DDSPortola Valley, CA [email protected] P.A. Parker, BDS, LDS RCS, MFGDP Harrogate, Great Britain
Editorial BoardJohn D.B. Featherstone, MSc, PhDGail S. Siminovsky, CAEJohn G. Sulewski, MADonald J. Coluzzi, DDSSteven P.A. Parker, BDS, LDS RCS, MFGDPAlan J. Goldstein, DMDDonald E. Patthoff, DDSPeter Rechmann, Prof. Dr. med. dent.
PublisherMax G. MosesMember Media
1844 N. LarrabeeChicago, IL 60614
312-296-7864Fax: 312-896-9119
Design and LayoutDiva Design
2616 Missum PointSan Marcos, TX 78666
512-665-0544Fax: 512-392-2967
Editorial Office3300 University Drive, Suite 704
Coral Springs, FL 33065
954-346-3776 Fax 954-757-2598
The Academy of Laser Dentistry is a not-for-profitorganization qualifying under Section 501(c)(3) ofthe Internal Revenue Code. The Academy of LaserDentistry is an international professional member-ship association of dental practitioners and sup-porting organizations dedicated to improving thehealth and well-being of patients through theproper use of laser technology. The Academy isdedicated to the advancement of knowledge,research and education and to the exchange ofinformation relative to the art and science of theuse of lasers in dentistry. The Academy endorsesthe Curriculum Guidelines and Standards forDental Laser Education.
Member American Association of Dental EditorsThe Journal of Laser DentistryThe mission of the Journal of Laser Dentistry is to provide a professional quarterly journalthat helps to fulfill the goal of information dissemination by the Academy of Laser Dentistry.The purpose of the Journal of Laser Dentistry is to present information about the use of lasersin dentistry. All articles are peer-reviewed. Issues include manuscripts on current indicationsfor uses of lasers for dental applications, clinical case studies, reviews of topics relevant tolaser dentistry, research articles, clinical studies, research abstracts detailing the scientificbasis for the safety and efficacy of the devices, and articles about future and experimental pro-cedures. In addition, featured columnists offer clinical insights, and editorials describe person-al viewpoints.
E D I TO R ’ S V I E W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4The New Journal of Laser DentistryJohn D.B. Featherstone, MSc, PhD
G U E S T E D I TO R I A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6If you would not be forgotten…Emile Martin, DDS
C O V E R S TO R YS C I E N T I F I C / C L I N I C A L R E V I E W A R T I C L EThe Use of Lasers in Bone Surgery ....................................................................9Steven P.A. Parker, BDS, LDS RCS, MFGDP
T E C H N O LO G Y R E V I E W A R T I C L E Dental Optical Coherence Tomography, Past and Future ......................14Linda L. Otis, DDS, MS
C L I N I C A L P E R S P E C T I V E : A C A S E R E P O R TElimination of a Venous Lake on the Vermilion of the Lower Lip Via810-nm Diode Laser ............................................................................................20Lawrence A. Kotlow, DDS
A D VA N C E D P R O F I C I E N C Y C A S E S T U D I E SIntroduction ............................................................................................................23
Deep Caries Removal, Bacterial Decontamination, CompositePreparation, Beveling, and Etching Using an Er:YAG Laser......................24Alfred D. Wyatt, Jr., DMD
The Use of an Er:YAG Laser (2940 nm) in Soft and Hard Tissue Surgery for Esthetic Enhancements ........................................28Raminta Mastis, DDS
Periapical Surgery and Guided Tissue Regeneration with an Er:YAG Laser ............................................................................................34Alberto Trigas Damian, DDS
The Use of a CO2 Laser in the Reduction of Maxillary Tuberosity ........................................................................................38George Romanos, DDS, Dr. Med. Dent., PhD
Caries Removal and Composite Preparation for Primary Teeth ............41Alfred D. Wyatt, Jr., DMD
RESEARCH ABSTRACTS........................................................................................44
Journal of Laser Dentistry
The New Journal of Laser DentistryJohn D.B. Featherstone, MSc, PhD, San Francisco, CaliforniaJ Laser Dent 2007;15(1):4-5
Editorials can be dull or they can beprovocative, thoughtful, mind-bending, illuminating, or plainboring. How often do you really takethe time to read an editorial unlessthe topic is compelling for you? Thisone is packed with a summary ofwhat you will see in the currentissue of the new Journal and issuesto come in the future.
Everyone who reads thisJournal has an interest in the useof lasers in dentistry. Our combinedefforts are aimed at making thisnew Journal of Laser Dentistrysomething that not only fills a needfor everyday clinical practice, butalso publishes relevant researchresults. Very importantly, it is avehicle to provide the reader withnew knowledge, to revise the old,and to have a menu with some-thing that everyone can enjoy andbenefit from.
With this issue the officialpublication of the Academy ofLaser Dentistry has a new name,a new format, a new editor-in-chief, a new publisher, andexpanded aims. As spelled out inthe guest editorial by EmileMartin (page 6), current Presidentof the Academy, the publicationsof the Academy have developedfrom small beginnings to become aseparate professional journal anda newsletter. It is my privilege asthe new editor-in-chief to lead theteam that puts our new Journal ofLaser Dentistry together everyquarter.
The Journal of Laser Dentistrywill continue to publish casereports provided by advanced profi-ciency candidates to help you withknowledge and ideas for youreveryday practice. We will alsoencourage the submission of arti-cles ranging from clinical practiceto research studies.
Every issue will have at leastone invited review of some aspectrelated directly to laser use indentistry. These reviews areprovided to update you with aseries that will form the basis forunderstanding what is done inpractice. You can refer back tothese for years to come.
One significant advancement isthat every article, whether it is acase study, a research report, or ascientific review, will be peer-reviewed. That means that at leasttwo “peers” who are experts in thefield have reviewed and critiquedthe article prior to its revision andacceptance for publication.Submitted articles that fail to passthe peer review process satisfacto-rily will be rejected and you willnever see them in print in theJournal.
We have a new editorial boardthat has been established to assistand advise us on the overallaspects of the Journal of LaserDentistry. The editorial boardmembers have already had a lot ofinput to bring us to where we arewith our first issue in the newformat. I am also building a panel
of reviewers with a range ofexpertise relevant to our Journal.Steven Parker and Don Coluzzi willcontinue as associate editorsresponsible for the clinical casestudies, Gail Siminovsky willcontinue as managing editor, andJohn Sulewski as consulting editor.Thank you to all of the above foragreeing to devote their time totheir tasks. Thank you also to DonPatthoff, our outgoing editor for ajob very well done.
I encourage you all to submitarticles for consideration for publication. I also encourage feed-back on what is good and what isnot about the Journal. You cansend your contributions directly to me at [email protected] or via ourexecutive director [email protected] to authors arepublished in every issue.
What qualifications do I have tobe the editor of the Journal ofLaser Dentistry? Firstly, a willing-ness to accept this challenge in myspare time. Secondly, I have beenwriting articles, reviewing, andguest editing now for more than 30years for a variety of journals andproceedings. I am on four editorialboards of scientific journals, on thereviewer panels for others, and Ireview several manuscripts everymonth for other journals. Lastly, Iwas involved with research in laserdentistry quite a few years beforethe first laser was used clinically inthe United States. I look forward totaking the Journal to the nextstage of being an internationallyrecognized publication.
AUTHOR BIOGRAPHYDr. John D.B. Featherstone isProfessor of Preventive andRestorative Dental Sciences at the
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Featherstone
S Y N O P S I S
John Featherstone, editor-in-chief, describes the content and the
future of the new Journal of Laser Dentistry, the official publication of
the Academy of Laser Dentistry.
E D I TO R ’ S V I E W
Featherstone
University of California, SanFrancisco (UCSF) and Director ofthe Program in Biomaterials,Biophysical Sciences, andEngineering. He earned his MSc inphysical chemistry from theUniversity of Manchester (UK) anda PhD in chemistry from theUniversity of Wellington (NewZealand). His research over thepast 32 years has covered severalaspects of cariology (study of toothdecay) including fluoride mecha-nisms of action, de- andremineralization of the teeth,apatite chemistry, salivary dysfunc-tion, caries (tooth decay)prevention, caries risk assessment,and laser effects on dental hardtissues with emphasis on cariesprevention and early cariesremoval. He was the year 2000recipient of the InternationalAssociation for Dental Researchdistinguished scientist award forresearch in dental caries, and theT.H. Maiman award for research inlaser dentistry from the Academyof Laser Dentistry in 2002. He haswon numerous other national andinternational awards. In 2005 hewas honored as the first lifetimehonorary member of the Academyof Laser Dentistry. Dr. Featherstonehas published more than 200papers. He is the editor-in-chief ofthe Journal of Laser Dentistry.
Disclosure: Dr. Featherstone has nopersonal financial interest in anycompany relevant to the Academy ofLaser Dentistry. He consults for, hasconsulted for, or has done researchfunded or supported by Arm &Hammer, Beecham, Cadbury, GSK,KaVo, NovaMin, Philips Oralcare,Procter & Gamble, OMNII OralPharmaceuticals, Oral-B, Wrigley, andthe National Institutes of Health. nn
Editorial PolicyThe Journal of Laser Dentistry is devoted to providing the Academy and its members with com-prehensive clinical, didactic and research information about the safe and effective uses oflasers in dentistry. All statements of opinions and/or fact are published under the authority ofthe authors, including editorials and articles. The Academy is not responsible for the opinionsexpressed by the writers, editors or advertisers. The views are not to be accepted as the viewsof the Academy of Laser Dentistry unless such statements have been expressly adopted by theorganization. Information on any research, clinical procedures or products may be obtainedfrom the author. Comments concerning content may be directed to the Academy’s main officeby e-mail to [email protected]
SubmissionsWe encourage prospective authors to follow JLD’s “Instructions to Authors” before submittingmanuscripts. To obtain a copy, please go to our Web site www.laserdentistry.org/press.cfm.Please send manuscripts by e-mail to the Editor at [email protected].
Disclosure Policy of Contributing Authors’ Commercial RelationshipsAccording to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscriptsfor JLD are expected to disclose any economic support, personal interests, or potential biasthat may be perceived as creating a conflict related to the material being printed. Disclosurestatements are printed at the end of the article following the author’s biography. This policy isintended to alert the audience to any potential bias or conflict so that readers may form theirown judgments about the material being presented.
Disclosure Statement for the Academy of Laser DentistryThe Academy of Laser Dentistry has no financial interest in any manufacturers or vendors ofdental supplies.
Reprint Permission PolicyWritten permission must be obtained to duplicate and/or distribute any portion of the Journalof Laser Dentistry. Reprints may be obtained directly from the Academy of Laser Dentistryprovided that any appropriate fee is paid.
Copyright 2007 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. Ifany omission or infringement of copyright has occurred through oversight, upon notification amend-ment will be made in a future issue. No part of this publication may be reproduced or transmitted inany fom or by any means, individually or by any means, without permission from the copyright holder.
The Journal of the Academy of Laser Dentistry ISSN# 1935-2557.
JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues arealso mailed to new member prospects and dentists requesting information on lasers in dentistry.
Advertising Information and RatesDisplay rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials should be sent to Bill Spilman, Innovative MediaSolutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, e-mail [email protected]. For a copy of JLD Advertising Guidelines go to www.laserdentistry.org/press_advguide_policy.cfm. The cost for a classified ad in one issue is$50 for the first 25 words and $2.00 for each additional word beyond 25. ALD membersreceive a 20% discount. Payment must accompany ad copy and is payable to the Academy ofLaser Dentistry in U.S. funds only. Classified advertising is not open to commercial enterpris-es. Companies are encouraged to contact Bill Spilman for information on display advertisingspecifications and rates. The Academy reserves the right to edit or refuse ads.
Editor’s Note on Advertising: The Journal of Laser Dentistry currently accepts advertisements for different dental laser educationalprograms. Not all dental laser educational courses are recognized by the Academy of Laser Dentistry.ALD as an independent professional dental organization is concerned that courses meet the stringentguidelines following professional standards of education. Readers are advised to verify with ALD whetheror not specific courses are recognized by the Academy of Laser Dentistry in their use of the CurriculumGuidelines and Standards for Dental Laser Education.
If you would not be forgotten…Emile Martin, DDS, Syracuse, New YorkJ Laser Dent 2007;15(1):6
Benjamin Franklin wrote, “If youwould not be forgotten as soon asyou are dead, either write thingsworth reading, or do things worthwriting.” It seems to me this is thegoal of an organization’s journal. Itis the chronicling of the journey ofthe organization. That process iscertainly true of the Journal that isproduced by the Academy of LaserDentistry (ALD). Regardless ofwhether it was a newsletter to themembership or the newest incarna-tion of the full-color journal, it is thethread that binds and serves toperpetuate that we were herehelping to foster the use and growthof laser therapy in dentistry.
This issue of the journal is thefirst under the editorship of JohnFeatherstone. He carries forth thegoal of making our journal the mostprestigious in the field of laserdentistry that has been the hall-mark of all who have come beforehim. John brings to the positionsubstantial knowledge and esteemin the field of laser dentistrythrough his many years of experi-ence in the academic community.We are certainly fortunate to havehim accept the challenge of takingthe journal to the next level. It ishoped that in the near future wewill see articles in the journalreceive the distinction of beingfound in appropriate online indexesof health sciences literature.Obtaining this status should help inattracting more submissions fromthe research and academic commu-nity. In addition, no effort is beingspared to attract the best in clinical
research and clinically relevantpapers to maintain our position asthe most clinically importantjournal in laser dentistry. The peerreview process is continually beingupdated and refined to provide uswith relevant information that weas readers can rely upon as beingunbiased and with conclusions thatare scientifically reliable.
With that in mind, the mastheadof the journal is being changed tothe Journal of Laser Dentistry. Thefeeling is that we want our journalto appeal to all areas of laserdentistry. We want to be inclusive toall the interests in laser dentistry.While the Journal is sponsored andproduced by the ALD, the namechange should assure all that thematerials submitted and printedwill pertain to all of the variousplayers in the dental laser field,now and in the future.
No congratulations to the neweditor can be complete without themention of previous editors whohave brought the journal to thispoint in time. The hard work andefforts of the following individuals,some of whom are still working onthe editorial board, cannot be over-stated as the leaders of thepublishing effort. They include:Robert Fuchs, Ana Triliouris, AlanGoldstein, Leo Miserendino, PhilHudson, Steven Parker, Don Coluzzi,and most recently Don Patthoff. TheAcademy is indebted to each of theseindividuals for their hard work anddetermination over the past 14 yearsto bring the Journal to its currentlevel. On behalf of the ALD, thank
you all and I hope you take pride inthe continuing development of theproject that you once led.
Finally I would ask the readers toremember what Franklin said and“either write things worth reading,or do things worth writing.” Yourcontributions to the field of laserdentistry will be much appreciatedand your Academy will be better foryour contribution to the literature.Contact John Featherstone([email protected]) or Gail Siminovsky([email protected]) forany information that you might needabout submissions.
Enjoy this first issue of theJournal of Laser Dentistry and themany others to come in the future.
A U T H O R B I O G R A P H YDr. Emile Martin is a graduate ofthe University of Virginia andTemple University School ofDentistry and currently serves asPresident of the Academy of LaserDentistry. He has attainedAdvanced Proficiency in Nd:YAGand Holmium:YAG as well asEducator status in ALD and hasused a dental laser in his privatepractice in Syracuse, New York since1994. Dr. Martin is a Diplomat ofthe American Board of OralImplantology, holds Mastership inthe Academy of General Dentistry,is a Past President of the AmericanAcademy of Implant Dentistry anda Past President of the AmericanAcademy of Dental Group Practice.He serves as a part-time instructorin St. Joseph’s Hospital GeneralPractice Residency program as theChief of the Treatment PlanningDepartment and lectures on dentallaser and dental implant topics.
Disclosure: Dr. Martin has nocommercial ties to any dental lasermanufacturer and owns no stock inany dental laser company. nn
S Y N O P S I S
Dr. Emile Martin, current President of the Academy of Laser
Dentistry, presents this guest editorial to describe the change to a
new editor-in-chief and a new name and format for the Journal.
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Martin
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Preparing Articles – An Overview forSuccessful PreparationWhen submitting articles for publica-tion, the author should provide the pro-fessional title, complete address, phone,fax, and e-mail information. Articlesmust be submitted electronically in aMicrosoft Word file.doc containing textonly. Charts, graphs, tables and photosmust be saved separately in tif, jpg, orbitmap files at a minimum 300 dpi reso-lution. A hard copy sample PDF file orword file showing placement of photos,charts, graphs, and tables must accom-pany each digital submission. Articlesshould be no more than 1250 wordsalthough longer articles will be consid-ered. A short biography of 4-5 sentencesand detailed disclosure informationmust be included. A digital personalprofessional photo should also beattached. Details are provided below.
Article ContentArticles may be scientific and technicalin nature discussing new techniques,research and programs, or may be appli-cations-oriented describing specific prob-lems and solutions. All articles must con-tain a brief abstract that summarizesthe content and conclusion of the articlein 150 words or less. While lasers are ourpreferred orientation, other high-technol-ogy articles, as well as insights into mar-keting, practice management, and otheraspects of dentistry that may be of inter-est to the dental profession may beappropriate. All articles will be peer-reviewed prior to acceptance, modifica-tion, or rejection. The Academy reservesthe right to edit articles.
CommercialismALD members are interested in learn-ing about new products and serviceofferings, however ALD stresses thatsubmitted manuscripts should be edu-cational in nature. The emphasis is onscientific research and sound clinicaland practical advice, rather than pro-motion of a specific product or service.
Graphic Images and PhotographsWhen sending digital photography forpublication, please keep in mind thatthe size and dpi (dots per inch) affectthe clarity of the image. When repro-ducing an image for a publication, theimage must be 300 dpi. In addition, theimage must be the size it will be print-ed or larger. In other words, a 2” x 2”photo with 300 dpi can only be printedat 2” x 2.” If you send a 5” x 7,” with 300
dpi it could be printed at 5” x 7” orsmaller. You can get digital images fromseveral sources:• Capturing them with a digital camera• Scanning a photograph• Creating images using a graphic
application (example: Photoshop,Illustrator, etc.)
Save them at the size they will be usedor larger and at 300 dpi. (Images canalways be reduced in size, but nevermade larger than the original.)Remember…Bigger is Better!Label images with descriptions thatadequately identify the image.
All images, tables, charts, and graphsmust include captions.
Note the location of each image withinthe text of the case study or article asfollows: [Insert Figure 1 with caption.Provide CAPTION within the text file.]
