GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY

SEMINAR ON
LASERS IN ORAL &
MAXILLOFACIAL SURGERY


Presented By:
Dr. Sambhav K Vora
II. MDS
1
CONTENTS-
1. Introduction
2. History of lasers
3. Laser physics
4. Laser design
5. Focusing
6. Laser types-
Caron-di-o!ide laser
"d#$%& laser
%rgon laser
'r#$%& laser
Ho#$%& laser
(. Interactions )ith iologic tissues
*. Laser effect on dental tissues
+. Lasers in ,reneoplasia of oral ca-ity
1.. Lasers for soft tissue e!cision
11. /0in resurfacing in the aesthetic 1one
12. 2esection of the cancer
13. Laser assisted u-ulopalatoplasty
14. Lasers in laryngeal surgery
15. Laser ha1ards 3 safety
16. Conclusion
1(. 2eferences
2
Introduction
Laser is an acrony45 )hich stands for light a4plification y sti4ulated
e4ission of radiation. /e-eral decades ago5 the laser )as a death ray5 the
ulti4ate )eapon of destruction5 so4ething you )ould only find in a science
fiction story. 6hen lasers )ere de-eloped and actually used5 a4ong other
places5 in light sho)s. 6he ea4 spar0led5 it sho)ed pure5 -irant and intense
colors. 6oday the laser is used in the scanners at the grocery store5 in co4pact
disc players5 and as a pointer for lecturer and ao-e all in 4edical and dental
field. 6he i4age of the laser has changed significantly o-er the past se-eral
years.
7ith dentistry in the high tech era5 )e are fortunate to ha-e 4any
technological inno-ations to enhance treat4ent5 including intraoral -ideo
ca4eras5 C%8-C%9 units5 2:&s and air-arasi-e units. Ho)e-er5 no
instru4ent is 4ore representati-e of the ter4 high-tech than5 the laser. 8ental
procedures perfor4ed today )ith the laser are so effecti-e that they should set
a ne) standard of care.
6his presentation intends to discuss the role of lasers in dentistry.
History of Lasers
%ppro!i4ately5 the history of lasers egins si4ilarly to 4uch of 4odern
physics5 )ith 'instein. In 1+1(5 his paper in ,hysi0ialische ;eil5 <;ur
=uantern 6heorie der /trahlung>5 )as the first discussion of sti4ulated
e4ission.
In 1+54 6o)nes and &ordon uilt the first 4icro)a-e laser or etter
0no)n as ?9%/'2@ )hich is the acrony4 for ?9icro)a-e %4plification
y sti4ulated '4ission of 2adiation@
In 1+5*5 6o)nes5 )or0ing )ith /cha)lo) at Aell Laoratories5 pulished
the first theoretic calculations for a -isile light 4aser B or )hat )as then
called a L%/'2.
3
In 9ay 1+6.5 6heodore 9ai4en at Hughes %ircraft co4pany 4ade the
first laser. He used a ruy as the laser 4ediu4.
Cne of the first reports of laser light interacting )ith tissue )as fro4
;aretD he 4easured the da4age caused y lasers incident upon rait
retina and iris.
6he first gas laser )as de-eloped y Ea-an et al in 1+61. 6his )as the first
continuous laser and used heliu4 B neon.
6he "oel ,ri1e for the de-elop4ent of the laser )as a)arded to 6o)nes5
Aasor and ,ro0ho-o- in 1+64.
6he neody4iu4 B doped F"dG# glass laser )as de-eloped in 1+61 y
/nit1er.
In 1+64 "d# $%& )as de-eloped y &eusic.
6he CC
2
laser )as in-ented y ,atel et al in 1+65.
In 1+6* ,olanyi de-eloped articulating ar4s to deli-er CC
2
laser to re4ote
areas.
,olanyi in 1+(. applied CC
2
laser clinically.
In 1++. Aall suggested opthal4ologic application of ruy laser.
Laser Physics
2
Laser is a de-ice that con-erts electrical or che4ical energy into light
energy.
In contrast to ordinary light that is e4itted spontaneously y e!cited
ato4s or 4olecules5 the light e4itted y laser occurs )hen an ato4 or
4olecule retains e!cess energy until it is sti4ulated to e4it it. 6he radiation
e4itted y lasers including oth -isile and in-isile light is 4ore generally
4
ter4ed as electro4agnetic radiation. 6he concept of sti4ulated e4ission of
light )as first proposed in 1+1( y %lert 'instein.
He described three processes:
1. %sorption
2. /pontaneous e4ission
3. /ti4ulated e4ission.
'instein considered the 4odel of a asic ato4 to descrie the
production of laser. %n ato4 consists of centrally placed nucleus )hich
contains H-ely charged particles 0no)n as protons5 around )hich the
negati-ely charged particles. i.e. electrons are re-ol-ing.
7hen an ato4 is struc0 y a photon5 there is an energy transfer causing
increase in energy of the ato4. 6his process is ter4ed as absorption. 6he
photon then ceases to e!ist5 and an electron )ithin the ato4 pu4ps to a higher
energy le-el. 6his ato4 is thus pu4ped up to an e!cited state fro4 the ground
state.
In the e!cited state5 the ato4 is unstale and )ill soon spontaneously
decay ac0 to the ground state5 releasing the stored energy in the for4 of an
e4itted photon. 6his process is called spontaneous emission.
If an ato4 in the e!cited state is struc0 y a photon of identical energy
as the photon to e e4itted5 the e4ission could e sti4ulated to occur earlier
than )ould occur spontaneously. 6his sti4ulated interaction causes t)o
photons that are identical in freIuency and )a-elength to lea-e the ato4. 6his
is a process of stimulated emission.
If a collection of ato4s includes5 4ore that are pu4ped into the e!cited state
that re4ain in the resting state5 a population in-ersion e!ists. 6his is necessary
condition for lasing. "o)5 the spontaneous e4ission of a photon y one ato4
)ill sti4ulate the release of a second photon in a second ato45 and these t)o
photon )ill trigger the release of t)o 4ore photons. 6hese four than yield
eight5 eight yield si!teen and so on. In a s4all space at the speed of light5 this
photon chain reaction produces a rief intense flash of 4onochro4atic and
coherent light )hich is ter4ed as ?laser@.
5
Properties of Laser
11
1. Coherent: Coherence of light 4eans that all )a-es are in certain phase
relationship to each other oth in space and ti4e
2. Mono- chromatic: Characteri1ed y radiation in )hich all )a-es are of
sa4e freIuency and )a-elength.
3. Coimated# 6hat 4eans all the e4itted )a-es are parallel and the ea4
di-ergence is -ery lo). 6his property is i4portant for good trans4ission
through deli-ery syste4s.
4. E!ceent concentration of ener"y: 7hen a calcified tissue for eg. dentin
is e!posed to the laser of high energy density5 the ea4 is concentrated at
a particular point )ithout da4aging the adJacent tissues e-en though a lot
of te4perature is produced ie *..-+..
o
C.
5. ;ero entropy.
Laser #esi"n
6he laser consists of follo)ing co4ponents.
