BYROBERT A . STRAUSS, DDS, MD

STEVEN D. FALLON, DMD

PRESENTED BYHANI S . AL -MOHARIB

Laser in Contemporary Maxillofacial Surgery

DENT CLIN N AM 48 (2004) 861–888

Outline1. Introduction.2. Types and Wavelenghts.3. Principles of Laser Physics.4. Advantages and disadvantages.5. Techniques for use in OMS.

IntroductionLasers are becoming the standard of care for

many oral and maxillofacial procedures.

They are being introduced as an efficient instrument for a variety of new applications.

IntroductionOral and maxillofacial surgery (OMS) has

included the use of lasers since the mid-1960s.

Lasers are becoming increasingly popular due to the advent of office-based lasers, which are:

1. Small.2. Portable.3. Easy to manipulate within the oral cavity.

Types and WavelenghtsThere are many different laser wavelengths that

have been used in OMS, Such as:1. CO2 laser.2. Nd:YAG laser.3. Er:YAG laser.4. Ho:YAG laser.5. Argon laser.6. Semiconductor diode lasers.

Nd: Neodymium, Y: Yttrium, A: Aluminum, G: Garnet, Er: Erbium, Ho: Holmium

CO2 Laser (10,600 nm)

CO2 laser is one of the most widely employed lasers in OMS.

CO2 laser is ideal for most soft tissue surgeries because it has excellent affinity for water-based soft tissues.

The absorbed energy causes:1. Vaporization of the intracellular and

extracellular fluid. 2. Blood vessels of approximately 500µ or less

are sealed spontaneously.

Nd:YAG Laser (1064 nm)The Nd:YAG laser’s active medium is a crystal

of yttrium, aluminum, and garnet doped with neodymium ions.

Nd:YAG laser exhibits:1. Minimal surface tissue absorption.2. Maximal penetration This allows for coagulation of tissue in depth so

that vessels 2 to 3mm in diameter can be ablated.

Nd:YAGBecause the pulse duration is shorter than the

time required to initiate a nerve action potential, Romanos et al., believed that most procedures could be performed without local anesthesia and minimal bleeding.

The Nd:YAG laser also is unique in that it can be used in a contact (excision) and a noncontact (coagulation) mode.

Nd:YAGThese properties have led to its use in a

variety of maxillofacial procedures, including :1. Coagulation of angiomatous lesions.2. Hemostasis in bleeding disorders. 3. Arthroscopic surgery of the TMJ.4. Resections in vascular tissues.5. Palliation of advanced neoplasms.

Er:YAG (2940 nm)Er:YAG laser is particularly attractive for use

in dental implant surgery. Because:1. Beam is reflected by polished metal

surfaces.2. No adverse effects on titanium surfaces.Application of the Er:YAG laser in dental

implant surgery has been advocated for:1. Preparation of hard tissue.2. Second-stage surgery.3. Revision of soft tissue.4. Treatment of peri-implantitis.

Ho:YAG (2100 nm)The Ho:YAG laser offers: 1. Minimal lateral heat transfer and less peripheral tissue

damage.2. Profound hemostasis.3. Precise cutting and controlled depth of penetration

compared with surgical shavers and scalpels.4. Can be used easily through saline solution or lactated

Ringer’s solution.

All of these characteristics make the Ho:YAG laser the perfect instrument for TMJ arthroscopic procedures, such as diskoplasty, diskectomy, and synovectomy.

Argon Laser (514 nm)Argon laser is indicated for treatment of

dermatologic, labial, and oral lesions with a large vascular component.

Argon laser is absorbed by pigment-containing tissues, including hemoglobin in erythrocytes, melanin in melanocytes, and other dark pigments.

Semiconductor Diode Lasers (805-980 nm)

The optical penetration is less than that of the Nd:YAG laser; this is potentially beneficial for the treatment of superficial and interstitial lesions.

Romanos and Nentwig et al., found that the incision margin using the diode laser is more precise compared with other systems, including the CO2 and Nd:YAG lasers.

Principles of Laser PhysicsLasers are totally absorbed by water within

the first 0.1 mm of the tissue surface, causing, at 100C:

1. Intracellular water to vaporize and expand.2. Leading to cellular rupture.3. Loss of 75% to 95% of the cell volume as

steam.4. At higher temperatures, the residual organic

matrix also vaporizes, resulting in total tissue ablation.