Case Study Format Text forPublicationUse a standard font such as Times NewRoman or Arial, font size 12, to avoidmisrepresentation of your data on com-puters that do not have the unusual orforeign language fonts.
Prepare case study, tables, legends, andfootnotes as double-spaced text (a mini-mum of 6 mm between lines). Figuresand tables should not exceed 8-1/2 x 11inches. IBM PC, Microsoft Word files arepreferred (Word for Windows, Text,WordPerfect are acceptable). Manuscriptsshould be “clean,” i.e., free of tabs andcodes. Bold and italic type should appearexactly as they will appear on the printedpage. Italicize items that will appear initalics; this will include the genus andspecies of an organism, Latin words andabbreviations (for example, e.g., i.e., invitro, in vivo, et al.), and journal names inthe References section. Tabs should beused to separate columns within tables.Avoid using unnecessary grid lines,spaces, or characters in tables.
Biography and PhotographProvide a brief biography that includesprofessional education and professionalaffiliations. Provide the full postal (includ-ing ZIP or Postal Code) and e-mailaddresses, telephone and fax numbers, asavailable. We will publish your e-mailaddress only, unless directed otherwise bythe author. Provide a color or black-and-white professional photograph of yourself.
Disclosure of Contributing Author’sCommercial RelationshipsAccording to the Academy’s Conflict ofInterest and Disclosure policy, authors ofmanuscripts for the Journal of LaserDentistry are expected to disclose anyeconomic support, personal interests, orpotential bias that may be perceived ascreating a conflict related to the materialbeing printed. Disclosure statements areprinted at the end of the article followingthe author’s biography. This policy isintended to alert the audience to anypotential bias or conflict so that readersmay form their own judgments about thematerial being presented.
Provide a disclosure statement thatincludes the company/institution, rela-tionship, type of compensation such ashonoraria or salary. If you have no rela-tionship with a company, organizationor institution, write “I do not have anycommercial affiliations.”
Unacceptable FormatsNote: The following submission formatsare unacceptable and will be returned.• PowerPoint presentations• Word files with embedded images in
the text file• Any text files with embedded images• Images in lower resolution than 300 dpi
Articles, Questions, IdeasQuestions about clinical cases, scientificresearch or ideas for other articles maybe directed to the editor by e-mail: JohnD.B. Featherstone, MSc, PhD,[email protected].
Submission of FilesBy e-mail:Send your completed files by e-mail ifcompressed to:John D.B. Featherstone, Editor-in-Chief,[email protected].
By Federal Express or Other InsuredCourier:If using a courier, please include a hardcopy of your manuscript with the CDROM and also send a verification by e-mail to Gail Siminovsky([email protected]).Gail SiminovskyAcademy of Laser Dentistry3300 University Drive, Suite 704Coral Springs, FL 33065Phone: (954) 346-3776.
Instructions to AuthorsALD Welcomes Your Articles for Submission
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The Use of Lasers in Bone SurgerySteven P. A. Parker, BDS, LDS RCS, MFGDP, Harrogate, North Yorks, Great BritainJ Laser Dent 2007;15(1):9-13
B O N E S T R U C T U R EBone is a connective tissue derivedfrom hyaline cartilage whosematrix, under the influence ofcalciferol, has been hardened bythe deposition of calcium and phos-phate to form a carbonatedhydroxyapatite-like mineral, acarbonate substituted form ofCa10(PO4)6(OH)2, as the groundsubstance. Collagen remains theprimary fibre in the matrix as it isin hyaline cartilage. Histologically,bone is composed of units termedHaversian systems or osteons inwhich concentric rings of osteocytesare arranged around a centralblood vessel. The blood supply isvia an arteriole-venule plexuswithin the peripheral periosteum,or via vessels contained within thebone substance. Cross-linkagebetween central canals is providedby Volkmann’s canals. This matrixis maintained by osteocytes, thecharacteristic cells of bone.
Of concern to the dentalsurgeon, the dentoalveolarprocesses of the maxillary andmandibular bones are composed ofan outer cortical plate, covered byperiosteum and an inner complexof trabecular or cancellous bone.The cortical plate of the mandibleis thicker than that found in themaxilla and remains fairly
constant during adult life.However, the volume of cancellousbone in both jaws will reduce withtime, following tooth extraction,indicating the purpose of thistissue as being supportive of thenatural dentition.1-3
With the exception of the centralneurovascular bundle, themandible derives its blood supplyfrom periosteal vessels and thisassumes greater relevance withage, due to reduction in diameter inthe inferior dental vessels. Theextensive blood spaces found in themaxilla provide a more homoge-neous blood supply in this bone,deriving from a central maxillaryartery source. It therefore followsthat, for surgical procedures thatrequire the cutting or ablation ofbone, care should be given to main-taining a contiguous relationshipbetween periosteum and bone inthe mandible, to prevent ischaemicatrophy.4-5
B O N E H E A L I N GFollowing injury or surgery and inthe absence of infection, thehealing of alveolar bone is similarto that of osteoid tissue elsewherein the skeleton. Early blood clottingallows a matrix for cellular andbiochemical activity, wherebypredominant osteoclastic action
removes any damaged or deadmineralized tissue. This resorptionstage will be longer in those caseswhere extensive damage hasoccurred, either due to trauma orthermal shock.6 Following this,early growth of new bone occurs,through osteoblastic activity, toform a callous and later, wovenbone, which over time is graduallyremodeled to mature bone.
L A S E R A B L AT I O N O FB O N E“Conventional” bone cutting with abur or bone saw may result in asubstantial temperature increasewhich far exceeds the threshold forprotein breakdown and leads topossible sequestration of damagedbone elements.7-8 Equally, studieson the effects of commerciallyavailable Nd:YAG and CO2 laserson bone show carbonisation andother structural damage.9-12
Consequently, a “best practice”approach to bone ablation andcutting would suggest the need fora modality that would produce clin-ically acceptable rates of cuttingwithout overheating. The current
S Y N O P S I S
The use of suitable laser wavelengths in the cutting and ablation of
bone during dentoalveolar surgery can offer distinct advantages over
rotary instrumentation. It is essential to use the correct laser wave-
length and power parameters to maximize predictable outcomes for
bone surgery in dentistry. This article presents a review of this topic
and provides examples from clinical practice.
A B S T R A C TThe development of laser use insurgical dentistry has expanded toinclude all oral hard tissues, withaccepted protocols for selectedwavelengths being adopted. Thepurpose of this article is todemonstrate the composite natureof alveolar bone, the microstruc-ture and processes commensurateupon bone damage, together witha review of the literaturesurrounding the applicableadjuncts of laser energy in theablation of this tissue.
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mid-infrared laser wavelengths,Er,Cr:YSGG (2780 nm) and Er:YAG(2940 nm), appear to offer suchmodalities.13
As with other hard tissue inter-action, it is essential to maintain aco-axial water spray to preventheat damage which would delayhealing. Studies of the rate ofthermal denaturation of collagen, amajor component of bone tissue,show that above a critical tempera-ture (74° C), the rate of collagendenaturation rapidly increases,causing rapid coagulation oftissue.14-15 In general at tempera-tures above 60-80° C, collagendenaturation, coagulation, andnecrosis are initiated. At tempera-tures above 100-300° C, there is theonset of dehydration, followed bycarbonisation of proteins and lipids.Above a few hundred degrees, theprotein of bone is pyrolised, leavinga carbon residue and possiblestructural changes in the mineralcomponents.
The two applicable lasers forbone ablation are the Er:YAG (2940nm) and the Er,Cr:YSGG (2780nm) wavelengths. Both Er,Cr:YSGGand Er:YAG laser wavelengths arewell absorbed in water, with theEr:YAG being somewhat morestrongly absorbed in water thanthe Er,Cr:YSGG. This absorption inwater is due to a relatively broadwater band around 3,000 nm.16-19 Inaddition, there is a small absorp-tion at around 2,800 nm by thehydroxyl group of the (carbonated)hydroxyapatite mineral of thetissues16,20-21 but this is faroutweighed by the whole-watereffects.
When incident laser energy isdirected onto bone, it is absorbedby the prime chromophore, water.For both Er:YAG and Er,Cr:YSGGlaser wavelengths this energy isabsorbed primarily by the waterand is rapidly converted to heat,which causes superheating and aphase transfer in the subsurfacewater, resulting in a disruptiveexpansion in the tissue. Early
study into the effect of the Er:YAGlaser on bone showed that, likeenamel and dentin ablation, tissuecutting is a thermally inducedexplosive process.22-23 Through thismechanism, whole tissue fragmentsare ejected and a hole is cut in thebone, with little or no alteration tothe mineral itself.
Figure 1 shows the absorptioncurve for dental enamel, themineral component of which is acarbonated hydroxyapatite similarto that of bone, surrounded bywater and a small amount ofprotein and lipid (inter-prismaticsubstance). The spectrum is not ascomplex as bone which also has theabsorption bands attributed togroups in the collagen molecule.This figure clearly illustrateswhere the Er,Cr:YSGG and Er:YAGlaser wavelengths are absorbed,primarily by the water. To a lesserextent the Er,Cr:YSGG will also beabsorbed by the mineral due to theOH- ion that forms part of themineral.
The use of erbium lasers in
dentoalveolar surgery represents aless traumatic experience for thepatient when compared to theintense vibration of the slow-speedsurgical bur. Ablation thresholdvalues of 10-30 J/cm2 have beenrecorded for bone of varyingdensity.24 In the author’s clinicalexperience, with maxillary alve-olar bone surgery, the speed oflaser cutting is comparable to thatof a surgical bur and slightlyslower in the mandible, reflectingthe greater mineral content of thelatter’s cortical bone. Such state-ments are subjective, especially asone study25 reports slower cuttingrates, although it does draw refer-ence to bone ablation in the thirdmolar region. What may be ofgreater relevance is the ability tocarry out laser ablation within aclinically acceptable time frame. Itis considered important thatpower parameters and water spraylevels are adequate in order toprevent a “stall-out” effect ofdebris (where ablation productsare allowed to accumulate and
Figure 1: Absorption curve of enamel (carbonated hydroxyapatite (HA)) and emissionwavelengths of the Er,Cr:YSGG, Er:YAG, and CO2 lasers. Carbonated HA exhibits a smallpeak at approximately 7,000 nm, coincident with (CO3)2- radical absorption. Waterabsorption is shown as a dotted line.
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absorb laser energy). Lasersettings of 350-500 mJ / 10-20 Hz(average power range 3.5-7.0Watts) with maximal water sprayappear to produce good ablationrates.
The ablation threshold foraverage bone is approximately 12-20 J/cm2. As an example, Table 1shows how easily that givenfluence can be far exceeded when abeam diameter is used that is toosmall and/or the energy per pulseis too high.
It is essential, therefore, thatcorrect power parameters areadopted so as not to produceunwanted heat effects in the targettissue site.
The poor haemostatic effect ofcurrent commercially availableEr:YAG lasers can be used toadvantage in the ablation of boneto ensure blood perfusion of thesurgical site (Figures 2-3).
However, the ablation processusing a pulsed laser and waterspray results in a considerablespatter of blood, and precautions(eye protection and mask) arerecommended. An additional riskmay be the creation of an airembolism in the tissue, due to theair-induced water spray, although areview of the literature has notrevealed an association. The abla-tion of bone using laser energy isassociated with a level of noise,which represents the explosiveinteraction with chromophores.This has been measured in onestudy at between 99 and 121 dB.26
However, in the author’s experi-ence, such sound level does not givecause for patient concern.
Scanning electron microscopeanalysis of the cut surface of bone(Figures 4-5) reveals little evidenceof thermal damage, and any charlayer appears to be restricted to aminimal zone of 20-30 µm indepth.27-28 Studies into the healingof laser-treated bone support thecontention that the reduced phys-ical trauma, reduced heatingeffects, and reduced bacterialcontamination lead to uncompli-cated healing processes when
compared to conventional use of asurgical bur.7,29-31
PA I N A S S O C I AT E DW I T H B O N E A B L AT I O NThe classic tissue response totrauma such as surgery, as withinfection, is inflammatory reaction.The five characteristics of calor(heat), dolor (pain), rubor (redness),tumour (swelling), and loss of func-tion can result in postoperativeoedema, pain, and trismus. It isconsidered that the level of kininproduction following surgery playsa large part in the degree of painand swelling. Anecdotally, thepatient response following boneablation with lasers appears to beone of greater comfort, compared tosurgery carried out with a rotarybur. The number of investigationsinto this subject appears to besmall. However, in a randomised
Beam Diameter
Energy Per Pulse
100 mJ 250 mJ 500 mJ
Fluence
300 µm 141 J/cm2 353 J/cm2 707 J/cm2
600 µm 35 J/cm2 88 J/cm2 175 J/cm2
1000 µm 13 J/cm2 32 J/cm2 64 J/cm2
Table 1: Relationship between laser beam diameter, energy per pulse, and resultingfluence values.
Figure 2: An Er:YAG laser has been usedto cut through the buccal plate of bone(2940 nm, 800-µm beam diameter, 350 mJ per pulse / 10 Hz / 3.5 Waverage power).
Figure 3: Appearance following removalof the root. Note the accuracy of the cutand the free flow of blood.
Figure 4: Scanning electron micrograph(SEM) of bone cut with an Er:YAG laser(2940 nm, 800-µm beam diameter, 400mJ per pulse / 10 Hz / 4.0 W averagepower). Minimal thermally inducedchanges to tissue structure are seen.
Figure 5: “Environmental” (wet) SEM ofbone cut with a surgical bur (Ash #12steel oral surgical bur). Note smearingand thermal cracking.
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controlled clinical trial,25 theEr:YAG laser was compared with asurgical bur for removal ofpartially erupted lower thirdmolars. Patients were allocatedrandomly to be treated by eitherlaser or bur. A total of 42 patients(laser = 22; bur = 20) were treated.The study reported a greater reduc-tion in the range of mouth openingafter laser than after bur treat-ment, presumably due to the longeroperating time taken althoughpostoperative pain was morecommon after bur treatment.
C O N C LU S I O NThe use of suitable laser wave-lengths in the cutting and ablationof bone during dentoalveolarsurgery can offer distinct advan-tages over rotary instrumentation.The reduction in heat productionand thermal collateral damage canresult in a less aggressive inflam-matory process in the host tissue.In addition, the reduction in tactilestimulation during surgery can bedeemed less unpleasant for thepatient. To avoid damaging effects,there is only a narrow range oflaser energy recommended for abla-tion of bone tissue. It is essential touse the correct laser wavelengthand power parameters to maximisepredictable outcomes for bonesurgery in dentistry.
AUTHOR BIOGRAPHYDr. Steven Parker studied dentistryat University College HospitalMedical School, University ofLondon, UK and graduated in 1974.He is in Private Practice inHarrogate, UK. He holds Fellowshipand Diplomate status with theInternational Congress of OralImplantologists. Dr. Parker hasbeen involved in the use of lasers indentistry since 1990. Prior tojoining the Academy of LaserDentistry in 1993, he was Presidentof the British Dental LaserAssociation. He joined the Board ofDirectors of the Academy in 1996and became chair of the
International Relations Committee.From 1999 through 2004, he waschair of the Committee forProficiency Recognition and co-editor of Wavelengths, the formerjournal of the Academy of LaserDentistry. He was awarded theLeon Goldman award for Excellencein Clinical Laser Dentistry by theAcademy in 1998. In addition, Dr.Parker holds Advanced Proficiencystatus in multiple laser wave-lengths and completed the AcademyEducator Course at the Universityof California – San Francisco in2000. He is an ALD-RecognisedStandard Proficiency CourseProvider. He has held consultancieswith multiple laser companies andhas presented courses, lectures, andworkshops worldwide. He hasauthored numerous articles on theuse of lasers in dentistry, includinga chapter “The Use of Lasers inFixed Prosthodontics” in theOctober 2004 Dental Clinics ofNorth America. Dr. Parker was the2005 President of the Academy ofLaser Dentistry. Dr. Parker may be contacted by e-mail at [email protected].
Disclosure: Dr. Parker has nocurrent affiliations with anycompany.
R E F E R E N C E S1. Moon H-S, Won Y-Y, Kim K-D,
Ruprecht A, Kim H-J, Kook H-K,Chung M-K. The three-dimensionalmicrostructure of the trabecularbone in the mandible. Surg RadiolAnat 2004;26(6):466-473.
2. Schwartz-Dabney CL, Dechow PC.Variations in cortical material prop-erties throughout the humandentate mandible. Am J PhysAnthropol 2003;120(3):252-277.
3. Peterson J, Wang Q, Dechow PC.Material properties of the dentatemaxilla. Anat Rec A Discov Mol CellEvol Biol 2006;288(9):962-972.
4. Chanavaz M. Anatomy and histo-physiology of the periosteum:Quantification of the periosteal bloodsupply to the adjacent bone with
85Sr and gamma spectrometry. JOral Implantol 1995;21(3):214-219.
5. McCord JF, Blum I. Prevention ofbone loss for edentulous patients.Eur J Prosthodont Restor Dent2003;11(2):71-74.
6. Fernandez-Tresguerres-Hernandez-Gil I, Alobera-Gracia MA,del-Canto-Pingarron M, Blanco-Jerez L. Physiological bases of boneregeneration. I. Histology and physi-ology of bone tissue. Med Oral PatolOral Cir Bucal 2006;11(1):E47-51.
7. Pourzarandian A, Watanabe H, AokiA, Ichinose S, Sasaki KM, Nitta H,Ishikawa I. Histological and TEMexamination of early stages of bonehealing after Er:YAG laser irradia-tion. Photomed Laser Surg2004;22(4):342-350.
8. Lewandrowski KU, Lorente C,Schomacker KT, Flotte TJ, WilkesJW, Deutsch TF. Use of the Er:YAGlaser for improved plating inmaxillofacial surgery: Comparison ofbone healing in laser and drillosteotomies. Lasers Surg Med1996;19(1):40-45.
9. Krause LS, Cobb CM, Rapley JW,Killoy WJ, Spencer P. Laser irradia-tion of bone. I. An in vitro studyconcerning the effects of the CO2 laseron oral mucosa and subjacent bone. JPeriodontol 1997;68(9):872-880.
10. McKee MD. Effects of CO2 laserirradiation in vivo on rat alveolarbone and incisor enamel, dentin,and pulp. J Dent Res1993;72(10):1406-1417.