1. $ aser medi%m or acti&e medi%m: 6his can e a solid5 liIuid or gas.
6his lasing 4ediu4 deter4ines the )a-elength of the light e4itted fro4
the laser and the laser is na4ed after the 4ediu4.
2' Ho%sin" t%be or optica ca&ity:
9ade up of 4etal5 cera4ic or oth.
6his structure encapsulates the laser 4ediu4.
Consists of t)o 4irrors5 one fully reflecti-e and the
other partially trans4itti-e5 )hich are located at
either end of the optical ca-ity.
6
3. Some form of an e!terna po(er so%rce: 6his e!ternal po)er source
e!cites or <pu4ps> the ato4 in the laser 4ediu4 to their higher energy
le-els. % population in-ersion happens )hen there are 4ore ato4s in the
e!cited state rather than a non-e!cited state. %to4s in the e!cited state
spontaneously e4it photons of light )hich ounce ac0 and forth et)een
the t)o 4irrors in the laser tue5 they stri0e other ato4s5 sti4ulating 4ore
spontaneous e4ission. ,hotons of energy of the sa4e )a-elength and
freIuency escape through the trans4itti-e 4irror as the laser ea4. %n
e!tre4ely s4all intense ea4 of energy that has the aility to -apori1e5
coagulate5 and cut can e otained if a lens is placed in front of the ea4.
6his lens concentrates the e4itted energy and allo)s for focussing to a
s4all spot si1e.
Laser Li"ht #ei&ery
Light can e deli-ered y a nu4ered of different 4echanis4s.
/e-eral years ago a hand held laser 4eant holding a larger5 se-eral hundred
pound laser usually the si1e of des0 ao-e a patient. %lthough the idea )as
co4ical at the ti4e5 it is eco4ing 4ore feasile as laser technology is
producing s4aller and lighter )eight lasers. In the 4ore future it is proale
that hand held lasers )ill e used routinely in dentistry.
1' $rtic%ated arms
Laser light can e deli-ered y articulated ar4s5 )hich are -ery si4ple
ut elegant. 9irrors are placed at 45
o
angles to tues carrying the laser light.
6he tues can rotate aout the nor4al a!is of the 4irrors. 6his results in a
tre4endous a4ount of fle!iility in the ar4 and in deli-ery of the laser light.
6his is typically used )ith CC
2
laser. 6he ar4 does ha-e so4e disad-antages
that include the ar4 counter )eight and the li4ited aility to 4o-e in straight
line.
2' Optica )iber
Laser light can e deli-ered y an optical fier5 )hich is freIuently
used )ith near infrared and -isile lasers. 6he light is trapped in the glass and
propagates do)n through the fier in a process called total internal reflection.
(
Cptical fiers can e -ery s4all. 6hey can e either tenths of 4icros or
greater than hundreds of 4icrons in dia4eter. %d-antages of optical fier is
that they pro-ide easy access and trans4it high intensities of light )ith al4ost
no loss ut ha-e t)o disad-antages5 one the ea4 is no longer colli4ated and
coherent )hen e4itted fro4 the fier )hich li4its the focal spot si1e and
second disad-antage is that the light is no longer coherent.
Patient to aser
%nother 4ethod of deli-ering laser light to the patient is actually to
ring the patient up to the laser. 'g# /lit la4p used in the ophthal4ologist gist
has een doing this for Iuite so4e ti4e. 6he ophthal4ic laser 4icroscope is
si4ply a slit la4p )ith a laser uilt into it. 6he doctor si4ply i4ages )hat he
)ants on the cornea or retina and then pushes the foot pedal to deli-er laser
ea4 to the target.
Cnce the laser is produced5 its output po)er 4ay e deli-ered in the
follo)ing 4odes.
1. Contin%o%s (a&e: 7hen laser 4achine is set in a continuous )a-e 4ode
the a4plitude of the output ea4 is e!pressed in ter4s of )atts. In this
4ode the laser e4its radiation continuously at a constant po)er le-els of
1. to 1.. ). 'g# CC
2
laser
2. *ated: 6he output of a continuous )a-e can e interrupted y a shutter
that <chops> the ea4 into trains of short pulses. 6he speed of the shutter
is 1.. to 5..4s.
3. P%sed: Lasers can e gated or pulsed electronically. 6his type of gating
per4its the duration of the pulses to e co4pressed producing a
corresponding increase in pea0 po)er5 that is 4uch higher than in
co44only a-ailale continuous )a-e 4ode.
4. S%per p%sed: 6he duration of pulse is one hundredth of 4icroseconds.
5. +tra p%sed: 6his 4ode produces an output pulse of high pea0 po)er that
is 4aintained for a longer ti4e and deli-ers 4ore energy.
*
6. ,-scotched: '-en shorter and 4ore intense pulse can e otained )ith
this 4ode.
)oc%ssin"
Lasers can e used in either a focussed 4ode or in a defocused 4ode.
% focussed mode is )hen the laser ea4 hits the tissue at its focal
points or s4allest dia4eter. 6his dia4eter is dependent on the si1e of lens
used. 6his 4ode can also e referred as cut 4ode. 'g. 7hile perfor4ing
iopsies.
6he other 4ethod is the defocused mode. Ay defocusing the laser ea4
or 4o-ing the focal spot a)ay fro4 the tissue plane5 this ea4 si1e that hits
the tissue has a greater dia4eter5 thus causing a )ider area of tissue to e
-apori1ed. Ho)e-er5 laser intensity K po)er density is reduced. 6his 4ethod is
also 0no)n as alation 4ode. 'g. In Frenecto4ies. In re4o-al of
infla44atory papillary hyperplasias.
Contact and Non contact modes
In contact 4ode5 the fier tip is placed in contact )ith the tissue. 6he
charred tissue for4ed on the fier tip or on the tissue outline increases the
asorption of laser energy and resultant tissue effects. Char can e eli4inated
)ith a )ater spray and then slightly 4ore energy )ill e reIuired to pro-ide
ti4e efficient results. %d-antage is that there is control feed ac0 for the
operator.
Non contact mode: Fier tip is placed a)ay fro4 the target tissue. 6he
clinician operates )ith -isual control )ith the aid of an ai4ing ea4 or y
oser-ing the tissue effect eing created.
/o generally laser can e classified as
+
8ental Lasers
6hose )or0 in
oth
/olely in the non Contact 3 focussed "on
contact contact
4ode 3
defocused
'g# CC
2
'g# %gon5 HC # $%&5
"d#$%&
Laser Types
I. Aased on )a-elength.
1. /oft lasers
2. Hard lasers
II. Aased on the type of acti-e K lasing 4ediu4 used
1. %rF e!ci4er
2. LrF e!ci4er
3. MeCl e!ci4er
4. %rgon ion
5. L6,
6. 2uy
(. "d# $%&
*. HC# $%&
+. $/&&
1.. 'r# $%&
11. CC
2
1.
-'
1. Soft Lasers# 7ith a )a-e length around 63244 /oft lasers are lo)er
po)er lasers.
'g# He "e5 &alliu4 arsenide laser.