Principles of Laser PhysicsGiven enough time, heat begins to leak

laterally by thermal conduction.This leads to useful hemostasis, 500 µm of

thermal damage in skin uniformly results in scarring.

Control of lateral thermal damage is paramount to the use of lasers in OMS.

Principles of Laser PhysicsThree parameters controllable by the surgeon

function to control the laser’s effect on tissues:

1. Power.2. Time on target.3. Effective spot size of the beam.By adjusting these parameters, one can

create a deep thin cut into tissue for incision or excision or a wide superficial surface vaporization for tissue ablation.

AdvantagesA. The hemostatic nature of the laser allows

surgery to be performed more precisely and accurately because of increased visibility of the surgical site.

B. Decreased swelling allows for increased safety when performing surgery within the airway.

AdvantagesC. Tissue healing and scarring also are improved

with the use of the laser due to a combination of:1- Decreased lateral tissue damage.2- Less traumatic surgery.3- Precise control of the depth of tissue damage.4- Fewer myofibroblasts in laser wounds compared with scalpel wounds.

D. Decreased postoperative pain often can be obtained with the use of lasers for surgery.

DisadvantagesA. Lasers does not yet compare favorably with

conventional techniques for osseous surgery (eg, extraction of impacted teeth and osteotomies).

B. Speed of healing usually is prolonged compared with other types of wounds due to:1- Sealing of blood vessels and lymphatics.2- The need for neovascularization for healing.- Typical intraoral healing takes 2 to 3 weeks for wounds that normally would take 7 to 10 days.

Techniques for use in OMSThere are basically three photothermal

techniques for laser use on soft tissues within the oral cavity and on the face:

1. Incisional procedures.2. Vaporization procedures. 3. Hemostasis.

Incisional and excisional procedures using the CO2 laser

This technique allows the surgeon to perform almost any intraoral procedure that normally would be done with a scalpel, such as incisional or excisional biopsy, lesion removal, or incision for flap access.

this technique would require a fairly high-power density using a small spot size to create a deep but thin cut, as would be needed to make an incision.

Typical lesions treated by excision and incision include the following:1. Fibroma.2. Mucocele.3. Papilloma.4. Gingival lesions.5. Benign salivary gland lesions.6. Salivary stones.7. Malignancy removal.8. Incisional biopsy.9. Excisional biopsy.10. Vestibuloplasty.11. Epulis fissurata.12. Hyperplastic tissue excision.13. Implant uncovering.14. Peri-implantitis.15. Tongue lesions.

Incisional and excisional procedures using the CO2 laser

basic technique for laser excision demonstrated in the removal of a mucocele.(A) Outlining specimen in a repeating pulse fashion. (B) Connecting outlined dots to create a vertical cut around lesion.(C) Undermining and removing the specimen.

Excision of T1N0M0 carcinoma of lateral tongue. (A) Outline of lesion. (B) Undermining and excision of lesion. (C) Resultant defect with large margins left unsutured. (D) Two-year postoperative view displays excellent healing with minimal scarring and functional deficit.

Excision of tissue for second-stage implant surgery. (A) Note lateral angulation of laser for exposure to avoid direct contact with implant fixture. An attempt should be made to minimize removal of attached tissue. (B) Exposure of implant.

Ablation and vaporization procedures

Tissue ablation (also called vaporization) is used when the surgeon wishes to remove only the surface of the target or to perform a superficial removal of tissue.

In these situations, the lesion usually is confined to the epithelium or to the epithelium and underlying superficial submucosa.

The laser is defocused by pulling the laser back from the target and allowing the beam to widen to a spot size of 1.5 to 3 mm.

Typical lesions treated by vaporization include the following:

1. Leukoplakias.2. Dysplasia.3. Lichen planus.4. Papillary hyperplasia.5. Hyperkeratosis.6. Oral melanosis.7. Papillomatosis.8. Tissue hyperplasia.

Ablation and vaporization procedures

Laser ablation of leukoplakia of buccal mucosa. (A) Diffuse leukoplakia of buccal mucosa. (B) Outline of lesion.