11. Nuss RC, Fabian RL, Sarkar R,Puliafito CA. Infrared laser boneablation. Lasers Surg Med1988;8(4):381-391.
12. Chen II, Saha S. Thermal analysisof the bone surface induced by laserradiation. Ann Biomed Eng1987;15(5):457-466.
13. Spencer P, Payne JM, Cobb CM,Reinisch L, Peavy GM, DrummerDD, Suchman DL, Swafford JR.Effective laser ablation of bonebased on the absorption characteris-tics of water and proteins. JPeriodontol 1999;70(1):68-74.
14. Thomsen S. Pathologic analysis ofphotothermal and photomechanicaleffects of laser-tissue interactions.
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Photochem Photobiol1991;53(6):825-835.
15. Thomsen SL, Cheong W-F, Pearce JA.Changes in collagen birefringence: Aquantitative histologic marker ofthermal damage in skin. In: Tan OT,White RA, White JV, ed. Lasers inDermatology and Tissue Welding, LosAngeles, California, Proc. SPIE 1422.SPIE – The International Society forOptical Engineering, Bellingham,Washington, 1992:32-42.
16. Featherstone JDB, Nelson DGA.Laser effects on dental hard tissues.Adv Dent Res 1987;1(1):21-26.
17. Seka W, Featherstone JDB, Fried D,Visuri SR, Walsh JT. Laser ablationof dental hard tissue: From explo-sive ablation to plasma-mediatedablation. In: Wigdor HA,Featherstone JDB, White JM, NeevJ, ed. Lasers in Dentistry II, SanJose, California, January 28-29,1996. Proc. SPIE 2672. SPIE – TheInternational Society for OpticalEngineering, Bellingham,Washington, 1996:144-158.
18. Fried D, Zuerlein M, FeatherstoneJDB, Seka W, Duhn C, McCormackSM. IR laser ablation of dentalenamel: Mechanistic dependence onthe primary absorber. Appl Surf Sci1998;127-129:852-856.
19. Zuerlein MJ, Fried D, FeatherstoneJDB, Seka W. Optical properties of
dental enamel in the mid-IR deter-mined by pulsed photothermalradiometry. IEEE J Sel TopQuantum Electron 1999;5(4):1083-1089.
20. Nelson DGA, Featherstone JDB.Preparation, analysis, and charac-terization of carbonated apatites.Calcif Tissue Int 1982;34(Suppl2):S69-S81.
21. Featherstone JDB, Fried D.Fundamental interactions of laserswith dental hard tissues. Med LaserAppl 2001;16(3):181-194.
22. Hibst R. Mechanical effects oferbium:YAG laser bone ablation.Lasers Surg Med 1992;12(2):125-130.
23. Peavy GM, Reinisch L, Payne JT,Venugopalan V. Comparison ofcortical bone ablations by usinginfrared laser wavelengths 2.9 to 9.2µm. Lasers Surg Med1999;25(5):421-434.
24. Fried NM, Fried D. Comparison ofEr:YAG and 9.6-microm TE CO2
lasers for ablation of skull tissue.Lasers Surg Med 2001;28(4):335-343.
25. Abu-Serriah M, Critchlow H,Whitters CJ, Ayoub A. Removal ofpartially erupted third molars usingan Erbium (Er):YAG laser: Arandomised controlled clinical trial.Br J Oral Maxillofac Surg2004;42(3):203-208.
26. Li ZZ, Reinisch L, Van de MerweWP. Bone ablation with Er:YAG andCO2 laser: Study of thermal andacoustic effects. Lasers Surg Med1992;12(1):79-85.
27. Wang X, Zhang C, Matsumoto K. Invivo study of the healing processesthat occur in the jaws of rabbitsfollowing perforation by anEr,Cr:YSGG laser. Lasers Med Sci2005;20(1):21-27.
28. Sasaki KM, Aoki A, Ichinose S,Ishikawa I. Ultrastructural analysisof bone tissue irradiated by Er:YAGLaser. Lasers Surg Med2002;31(5):322-332.
29. Walsh JT Jr, Deutsch TF. Er:YAGlaser ablation of tissue:Measurement of ablation rates.Lasers Surg Med 1989;9(4):327-337.
30. Wang X, Ishizaki NT, Suzuki N,Kimura Y, Matsumoto K.Morphological changes of bovinemandibular bone irradiated byEr,Cr:YSGG laser: An in vitro study.J Clin Laser Med Surg2002;20(5):245-250.
31. O’Donnell RJ, Deutsch TF, Flotte RJ,Lorente CA, Tomford WW, MankinHJ, Schomacker KT. Effect ofEr:YAG laser holes on osteoinduc-tion in demineralized rat calvarialallografts. J Orthop Res1996;14(1):108-113. nn
Dental Optical Coherence Tomography,Past and FutureLinda L. Otis, DDS, MS, Baltimore, Maryland; Quing Zhu, MS, PhD, Storrs,
Connecticut; Boon-Siew Ooi, BEng, PhD, Bethlehem, PennsylvaniaJ Laser Dent 2007;15(1):14-19
I N T R O D U C T I O NThe resolution, acquisition rate,and penetration depth of OCTsystems have significantlyimproved in recent years. We havesuccessfully applied many of thesenew OCT developments to dentalimaging (Figure 1). Our work hasbeen focused on studying instru-ment parameters that determineOCT image characteristics of teethand oral tissues. System compo-nents that we have studied includewavelength and power of the lightsource used, collection optics andlens systems, methods used tomodulate the interferometer refer-ence arm, handpiece designs thatminimize motion artifacts, and soft-ware algorithms to improve imagequality. We improved axial resolu-tion of our dental OCT prototypesfrom 13 to 20 µm and imaging timefrom 45 to 5 seconds.4-9
OCT measures the reflections oflight from tissues based on theprinciples of interferometry. Lightfrom a low-coherence source isdivided and reflected from a refer-ence mirror and the tissue. Whenthe path length of light from thereference mirror is the same as thetissue, an interference fringe isdetected. Because the reference
mirror is moved in known incre-ments, the position of the reflectedlight within the sample can bedetermined. The magnitude of thereflected signal is determined bythe optical scattering properties oftissues. The sample arm is raster-scanned across the tooth or tissuesurface and a two-dimensional,cross-sectional image is obtained.
O C T I M A G I N G O FC O M P O S I T ER E S TO R AT I O N SWe investigated the capacity ofOCT to image teeth and dentalrestorations using 9 extracted
S Y N O P S I S
Dr. Linda Otis was the 2006 recipient of the prestigious Academy of
Laser Dentistry’s T.H. Maiman Award for excellence in research. This
paper summarizes her work in the study of optical coherence
tomography (OCT) as a new optical imaging technique for dentistry
in the future. OCT has potential for use in periodontal as well as
dental caries applications.
A B S T R A C TOptical coherence tomography(OCT) is an emerging imaging tech-nology that detects tissue interfacesbased on their differential reflectionof light; it was first reported as an invivo method for cross-sectionalimaging of the tissues of the eye byHuang et al. in 1991.1 OCT imagesconsist of successive interferometricsignals that are compiled into a two-dimensional image. OCT isnoninvasive and uses wavelengthsof light in the infrared region (850-1550 nm) that have considerabledepth of penetration in tissue but noknown detrimental biological effects.Our research has shown that peri-odontal tissues, teeth, and osseousstructures are reliably depicted inOCT images. Moreover, the presenceof dental restorations does not inter-fere with the capacity to discernimportant anatomical landmarksand/or soft tissue-dental relation-ships in OCT images.Three-dimensional OCT images canbe used to measure marginaldiscrepancies of dental restorationsand provide a volumetric estimate ofrestorative dental material loss overtime. OCT images of the periodontaltissues and implant-soft tissue rela-tionships can be obtained withoutthe risks associated with periodontalprobing.2-3 Results in a small numberof patients suggest that OCT imagesof the soft tissue surroundingendosseous dental implants differ inhealth and disease. Dental OCTprovides noninvasive, high-resolutionassessments of the oral microstruc-ture in cross-section providinginformation that is similar to histo-logical sections. Finally, our studieshave shown that dentists, previouslyunfamiliar with OCT images, wereeasily trained to interpret clinicalfindings with a high degree of accu-racy and inter-examiner reliability.
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Figure 1: A comparison of OCTimages made of mandibular premo-lars for the mid-facial aspect usingtwo different OCT systems. Importantsoft and hard tissue landmarks areidentified by the arrows.
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premolars, with composite restora-tions placed into the facialsurfaces. The preparations werevaried to include 3 teeth with axialcavity depths of 1, 2, and 3 mm.Cavosurface margins (n = 18)included 5 shallow bevels (0.5 mm),3 deep bevels (1.5 mm), 7nonbeveled butt joint margins, and3 margins with extraneouscomposite material beyond themargin (flash). A reference pointwas marked on each tooth andOCT images were made in tripli-cate along the long axis of themid-facial surface. The teeth weresubsequently sectioned at the refer-ence point and photomicrographscorresponding to the OCT imagingplane were prepared. To evaluatethe accuracy of the OCT images,transparent overlay outlines of thecomposite restorations, dentino-enamal junction (DEJ), andexternal tooth contours were madefrom the photomicrographs usingAdobe Photoshop software. Theoverlays were superimposed ontothe corresponding OCT image anddifferences were quantified. Thesuperior and inferior borders of therestorations were imaged withfidelity in all of the OCT images.Marginal characteristics were accu-rately imaged in 17 of the 18images. The axial margins were notimaged in any of the restorationswith axial depths of 3 mm. Theaxial depths of these preparationswere selected to represent typicalrestorations (1 and 2 mm) andmaximal expected axial depth (3mm). Minimal spatial distortion ofthe axial wall was noted in therestorations with axial depth of 1and 2 mm. This distortion corre-sponded to an index of refraction ofapproximately 1.5 for the compositematerial.10 As a result of these find-ings, we incorporated softwarecontrols into our clinical prototypeto allow interactive input to correctfor index of refraction artifact.
During field epidemiologicstudies when decayed, missing, andfilled surfaces (DMFS) are quanti-
fied, it is often impossible to distin-guish occlusal surfaces that haveresin covering the fissures as eitherbeing sealed or having a preventiveresin restoration or a posteriorcomposite on that surface.Consequently, we investigated thecapacity of OCT to accuratelydiscriminate occlusal sealants andcomposite restorations. Twenty-onedentists were asked to interpretOCT images of 9 premolars thateither were not restored, containedan occlusal sealant, or wererestored with a composite restora-tion. Following a brief trainingperiod, these dentists evaluated theOCT images following a random-ized blind protocol. The sensitivityof OCT to discriminate compositeand sealants was greater than 0.92while the specificity of discrimina-tion was greater than 0.94. Thecapacity of OCT to discriminatesealants from nonrestored occlusalsurfaces was slightly less (sensi-tivity 0.88; specificity 0.86), butstill within a clinically acceptablelevel. We concluded that OCTrepresents a safe, reproduciblemethod to discriminate filledversus sealed tooth surfaces,thereby increasing the accuracy ofDMFS assessments. Inter- andintra-rater reliability as measuredby the kappa statistic also revealedexcellent performance by dentistsusing this new imaging technology(kappa = 0.82 to 1.0). This studyalso demonstrated that dentistswho were previously unfamiliarwith OCT images could be trainedto interpret the images.11
Using three-dimensional OCTimaging, we estimated wear andevaluated the structural integrityof composite resin restorations asan additional component of anongoing Institutional Review Board(IRB)-approved study of posteriorcomposite materials in adultdentate patients. In this study,composite wear was assessed usinga Moffa-Lugassy (M-L) scale, amethod that is commonly used toindirectly determine the loss of
anatomical form and wear in poste-rior composite restorations.Impressions of the composite arecompared to a standard set of cylin-ders in which the center portion isoffset to simulate the loss ofcomposite resins in a restoredtooth. The M-L system has beenshown to identify composite wearand allow reproducible quantifica-tion up to 25 micrometers.12
We used OCT to generatecontour maps of the restorationsurface that quantified volumetricloss or surface changes in therestorative material over time. Weanalyzed OCT composite contourmaps in 4 premolars withcomposite resin restorations atbaseline, insertion, and 12 months.Wear estimates as determined bythe OCT contour maps correlatedwell with the value as determinedby the traditional method of meas-uring composite wear, the M-Lscale (r = 0.86; p < 0.05). All of theOCT images recorded changes inthe restoration surface thatoccurred with occlusal function.One image demonstrated a regionof catastrophic failure. This abnor-mality (catastrophic failure) wasnot clinically or radiographicallyvisible, indicating OCT has thepotential to detect restorativedefects earlier than current diag-nostic methods.13
O C T I M A G I N G O FC R O W N M A R G I N SIn a small patient-oriented study,we investigated the potential ofOCT to assess the internal struc-ture and marginal adaptation ofcemented crowns.14 Cross-sectionalimages were made in duplicate onthe mid-facial surface of cementedfunctional crowns with well-adapted margins and no clinicalevidence of recurrent caries. Weimaged in vivo 8 teeth (3 posterior,5 anterior) with porcelain-fused-to-metal coronal restorations. Theinternal structure and marginaladaptation were clearly visualizedin all the teeth imaged. In 4 of the
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crowns, characteristic image layersthat corresponded to incisal andbody porcelain were visualized. Asapplied to the imaging of functionalcrowns, this study showed thatOCT has the potential to improveaccuracy of marginal assessmentsas compared to radiographicimaging. Only the mesial and distalaspects of crowns are visualized inradiographs; OCT offers advan-tages in imaging the crownadaptation on any aspect of thecoronal surface with improvedaccuracy as compared to tactileexploration. An OCT image of acrown is shown in Figure 2.
O C T I M A G I N G O F T H EP E R I O D O N T I U MIt is also feasible to use OCT todepict soft and hard tissue bound-aries of the periodontium. We havevisualized and measured soft tissuethickness, sulcular depth, andlength of the periodontal attach-ment around teeth in OCT images.Using porcine jaws, we measuredsulcular depth in duplicate usingstandard periodontal probing tech-niques. OCT images were preparedin duplicate using a prototypesystem with a 1310-nm wavelengthlight source, 140 µW, 95 dBdynamic range, 0.46 numericalaperture resulting in images thatwere 10 mm long and had an axialresolution of 17 µm. The hemi-mandibles were subsequentlyembedded in clear acrylic, trans-versely sectioned at the referencepoints, and photomicrographed.The DEJ, cementoenamel junction
(CEJ), and sulcus depth weredetected in all OCT images andcorresponded to their locations inthe photomicrographs. Probingdepths as measured with a conven-tional periodontal probe werestrongly correlated to thoseobtained in OCT images for buccalsites (r = 0.88; p < 0.05) and moder-ately correlated on the lingual sites(r = 0.57; p < 0.05).15
We also correlated clinical peri-odontal probing depth to sulculardepth as measured in OCT imagesin a small study of 5 healthyhuman volunteers. The mid-facialsurface of 14 nonrestored teeth (1mandibular and 3 maxillary inci-sors, 4 maxillary and 6 mandibularpremolars) were imaged using aprototype OCT system (1310-nmwavelength light source, 14 µW, 95dB dynamic range, 0.46 numericalaperture). Following OCT imaging,probing depths were measured induplicate using a Michigan 0 probe.Important anatomic featuresincluding soft tissue surfacecontour, gingival crest, periodontalsulcus, and DEJ were identified inOCT images of all of the teethexamined. The CEJ was identifiedin 18 of the 28 images; the alveolarbone was presumptively identifiedin 20 of the 28 images. Probingdepth as measured in OCT imageswas strongly correlated to probingdepth as measured by conventionalprobing measurement (r = 0.83; p <0.05). Restoration margins andinternal restoration contours werevisualized and did not interferewith interpretation of OCT images
of soft tissue landmarks.An all-fiber-optic clinical OCT
system was used to obtain 12-millimeter occluso-apical OCTimages that were made in dupli-cate at the mesial facial line angleof the premolars in 4 healthyvolunteers. This system employed a6-mW, 1310-nm light source andproduced images that had an axialresolution of 21 µm. Characteristicsignals representing the sulcus andattached tissues were identified inall images. Premolar sulcular depthas determined from the OCTimages ranged from 1.1 to 2.5 mmand was strongly correlated withprobing depth (r = 0.88; p < 0.05).We defined attached tissues in theOCT images by uniform signalintensity with no discernible tissueinterfaces, extending from the baseof the sulcus to the alveolar crest.Attached tissues in the OCTimages ranged from 1.1 to 3.8 mm.The lowest values for attachedtissues were found in 3 teeth withcoronal restorations. Signalspresumptively identified as thealveolar crest were identified in 60of the 64 images. The thickness ofthe gingiva covering the alveolarcrest ranged from 0.4 to 1.4 mm.Two teeth had characteristicsignals representative of the rootsurface covered by a thin mucosaltissue; these sites were presump-tively identified as fenestrationdefects. The results of this studydemonstrate the capacity of OCT todetermine gingival thickness andthe shape and contour of the alve-olar crest. Visualizing these
Otis
Figure 2: OCT image of a cemented crown. The crown wasimaged using OCT from the buccal, lingual, and occlusal aspects;the crown was subsequently sectioned along the image plane,and photomicrographs were prepared. As illustrated in thisimage, the signal void on the lingual was the complete reflectionfrom the metal margin approximately 2 mm in length on thelingual (red arrows) while the buccal metal margin was approxi-mately 0.5 mm in length (yellow arrows). The morphology of thecrown preparation and the thickness of the various porcelainlayers can be seen in the OCT image.
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anatomical features represents asignificant contribution to peri-odontal surgical treatmentplanning.
OCT is uniquely suited to clini-cally evaluate implant healthbecause it provides high-resolution,cross-sectional images of the softtissues that surround implants.Histological studies in animalshave shown that gingival connec-tive tissue forms a scar-like fibrousconnective tissue adjacent to tita-nium implant surfaces, whileperi-implantitis is characterized bya disorganized connective tissuecontaining more vascular elements.Our preliminary data demonstratethat in OCT images of healthyimplant sites, collagen appearswell-organized, and because of itsbirefringent nature, produces acharacteristic high OCT signalintensity. OCT images of soft tissuesurrounding failing implants aresignificantly different from imagesof healthy implant sites and arecharacterized by linear signaldeficits, low-intensity collagensignals, and pronounced increasesin vascular elements (Figures 3and 4).