6hese are e4ployed to relie-e pain and pro4ote healing eg. In
%pthous ulcers.
2. Hard asers: Lasers )ith )ell 0no)n laser syste4s for possile surgical
application are called as hard lasers.
'g# CC
2
5 "d# $%&5 %rgon5 'r#$%& etc.
CO
2
Lasers
.
6he CC
2
laser first de-eloped y ,atel et al in 1+64 is a gas laser and
has a )a-elength of 1.56.. nano4eters or 1..6 deep in the infrared range
of the electro4agnetic spectru4.
CC
2
lasers ha-e an affinity for )et tissues regardless of tissue color.
6he laser energy )ea0ens rapidly in 4ost tissues ecause it is asored y
)ater. Aecause of the )ater asorption5 the CC
2
laser generates a lot of
heat5 )hich readily caroni1es tissues. /ince this caroni1ed or charred
layer acts as a iological dressing5 it should not e re4o-ed.
6hey are highly asored in oral 4ucosa5 )hich is 4ore than +.N )ater5
although their penetration depth is only aout ..2 to 144. 6here is no
scattering5 reflection5 or trans4ission in oral 4ucosa. Hence5 )hat you see
is )hat you get.
CC
2
lasers reflect off 4irrors5 allo)ing access to difficult areas.
Onfortunately5 they also reflect off dental instru4ents5 4a0ing accidental
reflection to non-target tissue a concern.
11
CC
2
lasers cannot e deli-ered fier optically %d-ances in articulated ar4s
and hollo) )a-e guide technologies5 no) pro-ide easy access to all areas
of the 4outh.
2egardless of the deli-ery 4ethod used5 all CC
2
lasers )or0 in a non-
contact 4ode.
Cf all the lasers for oral use5 CC
2

13
is the fastest in re4o-ing tissue.
%s CC
2
lasers are in-isile5 an ai4ing heliu4 B neon FHe "eG ea4 4ust
e used in conJunction )ith this laser.
Nd: /$* Laser: Here a crystal of $ttriu4 B alu4inu4 B garnet is doped )ith
neody4iu4. "d# $%& laser5 has )a-elength of 15.64 n4 F..1.6 G placing it
in the near infrared range of the 4agnetic spectru4.
It is not )ell asored y )ater ut are attracted to pig4ented tissue. 'g#
he4ogloin and 4elanin. 6herefore -arious degrees of optical scattering
and penetration to the tissue5 4ini4al asorption and no reflection.
"d# $%& lasers )or0 either y a contact or non-contact 4ode. 7hen
)or0ing on tissue5 ho)e-er5 the contact 4ode in highly reco44ended.
6he "d# $%& )a-elength is deli-ered fier optically and 4any si1es of
contact fiers are a-ailale. Caroni1ed tissue re4ains often uild of on
the tip of the contact fier5 creating a ?hot tip@. 6his increased te4perature
enhances the effect of the "d#$%& laser5 and it is not necessary to rinse
the uild up a)ay. /pecial tips5 the coated sapphire tip5 can e used to
li4it lateral ther4al da4age. % heliu4-neon-ai4ing ea4 is generally
used )ith "d# $%& )a-elength.
,enetration depth is P 2 to 445 and can e -aried y upto ..5-444 in oral
tissues y -arious 4ethods.
% lac0 enhancer can e used to speed the action.
12
9ost dental "d# $%& lasers )or0 in a pulsed 4ode. %t higher po)ers and
pulsing5 a super heated gas called a plas4a can for4 on the tissue surface.
It is the plas4a that can e responsile for the effects of either
coagulation5 -apori1ation or cutting. If not cooled Fe.g. y running a )ater
strea4 do)n the fierG the plas4a can cause da4age to the surrounding
tissues.
/uffer fro4 dragaility
6he "d#$%& ea4 is readily asored y a4alga45 titaniu4 and non-
precious 4etals5 reIuiring careful operation in the presence of these dental
4aterials.
$r"on Lasers
%rgon lasers are those lasers in the lue-green -isile spectru4.
6hey operate at 4**n4 or 514.5n45 are gas li0e CC
2
lasers and are easily
deli-ered fier optically li0e "d#$%&.
%rgon lasers ha-e an affinity for dar0er colored tissues and also a high
affinity for he4ogloin5 4a0ing the4 e!cellent coagulators. It is not
asored )ell y hard tissue5 and no particular care is needed to protect the
teeth during surgery.
In oral tissues there is no reflection5 so4e asorption and so4e scattering
and trans4ission.
%rgon laser# end point is
Q)hiteningQ of lesion.
13
%rgon lasers )or0 oth in the contact and non contact 4ode
Li0e5 "d# $%& lasers5 at lo) po)ers argon lasers suffer fro4 ?dragaility@
and need s)eeping 4otion to a-oid tissue fro4 accu4ulating on the tip.
'nhances are not needed )ith %rgon lasers.
%rgon lasers also ha-e the aility to cure co4posite resin5 a feature shared
y none of the other lasers.
6he lue )a-elength of 4** n4 is used 4ainly for co4posite curing5 )hile
the green )a-elength of 51.n4 is 4ainly for soft tissue procedures and
coagulation.
Er: /$* aser
Ha-e a )a-elength of 2.+4 4.
% nu4er of researchers ha-e de4onstrated the 'r# $%& lasers aility to
cut5 or alate5 dental hard tissue effecti-ely and efficiently. 6he 'r# $%&
laser is asored y )ater and hydro!yapatite5 )hich particularly
accounts for its efficiency in cutting ena4el and dentin.
,ulpal response to ca-ity preparation )ith an 'r# $%& laser )as 4ini4al5
re-ersile and co4parale )ith pulpal response created y a high-speed
drill.
Ho: /$* aser 0Homi%m /$* asers1
Has a )a-elength of 251.. n4 and is a crystal
8eli-ered through a fier optic carrier.
14
% He-"e laser is used as an ai4ing light
8ragaility is less co4pared to "d# $%& and argon lasers
Li0e "d# $%&5 can e used in oth the contact and non-contact 4odes and
are pulsed lasers.
Ho# $%& laser has an affinity for )hite tissue and has aility to pass
through )ater and acts as a good coagulator.
Laser interaction (ith bioo"ic tiss%es
Light can interact )ith tissues in four different 4echanis4s
1. 2eflected
2. /cattered
3. %sored
4. 6rans4itted
2efection: 2eflected light ounces off the tissue surface and is directed
out)ard. 'nergy dissipates after reflection5 so that there is little danger of
da4age to other parts of 4outh and it li4its the a4ount of energy that enters
the tissue.
Scatterin": occurs )hen the light energy ounces fro4 4olecule to 4olecule
)ithin the tissue. It distriutes the energy o-er a larger -olu4e of tissue5
dissipating the ther4al effects.
$bsorption: occurs after a characteristic a4ount of scattering and is
responsile for the ther4al effects )ithin the tissue. It con-erts light energy to
heat energy 6he asorption properties of tissue and cells depends on the type
and a4ount of asoring pig4ents or chro4ophores. 'g. He4ogloin5 )ater5
9elanin5 Cytochro4es etc.