(C) Ablation completed and char layer removed. (D) Resultant tissue defect left unsutured.

Ablation and vaporization procedures

Many clinicians believe that the hemostatic effect of the laser results in decreased tendency for hematogenous or lymphatic seeding of the malignant cells.

Premalignant lesion of mandibular gingiva. (A) Preoperative photograph shows extensive growth, making excisional procedure difficult. (B) Defocused ablation of gingival lesion with remaining char layer.

Cosmetic Laser SurgeryA common procedure performed is cosmetic

skin resurfacing. This procedure treats facial lesions and skin

wrinkles by:1. Removing the surface layer of the epidermis

and superficial papillary dermis.2. Contracting the dermal collagen.3. Allowing the skin to reepithelialize in a more

uniform manner.

Ablation of pigmented facial nevus. (A) Pigmented facial nevus on left brow. (B) Resultant char layer after ablation of pigmented lesion. (C) Removal of char layer shows lack of remaining pigment.

Laser-assisted uvulopalatoplastyLAUP has become an attractive alternative to

traditional scalpel uvulopalatopharyngoplasty (UPPP) for treatment of snoring and mild sleep-disordered breathing.

The procedure is designed to enlarge the posterior airspace and reduce or eliminate pharyngeal obstruction during sleep.

Dental implantsApplications of the laser for implant surgery have

focused primarily on:1. Soft tissue revision.2. Second-stage surgery.3. Decontamination of implant surfaces.4. Treatment of peri-implantitis.

Dental implantsProperties of the laser offer significant advantages

for soft tissue management surrounding dental implants, including:

1. Improved control of possible hemorrhage.2. Less mechanical trauma to the soft and hard

tissues.3. Prevention of local infection.4. Less postoperative inflammation and pain.5. Improved healing.6. Decreased risk of postoperative bacteremia.

Dental implantsConcerns have been raised regarding the hazards of

laser applications around implants. When using the laser, some of the energy may be absorbed or transferred to the implant, causing deleterious effects.

Dental implantsKreisler et al., assessed the effects on different

implant surfaces of Nd:YAG, Ho:YAG, Er:YAG, and CO2 lasers and concluded that the first two types should not be used for implant surgery because they harm the surface of all endosseous implants. The CO2 and Er:YAG lasers can be used only at low power because they can affect the implant surface.

Dental implantsThermal damage also has been implicated in

implant failures with adjunctive laser surgery. Temperature increases of 47ºC to 50ºC have been

shown to induce tissue damage in the bone leading to necrosis and failed osseointegration.

Dental implantsIn second-stage implant surgery, bone often is

found above the healing cap or at the implant margins. Traditionally, this tissue has been removed using a combination of rotary or manual instruments.

In either case, extreme caution must be used to prevent damage to the implant surface. This situation has led to the advent of lasers for implant uncoverings.

Dental implantsPeri-implant infection results in inflammation of the

surrounding soft tissues and can induce a breakdown of the implant-supporting bone.

The CO2, Er:YAG, and diode lasers have been shown to be safe and effective for treating peri-implantitis.

Temporomandibular joint surgeryArthroscopic surgery has become the primary treatment of

choice for surgical internal derangements of the TMJ. Lasers have several advantages compared with conventional cutting instrumentation and techniques, such as:

1. Diseased tissues can be removed without mechanical contact.

2. Decreased trauma to the articular cartilage and synovial surfaces.

3. Hemostasis within the joint without causing thermal damage.

4. Technical precision of laser surgery is far superior.5. Eliminates the possibility of instrument breakage and

retrieval.

Using this technique, such procedures as:1. Diskectomy.2. Diskoplasty.3. Synovectomy.4. Hemostasis.5. Posterior attachment contraction.6. Eminectomy.7. Debridement of fibrous ankylosis - All these can be performed on an outpatient basis

through two incisions less than 2 mm each.

Temporomandibular joint surgery

Temporomandibular joint arthroscopy using a holmium:YAG laser. Separate ports are required to provide the surgeon with visibility of the laser tip during use.

SummaryThe incorporation of lasers OMS has led to exciting

advances in surgical therapy and improved patient care.

Advances in laser technology undoubtedly will yield new procedures and have a major role in the future of minimally invasive surgery.

Thank You