Based on these findings, weconducted preliminary studies todetermine whether OCT can be
used clinically to detect early peri-implantitis with greater sensitivitythan current diagnostic methods.We used a 6-mW, 1310-nm conven-tional OCT system that producedimages with 20 µm axial resolutionand image contrast ratio of 0.15 toassess the feasibility of OCT for thediagnostic evaluation of peri-implant soft tissues; we imaged 8implants in 3 patients. OCT imagesof failing implants characteristi-cally differed from healthy implantsites. Based on these findings, weanticipate that by examining alarger patient sample, we willestablish the best system parame-ters to characterize peri-implanttissues and demonstrate measur-able differences in healthy anddiseased implant sites.
I M P R O V I N G O C TI M A G E I N F O R M AT I O NWe also investigated methods toimprove dental OCT capabilities bycombining additional imaging anddetection schemes with conven-tional OCT. We added a functionalcomponent by combining a Dopplertechnique and OCT, producingimages (Figure 5) that detectedblood flow rates in superficial labialvessels.16-19 We also investigatedseveral instrument schemes toproduce polarization-sensitiveimages. Enamel and dentin exhibitstructural anisotropy because themacroscopic orientation of enamelrods and dentinal tubules are
linearly ordered (that is, form bire-fringence). In ourpolarization-sensitive (PS-OCT)system, vertical and horizontalpolarized signals were detected intwo channels and images werereconstructed by combining thesignals, thereby revealing withgreater detail the structuralfeatures of enamel and dentin. Anadditional advantage of polariza-tion-sensitive OCT as comparedwith conventional OCT is signifi-cantly improved signal-to-noiseratio and image contrast.20 In polar-ization-sensitive OCT images ofocclusal caries, the structural detailof caries and the dynamic nature ofthe carious lesion were revealed.Regions of demineralization hadlow signal intensity, while regionsof remineralization were character-ized by high signal intensity.Similar findings have beenreported by Fried and coworkerswho demonstrated that PS-OCT iswell suited for the imaging of inter-proximal and occlusal caries andearly root caries, and for imagingdecay under compositerestorations.21-23
F U T U R E D I R E C T I O N SThe axial resolution, imaging depth,and speed of current OCT systemsare limited by the bandwidth andthe optical power of the lightsource. Current OCT systems areusually time-domain instruments
Otis
Figure 3: OCT image of a healthy implantsite. The OCT image is made from themid-facial aspect of a healthyintraosseous implant site.
Figure 4: OCT image of a failing implantsite. Increased regions of signal voidsindicate an increase in vascular elements.
Figure 5: OCT Doppler image of thelower lips. Blood flow is measured usinga Doppler algorithm in a capillary looplocated in the labial submucosa.
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constructed using discrete compo-nents and bulk optics in free space.These systems are complex, havelarge footprints, and are of highcost. The major limitation of time-domain OCT systems is that theyuse a single-point motorized scan-ning mechanism to acquire thetomographic image. This limits theimaged region of interest to a fewmillimeters for most dental applica-tions. Mechanical scanning not onlyprolongs imaging time but alsorepresents the major challenge indevising a widely applicable clinicaldental imaging system. Recentlynew techniques known as Fourierdomain OCT have been investi-gated. Fourier domain OCTprovides higher acquisition speedand better signal-to-noise ratio thantraditional time-domain methods.
Authors Otis and Zhu haverecently collaborated with Dr.Boon-Siew Ooi of LehighUniversity who has pioneered thefabrication of a broad luminescentbandwidth light source that can becoupled with an on-chip spectrom-eter.24-25 We will integrate theessential elements of this novellight source and the essentialcomponents of an OCT system,creating a 4-channel Fourierdomain OCT system on a chip(OCT-SOC). The total chip size ofthis new prototype will be less than2 x 3 mm. When developed, theestimated production cost for afully packaged, single-elementOCT-SOC is expected to have aunit cost of less than $200.00. OCT-SOC will significantly increase thescanning throughput for a dentalOCT system, resulting in fasterimage acquisition, greater imagingdepth, and increased axial resolu-tion to approximately 10 µm.Compared with the bulk optics anddiscrete components of currentOCT systems, the OCT-SOC isanticipated to be significantlysmaller, lighter in weight, andlower in cost, making OCT dentalimaging systems a reality.
A U T H O R B I O G R A P H YDr. Linda Otis is presentlyProfessor of Oral and MaxillofacialRadiology at the University ofMaryland, Baltimore College ofDental Surgery, Department ofDiagnostic Sciences and Pathology.She began her pioneer work in thefield of Optical CoherenceTomography in dentistry in 1991 atthe University of California, SanFrancisco and in 1994 at theMedical Technology Program at theLawrence Livermore NationalLaboratory in Livermore,California. She lectures nationally,has authored many researchpapers, and has publishednumerous articles in peer-revieweddental journals. Dr. Otis may be reached via e-mail: [email protected].
Quing Zhu, MS, PhD, AssociateProfessor, Electrical and ComputerEngineering, The University ofConnecticut, Storrs, Connecticut,[email protected].
Boon-Siew Ooi, BEng, PhD,Associate Professor, Department ofElectrical and ComputerEngineering and Center for OpticalTechnologies, Lehigh University,Bethlehem, Pennsylvania,[email protected].
Disclosure:Dr. Otis is Vice President of ClinicalResearch for Lantis Laser Inc., acompany formed to commercialize theapplication of novel technologies inthe dental industry, including OCTDental Imaging. Dr. Otis is named onthree OCT-related patents, and hasbeen the recipient of research grantsfrom the U.S. Department of Healthand Human Services NationalInstitutes of Health for her work.
R E F E R E N C E S1. Huang D, Swanson EA, Lin CP,
Schuman JS, Stinson WG, Chang W,Hee MR, Flotte T, Gregory K,Puliafito CA, Fujimoto JG. Opticalcoherence tomography. Science1991;254(5035): 1178-1181.
2. Holt LA, Williams KB, Cobb CM,
Keselyak NT, Jamison CL, BrandVS. Comparison of probes for micro-bial contamination following use inperiodontal pockets of variousdepths. J Periodontol2004;75(3):353-359.
3. Hammerle CH, Glauser R. Clinicalevaluation of dental implant treat-ment. Periodontol 20002004;34:230-239.
4. Piao D, Zhu Q, Dutta NK, Yan S,Otis LL. Cancellation of coherentartifacts in optical coherence tomog-raphy imaging. Appl Opt2001;40(28):5124-5131.
5. Otis LL, Everett MJ, Sathyam US,Colston BW Jr. Optical coherencetomography: A new imaging tech-nology for dentistry. J Am DentAssoc 2000,131(4):511-514.
6. Colston BW Jr, Sathyam US,DaSilva LB, Everett MJ, Stroeve P,Otis LL. Dental OCT. Opt Express1998;3(6):230-238.
7. Otis LL, Colston BW, Armitage G,Everett M. Optical imaging of peri-odontal tissues. J Dent Res1997;76(Spec Iss):383, abstract 2956.
8. Sapia MA, Colosi DC, Otis LL.Reduction of speckle noise in OCTimages. J Dent Res 2000;79(SpecIss):550, abstract 3251.
9. Colston BW, Everett MJ, Da SilvaLB, Otis LL, Stroeve P, Nathel H.Imaging of hard- and soft-tissuestructure in the oral cavity byoptical coherence tomography. ApplOpt 1998;37(16):3582-3585.
10. Otis LL, Meiers JC. Refraction arti-facts cause spatial distortion in OCTimages. J Dent Res 2000;79(SpecIss):456, abstract 2503.
11. Otis LL, al-Sadhan RI, Meiers J,Redford-Badwal D. Identification ofocclusal sealants using opticalcoherence tomography. J Clin Dent2003;14(1):7-10.
12. Lugassy AA, Moffa JP: Laboratorymodel for the quantification of clin-ical occlusal wear. J Dent Res1985;64:181, abstract 63.
13. Ziemiecki TL, Colston BW, EverettMJ, Otis LL. Optical coherencetopography: A novel assessment ofcomposite wear. J Dent Res 1998;77(Spec Iss A):276, abstract 1367.
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14. Otis LL, Everett MJ, Colston BW.Optical coherence tomography: Anovel assessment of coronal restora-tions. J Dent Res 1998;77(Spec IssB):824, abstract 1541.
15. Otis LL, Colston BW Jr, Everett MJ,Nathel H. Dental optical coherencetomography: A comparison of two invitro systems. DentomaxillofacRadiol 2000;29(2):85-89.
16. Otis LL, Piao D, Gibson CW, Zhu Q.Quantifying labial blood flow usingoptical Doppler tomography. OralSurg Oral Med Oral Pathol OralRadiol Endod 2004;98(2):189-194.
17. Piao D, Otis LL, Zhu Q. Dopplerangle and flow velocity mapping bycombined Doppler shift and Dopplerbandwidth measurements in opticalDoppler tomography. Opt Lett2003;28(13):1120-1122.
18. Otis LL, Zhu Q. Optical Dopplertomography (ODT) and blood flow. J
Dent Res 2002;81(Spec Iss A):abstract0978 (www.dentalresearch.org).
19. Piao D, Otis LL, Dutta NK, Zhu Q.Quantitative assessment of flowvelocity-estimation algorithms foroptical Doppler tomography imaging.Appl Opt 2002;41(29):6118-6127.
20. Chen Y, Otis L, Piao D, Zhu Q.Characterization of dentin, enamel,and carious lesions by a polariza-tion-sensitive optical coherencetomography system. Appl Opt2005;44(11):2041-2048.
21. Jones RS, Fried D. Remineralizationof enamel caries can decreaseoptical reflectivity. J Dent Res2006;85(9):804-808.
22. Jones RS, Darling CL, FeatherstoneJD, Fried D. Imaging artificialcaries on the occlusal surfaces withpolarization-sensitive optical coher-ence tomography. Caries Res2006;40(2):81-89.
23. Fried D, Xie J, Shafi S, FeatherstoneJD, Breunig TM, Le C. Imagingcaries lesions and lesion progressionwith polarization sensitive opticalcoherence tomography. J BiomedOpt 2002;7(4):618-627.
24. Ooi BS, Hamilton CJ, McIlvaney K,Bryce AC, De La Rue RM, MarshJH, Roberts JS. Quantum-wellintermixing of GaAs-AlGaAs struc-tures using pulsed laser irradiation.IEEE Photonic Technol Lett1997;9(5):587-589.
25. Ooi B-S, McIlvaney K, Street MW,Helmy AS, Ayling SG, Bryce AC,Marsh JH, Roberts JS. Selectivequantum-well intermixing in GaAs-AlGaAs using impurity-free vacancydiffusion. IEEE J Quantum Electron1997;33(10):1784-1793. n n
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Elimination of a Venous Lake on the Vermilion of the Lower Lip Via 810-nm Diode LaserLawrence A. Kotlow, DDS, Albany, New YorkJ Laser Dent 2007;15(1):20-22
I N I T I A L D I A G N O S I SA venous lake or pool presents as abluish, soft, discrete, painlessnodule beneath the epithelium ofthe lower lip. Although this lesionis usually seen in individuals over40 years of age, this patientpresented with it at age 8 (Figure1). There is no gender predilection,and in many instances the lesion islocated on the lower lip mucosa orvermilion, or on the buccal mucosa.Pressure on the feeder vessel willproduce blanching, and the lesion isalmost never larger than 6 mm indiameter. These types of lesions areusually observed as a single,perhaps tortuous, dilated veinlocated superficially beneath thesurface epithelium, above the stri-ated lip muscles. This lesion is alsoknown as a traumatic angiomatouslesion. It differs from hereditaryhemorrhagic telangiectasias andsimilar developmental disorders bythe pattern and increased numbersof vascular lesions associated withmore complex disorders.
P R E T R E AT M E N TA. Outline of Case1. Clinical ExaminationAn 8-year-old Caucasian female
presented for an initial dentalexamination. Her oral evaluationindicated an age-appropriatecomplement of teeth, no dentaldecay, and normal occlusion. Therewere no intraoral lesions or otherabnormalities. Her present andpast medical histories were unre-markable. Examination of theexternal head and neck arearevealed a small elevated bluelesion in the middle of the lowerlip. The lesion was consistent withthe diagnosis of a venous pool asdescribed above.
2. Radiographic DentalExaminationThe radiographs of the patientwere consistent with a normaldeveloping dentition.
3. Past Oral HistoryThe patient had sustained a slighttrauma to the lower lip approxi-mately one year ago. As the resultof the accident, the small lesiondeveloped in the middle of thelower lip (Figure 1). According tothe child’s mother, the patient hadbeen examined previously by aplastic surgeon for evaluation ofthe lesion. The plastic surgeon hadrecommended leaving the lesionalone. At this time, she consultedwith my office to explore possibili-ties for eliminating the lesion. Boththe child and the mother felt thelesion was unsightly and seemedeager to have it removed.
B. Diagnosis and TreatmentPlan1. DiagnosisThe lesion was consistent in history
S Y N O P S I S
This article describes the successful removal of a venous lake lesion
from the lip of an 8-year-old using an 810-nm diode laser. The
procedure was successful and the follow-up visits showed continued
healing.
A B S T R A C TA venous lake or pool oftenappears at the site of an injury tothe lower lip. In most instances,this condition may be found inadults over the age of 40. Thiscase presents a lesion whichdeveloped due to trauma in an 8-year-old patient. Treatment usingan 810-nm diode laser ablated thelesion with topical anesthesic only.
Figure 1: Venous lake lesion as itappeared when the patient presented, asviewed through the operating microscope.
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and appearance as a venous lake(Figure 2).
2. Informed ConsentA discussion was held with theparents and the child. They wereadvised that it was impossible toguarantee the final results oftreatment. Possible outcomesincluded the successful removalof the lesion; inability tocompletely remove the lesion; andpermanent scarring at the site(though this was consideredunlikely).
3. Treatment RecommendationRemoval of the lesion using an 810-nm diode laser using topicalanesthetics.
4. Alternatives to TreatmentSeek additional consultationswith plastic or oral surgeons.Accept the prior medical recom-mendation to leave the lesionuntreated.
5. Indication for Treatment Usingan 810-nm Diode LaserThe source of the lesion is a feedervessel that extended an appendageinto the epithelium of the lip. Withits ability to be absorbed by hemo-globin, the 810-nm diode lasertargets the small vessel thatdelivers blood to the lesion. Thusthe laser has the potential todestroy the lesion by shuttingdown the extension of the feedervessel without damaging the lip orscarring the area of the lesion.There is little collateral damagewith treatment with an 810-nmdiode laser. The lesion can beremoved with immediate resultsusing a minimally invasive treat-ment under a topical anestheticagent.
6. ContraindicationsNone in this case. Potential forbleeding was discussed during theinformed consent discussion.However, this was not considered tobe a contraindication.
T R E AT M E N TA. ObjectiveAblate the venous pool withoutleaving any undesired remnants ofthe lesion.
B. Laser Operating ParametersA diode laser (DioDent™, HOYAConBio, Fremont, Calif.) was usedto remove the lesion.• Power setting: 0.6 Watt• Delivery system: 400-micron fiber• Emission mode: CW (continuous
wave)• Wavelength: 810 nm• Total time: Approximately 90
seconds from start to finish
C. Treatment DeliverySequence• Safety glasses appropriate for the
810-nm diode laser were placedon the seated patient.
• The assistant then put on safetyglasses.
• A topical anesthetic agent (TAC20%) was placed on the targetarea for approximately 3minutes.
• The laser fiber was cleaved andtested for a good surgical beam.
• The entire surgical field wasviewed through a dental oper-ating microscope (Global SurgicalCorporation, St. Louis, Mo.) fittedwith safety lenses to protect thedentist’s eyes.
• High-speed suction was turned on.• For the initial treatment the fiber
was not initiated, allowing thearea to be heated slowly.
• The non-initiated tip was movedin a circular motion approxi-mately 2-4 mm above the lesionfor about 45 seconds.
• The tip was then initiated usinga small piece of blue articulatingpaper. The author’s clinical obser-vation was that this allowed thetarget tissue temperature to risefaster without causing the tip tooverheat.
Figure 2: Appearance of the lesion immediately prior to treatment.
Figures 3-5: Progressive appearance ofthe lesion during ablation by the diodelaser.
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• The fiber was then brought intolight contact over the areacontaining the lesion. The sitewas then abraded until the areaturned white where the bluelesion had been present. Thistook approximately 45 seconds ofintermittent contact until thedesired results were achieved(Figures 3-5).
D. Management ofComplicationsThere were no complications. Thearea appeared white without anysigns of bleeding. The patient didnot appear to have any significantdiscomfort during or immediatelyafter the treatment.
E. Postoperative PrognosisThe immediate postoperativeappearance indicated total ablationof the lesion (Figure 6).
F. Treatment RecordsAll operating parameters werenoted in the patient’s chart.Photographs of the pre- and post-treatment conditions of the areawere taken and placed in thedigital record of the child. Theprocedure was videotaped using aHD video camera attached to themicroscope.
G. Postoperative Care andInstructionsThe parents were advised to giveappropriate pain medication if thechild indicated that she washaving discomfort, and to call ifany bleeding or concerns devel-oped. The procedure wascompleted in a morning appoint-ment and a follow-up phone callwas made that evening. No prob-lems had occurred and the patientwas comfortable.
The patient was appointed toreturn in 2 weeks for an observa-tion of the area. The appearance isshown in Figure 7. (Normally thepatient would be seen after 1 week;however, the family was leaving forvacation in 2 days.)
F O L LO W- U P C A R EA. Side Effects andComplicationsThere were no undesired sideeffects or complications of thetreatment.
B. Assessment of Treatmentand HealingThe patient returned for evaluationof the area on day 13. There wereno signs of either the lesion or scar-ring (Figure 7). Both parents and
the child were extremely happywith the results.
C. Long-Term ResultsExcellent. The area was completelyfree of the lesion. Follow-up willoccur at routine periodic preventivemaintenance visits. The appearanceof the treatment area three monthsafter the procedure is shown inFigure 8.
A U T H O R B I O G R A P H YDr. Lawrence Kotlow is a BoardCertified Pediatric Dentist andhas a private practice in Albany,New York. He has receivedAdvanced Proficiency Certificationin Er:YAG Laser and StandardProficiency in diode laser from TheAcademy of Laser Dentistry. Hecontributed a chapter in theOctober 2004 issue of the DentalClinics of North America on usingthe erbium laser in pediatricdentistry, and has written manyarticles on using lasers in pedi-atric dentistry. Dr. Kotlow may bereached via e-mail:[email protected].
Disclosure: Dr. Kotlow lectures andconducts instructional courses forHOYA ConBio and receives an hono-rarium for his seminars.
R E F E R E N C E S1. Rice JH. Removal of venous lake
using a diode laser (810 nm).Wavelengths 2004;12(1): 20-21.