Transmission: Light can also tra-el eyond a gi-en tissue oundary. 6his is
called trans4ission. 6rans4ission irradiates the surrounding tissue and 4ust
e Iuantified. Its effects should e considered efore laser treat4ent can e
Justified.
15

Tiss%e effects on aser irradiation
7hen radiant energy is asored y tissue 4 asic types of interactions
occurs.
Laser effects on #enta Hard Tiss%es
6he asorption and trans4ission of laser light in hu4an teeth is 4ainly
dependent on the )a-elength of the laser light.
For eg. B Oltra-iolet laser light is )ell asored y teeth.
In )ater and in hydro!yapatite5 there is a -ery lo) asorption at a
)a-elength of 2 4 in co4parison to high asorption of laser energy at 3 4
and 1. 4.
6he laser effects can e grouped as#
16
1' Therma effects:
6he est 0no)n laser effect in dentistry is the ther4al -apori1ation of
tissue y asoring laser light i.e. the laser energy is con-erted into ther4al
energy or heat that destroys the tissues.
Fro4 45
o
B 6.
o
denaturation occurs
R6.
o
coagulation and necrosis
%t 1..
o
C )ater inside tissue -apori1es
R3..
o
C caroni1ation and later hydrolysis )ith
-apori1ation of ul0y tissues.
2' Mechanica effects:
High energetic and short pulsed laser light can lead to a fast heating of
the dental tissues in a -ery s4all area. 6he energy dissipates e!plosi-ely in a
-olu4e e!pansion that 4ay e acco4panied y fast shoc0 )a-es. 6hese shoc0
)a-es lead to 4echanical da4age of the irradiated tissue.
3' Chemica effects:
Here 4olecules can e associated directly )ith laser light of high
photon energies.
Histoo"ic 2es%ts:
7ith continuous )a-e and pulsed CC
2
lasers.
7hen continuous )a-e and pulsed CC
2
lasers )ere used5 structural
changes and da4age in dental hard tissue )ere reported. 9icrocrac0s and
1ones of necrosis and caroni1ation are una-oidale. Aecause of drying
effects5 the 4icrohardnes of dentin increases. 6he crystalline structure of
hydro!yapatite changes and a transfor4ation of apatite to tricalciu4
phosphate ta0es place.
Nd: /$* Lasers:
1(
6he "d# $%& laser sho)s lo) asorption in )ater as )ell as in
hydro!yapatite. 6herefore the laser po)er diffuses deeply through the ena4el
and dentin and finally heats the pulp. In dentin5 at the laser i4pact5 1ones of
deris and caroni1ation are surrounded y an area of necrosis can e seen.
9icrocrac0s appear )hen energies ao-e a threshold of 1..4J K pulse are
used. Aut the appearance and the e!tent of the side effects are not predictale.
Er: /$* Laser:
In dentin5 shallo) ca-ities )ere surrounded y a 1one of necrosis of 1-
3 4 thic0ness )hen )ater-cooling syste4s )ere used. In deeper ca-ities
areas of caroni1ation and 4icrocrac0s )ere oser-ed. %lating ena4el
al)ays crac0ed and deep 1ones of deris appeared.
E!cimer Lasers:
"o pathologic changes in the tissue layers adJacent to the dissected
areas )ere found after the alation.
6he alation effects of dental hard tissues are predictale. Co4pared to
con-entional dia4ond and urs5 ho)e-er5 the effecti-eness is lo). 6her4al
side effects increase as photon energies of e!ci4er lasers decrease.
Laser Effects on #enta P%p:
2ecent histologic e-idence suggests that a nor4al odontolasts layer5
stro4a and -iale epithelial root sheath can e retained follo)ing laser
radiation pro-ided da4age threshold energy densities are not e!ceeded. If pulp
te4peratures are raised eyond the 5SC le-el5 research has sho)n that the
odontolasts layer 4ay not e present. Characteristics of the dentinogenesis
process related to root de-elop4ent5 predentin and reparati-e dentin
for4ation5 dentinal ridge presence5 typically reflect the o-erall trau4a that
has een induced in the odontolasts.
1*
$ppication of Lasers in #entistry:
$ppication Possibe Laser Types
Aasic research
Laser tissue interaction
6echnical de-elop4ent of applications
of lasers in dentistry
%ll types
%ll types
9easure4ent and diagnosis
Holography
Laser 8oppler fo)4etry
/pectroscopy Fcaries diagnosisG
He "e5 diodes
He "e5 diodes
:arious types
Cral and 9a!illofacial /urgery
Cutting and Coagulation
,hotodyna4ic therapy
CC
2
5 "d# $%&5 %r5 dye
8ye5 %u-Cu -apour
Conser-ati-e dentistry
,re-enti-e dentistry Ffissure sealingG
Caries treat4ent
Co4posite resin light Curing
6ooth surface conditioning
CC
2
5 "d#$%&5 ruy
CC
2
5 "d#$%&5 'r# $%&5 '!ci4er
%r5 dye5 HeCd
'!ci4er5 CC
2
5 "d#$%&5 'r#$%&
'ndodontics
2oot canal treat4ent
%picoecto4y
"d# $%&5 CC
2
5 '!ci4er
CC
2
5 "d#$%&
,eriodontics
1+
Laser sealing of affected root surfaces
'!cision of gingi-al soft tissues
CC
2
5 e!ci4er
CC
2
%nalgesic effect and io-sti4ulation
/ti4ulation of )ound healing
Lo) po)er laser radiation )ith analgesic
'ffects
He "e5 diodes
"d# $%&
Other appications:
Laser processing of dental 4aterials
7elding of dental alloys
Coalt B chro4e B 4olydinu4
"ic0el B chro4e B alu4inu4
/il-er ,alladiu4
6itaniu4 alloys
7elding of cera4ic 4aterials
/till under in-estigation
$d&anta"es of aser (edin":
1. High ond strength and corrosion resistance since laser )elding is a for4
of s)eating that does not use solders of different 4aterials.
2. 2educed o!idation )hen argon gas is used for )elding.
3. 8ecreased ther4al influence and greater precision in processing than )ith
soldering or other techniIues.
.
Lasers in S%r"ica Systems:
2.
Lasers are an alternati-e to con-entional surgical syste4s. /tated est
y %pfelerg in 1+*(5 lasers are a <ne) and different scalpel> Foptical 0nife5
light scalpelG.
$d&anta"es:
'asy access to the anato4ic site
,ossess inherent he4ostatic properties.
Capale of alation of lesions in pro!i4ity to nor4al
structures5 )ith 4ini4al da4age to nor4al structures.
2educed pain during surgical procedures and less post
operati-e pain.
'nhanced healing
Aactericidal and -irucidal effects of laser result in decreased
rates of )ound infection.
