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Traumatic fibroma, also known as irritation fibroma,is a common benign exophytic oral lesion that de-velops secondary to tissue injury. The traumatic fi-broma is among the most common benign reactivelesions.1,2 A review of benign oral soft tissue tumors inwhite Americans older than 35 years identified irrita-tion fibroma as the second most common benign oral

lesion.1 Fibroma is a result of a chronic repair processthat includes granulation tissue and scar formation re-sulting in a fibrous submucosal mass. Recurrences arerare and may be caused by repetitive trauma at thesame site. This lesion does not have a risk for malig-nancy3. The most common sites of traumatic fibromaare the tongue, buccal mucosa, and lower labial mu-

Association of Two Lasers in the Treatmentof Traumatic Fibroma: Excision withNd:YAP laser and PhotobiomodulationUsing InGaAlP: A Case Report

Irineu Gregnanin Pedrona, Karen Muller Ramalhob, Luciano Artioli Moreirac, Patrcia Moreira de Freitasd

a Researcher, Periodontist of the Dentists Officers Staff, Brazilian Air Force, Hospital da AeronauticadeSo Paulo, Brazil.

b PhD Student, Department of Stomatology, School of Dentistry, University of So Paulo, Brazil; Spe-cial Laboratory of Laser in Dentistry (LELO), School of Dentistry, University of So Paulo, Brazil.

c Professor, Department of Stomatology and Laser in Dentistry, School of Dentistry, Cruzeiro do SulUniversity, So Paulo, Brazil.

d Professor, Department of Restorative Dentistry, School of Dentistry, University of So Paulo, Brazil;Special Laboratory of Laser in Dentistry (LELO), School of Dentistry, University of So Paulo, Brazil.

Summary: Traumatic or irritation fibroma is a common benign exophytic oral lesion that develops secondary totissue injury. It is the most common benign reactive lesion, and the treatment of choice is surgical excision. Theuse of lasers in different dental procedures has become very common in the last few years. In oral surgeries, ituse is usually associated with no or little bleeding and a better postoperative period. Nd:YAP (Neodymium:Yt-trium-Aluminum-Perovskite) laser has been reported in the literature mainly in hard tissue procedures. The litera-ture contains no reports of the use of ND:YAP laser in oral soft tissues surgery. This report describe the use ofNd:YAP laser (1.34 m, 250 mW, 30 Hz) on the excision of a traumatic fibroma in combination with daily pho-totherapy with low-intensity laser (InGaAlP; 660 nm;40 mW; 3 J/cm2). The excision of the fibroma using theNd:YAP laser consisted was a quick clinical procedure, without bleeding. During the days following surgery, thepatient reported no pain or discomfort. The wound healing of the soft tissue was satisfactory and no scarringcould be seen in the region of the surgery. The excision of the fibroma with the Nd:YAP laser is a safe, quick pro-cedure, and the postoperative photobiomodulation with low-intensity laser reduces edema and improves woundhealing.

Keywords: Nd:YAP laser, InGaAlP, irritation fibroma, oral surgery, oral pathology.

J Oral Laser Applications 2009; 9: 49-53.

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Not for Publicationcosa. Clinically, they appear as broad-based lesions,lighter in color than the surrounding normal tissue,with the surface often appearing white because of hy-perkeratosis or with surface ulceration caused by sec-ondary trauma. The growth potential of fibroma doesnot exceed 10 to 20 mm in diameter.4 Surgical excisionis the treatment of choice. Differential diagnosis ofother lesions, including benign tumors (neurofibroma,neurilemona, granular cell tumor, salivary gland tu-mors, lipoma) and mucocele should be ruled out bybiopsy.3 The application of high intensity lasers such asCO2 ( = 10.6 m), Nd:YAG ( = 1.64 m), Er:YAG(= 2.94 m), Er:YSGG (2.78 m) and diode lasersfor oral surgery are well established in the literature.The use of neodymium:yttrium-aluminum-peroviskite(Nd:YAP) laser in dentistry has been largely restrictedto hard tissues, and there are still no studies in the lit-erature describing its use in surgical operations. Thiscase report illustrates the excision of a traumatic fi-broma using the Nd:YAP laser (1.34 m) followed byphotobiomodulation with InGaAlP laser.

CASE REPORT

Case 1: A 32-year-old female patient reported a masson the tongue increasing in volume. Clinically, the pa-tient presented a lesion on the lateral border of thetongue, with no alteration of the color and no symp-toms (Fig 1). The lesion had a sessile base. The patientwas norm reactive and presented extreme anxiety re-lated to surgical procedures.

Case 2: A 44-year-old female patient complained ofa red-colored mass with increasing volume on the jugaloral mucosa with a sessile base (Fig 2). The patient wasnorm reactive. The etiology of the trauma was relatedto absence of a first molar.