2. Neumann RA, Knobler RM. Venouslakes (Bean-Walsh) of the lips –Treatment experience with theargon laser and 18 months follow-up. Clin Exp Dermatol1990;15(2):115-118.
3. Bekhor PS. Long-pulsed Nd:YAGlaser treatment of venous lakes:Report of a series of 34 cases.Dermatol Surg 2006;32(9):1151-1154.
4. del Pozo J, Pena C, Garcia Silva J,Goday JJ, Fonseca E. Venous lakes: Areport of 32 cases treated by carbondioxide laser vaporization. DermatolSurg 2003;29(3):308-310. nn
Figure 6: Appearance of the treated areaimmediately post-treatment.
Figure 7: Appearance of the treated area13 days post-treatment.
Figure 8: Appearance of the treated area3 months post-treatment. Area remainedfree of lesion.
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Deep Caries Removal, BacterialDecontamination, CompositePreparation, Beveling, and EtchingUsing an Er:YAG LaserAlfred D. Wyatt, Jr., DMDCollege Park, Georgia
The Use of an Er:YAG Laser (2940 nm)in Soft and Hard Tissue Surgery forEsthetic EnhancementsRaminta Mastis, DDSSt. Clair Shores, Michigan
Periapical Surgery and GuidedTissue Regeneration with an Er:YAGLaserAlberto Trigas Damian, DDSCarballino, Ourense, Spain
The Use of a CO2 Laser in theReduction of Maxillary Tuberosity George Romanos, DDS, Dr. Med. Dent.,
PhDNew York, New York
Caries Removal and CompositePreparation for Primary TeethAlfred D. Wyatt, Jr., DMDCollege Park, Georgia
The following cases were presented by three recentsuccessful Advanced Proficiency candidates during the last two Academy of Laser Dentistry annual conferences.1. Dr. Alfred Wyatt uses an Er:YAG laser for two clin-
ical cases. In the first, the laser was used withoutanesthesia for removal of carious lesions in two anterior teeth, and then composite resin restorationswere placed. A second pediatric patient receivedsimilar treatment for removal of carious lesions intwo molars.
2. Dr. Raminta Mastis utilizes an Er:YAG laser foresthetic crown lengthening. This wavelength is idealfor removing and recontouring both the gingiva andthe underlying osseous structures to achieve thedesired new tooth proportions prior to restoration.
3. Dr. Alberto Trigas Damian utilizes an Er:YAG laserfor treatment of a periapical abscess which developedafter conventional endodontic obturation. The laserperformed the soft tissue incision, osteotomy, and rootresection. The laser also contoured and prepared theosseous area for guided bone regeneration.
4. Dr. George Romanos uses a carbon dioxide laser toexcise hypertrophic tuberosity soft tissue to achieveimproved physiologic contour before placement of anew maxillary denture.
These cases show various clinical applications ofthree individual wavelengths and demonstrate howthose lasers, in their specific tissue interactions, can beeffectively used for successful treatment outcomes. nn
Advanced Proficiency Case Studies
Deep Caries Removal, BacterialDecontamination, CompositePreparation,Beveling, and EtchingUsing an Er:YAG LaserAlfred D. Wyatt, Jr., DMD, College Park, GeorgiaJ Laser Dent 2007;15(1):24-27
P R E T R E AT M E N TA. Outline of Case1. Full Clinical DescriptionA 58-year-old male patientpresented to the office for thespecific purpose of “having hisbroken front teeth fixed” (Figure 1).The patient’s medical history wasfree of any ailments or conditionsthat needed to be addressed priorto treatment. He had been seenpreviously in the office for thepurpose of a comprehensive exami-nation and treatment plan. Thepatient proceeded with only someof the recommended treatment.Intraorally, the majority of hisposterior dentition was missing andthe remaining teeth exhibitedgeneralized gingival recession aswell as periodontal disease. He wasin Class I occlusion and exhibitednormal mandibular range ofmotion.
2. Radiographic ExaminationA panoramic radiograph revealedseveral missing teeth as well asadvanced generalized bone loss inboth arches. Otherwise, no visibleabnormalities, significant radiolu-cencies or radiopacities werepresent in the maxilla or themandible. A periapical radiographrevealed caries in teeth #7 and 8 on
the distal aspect of the root surface(Figure 2).
3. Soft Tissue StatusPrior to treatment, oral cancer andperiodontal examinations wereperformed. The probing chart isshown in Figure 3 and the patientwas diagnosed with moderate-to-severe periodontitis and wasundergoing therapy for this condi-tion. Previously, he had receivedscaling and root planing whichreduced bleeding and inflammation.The buccal mucosa, sublingual
areas, and palate exhibited no signsof any suspicious lesions; tissueexhibited no hyperkeratosis whichcan often appear on the tissue ofcigarette-smoking patients.
4. Hard Tissue StatusAs shown in Figure 4, in themaxilla, only the anterior teeth
S Y N O P S I S
An Er:YAG laser was used without anesthesia for removal of carious
lesions in two anterior teeth, and then composite resin restorations
were placed.
Figure 1: Preoperative facial viewshowing fractured structure of tooth #7and a carious lesion on tooth #8
Figure 2: Preoperative radiographshowing pulpal proximity to the defectivetooth structure
Figure 3: Preoperative periodontal chartshowing moderate periodontitis
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were present; three molars weremissing in the mandible. Due tothe patient’s periodontal status, theridge level was less than desirable.Also, bone loss around theremaining teeth was no less than30% resorbed at its greatest height.Teeth #7 and 8 exhibited decay aswell as staining from smoking. Theteeth tested vital.
5. Other TestsBlood pressure levels were withinnormal ranges. Occlusal evaluationdemonstrated mandibular range ofmotion within normal limits.
B. Diagnosis and Treatment Plan1. Provisional DiagnosisA mesial incisal fracture of tooth #7.
2. Final DiagnosisExtensive caries close to the pulpon both teeth #7 and 8. Tooth #7had significant loss of incisal edgestructure and there was extensiveroot surface caries on the distal oftooth #8. Both teeth may requireendodontic therapy after cariesremoval.
3. Treatment Plan OutlineThe primary objective was to restoreteeth #7 and 8 using an Er:YAGlaser in the following sequence:a.Remove all decayed tooth struc-
ture
b. Decontaminate bacteria in areasof tooth preparation close to thedental pulp
c. Refine composite preparation byshaping, etching, and bevelingthe enamel
d.Restore cavity with hybridcomposite resin, and then eval-uate both the pulpal status andthe necessity for crown restora-tions.
4. IndicationsCaries removal is necessary for thetooth restoration, and the Er:YAGlaser can easily remove thediseased structure. This laser wave-length is more readily absorbed bytissue with a higher water contentsuch as a carious lesion; therefore itis possible to more easily conservehealthy tooth structure. In addition,the relative lack of tactile stimula-tion offered by laser treatmentcompared to conventional high-speed handpieces often allows theprocedure to be performed withoutthe need for needle analgesia.
5. ContraindicationsThere are no absolute contraindica-tions for performing the procedure,except that the time required forthe laser to accomplish cariesremoval and tooth preparation canbe longer than when a high-speedhandpiece is used.
6. PrecautionsAdequate water spray must bemaintained as caries are beingremoved. Since the erbium laserpreferentially interacts withdiseased tooth structure, good visi-bility and low power will benecessary for careful preparation inorder to avoid both thermaldamage and excessive removal oftooth structure.
7. Treatment AlternativesAlternatives to treatment methodsinclude the use of injected anes-thetics and conventional handpiecewith burs for cavity preparationand preparation refinement.
8. Informed ConsentUpon receiving a full explanation ofthe procedure, with associatedrisks, benefits, and alternatives, thepatient gave verbal consent toperform the treatment.
T R E AT M E N TA. Treatment ObjectivesStrategyThe primary objective was toperform the majority of the cariesremoval, cavity preparation,enamel etching, and bevelingutilizing the Er:YAG laser comfort-ably and efficiently without the useof injectable dental anesthetics.
B. Laser Operating ParametersThe Er:YAG laser (DELight, HOYAConBio, Fremont, Calif.) with awavelength of 2940 nm was usedwith its fiber delivery system and a600-micron quartz tip. It operatesin a free-running pulse mode witha pulse duration of 300 msec. Thelaser was used at 30 Hz, 180 mJ,5.4 W, and also at 30 Hz, 70 mJ,2.1 W, both with water spray,during the procedure. The tip wasused in both contact and noncon-tact (defocused) modes.
C. Treatment DeliverySequencePrior to commencing the proce-dure, the patient was familiarized
Wyatt, Jr.
Figure 4: Preoperative restorative chart
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with the procedural steps.Subsequently, all laser safetyprecautions were performed.These included but were notlimited to the administering oflaser safety glasses to the patientand operators, displaying laserhazard signage, and inspectingthe mechanical aspects of thelaser. Once safety systems were inplace, the laser was test-fired toinsure proper beam function andwater spray delivery. The laserpulse rate was set to 30 Hz andthe laser energy was set to 180mJ which produced a power of 5.4W. As the target tissue wasaddressed, high-volume suctionwas used continuously. The laserbeam was defocused approxi-mately 2 cm from the targettissue for 90 seconds (Figure 5).The beam was directed closer tothe decay with a brushing-likemotion until ablation began. Thetip was kept in a close noncontactposition as the decay was removeduntil the preparation depthextended close to the pulp. Theenergy was then lowered to 70 mJ(2.1 W of power) for further cariesremoval and bacterial decontami-nation. After the caries wereremoved, the settings werereturned to 30 Hz/180 mJ for thepurpose of beveling and “laser-etching” the enamel (Figure 6).Clearfil SE Bond (KurarayAmerica, Inc., New York, N.Y.) wasapplied to enamel and dentinsurfaces and a 0.4-micron filler
size composite was used as therestorative material. Finishing ofthe restoration was performedwith coarse diamond burs, 12-blade finishing burs, and finishingdiscs (Figure 7).
D. Postoperative InstructionsThe patient was told that he couldresume normal activities due to thelack of numbness as a result of noinjections. The patient was told tocall the office if pain or any otherunusual symptoms occurred.
E. ComplicationsNo complications occurred duringor after the procedure.
F. PrognosisThe prognosis for the success of theprocedure and restorations wasgood. The patient was informedthat the lesions were close to thepulp and may require endodontictherapy. Due to the size of thelesion, it was recommended tooth#7 receive a crown in the future.
G. Treatment RecordsTreatment records, including thedetails outlined above, wereincluded in the patient’s chartnotations.
F O L LO W- U P C A R EA. Assessment of TreatmentOutcomeThe objectives originally set wereachieved. The entire procedure wasperformed with success without theuse of dental anesthetic. In addi-tion, satisfactory esthetic resultswere obtained.
B. ComplicationsAt 6 months, an incisal fracturewas observed on tooth #8 (Figure8). The patient stated that the frac-ture was the result of a mophandle hitting him in the mouth.The incident did not affect theintegrity of the restoration or thevitality of the tooth.
C. Long-Term ResultsAt the 6-month postoperative visit,the integrity of the restoration andvitality of the teeth restored wereevaluated. The patient stated thathe had experienced no problemswith either restoration. Both teethmaintained healthy vitality testsand the surfaces were sealed(Figure 8). Periodontally, thegingiva exhibited slight inflamma-tion that can be resolved with aperiodontal maintenance proce-dure. The incisal edge of tooth #8was repaired using the laser andcomposite, and the patient wasinstructed to improve his oralhygiene (Figure 9). The radiograph
Wyatt, Jr.
Figure 5: View showing laser orientationto begin caries removal and tooth prepa-ration
Figure 6: Laser preparations completedFigure 7: Immediate postoperative viewof completed restorations
Figure 8: Six-month postoperative view.Restorations are intact. Note the incisalfracture of tooth #8
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at 6 months showed healthy peri-apical tissues (Figure 10).
D. Long-Term PrognosisAlthough the restorations of thetreated teeth show good integrityand function, the long-term prog-nosis is dependent upon properperiodontal maintenance, replace-ment of posterior teeth, and thepatient’s oral lifestyle.
AUTHOR BIOGRAPHYDr. Alfred Wyatt, Jr. is a graduateof the Medical College of GeorgiaSchool of Dentistry where he servesas Associate Professor of OralRehabilitation. He maintains aprivate practice in College Park,Georgia. Currently, he serves onthe Board of Directors of theAcademy of Laser Dentistry as wellas on the American DentalAssociation working group for laserusage. Dr. Wyatt presently utilizesEr:YAG and diode lasers in hispractice and has attained AdvancedProficiency and Certified EducatorStatus through ALD. Dr. Wyattmay be reached via e-mail:[email protected].
Disclosure: Dr. Wyatt has no finan-cial connections with or interests inany dental companies. nn
Wyatt, Jr.
Figure 10: Six-month postoperative radi-ograph showing the lack of periapicalpathology
Figure 9: Six-month postoperative view.Incisal edge of tooth #8 is repaired
The Use of an Er:YAG Laser (2940 nm)in Soft and Hard Tissue Surgery forEsthetic EnhancementsRaminta Mastis, DDS, St. Clair Shores, MichiganJ Laser Dent 2007;15(1):28-33
P R E T R E AT M E N TA. Outline of Case1. Full Clinical DescriptionA 44-year-old male patientpresented for a cosmetic consulta-tion for improving his smile. He wasseeking a third opinion because hisown dentist and a second opinionoffered him very differing treatmentplans and he was confused. Thepatient stated that he was recentlydivorced and also quit smoking andnow wants to do something abouthis teeth. He did not like theappearance of his teeth becausethey were “short and stained.” Healso had spaces between his teeththat he did not like.
The consultation addressedesthetic principles. Clinical examina-tion revealed severe incisal attritionof both maxillary and mandibularanterior teeth. The patient had at
least a 1.0-mm diastema betweenthe maxillary central incisors (withevidence of bonding attempts tominimize space), with a low labialfrenum insertion just above theteeth (Figures 1-3). There was noevidence of caries or of additionalfracture; however, several posteriorteeth exhibited some evidence ofcervical abfractions. Additionally, thepatient had occlusal wear facets onposterior teeth, which confirmedparafunction such as bruxism. BothTMJs appeared normal to palpationand movement.
The patient’s medical historyincluded recently quitting smoking.The patient was taking Lipitor® forhis cholesterol levels and had anallergy to codeine. The patient hadno medical concerns or contraindi-
cations for treatment.Dental history included multiple
posterior teeth restored withmoderate-size fillings. Severalmolars (#1, 14, 18, and 30) wereremoved in the military more than20 years ago. The patient had anatural dentition with a Class Iocclusion and had maintained
S Y N O P S I S
The use of an Er:YAG laser for esthetic crown lengthening is
reported. This wavelength can be used for removing and recon-
touring both the gingiva and the underlying osseous structures to
achieve the desired new tooth proportions prior to restoration.
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Mastis
Figure 1: Preoperative close-up view ofpatient’s smile
Figure 2: Preoperative view of fibrous labialfrenum with insertion just above teeth.Note also the wide band of attachedgingiva which is pink and stippled
Figure 3: Preoperative view of patient incentric occlusion
Figure 4: Preoperative panoramic radiograph
Figure 5: Preoperative periapical radi-ographs
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regular recall appointments.
2. Radiographic ExaminationBoth periapical and panoramicradiographs of the maxillary teethshowed no evidence of osseous orperiapical pathologies (Figures 4-5). There was no significant boneloss surrounding any of the maxil-lary anterior teeth, which would betypically associated with peri-odontal disease. Teeth #1, 14, 18,and 30 were missing, resulting insome mesial tipping of remainingmolars. There were moderate-sizerestorations on posterior teeth aswell as a large composite on tooth#9, with no evidence of uncon-trolled caries.
3. Soft Tissue StatusThe patient had generalizedhealthy peridontium. The peri-odontal probings were 1-3 mmthroughout the maxillary anteriorregion with no bleeding. The ante-rior teeth were surrounded with abroad band (9-14 mm width) ofattached gingiva with stippling.The tissue was pink, firm, andhealthy. Periodontal probings of theposteriors ranged from 2-5 mm.Some of the deeper probings wereassociated with the mesial tippingof molars after neighboring toothloss. The tongue, floor of mouth,palate, cheeks, and lips were allwithin normal limits.
4. Hard Tissue StatusExamination of dental hard tissuerevealed the following of note: Tooth#9 had a large bonded restoration,and was slightly shorter than #8(resulting from trauma to tooth #9more than 20 years ago). Severalposterior teeth had moderate-sizerestorations which appeared insatisfactory condition. The maxil-lary laterals exhibited rotation.Spacing was evident in the poste-rior region from drifting into areasof molar extraction sites (Figure 6).The patient had evidence ofbruxism (or similar parafunction)due to the wear patterns on
occlusal surfaces. Despite this, histemporomandibular joints wereasymptomatic.
5. Other TestsA diagnostic cosmetic mock-up wasmade as a guide for visualizing therestorative plan as well as formeasurement purposes for theproposed crown lengthening proce-dures. Additionally, bone sounding(with local anesthetic) wasperformed prior to surgery to eval-uate bone levels for maintainingbiologic width.
B. Diagnosis and Treatment Plan1. Provisional DiagnosisHealthy periodontium with short-ened teeth due to excessive incisalwear.
2. Final DiagnosisA final diagnosis was made ofhealthy periodontal tissues withesthetically compromised maxillaryanterior teeth, where the gingivahad encroached onto the enamel inthe cervical areas. In addition, alow attachment of the maxillarylabial frenum with an insertionpoint just above the central incisorscontributed to the diastema as wellas to limiting lip retraction andwas at a height which compromiseda full smile.
3. Treatment Plan OutlineIt was decided to perform a fullgingivectomy at the upper ante-rior segment, employing anassociated flap procedure and
labial frenectomy. In this way, themobility of the upper lip would beimproved and a more pleasingesthetic appearance of the ante-rior teeth obtained. The objectivewas to reduce the gingiva by 2 to3 mm, with osseous recontouringto maintain the biologic width. Alltreatment would involve the useof an erbium:YAG laser. Followinga healing phase, the final restora-tive plan would include theprovision of esthetic porcelainrestorations.
4. Treatment Plan AlternativesAlternatives to laser use:• The use of traditional surgical
procedures including scalpel forthe incision and raising the flap,followed by rotary instrument forosseous recontouring. The use ofscalpel or electrosurgery for thelabial frenectomy and gingivec-tomy.
• Since the proposed treatmentwas elective to aid in improvingthe esthetic result, an alterna-tive included refraining fromsurgery altogether and acceptingcompromises in restorativeattempts.