Certain pro&en %ses for denta soft tiss%e proced%res %sin" asers are:
1. Frenecto4y
9a!illary 4idline
Lingual F6ongue tieG
2. Incisional and e!asional iopsies.
3. 2e4o-al of enign lesions
)ibro%s
,apillous
,yogenic granulo4a
Lichen ,lanus
'rosi-e lichen planus
"icotinic sto4atites
:erruca -ulgaris
Infla44atory papillary hyperplasia
21
Ep%i
4. &ingi-oplasty
5. /oft tissue tuerosity reduction.
6. /oft tissue distal )edge procedure.
(. &ingi-ecto4y
%. 2e4o-al of hyperplasias
1. 8ilantin etc
2. Idopathic
A. Cro)n trough.
*. %phthous ulcer
+. Cperculecto4y
1.. 2e4o-al of hyper0eratotic lesions
11. 2e4o-al of 4alignant lesions
12. /oft tissue cro)n lengthening
13. Coagulation.
%. &raft donor sites.
A. /eepage around cro)n preparation.
14. :estiuloplasty
15. 2e4o-al of granulation tissue B periodontal clean out
16. 2e4o-al of -ascular lesions
%. He4angio4s
A. ,yogenic granulo4a
22
1(. 2e4o-al of lesion in patients )ith he4orrhagic disorders.
%. He4ophelia etc.
1*. I4plants B /tage II B at the ti4e of reco-ery.
%. /oft tissue re4o-al
Lasers in Preneopasia of the ora ca&ity-
/uccessful treat4ent of superficial 4ucosal disease of the oral ca-ity
4andates selecti-e alation of the anor4al epitheliu4 including the
paraasal layer attached to the ase4ent 4e4rane. 6he caron dio!ide laser
does not i4part 4agical properties to the tissues5 ut it does pro-ide a
selecti-e therapeutic ad-antage for the treat4ent of intra4ucosal ,reneoplasia
y a-oiding da4age to suJacent tissue5 therey eli4inating scar for4ation
and the creation of oral defor4ities. ,reneoplastic lesions of the oral 4ucosa
include leu0opla0ia
6
5 erythropla0ia5 and oral su4ucous firosis5 )ith *5N of
the preneoplasias eing accounted for y leu0opla0ia.
S+2*-C$L T2E$TMENT: C 4 2 L$SE2
12
Con-entional surgical treat4ent5 )hich consists of e!cision )ith a scalpel5 is
successful and adeIuate for li4ited local disease. 6he literature reports control
rates of around +. N .Failure eco4es li0ely )hen this local treat4ent is
applied to e!tensi-e disease. Aecause the 4ulticentric nature of precancer Fthe
conde4ned 4ucosa conceptG 4anifests itself as 4ultifocal disease y
occurring at 4ultiple sites in the oral ca-ity and oropharyn!5 a 4ore gloal
treat4ent concept than local e!cision is reIuired. Failure rates follo)ing local
surgical e!cision are as high as 33N.4 9uliicentricity de4ands e!cision of
topographically large areas of 4ucosa. Ho)e-er5 the denudation of large areas
of oral 4ucosa results in scarring and )ound contraction as )ell as
postoperati-e pain5 ede4a5 and nutritional depletion. 8espite the greatest care5
the 4ini4u4 thic0ness of tissue re4o-ed )ith a scalpel results in e!posure
and re4o-al of the su4ucosa. Aoth scarring and inco4plete epithelial
regeneration occur. 6he traditional solution to this prole4 is to replace the
4ucosa )ith a split-thic0ness s0in graft. 6his5 ho)e-er5 is an unsatisfactory
solution ecause s0in de)s not function as )ell as 4ucosa. 6he graft
ulti4ately contracts as ti4e passes5 and the grafted s0in co-ers re4aining
ele4ents of regenerated 4ucosa that 4ay e unstale. Lastly5 e-en for local
23
treat4ent5 site-specific conseIuences 4ay dictate against locally in-asi-e
surgery that induces scarring. For e!a4ple5 re4o-al of the thinnest layer of
4ucosa o-er the opening of 7hartonTs or /tensenTs duct 4ay cause scarring5
glandular ostruction5 and infection. '!cision of large lesions at the oral
co44issure causes defor4ity of the oral sto4a. 6he ad-antage of replacing
traditional e!cisional techniIues )ith C . 2 laser photoalation is that the laser
per4its re4o-al of the da4aged epitheliu4 )ith as little as ..1 to ..2 44 of
re-ersile ther4al inJury to the su4ucosa. ,recise control of ther4al da4age
4a0es it possile to re4o-e e-en the epitheliu4 directly o-er the sali-ary duct
orifices )ithout inducing sialodochitis and glandular ostruction. '!tensi-e
areas of 4ucosa 4ay e alated )ithout s0in grafting ecause epitheliu4 is
regenerated fro4 nor4al tissue at the )ound periphery in no 4ore than 5
)ee0s for lesions as large as 4. c42 . %fter healing5 the 4ucosa al ris0 is still
oser-ale y direct -isual inspection during recall e!a4ination. Cf eIual
i4portance5 there is little postoperati-e s)elling and patients 4ay ta0e oral
fluids i44ediately after surgery. 6hese patients 4ay e operated upon as
outpatients5 and there is usually no leeding or s)elling. ,ain5 )hich is highly
-ariale5 is easily 4anaged )ith oral analgesics5 rarely lasts 4ore than a fe)
days5 and only occasionally sho)s a secondary increase in intensity on days 3
to 55 )hich then aruptly ter4inates.
S+2*-C$L
TECHN-,+E-
6he oral 4ucosa is assessed
and the reIuisite iopsies are
otained in the 4anner
pre-iously descried. %t the
ti4e of laser surgery5 the
-ital staining is repeated.