Description of clinical procedures (cases 1 and 2)

For the removal of both lesions, a Nd:YAP laser (LokkiDT Laser; Vienne, France) with 1.34 m wavelengthwas used. Local anesthesia was applied on the lesionareas. Lesions were removed using the Nd:YAP laserwith a 200-m-diameter optic fiber and the followingparameters: 250 mJ and 30 Hz (Figs 3 and 4). The op-erations were performed without bleeding (Figs 5 and6). After excision, lesions were fixed in 10% formoland sent to pathology analysis, confirming the clinicaldiagnosis of fibroma. Immediately following fibroma re-moval with Nd:YAP laser and 5 days postoperatively,

laser phototherapy (LPT) was performed (InGaAIPlaser, 670 nm, 40 mW, 3 J/cm2, 3 s/point; Dentoflex;So Paulo, Brazil). The irradiation was performed at 6points above and around the region of the excision, inorder to obtain a better postoperative period, with lesspain and edema, and to improve wound healing (Fig 7).During the subsequent days after the surgery, no painmedication was required and no pain or discomfortwas reported by the patients. The wounds healedproperly in both cases and no scarring could be seen inthe region of the surgery.

DISCUSSION

This case report described the use of Nd:YAP laser onthe treatment of a traumatic fibroma. Different wave-lengths of high power lasers have been used to per-form oral soft tissue surgery, such as CO2 ( = 10.6m), Er:YAG ( = 2.94 m), Er:YSGG ( = 2.78 m),Nd:YAG ( = 1.64 m), and diode lasers.5,6 The litera-ture supports their clinical indication as an alternativemethod for soft-lesion surgery. The high intensity lasersused in surgery procedures have shown several advan-tages compared to conventional treatment, such as theeasier technique, reduction of operation time, lesstrauma induced in the tissue, less or no bleeding duringthe procedure, better visualization of the surgical site,and greater comfort for and better acceptance by pa-tients. Up to the present, there are no reports in theliterature using Nd:YAP laser for the treatment of be-nign oral lesions, or even for any oral surgical proce-dures. The use of Nd:YAP laser has been mostlydescribed for hard-tissue management, especially inrestorative dentistry and endodontic procedures. Stud-ies are relatively common which describe the use ofNd:YAP laser on root canal cleaning and bacterial re-duction, dentin hypersensitivity treatment, periodon-tics, or which evaluate roughness, microleakage andmineral content of enamel and dentin after irradiation,or analyze temperatures after Nd:YAP ablation.7-15

Oral soft tissues consist of collagen, water, pigmentedconnective tissue, blood, and lymphatic vessels; each ofthese structures may be considered target chro-mophores and all commercially available laser wave-lengths in dentistry will interact with these componentsto a greater or lesser extent. What is of prime impor-tance is the predominant chromophore in the targettissue and the best laser wavelength to achieve maxi-mum absorption of light energy. Laser surgery can pro-mote homeostasis, avoiding the need for dressing orsutures. Depending on the wavelength, it can lead to

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Fig 1 Traumatic fibroma on the lateral border of the tongue. Fig 2 Traumatic fibroma in oral jugal mucosa.

Fig 5 Immediately after surgery, showing peripheral zone ofedema.

Fig 6 Immediately postoperatively, showing peripheral zone ofedema.

Fig 3 Excision of the traumatic fibroma on the lateral border ofthe tongue using a Nd:YAP laser.

Fig 4 Excision of the traumatic fibroma in oral jugal mucosa usinga Nd:YAP laser.

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better homeostasis and greater potential for cutting,but irrespective of wavelength, all soft tissue healing isby secondary intention.16 Shorter laser wavelengths(diode 801, 980 nm; Nd:YAG 1064 nm) pass throughthe epithelium and penetrate 2 to 6 mm into the tissue,whereas longer wavelengths (Er,Cr:YSGG 2780 nm,Er:YAG 2940 nm, CO2 10,600 nm) have minimal pen-etration. As surgical cutting proceedings, the heat gen-erated by the laser can seal small blood and lymphaticvessels and reduce or eliminate bleeding and edema.16

The denatured proteins from tissue and plasma giverise to a surface which protects the surgical woundfrom frictional or bacteria action. The area of reactivetissue edema surrounding the ablation site shows thepenetrating conductive thermal effects related to shor-ter wavelength lasers. Using longer wavelengths, therisk of deep penetration is minimized and surgical inci-sions can be deemed less potentially damaging.16 Al-though surgery with Nd:YAP laser showed a peripheralzone of edema (Figs 5 and 6), clinically, this thermal ef-fect did not impair wound healing. In the present cases,Nd:YAP laser proved to be safe for surgical proce-dures, since postoperative wound healing occurredproperly without pain or discomfort, and little edema.No medication was required and no pain was relatedby the patients.