5. Indications for LaserThe use of an Er:YAG laser isconsidered ideal for this type ofhard and soft tissue surgical proce-dure because the same instrumentcan be used to perform the variousstages of treatment. Laser osseouscontouring offers improved visuali-zation of the surgical site becauseof the small laser operating tip, asopposed to restrictions of visualiza-tion with the head of a rotaryhandpiece. Additionally, the laser isan asset for efficient osseous abla-tion due to minimal trauma to vitaltissue, as opposed to rotary instru-mentation, and has an advantagefor clearing debris from thesurgical site rather than creating asmear layer on freshly cut bone bya rotary handpiece. Anecdotally, thelaser may result in less postopera-tive discomfort.
Mastis
Figure 6: Preoperative maxillary occlusalview
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6. Contraindications for LaserThere were no absolute contraindi-cations for the use of the laser onthis patient. Proper energy controlneeds to be adjusted for the tissuestreated both to avoid tissue over-heating and also to preventcollateral thermal damage to adja-cent tissue structures. Care mustbe taken to avoid an air embolismin a flapped surgical site bydirecting the air away from theattachment.
7. PrecautionsThe Er:YAG laser wavelengtheasily interacts with both hard andsoft tissue, so care must be taken toavoid interaction with any associ-ated healthy tissue, especially harddental tissue. It is important thatadequate water spray be usedduring soft tissue ablation to avoidthermal damage through charring.
8. Informed ConsentThe patient was well informed aboutthe treatment proposal and the bene-fits and risks involved. The patientwas also given the option to have thesurgical procedures performed by aperiodontist. Written and verbalconsent were obtained from thepatient for the surgical procedures aswell as use of the photographs.
T R E AT M E N TA. Treatment ObjectivesStrategyThe Er:YAG (2940 nm) laser wouldbe used to carry out the followingstages of treatment:• Ablate the fibrous tissue of the
maxillary frenum• First probe pocket depths (Figure
7), mark and outline theproposed gingivectomy (Figure8), then incise the soft tissue,following this outline to removegingival tissue for the gingivec-tomy procedure
• Assist in raising a full thicknessflap for access to the surgical site
• Contour the crestal bone adjacentto the anterior teeth to aminimum measurement of 3.0
mm below the height of thegingiva for establishment of ahealthy dentogingival complex.Following surgical correction,
the flap would be sutured andallowed to heal.
B. Laser Operating ParametersA 2940-nm wavelength free-running pulsed Er:YAG laser(HOYA ConBio, Fremont, Calif.)was used. The energy was deliveredthrough an optical zirconiumaluminum fluoride fiber to a 600-micron quartz tip with an80-degree curve.
The frenectomy was performedwith settings of 20 Hz repetitionrate and 70 mJ per pulse, withwater, for approximately 30 secondstotal. For the gingival outlining, asetting of 10 Hz repetition rate and35 mJ per pulse, without water,was used. For the gingivectomy,water was added and the surgicalsettings were increased to 20 Hzrepetition rate and 70 mJ perpulse, for a total of 30 seconds pertooth. The tip was kept in noncon-tact mode (about 0.5 mm away
from the tissue surface). The inci-sion for the flap was continued atthe same settings as for thegingivectomy, with water. For theosseous recontouring, the samesetting of 20 Hz and 70 mJ wasused with water for a total of about40 seconds per tooth in a combina-tion of noncontact and light-contactmode. The average power for thesoft and hard tissue procedureswas 1.4 Watts.
C. Treatment DeliverySequenceAll safety precautions, whichincluded laser protective eyewearfor the patient, doctor and assis-tant, were verified by the lasersafety officer. The laser was test-fired into water, using minimumoperating parameters, to establishcorrect function and patency of thedelivery system. Local anestheticwas administered with buccal infil-tration and allowed to take effect.The laser was set to the soft tissuesettings and test-fired outside themouth. The upper lip was retractedto maintain tension on the frenum.The laser was fired (with water) atthe fibrous attachment in order tofacilitate release and then used toablate fibrous connective tissue atthe site of frenum insertion on thealveolus. The laser was used innoncontact and light-contact mode.No sign of charring was observed(Figure 9). No sutures wererequired.
The laser settings were reduced,the tip was examined and the laser
Mastis
Figure 7: Proposed levels for tissuereduction were marked with a Sharpiemarking pen, measured, and recorded
Figure 8: All anterior teeth were probedfor pocket depths
Figure 9: Laser being used to ablate thedense fibers of the frenum to facilitaterelease
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was test-fired outside the mouth.The laser was then used withoutwater to mark reference spots(Figure 10) and to outline thegingival contours of the proposedgingivectomy as an aid to deter-mine how much tissue would beremoved or contoured for thedesired cosmetic result (using thediagnostic mock-up as a guide). Thelaser settings were reset to the softtissue surgical settings and test-fired again outside the mouth. Thegingivectomy excision wasperformed (Figure 11) using anoncontact mode first on the rightside on teeth #6, 7, and 8, thenrepeated on the left side on teeth#9, 10, and 11. Water was used toaid in cooling neighboring tissueand underlying bone and thusreduce collateral thermal injury. Nosign of charring was observed(Figure 12).
The level of the alveolar crest onthe facial surface of each of theanterior teeth was again verifiedwith bone sounding and confirmed
to be deficient for maintaining ahealthy dentogingival complex. Thelaser tip was examined, cleaned,and test-fired outside the mouth. Avertical releasing incision was made(with water, noncontact mode) onthe distal aspect of the interdentalpapilla between teeth #5 and 6. Thelaser was used in contact mode toaid in the release of the attachedgingiva by directing the tip (withwater and soft tissue settings) inthe pocket parallel to the surface ofthe tooth. A periosteal elevator wasused to reflect the full thicknessflap on the right side from tooth #6to #8. The osseous tissue wascontoured with the laser in shortintervals, utilizing noncontact modewith water. Care was taken to keepthe tip parallel to the root surface(Figure 13) to avoid removingcementum or ablating the rootsurfaces of the vital teeth. Also carewas taken to aim the water/airspray away from the soft tissue flapto avoid an air embolism. High-speed suction was used throughoutthe procedure for the purpose ofcooling, removing plume, and evacu-
ating debris and water to allowproper visualization of the postoper-ative surgical site (Figure 14). Theprocedure was repeated on the leftside (Figure 15) with the verticalreleasing incision on the distalaspect of the interdental papillabetween teeth #11 and 12, and afull thickness flap raised from tooth#11 to the midline for osseousrecontouring. The same settingsand procedure used on the rightside were repeated on the left. Theflap was repositioned over themaxillary anteriors (Figure 16),sutured into place (Figure 17), andallowed to heal.
D. Postoperative InstructionsThe patient was instructed to mini-mize disturbance of the suturedarea, but to begin gentle warm saltwater rinses the following day. Thepatient was also instructed to pullup on his upper lip once per hourduring waking hours for severaldays and to keep site clean. He wasinstructed to maintain oral hygieneof the rest of his teeth. A prescrip-tion for Motrin® 800 mg waswritten to relieve pain, if any. The
Mastis
Figure 10: Laser being used withoutwater at low settings to outline proposedtissue reduction prior to surgery, and veri-fied. Note outline on left side as well
Figure 11: Laser being used for gingivec-tomy procedure
Figure 12: Immediate postoperative viewof gingivectomy
Figure 13: Laser tip is angled parallel toroot surfaces when contouring crestalbone
Figure 14: Immediate postoperative viewshowing recontoured crestal bone
Figure 15: Procedure repeated on left sidewith the laser to recontour crestal bone
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patient was advised to call theoffice immediately if he noted anyadverse reactions or problems.
E. Complications – Types,Events, ManagementAfter the completion of the surgicalprocedures, a hematoma was notedin the maxillary right vestibule nearthe site of the frenectomy. This wasassociated with the manipulation ofthe lips for retraction during theappointment. Management includedwatching the area at postoperativeappointments, with no specific inter-vention at this time. The patientwas contacted the following day andhe reported no discomfort and hadno need to use any analgesics. Thepatient was seen two days later forevaluation, and the area washealing uneventfully with no post-operative discomfort. One weekafter the surgery, the sutures wereremoved. The hematoma in themaxillary labial vestibule wasresolving uneventfully. The healingof the surgical sites was progressingsatisfactorily and the patient wascomfortable throughout the period.
The patient was instructed toresume normal oral hygiene homecare. At the two-week postoperativevisit, the gingival tissue was pinkand adhering to underlying bonewith no evidence of inflammation.The patient had no complaints ofdiscomfort and was happy with theelongation of his teeth.
F. PrognosisThere were no significant complica-tions arising from the procedures,and the long-term prognosis for thegingival healing from the crownlengthening procedure as well asthe frenectomy was excellent.
G. Treatment RecordsAll treatment data, including thetype of laser used, operatingparameters, materials used, intra-oral photos and radiographs, wererecorded along with the writtendocumentation.
F O L LO W- U P C A R EA. Assessment of TreatmentOutcomeThe patient was asked to return attwo-day (Figures 18-19), one-week,two-week, and at one-month and
three-month intervals. He wascontacted the next day after surgery.He reported no discomfort and wasnot taking any analgesics. At theone-week follow-up, the sutures wereremoved, the tissue looked pink, theincisions were healing satisfactorily(Figures 20-21), and the patient hadno complaints. At the second-weekfollow-up, the tissue continued toheal satisfactorily with no evidenceof swelling or inflammation (Figure22). At the one-month follow-up, thefrenum had healed in a more supe-rior position. The tissue surroundingthe teeth looked pink and firm, andthe tissue height remained stable(Figure 23). The patient was happywith his longer teeth, but was now
Mastis
Figure 22: Two-week follow-up showinghealthy gingival healing with no inflam-mation
Figure 16: Full thickness gingival flapspassively repositioned over teeth postop-eratively
Figure 17: Immediate postoperative viewwith sutured surgical site. Note also thefrenum release site
Figure 18: Two-day follow-up view ofgingival healing with minimal inflammation
Figure 19: Two-day follow-up view offrenectomy. Healing is uneventful
Figure 20: One-week follow-up aftersuture removal
Figure 21: One-week follow-up of frenec-tomy healing well
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concerned about the color andstaining from years of smoking.Impressions were made for take-home bleaching trays and deliveredtogether with a 30% carbamideperoxide gel (Life-Like CosmeticSolutions, Harbor Dental BleachingGroup, Inc., Santa Barbara, Calif.)and instructions. Periodontal prob-ings were performed at thethree-month follow-up and confirmedgood gingival health and reestablish-ment of a healthy dentogingivalcomplex; sufficient biologic width toproceed with esthetic restorativeprocedures was noted Figures 24-27).An average of 2.0 to 3.0 mm of crownlength was gained through thesurgical procedures, and thus thetreatment objectives were met.
B. ComplicationsAside from the self-resolvinghematoma in the labial vestibule,no complications were noted andthe patient was comfortablethroughout the healing period.
C. Long-Term Results andPrognosisThe long-term outlook for thefrenectomy and crown length-ening procedures is consideredexcellent. The patient now hasgood bony support for the crown-lengthened teeth, and has goodgingival architecture withadequate attached keratinizedgingiva. A healthy dentogingivalcomplex had been established andprepared for the esthetic restora-tive procedures. The area ishealthy, stable, and maintainablefor the patient with normal oralhygiene home care. The patient ishappy with the results and is
motivated to refocus his financialconcerns to proceed with theproposed esthetic restorativephase of the treatment plan.
A U T H O R B I O G R A P H YDr. Raminta Mastis received herdental degree from the University ofIllinois College of Dentistry in 1987.She maintains a private practice inSt. Clair Shores, Michigan, focusingon integrating cutting-edge tech-nology in general dentistry. She is amember of the Academy of LaserDentistry and has StandardProficiency certification in Er:YAG,Er,Cr:YSGG, diode, and CO2 laserwavelengths. In 2006 she achievedAdvanced Proficiency in the Er:YAGlaser wavelength. Dr. Mastis may bereached via e-mail: [email protected].
Disclosure: Dr. Mastis has nocommercial relationships relative tothis case study. n n
Mastis
Figure 23: One-month follow-up. Notehealthy tissues with broad band ofattached gingiva and healthy appearanceof released frenum
Figure 24: Three-month postoperativeradiographs
Figure 25: Periodontal charting at three months
Figure 26: Three-month follow-up afterpatient’s use of home whitening trays
Figure 27: Three-month follow-up viewshowing fuller smile
Periapical Surgery and Guided TissueRegeneration with an Er:YAG LaserAlberto Trigas Damian, DDS, Carballino, Ourense, SpainJ Laser Dent 2007;15(1):34-37
P R E T R E AT M E N TA. Outline of Case1. Clinical ExaminationA 52-year-old female patientpresented pain to percussion and abuccal abscess on tooth #19 (Figure1). She did not present with anyalterations of the TMJ or abnormali-ties in the soft tissues, but exhibitedpoor oral hygiene. Occlusion wasAngle’s classification Class I. Thepatient’s medical history revealedno significant medical history orpredisposing risk factors.
2. Radiographic ExaminationIntraoral and panoramic X-rays(Figures 2 and 3) showed the originof the abscess, a periradicular radi-
olucency associated with the distalroot apex of tooth #19. A gutta-percha indicator point was insertedfor clarity (Figure 4); it marked anendodontic periapical abscessmimicking a deep periodontal pocket.The fistula drained into the sulcus.
3. Soft Tissue StatusThere was buccal gingival inflam-mation adjacent to tooth #19, andthe periodontal probe reached adepth of 12 mm (Figure 5). All otherpockets probed less than or equal to3 mm. Except for the facial aspectof tooth #19, all other soft tissuespresented a normal appearance.
4. Hard Tissue StatusTooth #19 was nonvital, havingbeen previously endodonticallytreated. Teeth #15 and #30 weremissing; there were no cariouslesions present, and the threeexisting amalgam restorationswere intact. The osseous structuresappeared normal.
5. Other TestsThe test to percussion was positiveon tooth #19 and the occlusion ofthe porcelain-fused-to-metal (PFM)crown was greatly reduced in orderto alleviate the chewing pain.
B. Diagnosis and Treatment Plan1. Provisional DiagnosisDraining fistula of endodontic origin.
S Y N O P S I S
Successful use of an Er:YAG laser is reported for treatment of a peri-
apical abscess which developed after conventional endodontic
obturation. The laser performed the soft tissue incision, osteotomy,
and root resection. The laser also contoured and prepared the
osseous area for guided bone regeneration.
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Trigas
Figure 1: Initial view of the buccal fistulaon tooth #19. The crown had just beenremoved
Figure 2: Preoperative panoramic film
Figure 3: Preoperative periapical filmshowing radiolucency at the apex of thedistal root of tooth #19
Figure 4: Preoperative film of a gutta-perchapoint that was placed into the fistula,extending toward the periapical area
Figure 5: Preoperative view of periodontalprobing of a 12-mm buccal pocket
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2. Final DiagnosisEndodontic periapical abscess origi-nated by the failure of the distal rootendodontic treatment of tooth #19.
3. Treatment Plan OutlinePeriapical surgery of the distal rootof tooth #19 with the use of anEr:YAG laser, and the guided tissueregeneration of the bone defect.
4. IndicationsTreatment is necessary to removethe infectious process and restorethe periodontal support of thetooth.
The Er:YAG laser is indicatedfor the treatment due to the factthat this wavelength (2940 nm) isvery well absorbed by the water ofthe gingiva and by the water andthe mineral of the dental andosseous tissues.
5. ContraindicationsNo contraindications were consid-ered for laser treatment.6. PrecautionsAdequate water cooling must beused during osseous surgery andthe air component of the spraymust be minimized to avoid thepossibility of an air embolism inthe soft tissue flap.
7. Treatment AlternativesTreatment alternatives includedendodontic retreatment and peri-apical surgery with conventionalinstruments, or the extraction ofthe tooth and a prosthodonticprocedure.
8. Informed ConsentThe risks and benefits of treatmentwere explained. Verbal consent wasobtained from the patient.
T R E AT M E N TA. Treatment ObjectivesStrategyUse of an Er:YAG laser to performosteotomy and root resectionwithout vibration or discomfort,and to provide bacterial reductionof the bone cavity, less contamina-
tion of the surgical site, and betterhealing and postoperative course.
B. Laser Operating Parameters• Er:YAG laser used: Opus Duo E
(Opusdent, Yokneam, Israel)• Wavelength: 2940 nm• Delivery system: Hollow wave-
guide with angulated handpiece• Emission mode: Free-running
pulsed• Spot size: 400 µm in soft tissue,
800 µm on dental tissue, and1300 µm in bone tissue
• Energy per pulse: 250 mJ (softtissue) and 500 mJ (hard tissue)
• Hertz: 20 pulses per second (insoft tissue) and 12 pulses persecond (in hard tissue and ingranulation tissue)
• Power ranging from 3 to 6 W• Water cooling used for all proce-
dures
• Total time: 19 minutes of laserenergy exposure.
C. Treatment DeliverySequenceThe safety measurements wereestablished: a test-fire of the laserwas performed to establish correctworking and patency of the wave-guide delivery system. A safetyarea check (only required personnelpresent, safety warning signsposted, and minimal reflectivesurfaces) was carried out. Thepatient and all personnel withinthe above-mentioned safety areawere issued protective glasses.High-volume evacuation was usedfor tissue cooling and suction ofremoved tissue.
Local anesthesia of 2% lidocaineHCl with epinephrine at 1:100,000was administered. With an initialaverage power of 5 Watts (250 mJ,20 pps), an intrasulcular laser inci-sion was performed using a 400-µmHPX™ Conical Sapphire Tip withlight brush strokes (contact mode)(Figure 6). The flap was elevatedwith hand instruments. There wasan 8-mm probing depth osseousdefect (Figure 7). The osteotomywas performed using an averagepower of 6 Watts (500 mJ, 12 pps)(noncontact mode), and the lasertip (1300-µm Sapphire NoncontactTip™) was focused 2 to 3 mm awayfrom the bone surface (Figure 8).The granulation tissue was
Trigas
Figure 6: Laser beginning an intrasulcularincision
Figure 7: Soft tissue flap elevated andosseous defect exposed
Figure 8: Laser being used for osseoustissue removal
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removed with hand instrumentsand lased with an average power of3 Watts (250 mJ, 12 pps) (1300-µmSapphire Noncontact Tip™)(noncontact mode) (Figure 9). Theroot apex was excised (Figure 10)and the remaining root area wasdisinfected using an average powerof 6 Watts (500 mJ, 12 pps). Thelaser tip (800-µm HPX™ ConicalSapphire Tip) was again focused 2to 3 mm away from the rootsurface, avoiding contact with thepost. No retrofilling material wasused (Figure 11). Natural bonemineral of bovine origin (Bio-Oss®,Osteohealth, Shirley, N.Y.) (Figure12) and a collagen membrane (Bio-Gide®, Osteohealth) were used forthe guided tissue regeneration.Flaps were sutured in place with 4-0 silk sutures (Figure 13). Apostoperative intraoral X-ray wastaken (Figure 14).