Local anesthesia is used
unless the patient recei-es a
general anesthetic. "o pre-
or perioperati-e antiiotics
are gi-en and no antiseptic
preparation solution is used for the 4outh. 6he face is protected )ith )et
surgical drapes and the eyes are co-ered. If endotracheal intuation is utili1ed5
the hypopharyn! is pac0ed )ith a )et gau1e. %fter identifying the e!tent of
the pathology5 the laser is set at an a-erage po)er of 2. to 3. 7 for pulsed
4odes5 and 15 to 2. 7 for C7 4ode. 6he spot si1e )ill -ary et)een 2 and 3
24
44 in dia4eter. 6he clinical end point for alation of the 4ucosa is to cause a
Qrapid uling of the epitheliu4 )hich is opalescent in color and is
acco4panied y a crac0ling noise.Q2 1 6he lesion is outlined )ith a suitale
4argin of se-eral 4illi4eters and then parallel lines of application of the laser
are placed )ithin the 4arginal outline 6his is called rastering. %fter
co4pletion of this first layer of lasing5 there should e al4ost no
caroni1ation. If the )ound appears lac0ened5 there has een e!cessi-e heat
conduction ecause of prolonged contact et)een the laser ea4 and the
tissue as a result of e!cessi-ely slo) hand speed in 4o-ing the handpiece or
4icroscope Joystic0-directed laser ea4 across the lesion. 6he 4ore heat
conducted5 the greater the desiccation occurring at surgery. % 4oist gau1e is
no) used to )ipe a)ay the treated area of 4ucosa. 6his allo)s one to assess
the depth of penetration of the laser. % pale pin0 ase that does not leed
indicatesre4o-al of the epitheliu4 at the le-el of the ase4ent 4e4rane . If
there are scattered droplets of lood5 then the superficial aspect of the
su4ucosal plane has een reached. If the depth of penetration is too
superficial5 a second raster is applied to reach the reIuired depth5 )hich results
in re4o-al of the entire thic0ness of the epitheliu4. In areas of thic0
hyperplasia as for nicotine sto4atitis or firoepithelial hyperplasia ofthe palate
5se-eral layers of rastering 4ay e reIuired. 6he su4ucosal layer is identified
oth y the appearance of lood -essels and y the appearance of tissue of
granular appearance and yello) color. %t the conclusion of surgery the
anor4al Fissue has een re4o-ed and there should e no leeding e!cept
)here it )as necessary to e!tend tissue re4o-al into the su4ucosa. as 4ay
e reIuired in this case of papillary hyperplasia of the palate )here four
rasters are needed for co4plete tissue re4o-al. 6he firin coagulu4 that
for4ed )ithin the first 24 hours is still present at one )ee0. Co4plete 4ucosal
reepitheliali1ation and healing has occurred )ithin 5 )ee0s
Lasers for soft tiss%e e!cision-
)-52OEP-THEL-$L POL/P-
6he polyp arising fro4 the
dorsal 4idline of the
anterior tongue )as oth
interfering )ith suc0ling
and causing consternation
for the parents and the
25
pediatrician. %t appro!i4ately ( )ee0s of age the patient )as rought to the
operating roo4 )here5 using general anesthesia deli-ered y an oral
endotracheal tue and )ithout supple4ental local anesthesia5 the polyp
)as loodlessly re4o-ed in one 4inute of operating ti4e. Laser para4eters
)ere handheld CC# rapid superpulsed laser at 5. pps. e-aporati-e spot siK.e of
..3 445 a-erage po)er output of 1. 7
E$2 T$*-
/0in tags occasionally
occur in ne)orns as )ell
as adults. In this illustrati-e
case a consultation )as
recei-ed fro4 the ne)orn
nursery to re4o-e an ear
tag. Ctologic and auditory
e!a4inations )ere nor4al.
6he ay )as rought to
the laser la )here he )as
first fed. 6hen5 after falling
asleep the ase of the
lesion )as inliltrated )ith ..25 4L of 2N lidocaine. 6he lesion )as then
re4o-ed )ith the superpulsed CC5 laser at 6 7 a-erage output po)er5 ..3-44
spot si1e using a handpiece at 11* pps. 6he operation reIuired less than a
4inute and there )as no lood loss
E6POS+2E O) -MP$CTE# TEETH-
%lthough e!posure of i4pacted teeth Fsoft tissue i4pactionG is easily
acco4plished in the dental operatory using local anesthesia and a loop cautery5
there is less s)elling5 less postoperati-e pain5 and less chance of ther4al
inJury to the e!posed tooth if the free ea4 C . 2 or the contact
heody4iu4#yttriu4-alu4inu4-garnet F"d#$%&G laser is used.
6he C . 2 laser 4ay e used at ,8 of appro!i4ately 1.5... 7Kc42 at 5. ,,/5
1. 7 a-erage output po)er and ..3 44 spot si1e to incise around the
i4pacted cro)n of the tooth. %s dissection proceeds5 the 4ucosal flap is
ele-ated. 9ucosa )ell healed at 3 )ee0s. Aonded rac0et ready to e used to
start tooth 4o-e4ent. )ith tissue forceps until the underlying cro)n is
identified. %t this point5 the handpiece is 4o-ed a)ay fro4 the tissue to
26
di4inish ,85 therey per4itting dissection of the 4ucosa a)ay fro4 the
cro)n )ithout 4arring.Ihe ena4el surface fro4 inad-ertent laser stri0es
at high ,8. %lternati-ely5 the "d.$%& laser in contact 4ode using a short
scalpel tip at 5 to 1. 7 a-erage output po)er is used to e!cise the gingi-al
cuff. 2apid identification of the cro)n per4its the operator to a-oid
inad-ertently da4aging it y e!cessi-e heating fro4 the scalpel tip.
6here is no leeding.
HEM$N*-OM$S $N# 7$SC+L$2
M$L)O2M$T-ONS-
He4angio4as in the oral ca-ity are 4ost effecti-ely treated )ith the argon
laser y direct application after co4pressing the lesion )ith a glass slide or for
larger lesions y
intralesional introduction of
the lier. Large5higher-flo)
lesions are occasionally
treated )ith the "d#$%&
laser. Ho)e-er5 s4all5
locali1ed5 lo)-flo) lesions
4ay e e!cised )ith the C .
2 laser. % s4all -ascular
4alfor4ation of the laial
2(
sulcus )as e!cised
)ith the C . 2 laser.
*-N*-7$L H/PE2T2OPH/-
Ley ele4ents of laser
techniIue for gingi-oplasty
include the use of a
superpulsed CC# laser )ith the
handpiece at a ,8 of 5.. to
625 7Kc42 y -arying the
spot si1e et)een 2.. and 2.5
44 at 5* pps 6.. 4EKpulse at
an a-erage po)er output of 25
7. % 4atri! and is secured
around the cer-ical 4argin of
the tooth elo) the free
4argin of the gingi-a to
protect the ena4el and ce4entu4 fro4 inJury y the laser ea4. &ingi-a
re4o-ed y each raster is )iped a)ay to re4o-e the caroni1ation prior to
applying additional rasters )ith the laser.
)$C-$L NE7--
:apori1ation techniIue )ith rapid super pulsed F2/,G C . 2 laser )as chosen
to reduce scarring. Laser para4eters# 2/, C . 2 laser F11. 4EKpulseG at 1.*
pps using the 4icroscopic and 4icroslad syste4. 6he laser spot si1e )as 2..
44 at an output po)er of 15 7 and a ,8 of appro!i4ately 45. 7Kc42 . 6he
target site )as anestheti1ed y infiltration of 1N lidocaine local anesthetic. "o
s0in preparation )as perfor4ed . 6)o raster@s )ere ad4inistered under 1.M
4agnification and the surface of the target tissue )as derided )ith a )et
2*
gau1e sponge after the first and second raster. Cne year later there )as only a
faint depression at the treat4ent site and there )as no change in s0in color.
S8-N 2ES+2)$C-N* -N $ESTHET-C S+2*E2/-
/0in )rin0les5 or rhylidcs fro4 e!cessi-e sun e!posure5 particularly those
occurring on and around the lips and eyes5 4ay e reduced y treat4ent )ith
the CCs laser using an auto4ated scanner such as the /il06ouch flash-scanner.