Low-intensity red laser light was first used to accel-erate wound healing in the 1970s.17 After that, manystudies involving the use of low-intensity lasers showedthat the healing process is enhanced by such thera-py.18-21 In recent years, researchers have described sev-eral important biological effects associated with low-

intensity laser therapy.18,22 It has been shown that thistherapy presents advantages such as pain control, anti-inflammatory action, increase of collagen production,f ibroblastic proliferation, and increase of local mi-crovascularization.18-20,22,23 This biological effect oc-curs due to the increase of ATP synthesis, increase ofnuclear acid production, and gene expression.20,24 Inthe current study, laser phototherapy contributed towound healing after fibroma excision.

CONCLUSION

It can be concluded that the excision of traumatic fi-broma with Nd:YAP laser is a safe, quick procedure,and postoperative laser phototherapy can reduceedema and improve wound healing.

REFERENCES

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3. Esmeili T, Lozada-Nur F, Epstein J. Common benign oral tissuemasses. Dent Clin North Am 2005;49:223-240.

4. Regezi JA, Sciubba JJ, Jordan RC, Abrahams PH. Oral pathology:clinical pathologic correlations. 5th edition. St Louis (MO): WBSaunders, 2003:165-166.

5. Boj JR, Hernandez M, Espasa E, Poirier C. Laser treatment of anoral papilloma in the pediatric dental office: a case report. Quin-tessence Int 2007;38:307-312.

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7. Leandri M, Saturno M, Spadavecchia L, Iannetti GD, Cruccu G,Truini A. Measurement of skin temperature after infrared laserstimulation. Neurophysiol Clin 2006;36:207-218.

8. Chen CC, Huang TH, Kao CT, Ding SJ. Effect of conditioners onbond durability of resin composite to Nd:YAP laser-irradiateddentin. Dent Mater J 2006;25:463-469.

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10. Lee BS, Chang CW, Chen WP, Lan WH, Lin CP. In vitro study ofdentin hypersensitivity treated by Nd:YAP laser and bioglass.Dent Mater 2005;21:511-519.

11. Ambrosini P, Miller N, Brianon S, Gallina S, Penaud J. Clinicaland microbiological evaluation of the effectiveness of the Nd:YAPlaser for the initial treatment of adult periodontitis. A random-ized controlled study. J Clin Periodontol 2005;32:670-676.

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Fig 7 Laser phototherapy.

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canal using Nd:YAP laser and its effect on the mineral content ofthe dentin. J Clin Laser Med Surg 2004;22:87-89.

14. Armengol V, Jean A, Enkel B, Assoumou M, Hamel H. Microleak-age of class V composite restorations following Er:YAG andNd:YAP laser irradiation compared to acid-etch: an in vitro study.Lasers Med Sci 2002;17:93-100.

15. Armengol V, Laboux O, Weiss P, Jean A, Hamel H. Effects ofEr:YAG and Nd:YAP laser irradiation on the surface roughnessand free surface energy of enamel and dentin: an in vitro study.Oper Dent 2003;28:67-74.

16. Parker S. Lasers and soft tissue: loose soft tissue surgery. BrDen J 2007;202:185-191.

17. Mester E, Spiry T, Szende B, Tota JG. Effect of laser rays onwound healing. Am J Surg 1971;122:532-535.

18. Pejcic A, Zivkvic V. Histological examination of gingival treatedwith low-level laser in periodontal therapy. J Oral Laser Appl2007;71:37-43.

19. De Arajo CE, Ribeiro MS, Favaro R, Zezell DM, Zorn TM. Ul-trastructural and radiographical analysis show a faster skin repairin He-Ne laser treated wounds. J Photochem Photobiol B 2007;86:87-96.

20. Karu T. Photobiology of low-power laser effects. Health Phys1989;56:691-704.

21. Tuner J, Hode L. Low Level Laser Therapy. Clinical Practice andScientific Background. Grangesburg [Sweden]: Prima Books,1999:161-164.

22. do Nascimento PM, Pinheiro AL, Salgado MA, Ramalho LM. Apreliminary report on the effect of laser therapy on the healing ofcutaneous surgical wounds as a consequence of an inversely pro-portional relationship between wavelength and intensity: histolog-ical study in rats. Photomed Laser Surg 2004;22:513-518.

23. Karu T. Primary and secondary mechanisms of action of visible tonear-IR radiation on cells. J Photochem Photobiol B 1999;49:1-17.

24. Zhang Y, Song S, Fong CC, Tsang CH, Yang Z, Yang M. cDNAmicroarray analysis of gene expression profiles in human fibrob-last cells irradiated with red light. J Invest Dermatol 2003;120:849-857.

ACKNOWLEDGMENTS

The patients visited the Stomatology Clinic of the Dental School ofthe University of Cruzeiro do Sul (UNICSUL).

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Contact address: Irineu Gregnanin Pedron, Departamentode Estomatologia, Faculdade de Odontologia, Universidadede So Paulo, Av. Prof. Lineu Prestes, 2227 - Cidade Univer-sitria, So Paulo, SP, Brazil 05508-900. Tel/Fax: +55-11-3091-7813. e-mail: igpedron@usp.br