D. Postoperative InstructionsThe patient was instructed to stayon a soft diet, and she wasprescribed 0.12% chlorhexidinegluconate mouthrinse, amoxicillin500 mg every 8 hours for 7 days toavoid infection, and ibuprofen 600
mg every 8 hours if she had pain.She was told to return for a follow-up appointment in two weeks.
E. Immediate ComplicationsThere were no complicationsduring or after treatment and noside effects were noted.
F. PrognosisAll objectives of treatment weremet and the prognosis was consid-ered excellent.
G. Treatment RecordAll the information of the treat-ment was stored in the clinicalrecord of the patient.
Trigas
Figure 12: Bone grafting material placedinto area
Figure 14: Immediate postoperative radi-ograph showing complete debridementof the periapical area
Figure 13: Flap repositioned and suturesplaced
Figure 15: Two-week postoperative viewshowing initial tissue healing
Figure 16: One-month postoperative radi-ograph showing healing of osseous defect
Figure 9: Laser being used for removal offinal amount of granulation tissue
Figure 10: A view of the resected portionof the tooth root
Figure 11: Laser used for final debride-ment and disinfection of the surgical site
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F O L LO W- U P C A R EA. Assessment of TreatmentOutcomeFollow-up assessment was carriedout at two weeks (Figure 15), onemonth (Figures 16 and 17), fourmonths, and one year. At fourmonths, the radiograph showed goodhealing (Figure 18) with the probingdepth decreased to 4 mm, althoughhealing was still taking place(Figure 19). The PFM crown wasreplaced at four months (Figure 20).
B. ComplicationsThere were no side effects orcomplications.
C. Long-Term ResultsExcellent healing of the soft andbone tissues was observed at oneyear, both radiographically (Figure21) and clinically, with the pocketreduce to 2 mm (Figure 22).
A U T H O R B I O G R A P H YDr. Alberto Trigas received hisdental degree from the Faculty ofMedicine and Dentistry, Universityof Santiago de Compostela, Spain.He is a practicing general dentistin Carballino, Ourense, Spain. Dr.Trigas is a member of the Spanish
Society of Oral Surgery (SECIB),the Spanish Society of Periodont-ology and Osseointegration (SEPA),the European Federation ofPeriodontology (EFP), the SpanishSociety of Lasers in Dentistry(SELO), the European Society forOral Laser Applications (ESOLA),and the Academy of LaserDentistry (ALD). He has completedhis Advanced Proficiency in theEr:YAG laser wavelength. Dr.Trigas can be reached by e-mail [email protected].
Disclosure: Dr. Trigas has no finan-cial relationship with any dentallaser manufacturer. n n
Trigas
Figure 19: Four-month postoperative viewof pocket probing, showing improvementto 4 mm. The soft tissue has not fullyhealed
Figure 20: Four-month postoperative viewof the final crown restoration
Figure 21: One-year postoperative radi-ograph showing complete osseoushealing, including furcation area
Figure 22: One-year postoperative viewshowing periodontal probing depth of 2 mm, indicating good soft tissue reattachment
Figure 18: Four-month postoperative radi-ograph showing complete healing of theosseous defect
Figure 17: One-month postoperative viewof tissue healing
The Use of a CO2 Laser in theReduction of Maxillary Tuberosity George Romanos, DDS, Dr. Med. Dent., PhD, New York, New YorkJ Laser Dent 2007;15(1):38-40
P R E T R E AT M E N TA. Outline of Case1. Full Clinical DescriptionA 43-year-old white male patientpresented for consultation as areferral. His medical history wasuneventful. His prime dentalcomplaint was the presence ofenlarged bilateral maxillarytuberosities, which hindered thecomfortable wearing of a full upperdenture. Clinical examinationconfirmed the presence of largefibrous overgrowths in the left andright tuberosity region of themaxilla. He was edentulous andhad worn upper and lower fulldentures for many years, with somedifficulty.
2. Radiographic ExaminationThe pretreatment Panorex radi-ograph showed no remaining rootsin the jaws, no cystic lesions, orother findings of pathology. Themaxillary sinuses were slightlyenlarged, but did not account forthe increase in size of thetuberosities.
3. Soft TissueTwo soft tissue tumors were foundfrom the tuberosities over the alve-olar ridges at the left and right sideof the maxillary ridge. The depth ofthe vestibulum on both sides wasnormal. The soft tissue was notinflamed and not irritated. The
color and consistency was normal,without any hardness. Eachtuberosity was covered by kera-tinized tissue. All other oral softtissues were normal.
4. Hard Tissue TestsNo hard tissue tests were performed.
5. Other TestsWith the full upper denture inplace, the occlusion was normal,both in centric and excursive move-ments. TMJ function appearednormal.
B. Diagnosis and TreatmentPlan1. Provisional DiagnosisA provisional diagnosis was madeof symmetrical soft tissue tumorsat the left and right side of themaxilla over the alveolar ridge(Figure 1).
2. Final DiagnosisPalpation of the fibrous massesindicated a bilateral fibrous over-growth of keratinous postextractiongingival tissue, consistent withphased extractions and an ill-fitting upper denture. Following allinvestigations, a final diagnosiswas made, which formed the basisfor corrective treatment.
3. Treatment Plan OutlineThe enlargement of both maxillary
tuberosities had made the fittingand comfort of the denture difficult.It was considered that treatmentshould be offered to excise thehypertrophic tuberosity tissue, inthe regions of teeth #1-5 and #11-16 using a CO2 laser, and toredefine an acceptable, stable softtissue profile prior to provision of anew maxillary full denture. It wasconsidered that postoperative andfuture management depended onthe outcome of surgical treatment.
4. Indications for TreatmentThe CO2 laser wavelength is char-acterized by a surface ablation oftissue containing water.Consequently, this would allow softtissue excision and ablation, usinga dissecting technique, with thebenefit of hemostasis and obviationof soft tissue dressings. Careful useof the laser would preventunwanted thermal damage to theunderlying tissues. Removal of thetumors would be advised in orderto control continuous tumor growthand in order to establish a goodprosthetic environment for the baseof a new full denture.
5. Contraindications for Treatment
S Y N O P S I S
This case report describes the successful use of a carbon dioxide laser
to excise hypertrophic tuberosity soft tissue to achieve improved
physiologic contour before placement of a new maxillary denture.
Figure 1: Preoperative appearanceshowing bilateral hypertrophy of maxil-lary tuberosity region
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Standard Treatment:Whenever tumor removal in thepalate is involved, attention must begiven to the anatomical limitationssuch as the lesser palatine artery inthis area, in order to control sponta-neous bleeding. The full denturewould need to be relined immedi-ately after surgery to reduceswelling and control bleeding.
Laser Treatment: The CO2
laser wavelength easily interactswith the soft tissues, without highpenetration depth. Care must beexercised to use suitable laserpower, in order to prevent thebuild-up of char and also to removeany char at frequent intervals.
6. PrecautionsThere is a need to recognize thelimitations of both continuous waveand (gated) chopped emissionmodes, in relation to the thermalrelaxation potential for targettissue. The potential for conductiveheat transfer during laser use maybe high, where the soft tissue isthin and underlying alveolar boneis exposed to such transfer. The useof possible precooling of tissue anddamp gauze to remove charredtissue remnants at frequent inter-vals during treatment must beconsidered.
7. Treatment AlternativesAlternatives to be consideredinclude:• Conventional soft tissue surgical
excision, using a scalpel, underlocal anesthesia
• Similar excision using anothertype of laser wavelength.
8. Informed ConsentThe need, benefits, and risks of theprocedure were outlined and verbalconsent was obtained from thepatient. These were recorded in thetreatment notes.
T R E AT M E N TA. Treatment ObjectivesStrategyUse of a CO2 laser (10,600 nm
wavelength) for tumor excision aswell as ablation and coagulation.Strategic factors include the use ofsuitable power levels to cut fibroustissue without causing collateraldamage, the employment of adissection technique, placing tissueto be excised under tension to aidin the surgical excision.
B. Laser Operating ParametersThe laser operating parametersused were as follows:• Laser: CO2 laser (SC 30, Weil
Dental, Rosbach, Germany)• Wavelength: 10,600 nanometers• Delivery System: Articulated
arm. Handpiece with a ceramictip of 0.8-mm diameter withadjustable air spray
• Power: 0.1 to 10.0 Watts• Repetition rate (gated [super-
pulsed] emission mode): 0.1 to 3kHz; pulse length: 140 µsec
• Laser Settings: Initial incisions:Focused, noncontact super-pulsemode and a control panel powersetting of 8 Watts (continuouswave); distance from the tissue 2 mm
• Ablation of the tissue: Defocusedbeam with a distance from thetissue more than 2 mm. Timetaken, per tissue site: 2 min.
C. Treatment DeliverySequencePrior to patient treatment, theoperating room was secured andproper laser warning signs placed.The laser was set up and test-fired,using minimum operating parame-ters, to ensure proper function andpatency of the delivery system.Supplies were dispensed and equip-ment and sterile instrumentsarranged for treatment. Thepatient was seated, the treatmentplan reviewed, and consentaffirmed. Correct safety eye protec-tion was provided for both patientand operating personnel.
Local anesthesia (lidocaine 2%,epinephrine 1:80,000) was adminis-tered buccally and palatally at eachtumor site.
Laser Procedures: A focusedbeam of the CO2 laser was used toperform an excision at the base ofeach tuberosity in turn, taking careto remain above the periosteum.Laser energy was delivered to sepa-rate the excess tissue, using afocused, noncontact mode and apower setting of 8 Watts (contin-uous wave) at a distance from thetissue of 2 mm, with a ceramic tipof 0.8-mm diameter. The handpiecewas kept parallel to the base of thetumor in order to cut efficientlyand to avoid penetration in thedeeper areas (Figure 2). A signifi-cant coagulation was performedusing the CO2 laser in order to helpprevent spontaneous bleeding andpostoperative infection (Figure 3).
The excised tumor was sent forhistological examination with anote indicating tissue removal wasaccomplished via laser.Immediately after laser surgery,the upper denture was relined witha self-polymerizing base and fitted.
Romanos
Figure 2: Surgical excision of excesstissue. The tissue is held under traction toassist laser cutting. Care is taken to keepthe zone of the excision above the levelof the periosteum
Figure 3: Treatment sites immediatelyafter laser excision
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D. Postoperative InstructionsThe patient was instructed tocontinue home care, and mouthrinsing with Listerine® twice dailywas recommended. No limitationswere considered necessary on eatingor drinking. The patient was advisedto call if any problems were to occur.The patient was reappointed for one-week and one-month recall visits.
E. Management ofComplicationsThe patient was advised of thelikely outcome of surgery in termsof initial soreness. No other compli-cations were reported.
F. PrognosisFollowing the correct use of thelaser in this procedure in achievingthe desired outcome, it wasbelieved that the prognosis forsuccess was good.
G. Written NotesThe details of treatment provided,laser operating parameters, andclinical outcome were recorded inthe patient’s notes.
F O L LO W- U P C A R EA. Assessment of treatment:The patient was assessed at oneweek, one month, and six months.
At the one-week appointment,no problems were noted and woundhealing was uneventful. Fibrintissue covered the whole woundarea. At the edges of the laserwound new capillaries wereobserved giving the appearance ofregeneration of a new, healthy
tissue. No irritation or inflamma-tory reaction was found.
At one month, no irritations orinflammatory reaction were foundand no evidence of scar tissueformation was observed. At thistime the patient was referred to theDepartment of Prosthodontics forthe fabrication of a new denture.The final result of the histologicalexamination showed that thetumors were fibromas without anykind of malignancy.
B. ComplicationsNo complications occurred in themanagement of this case.
C. Long-Term ResultsConsiderable excess tissue hadbeen removed during this treat-ment. Through the care taken andthe necessary changes to the fitsurface relationship of the denturewith the surgical sites, the tissueresolution had occurred in line withexpectations.
D. Long-Term PrognosisThe long-term prognosis and the
stability of the clinical result wereconsidered good. Clinical recallexaminations were advised duringthe six months following surgery, inorder to control any possible recur-rence. Six months after surgery thesoft tissue was completely healthy(Figure 4).
A U T H O R B I O G R A P H YDr. George Romanos studieddentistry at the University ofAthens, Greece. He moved toGermany to finalize his postgrad-uate studies in the areas ofperiodontics, prosthodontics, andoral surgery. He is fully trained inall of these specialties. He has beenusing lasers in dentistry for 14years and is a board member of theGermany Society for Lasers inDentistry (DGL) and theInternational Society for Lasers inDentistry (ISLD). He is the authorof more than 100 articles, the mainauthor of a laser book in the field oforal surgery, and is on the editorialboard of several peer-reviewed jour-nals. He received his PhD at theUniversity of Frankfurt, Germany.Since August 2004 he has been aClinical Professor of Periodontologyand Implant Dentistry in the NewYork University College ofDentistry, New York, where he alsoserves as Director of LaserSciences. Dr. Romanos may bereached via e-mail: [email protected].
Disclosure: Dr. Romanos has noaffiliation with any company relevantto this article. n n
Romanos
Figure 4: Six-month follow-up, showingareas healed and of normal appearance
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Caries Removal and CompositePreparation for Primary TeethAlfred D. Wyatt, Jr., DMD, College Park, GeorgiaJ Laser Dent 2007;15(1):41-43
P R E T R E AT M E N TA. Outline of Case1. Full Clinical DescriptionA 9-year-old girl presented to theoffice for restoration of her primaryupper left molars (Figure 1). Shehad previously been seen for thepurpose of examination and treat-ment planning. Her medical historyexhibited no sign of any ailmentsor conditions that wouldcontraindicate routine dental treat-ment. The patient was receivingearly orthodontic therapy due tosevere crowding in the incisorregion. Her occlusion was classifiedas a skeletal and dental Class I.She had normal mandibular rangeof motion and exhibited excellentbehavior in the chair.
2. Radiographic ExaminationPanoramic and bitewing radi-ographs revealed crowdeddentitions with caries present inteeth I and J. Otherwise, no visiblelesions or abnormalities werepresent (Figures 2 and 3).
3. Soft Tissue StatusThe crowding in the patient’s ante-rior segments had contributed toslightly inflamed interproximalpapillae. Visual examinationrevealed no other sites with lesions,infection, or inflammation.
4. Hard Tissue StatusThe patient exhibited maxillaryand mandibular tooth/arch/sizediscrepancies. The crestal bone
levels for a patient of her age werenormal. Carious lesions had previ-ously been restored and primaryteeth had been extracted. Noskeletal lesions or abnormalitieswere observed.
5. Other TestsDue to the patient’s age, many otherroutine tests were not performed.
B. Diagnosis and Treatment Plan1. Provisional DiagnosisDistal-occlusal caries present intooth I, mesial-occlusal cariespresent in tooth J.2. Final DiagnosisBoth teeth had carious lesions thatextended close to the pulp.
3. Treatment Plan OutlineThe primary objective of treatmentis to restore teeth I and J using anEr:YAG laser in the followingmanner:a. Remove all decayed tooth struc-
tureb. Decontaminate bacteria in areas
of the tooth that may be close tothe pulp.
c. Restore carious lesions withlight-cured composite resin
d. Perform treatment without theuse of needle anesthesia.
4. IndicationsCaries removal is necessary for thetooth restoration, and the Er:YAGlaser can easily remove the diseasedstructure. This laser wavelength ismore readily absorbed by tissue with
a higher water content such as acarious lesion; therefore it is possibleto more easily conserve healthy toothstructure. Moreover, this wavelengthdoes not appear to cause a pulpaltemperature rise, and if pulp cappingis necessary, there appears to be agood prognosis for a successfuloutcome. In addition, the relative lack
S Y N O P S I S
An Er:YAG laser was successfully used for removal of carious lesions
in two molars in a child prior to placement of restorations.
Figure 1: Preoperative view of cariouslesions in the primary left molar teeth
Figure 2: Preoperative panoramic radi-ograph
Figure 3: Preoperative bitewing radi-ograph showing extent of carious lesions
Wyatt, Jr.
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of tactile stimulation offered by lasertreatment compared to conventionalhigh-speed handpieces often allowsthe procedure to be performedwithout the need for needle analgesia.
5. ContraindicationsThere are no absolute contraindica-tions for performing the procedure,except that the time required forthe laser to accomplish cariesremoval and tooth preparation canbe longer than when a high-speedhandpiece is used.
6. PrecautionsAdequate water spray must be main-tained as caries are being removed.Since the erbium laser preferentiallyinteracts with diseased tooth struc-ture, good visibility and low powerwill be necessary for careful prepara-tion in order to avoid both thermaldamage and excessive removal oftooth structure.
7. Treatment AlternativesAlternatives to treatment methodsinclude the use of injected “-caine”analgesics with high-speed hand-piece for cavity preparation.Amalgam or composite materialmay be used for the restorations.
8. Informed ConsentPrior to the procedure, the patient’smother was given a detailed expla-nation of how the laser would beused and she enthusiastically gaveverbal informed consent.
T R E AT M E N TA. Treatment Objective StrategyThe primary objective is to performthe majority of the caries removal,cavity preparation, and preparationdecontamination utilizing theEr:YAG laser comfortably and effi-ciently without the use of injectableanesthesia.
B. Laser Operating ParametersThe Er:YAG laser (DELight, HOYAConBio, Fremont, Calif.) with awavelength of 2940 nm was usedwith its fiber delivery system and a
600-micron quartz tip. It operatesin a free-running pulse mode witha pulse duration of 300 msec. Thelaser was used at 30 Hz, 180 mJ,5.4 W, and also at 30 Hz, 70 mJ, 2.1W, both with water spray, duringthe procedure. The tip was used inboth contact and noncontact (defo-cused) modes.