6he )rin0le is treated y alating the area adJacent to the deepest point of the
)rin0le fold )ith the laser set at ( 7 a-erage output po)er in the pulsed 4ode
at ..2-s cycles. 6his per4its assess4ent of the laser effect after co4pletion of
a single cycle Fone co4plete re-olution
of the flash scanner )ithin its target
circleG. %s al)ays5 the target tissue is
re4o-ed )ith a saline 4oistened gau1e
sponge. ,ending the area to e treated5a
second and third pass 4ay e necessary
to penetrate into or through the
papillary der4is. %lternati-ely5 a
Co4puter ,attern &enerator FCoherent
LasersG can e used )ith an ultrapulse
C . 2 laser at 1(5 to 3.. 4EKpulse and an a-erage po)er of et)een 6. and
1.. 7. Aenign cutaneous gro)ths and atrophic scars and pits can e treated
si4ilarly. ,ostoperati-e results are consistently good. C.2 lasers resurfacing
)ith Coherent Oltrapulse 5...C C,& scanner at 225 4l5 6.7. )ith one pass
at 4oderate density o-er lo)er lid and 2-3 passes o-er lateral and infraoritalK
4alar areas.
2+
EP+L-S )-SS+2$T+M-
'pulis fissuratu45 )hich consists of hyperplastic 4ucogingi-al folds fro4
firoepithelial
proliferation
secondary to ill-fitting
dentures5 pre-ents
proper denture seating
on a stale ase. It
responds )ell to laser
e!cision )ith 4ini4al
postoperati-e
disco4fort and
s)elling. In this case5
a defo cused ea4 at
5 to 1. 7 C7 is used
to aid he4ostasis and
pro4ote a dry field.
%lternati-ely5 a pulsed )a-efor4 at 2. 75 ,22 U 5.-2.. pps at 2.. to 3..-
44 spot si1e 4ay e used. 6he e!isting denture is relined )ith soft denture
liner. 6he )ound re-epitheliali1es in aout 3 )ee0s )ith little loss or no loss
of sulcus depth
Lasers in resection of the cancers-
6ransoral resection of
stages I and II oral cancer
is a )ell-accepted
treat4ent 4ethod in
oncologic surgery. 6he
specific surgical techniIue
is less i4portant than is
the sound application of
oncologic principles to
achie-e adeIuate resection
of the tu4or. 6he gold
standard for outco4e is
the result achie-ed y scalpel resection. %ny other techniIue such as
3.
electrosurgery5 cryosurgery5 or laser surgery 4ust produce co4parale or
i4pro-ed cure rates. Cure rates achie-ale )ith the surgical laser 4atch those
attriuted to scalpel or electrosurgery5 and also pro-ide the significant
ad-antages of etter he4ostasis5 less postoperati-e ede4a5 shorter hospital
stay5 di4inished infection rates5 and eli4ination of the need for split-thic0ness
s0in grafting. In
addition5 in theory5 ecause of the laserTs aility to seal s4all lood -essels
and ly4phatics5 there is a reduced li0elihood of inducing tu4or 4icroe4oli
during surgical e!tirpation of the tu4or5 )hich in turn reduces the chances of
QseedingQ the surgical site or the -ascular or the ly4phatic syste4.
Co4pared )ith patients ha-ing stages I and II oral ca-ity tu4ors that )ere
treated y con-entional surgery using transoral resection techniIue5 the laser-
treated cases did not sho) increased local recurrence or regional 4etastases.
6he 4ost i4portant negati-e aspect to consider in e-aluating laser surgery is
)hether the laser ea4 itself 4ight ha-e any tu4or-pro4oting effects that
4ight enhance recurrence or spread to loco-regional or distant sites. Aecause
the ea4 is applied only to clinically nor4al tissue at the resection 4argin and
not on the tu4or itself5 any enhance4ent of spread )ould e e!pected to e a
conseIuence of direct handling of the neoplastic tissue y retraction
instru4ents. 6his eing the case5 one )ould not e!pect to find a di4inished
control rate )ith laser use and5 in fact5 the literature does not support such a
negati-e outco4e in surgical laser treat4ent of hu4an oral 4alignancies
Laser assisted %&%opaatopasty-
6he laser-assisted u-ulopalatoplasty FL%O,G is a surgical techniIue designed
to correct reathing anor4alities during sleep that result in snoring or 4ild to
4oderate ostructi-e sleep apnea syndro4e. 6his is a short operation
perfor4ed in the office using local anesthesia and a surgical laser. 6he
oJecti-e is to reduce pharyngeal air)ay ostruction y reducing tissue
-olu4e in the u-ula5 the -elu45 and the superior part of the posterior
pharyngeal pillars.
contraindications to L%O, are se-ere 4aeroglossia and 4orid oesity )ith
hypopharyngeal ostruction at the tongue ase. In the rare condition of floppy
epiglottis5 L%O, is also not of enefit.
6he C . 2 laser or contact neody4iu4#yttriu4- alu4inu4-garnet F"d#$%&G
laser is preferred to the use of the "d#$%& fier-deli-ered laser in this
procedure ecause of the lo) -olu4e of asorption of the C . 2 laser ea4 or
contact "d#$%& in tissue. 6his property pre-ents e!cessi-e ther4al necrosis
of the target tissue. 6he $%& laser also does not ha-e a ac0stop5 although
31
this prole4 is eli4inated for contact $%& lasers. %n additional ad-antage of
the C . 2 laser is its use as a Qno-touchQ techniIue5 therey eli4inating contact
)ith the palate and pharyngeal )alls. 6his property reduces gagging5
especially for the hypersensiti-e indi-idual )hose gagging occurs on a
psychological asis despite ha-ing adeIuate anesthesia at the surgical site.
L%O, is perfor4ed )ith a free-ea4 CC5 laser )ith a ac0stop. Aea4
guidance is pro-ided y a coa!ial heliu4 neon FHe"eG laser. /tandard C C #
laser safety precautions ha-e to e follo)ed. 6he output po)er is set at 2. to
3. 7 a-erage po)er in a pulsed 4ode5 depending on the thic0ness of tissue
that is to e incised. % specific snoring handpiece is used )ith a -ariale spot
si1e of ..6 to 3.51 44 at a focal length of 3.. 44. 6his handpiece has a
focus-defocus ring# focus to cut. and defocus to coagulate
6his procedure can e done in
/ingle stage procedure
9ultiple stage procedure
Lasers in aryn"ea s%r"ery-
Laryngeal papillo4as are cauliflo)er-li0e lesions caused y infection )ith the
hu4an papillo4a -irus FH,:G. 6his lesion is the 4ost co44on enign
neoplas4of the laryn!. 8uring infancy or adulthood its presenting sy4pto4s
are hoarseness or air)ay ostruction. 6he natural history of this disease is one
32
of 4ultiple recurrences5 especially )ith the Ju-enile onset type co laser
-apori1ation of these lesions5 although the accepted procedure
of choice today5 is thought to e only palliati-e in 4ost cases. 9ultiple
recurrences are thought to e caused y persistent gro)th of H,: in
suclinically infected nor4al-appearing tissue ordering the area of treat4ent.
6he goal of laser -apori1ation is to eradicate this lesion and estalish an
adeIuate air)ay and functional -oice )ithout causing su4ucosal da4age
that 4ay result in -ocal fold scarring and firosis. /i4ultaneous re4o-al of
papillo4as fro4 oth sides of the anterior or posterior co44issure should e
a-oided5 as this 4aneu-er al)ays results in co44issure )e for4ation.