C. Treatment Delivery SequencePrior to commencing the procedure,the patient was familiarized withthe intended treatment steps.Subsequently, all laser safetyprecautions were performed. Theseincluded but were not limited to theadministering of laser safety glassesto the patient and operators,displaying laser hazard signage, andinspecting the mechanical aspects ofthe laser. Once safety systems werein place, the laser was test-fired toinsure proper beam function andwater spray delivery. The laser pulserate was set to 30 Hz and the laserenergy was set to 180 mJ whichyielded a power of 5.4 W. High-volume suction was usedcontinuously to evacuate the laserplume. The laser beam was defo-cused approximately 2 cm from thetarget tissue for 90 seconds (Figure4). The beam was directed closer tothe decay with a brushing-likemotion until ablation began. The tipwas kept in a close noncontact posi-tion as the decay was removed untilthe preparation depth extendedclose to the pulp. The energy wasthen lowered to 70 mJ (for a powerof 2.1 W) for further caries removal
and bacterial decontamination. Thepreparations were completed(Figure 5) and the teeth wereisolated for restoration. Clearfil SEbond (Kuraray America, Inc., NewYork, N.Y.) was applied to enameland dentin surfaces and a 0.4-micron filler particle size compositewas used as the restorative mate-rial. Finishing of the restoration wasperformed with coarse diamondburs, 12-blade finishing burs, andfinishing discs (Figure 6).
D. Postoperative InstructionsThe patient was told that she couldresume normal activities due to thelack of numbness as a result of noinjections. The patient’s mother wastold to call the office if pain or anyother unusual symptoms occurred.
E. ComplicationsNo complications occurred duringor after the procedure.
F. PrognosisThe prognosis for the success of theprocedure and restorations is good.The patient and her mother wereinformed that the lesions were
Wyatt, Jr.
Figure 4: Laser initially used in a defo-cused mode, approximately 2 cm fromthe target teeth
Figure 5: Laser preparations completed
Figure 6: Composite restorationscompleted
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close to the pulp and if the teethbecame painful other treatmentmay be necessary. Otherwise, therestorations should be functionaluntil the time of natural exfoliationof the teeth.
G. Treatment RecordsTreatment records, including thedetails outlined above, were includedin the patient’s chart notations.
F O L LO W- U P C A R EA. Assessment of TreatmentOutcomeThe objectives originally set wereachieved. The entire procedure wasperformed with success without theuse of dental anesthetic. Also, satis-factory esthetic and functionalresults were obtained.
B. ComplicationsNo complications were experiencedduring or after treatment.
C. Long-Term ResultsAfter 3 months, the restorationswere evaluated for integrity andtooth health (Figure 7). Therestorations were performing welland the patient expressed noconcerns or discomfort.
D. Long-Term PrognosisIt is expected that the restorationperformed should last until the
teeth naturally exfoliate as herpermanent teeth erupt.
A U T H O R B I O G R A P H YDr. Alfred Wyatt, Jr. is a graduate ofthe Medical College of GeorgiaSchool of Dentistry where he servesas Associate Professor of OralRehabilitation. He maintains aprivate practice in College Park,Georgia. Currently, he serves on theBoard of Directors of the Academy ofLaser Dentistry as well as on theAmerican Dental Associationworking group for laser usage. Dr.Wyatt presently utilizes Er:YAG anddiode lasers in his practice and hasattained Advanced Proficiency andCertified Educator Status throughALD. Dr. Wyatt may be reached viae-mail: [email protected].
Disclosure: Dr. Wyatt has no finan-cial connections with or interests inany dental companies. n n
Wyatt, Jr.
Figure 7: Three-month postoperative view.Teeth are comfortable and functional
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Editor’s Note: The following seven abstracts are offered as topics of current interest. Readers are
invited to submit to the editor inquiries concerning laser-related scientific topics for possible
inclusion in future issues. We’ll scan the literature and present relevant abstracts.
Dr. Alfred Wyatt, in his case study “Caries Removal andComposite Preparation for Primary Teeth” (pages 41-43),describes his use of an Er:YAG laser for restorativetreatment in a 9-year-old girl. Investigations and reportsof laser use on pediatric patients first appeared in the1970s with descriptions of helium-neon laser treatmentof herpetic lesions. Subsequent pediatric-oriented articlesexplored the use of carbon dioxide and Nd:YAG lasers for intraoral soft tissue surgery, and the experimentalinhibitory effect of combined laser irradiation and fluoride application on enamel demineralization, amongother topics.
This issue provides a sampling of more recentstudies describing use of erbium lasers in pediatricdentistry. The first two clinical studies confirm the
safety and effectiveness of Er:YAG laser use for cavitypreparation in children.
A variety of in vitro studies investigated themarginal microleakage and/or bond strength of restora-tions placed subsequent to Er:YAG laser-assisted cavitypreparation. Some studies compared laser results withother technologies. As might be expected, resultsvaried, and were dependent upon technique andrestorative materials used, and whether or not supple-mental surface conditioning was employed.
As always, clinicians are advised to review thespecific indications for use of their lasers and to reviewtheir operator manuals for guidance on operatingparameters before attempting similar techniques ontheir patients.
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E R : YA G L A S E R S I N P E D I AT R I CR E S TO R AT I V E D E N T I S T RY
Objective: The purpose of this study was to determinethe clinical usefulness of Er:YAG laser for cavity prepa-ration in children. Background Data: The conventionalmethods for cavity preparation instill fear and discom-fort in pediatric patients. The Er:YAG laser is a new tooldeveloped for cavity preparation; however, there are fewreports of its clinical application. Materials andMethods: A clinical evaluation using an Er:YAG laserwas carried out using 32 subjects (with 16 deciduousand 19 permanent teeth) with ages ranging from 2 to 12years. All cavities were restored with light-cured
composite resin following the application of bondingagent, but without acid etching or primer conditioning.Results: During laser treatment, the pediatric patientswere very cooperative and hardly complained of anypain, and no tooth showed undesirable effects duringthe 3-year period of observation. Conclusion: It can beconcluded from the results of this study that an Er:YAGlaser would be a useful alternative method for cavitypreparation for composite resin restoration in children.
Copyright 2003 Mary Ann Liebert, Inc.
C L I N I C A L A P P L I C AT I O N S O F E R : YA G L A S E R F O R C A V I T Y P R E PA R AT I O N I N C H I L D R E N
Junji Kato, PhD1; Kayoko Moriya, DDS1;Jayanetti Asiri Mayawardena, PhD2;Rafel Luxhmen Wijeyeweera, PhD2
1Tokyo Medical and Dental University, Tokyo, Japan2University of Peradeniya, Faculty of Dental Sciences, Peradeniya, Sri Lanka
J Clin Laser Med Surg 2003;21(3):151-155
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Purpose: The erbium:YAG laser has been shown to besafe and effective for caries removal and cavity prepa-ration in adults. In this study, we report a prospectiveparallel controlled randomized multicenter clinical trialof this laser for dental caries removal and cavity prepa-ration in children. Methods: At two separate sites, atotal of 124 patients from 4 to 18 years old, having atleast one tooth with caries requiring restoration, wererandomized for treatment in a 2:1 ratio, laser toconventional dental drill. Caries were removed, theteeth were restored and follow-up evaluations werecompleted after 3 months. Determination of safe andeffective treatment included four criteria: (1) acceptablecaries removal, (2) acceptable cavity preparation, (3)pulp vitality, and (4) intact and serviceable restoration.
Results: All 42 drill procedures and 81 out of 82 laserprocedures were found to be successful in terms ofsafety and effectiveness. No significant difference inpain reported was found between drill or laser treat-ments, and no complications or adverse events werereported after treatment or at any other time duringthe study. Subject satisfaction with treatment proce-dures as reported was equivalent in the laser and drillgroups. The only significant difference found betweentreatment groups was in the greater use of anesthesiaduring drilling procedures. Conclusions: Theerbium:YAG laser is safe and effective for both cariesremoval and cavity preparation in children.
Copyright 2001 Urban & Fischer
T H E S A F E T Y A N D E F F E C T I V E N E S S O F A N E R : YA G L A S E RF O R C A R I E S R E M O VA L A N D C A V I T Y P R E PA R AT I O N I N C H I L D R E N
Pamela K. Denbesten,1 Joel M. White,1 José E.P. Pelino,1
Guy Furnish,2 Anibal Silveira,2 Frederick M. Parkins2
1University of California School of Dentistry, San Francisco, California2University of Louisville School of Dentistry, Louisville, Kentucky
Med Laser Appl 2001;16(3):215-222
Purpose: The purpose of this study was to assess in vitrothe influence of 3 cavity preparation devices (carbidebur, Er:YAG laser, and air abrasion) on the microleakageof flowable composite restorations in primary teeth.Methods: Fifteen primary second molars were selected,and Class V cavities were prepared on the buccal/lingualsurfaces, being assigned to 3 groups (n = 10). Group 1(control) was prepared using a high-speed handpiece andwas acid etched. Group 2 was prepared and treated withan Er:YAG laser (400 mJ / 4 Hz and 80 mJ / 4 Hz,respectively) and was acid etched. Group 3 was preparedand treated with an air abrasion system and was acid
etched. Cavities were restored and stored for 7 days.Restorations were polished, thermocycled, immersed in0.2% rhodamine B, sectioned, and analyzed for leakage.Results: Er:YAG laser-prepared cavities showed thehighest degree of infiltration. The performance of the airabrasion device was comparable to that of the high-speed handpiece. Conclusion: It may be concluded thatthe method of cavity preparation affected themicroleakage of Class V cavities restored with flowablecomposite in primary teeth.
Copyright 2006 American Academy of Pediatric Dentistry
C O M PA R I S O N O F M A R G I N A L M I C R O L E A K A G E O F F LO WA B L E C O M P O S I T E R E S TO R AT I O N S I N P R I M A RY M O L A R S P R E PA R E D B Y H I G H - S P E E D C A R B I D E B U R , E R : YA G L A S E R , A N D A I R A B R A S I O N
Maria Cristina Borsatto, Silmara Aparecida Milori Corona, Michelle Alexandra Chinelatti, Renata Pereira Ramos, Renata Andréa Salvitti de Sá Rocha, Jesus Djalma Pecora,
Regina Guenka Palma-Dibb
University of São Paulo, Ribeirão Preto School of Dentistry, Brazil
J Dent Child 2006;73(2):122-126
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Objectives: The aim of this study was investigatewhether the shear bond strength of a coloredcompomere was affected by different methods of cariesexcavation on the dentine. Methods: 40 freshlyextracted human deciduous teeth were divided intothree experimental groups and one control group. Inthe treatment groups (n = 10), the dentine surface wastreated with either a chemical method of cariesremoval (Carisolv), air abrasion, or the Er:YAG laser.Caries excavation was carried out in the control group(n = 10) using the conventional method with a bur.Complete caries removal was ensured as each dentinesurface was tested with DIAGNOdent (Kavo,Germany). The surface roughness was evaluated usingoptical scanning. The teeth were then sectioned intorods and each exposed dentine surface was then bondedwith a colored compomer (Twinky Star, VOCO,Germany) using a resin dentine adhesive (Futuabond,VOCO, Germany). Fifty percent of the samples were
pretreated with acid etching using 35% phosphoric acidfor 30 secs. The bond strength of each sample was eval-uated by tensile testing at a cross-head speed of 0.5mm/min using an Instron machine. Data was analysedstatistically. Results: Bond strength after air abrasionand acid etching was significantly higher (p < 0.05)than the other etched groups. Laser treatment withand without etching gave the lowest bond strength.Etching increased the bond strength in conjunctionwith Carisolv, air abrasion, and the Er:YAG laser butdecreased the bond strength in the control group.Conclusions: Air abrasion produced the roughestdentine surface which increased the mechanical reten-tion of the compomere and therefore the shear bondstrength. Acid etching increased the bond strength inall experimental groups but lowered the bond strengthwhen a bur was used.
Copyright 2003 International Association for Dental Research
B O N D S T R E N G T H O F A C O LO R E D C O M P O M E R TO D E C I D U O U S D E N T I N F O L LO W I N G T R E AT M E N T W I T H C A R I S O LV, A I R A B R A S I O N ,
E R : YA G L A S E R , A N D A C O N V E N T I O N A L B U RM. Geserick, F. Zeller, E. Kaiser, A. Wichelhaus
University of Basel, Switzerland
J Dent Res 2003;82(Spec Iss B):abstract 2925 (www.dentalresearch.org)
Objective: The purposes of this study were to investigatecavity surfaces morphologically, and comparemicroleakage at cavities prepared by Er:YAG laser aftercomposite resin restoration versus conventional mechan-ical treatment in human primary teeth in vitro.Background Data: There have been few reports onmicroleakage at cavities prepared by Er:YAG laser irradi-ation. Materials and Methods: A total of 30 cavities (classV) in human primary teeth were used. Half of the cavitieswere prepared by an Er:YAG laser system at 300 mJpulse energy and 4 Hz, and the other half were preparedwith a high-speed diamond bur. Five cavities from eachgroup were investigated by scanning electron microscopy(SEM) and histopathological examination. Remainingcavities were filled with a composite resin without an
acid-etching technique and then subjected to microleakagetest in 0.6% rhodamine B solution under thermocycling.Results: Microleakage (score: 2.45 +/- 1.07) at cavitiesprepared by laser was significantly less than that by bur(score: 1.30 +/- 0.95; p < 0.05). SEM observation showedthat, compared with the relatively flat appearance of cavi-ties prepared by bur, cavity margins prepared by laserwere irregular but there was almost no smear layer at thecavity walls. Conclusion: It can be concluded that cavitysurfaces prepared by Er:YAG laser are irregular, butmicroleakage at cavities prepared by the laser after fillingwith composite resin is better than that by mechanicalbur using the dye penetration method.
Copyright 2002 Mary Ann Liebert, Inc.
M O R P H O LO G I C A L A N D M I C R O L E A K A G E S T U D I E S O F T H E C A V I T I E SP R E PA R E D B Y E R : YA G L A S E R I R R A D I AT I O N I N P R I M A RY T E E T H
Eduardo Kazuo Kohara, DDS; Mozammal Hossain, BDS, PhD; Yuichi Kimura, DDS, PhD; Koukichi Matsumoto, DDS, PhD; Mitsuko Inoue, DDS, PhD; Ryuji Sasa, DDS, PhD
Showa University School of Dentistry, Tokyo, Japan
J Clin Laser Med Surg 2002;20(3):141-147
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Objectives: The evaluation of microleakage in class Vrestorations of deciduous teeth prepared using Er:YAGlaser and comparison to the ones observed whenconventionally prepared, using composite resin andglass ionomer cement, was the subject of this study.Methods: The laser used was the KaVo KEY II withwavelength of 2.94 µm, energy of the 300 mJ, repetitionrate of 3 Hz, and energy density of 86 mJ/cm2. Twenty-eight deciduous teeth were divided into four groups: G1– prepared with high-speed drill + composite resin; G2 –prepared with high-speed drill + glass ionomer cement;G3 – prepared using Er:YAG laser + composite resin;and G4 – prepared with Er:YAG + glass ionomercement. After the restoration the specimens were storedat 37° C for 24 hours, thermally stressed, immersed in50% aqueous solution of silver nitrate for 24 hourswhile kept in the dark. The specimens were rinsed inwater, soaked in photodeveloping solution, and exposedto fluorescent light for 6 hours. After this process the
samples were sectioned and observed by stereomi-croscopy. For comparison the groups were divided intoocclusal and cervical microleakage. The results wereanalyzed under the Kruskal-Wallis test. Results: For theocclusal microleakage the statistical significance was5% among the groups and the average comparisonshowed higher microleakage for G1 (M = 35.1) than forG2 (M = 24.0) as well as compared to G3 (M = 22.3). Theother groups did not present statistical differencesamong them. For the cervical microleakage the Kruskal-walls test did not present any statistical difference.Comparing the occlusal and cervical microleakage data,for every group, using the Wilcoxon test, no statisticaldifferences was observed. Conclusions: This studyshowed the Er:YAG laser to be effective for class Vrestorations and to result in a smaller microleakagedegree using the composite resin.
Copyright 2002 International Association for Dental Research
M I C R O L E A K A G E I N C L A S S V R E S TO R AT I O N S O F D E C I D U O U S T E E T H P R E PA R E D W I T H E R : YA G L A S E R
A. Ramos,1 N. Pulga,2 M. Vieira,3 C.P. Eduardo4
1University of São Paulo; University of Fortaleza, Fortaleza/CE, Brazil2University of São Paulo; IPEN, Fortaleza/CE, Brazil
3IPEN, Fortaleza/CE, Brazil4University of São Paulo, Fortaleza/CE, Brazil
J Dent Res 2002;81(Spec Iss A):abstract 1881.
Aim: The purposes of this study were to investigate thesurface morphology of cavities prepared by Er:YAGlaser irradiation and to compare the microleakagedegree after composite resin restoration with etched burcavities in primary teeth, in vitro. Materials andMethods: On the buccal (facial) and lingual (palatal)surfaces of 25 primary teeth, a round cavity wasprepared with the Er:YAG laser system and with ahigh-speed diamond bur, respectively. Five cavities fromeach group were investigated by scanning electronmicroscopy (SEM). The remaining cavities were filledwith a composite resin and subjected to a microleakagetest (0.6% rodamine B solution) under thermocycling.Only bur cavities were acid-etched before filling.Statistical analysis was performed using the Mann-Whitney’s U test; a value of p < 0.01 was consideredsignificant. Results: SEM observation of the laser andetched bur cavities revealed an absence of a smear
layer; enamel rods and opening of dentinal tubules wererecognized. No statistically significant differences werenoted between microleakage of composite resin restora-tions of the laser and the etched bur cavities. Crosscutsections of the cavities with no microleakage showedgood adhesion between the restorative material anddental hard tissues; there was also no gap at the inter-face. Discussion: The highly irregular surface or theremoval of the debris-like smear layer after laser irradi-ation may facilitate good adhesion of composite resinwith enamel or dentine, and these surfaces might play amajor role in decreasing microleakage of laser cavities.Conclusion: It can be concluded that cavities preparedby Er:YAG laser are capable of decreasing microleakageof composite resin restorations in primary teeth, andthe efficiency is similar to etched bur cavities.
Copyright 2002 European Academy of Paediatric Dentistry n n
M I C R O L E A K A G E O F C O M P O S I T E R E S I N R E S TO R AT I O N I N C A V I T I E SP R E PA R E D B Y E R : YA G L A S E R I R R A D I AT I O N I N P R I M A RY T E E T H
Y. Yamada, M. Hossain, Y. Nakamura, Y. Murakami, K. Matsumoto
Showa University School of Dentistry, Tokyo, Japan
Eur J Paed Dent 2002;3(1):39-45
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