6ypical co laser settings for such a procedure includes using a .2544 spot
si1e at a )or0ing distance of 4.. 445 2- to 3-7 po)er 3 ..5 to 1.. second
pulse duration.
L%2$"&'%L %"8 /OA&LC66IC H'9%"&IC9%/
He4angio4as are unco44on neoplas4s that 4ay occur any)here in the
laryn! and histologically are capillary5 ca-ernous5 or 4i!ed
capillaryKca-ernous lesions. 6hey 4ay present in a pediatric or adult for4D the
pediatric for4 is predo4inantly capillary in nature and the adult for4 4ore
often 4i!ed or ca-ernous. 6he pediatric he4angio4a characteristically
presents shortly after irth5 has a proliferati-e phase that 4ay last up to 1 year
follo)ed y an in-olutional phase occurring fro4 1 to ( years of age. 6hese
lesions often occur suglottically and 4ay progress in si1e5 resulting in air)ay
ostruction.co laser treat4ent 4ay e used safely to re4o-e these lesions
)hile si4ultaneously 4aintaining a patent air)ay and therey a-oiding need
for a tracheoto4y.TT 7ith the use of a suglottoscope and a laser )ith
increased pulse duration settings to allo) for 4ore ther4al diffusion and
etter coagulation of s4all -essels5 capillary he4angio4as 4ay e effecti-ely
treated. 6hese lesions can e 4anaged using a laser )ith a ..25-44 spot
si1e at a 4..-44 focal distance5 2- to 3-7 po)er5 and ..5- to 1..-second pulse
durations. Ca-ernous lesions often present leeding prole4s during re4o-al
that are not effecti-ely controlled using the co laser5 therey reIuiring the use
of other for4s of therapy.
2ein0eTs 'de4a %nd :ocal Fold ,olyps5 &ranulo4a5 3 9alignant "eoplas4s
are the conditions )hich also can e treated y laser therapy.
Laser-%ssisted 6e4poro4andiular Eoint /urgery-
%d-ances in arthroscopic instru4entation and techniIue for s4all Joint
surgery ha-e recently found application in surgery for the te4poro4andiular
Joint F69EG. Coupled )ith the ad-ent of high-resolution 4agnetic resonance
i4aging F92IG the accuracy of diagnosis of 69E disorders has een greatly
enhanced. %rthroscopy of the 69E has conseIuently progressed fro4 an
instru4ent of diagnosis to one of treat4ent. %s its usefulness for the treat4ent
33
of internal derange4ents5 particularly nonreducing dis0 displace4ent Fclosed
loc0G5 has eco4e generally accepted5 the search for i4pro-ed instru4entation
has resulted in the de-elop4ent of -arious laser syste4s for 69E surgery
6he Ho#$%& laser
4
configured for arthroscopic surgery consists of a free-
ea4 laser )ith a sterile fier-optic deli-ery syste4 and the appropriately
adapted arthroscope and -ideo syste4. Aecause the Ho#$%& e4ission is
highly asored y )ater )ith an a-erage depth of asorption of ..3 44. It
re4o-es tissue precisely. Aecause the target tissueitself has a high )ater
content and the laser operates )ithin ////a fluid 4ediu45 there is -ery little
un)anted ther4al da4age lateral to the -apori1ation crater. "e-ertheless5
e-en )ith 4ini4al un)anted heat effects the actual ther4al inJury 4ay -ary
fro4 ..1 to 1.. 44 depending on tissue type and the e!posure para4eters of
the indi-idual laser. 6arroQ 4easured tissue necrosis )ith Ho#$%& and found
it to e ..4 to ..6 445 )hereas electrocautery produced necrosis of ..( to 1.*
44. In addition to the ther4al effects the short pulse )idth of 35. ps
associated )ith high fluence rates 4ay also induce photo4echanical and
photoacoustic effects that also contriute to tissue alation.
Co44ercially a-ailale lo) output Ho#$%& lasers
*
are Iuite adaptale for
69E arthroscopic surgery. /e-eral fier deli-ery 4ethods are a-ailale. 6he
specific styles and specifications -ary a4ong 4anufacturers. It is rare to
reIuire an output po)er in e!cess of 1. 7 or a post-repetition rate F,22G
e!ceeding 1. H1 to resect firocartilage or recontour one. Lo)er settings are
suggested for 4a0ing releasing incisions.
5iostim%ation and Photodynamic Therapy:
,hotodyna4ic therapy is an e!peri4ental cancer treat4ent that is
ased on a cytoto!ic photoche4ical reaction. 6his reaction reIuires 4olecular
o!ygen5 the photoacti-e drug dihe4atoporphyrin ether5 a he4atophorphyrin
deri-ati-e and intense light5 )hich is typically deli-ered y a laser.
8ihe4atoporphyrin )hich is relati-ely retained in 4alignant tissue after
se-eral days5 is gi-en intra-enously to a patient. Laser light at a )a-elength
corresponding to the asorption pea0 of the drug is used to acti-ate the drug to
an e!cited state. 6he drug then reacts )ith 4olecular o!ygen to produce
singlet o!ygen5 a highly reacti-e free radical )hich ulti4ately leads to tissue
necrosis.
Laser Ha9ards and Laser Safety:
6he suJect of dental laser safety is road in scope5 including not only
an a)areness of the potential ris0s and ha1ards related to ho) lasers are used5
34
ut also a recognition of e!isting standards of care and a thorough
understanding of safety control 4easures.
Laser Ha9ard Cass for accordin" to $NS- and OSH$ Standards:
Cass - - Lo) po)ered lasers that are safe to -ie)
Cass --a - Lo) po)ered -isile lasers that are ha1ards only )hen
-ie)ed directly for longer than 1... sec.
Cass -- - Lo) po)ered -isile lasers that are ha1ardous )hen -ie)ed
for longer than ..25 sec.
Cass ---a - 9ediu4 po)ered lasers or syste4s that are nor4ally not
ha1ardous if -ie)ed for less than ..25 sec )ithout 4agnifying
optics.
Cass ---b - 9ediu4 po)ered lasers F..5) 4a!G that can e ha1ardous if
-ie)ed directly.
Cass -7 - High po)ered lasers FR..57G that produce ocular5 s0in and
fire ha1ards.
35
The types of ha9ards can be "ro%ped as foo(s:
1. Ccular inJury
2. 6issue da4age
3. 2espiratory ha1ards
4. Fire and e!plosion
5. 'lectrical shoc0
1' Oc%ar -n:%ry:
,otential inJury to the eye can occur either y direct e4ission fro4 the
laser or y reflection fro4 a specular F4irror li0eG surface or high polished5
con-e! cur-atured instru4ents. 8a4age can 4anifested as inJury to sclera5
cornea5 retina and aIueous hu4or and also as cataract for4ation. 6he use of
caroni1ed and non-reflecti-e instru4ents has een reco44ended.
2' Tiss%e Ha9ards:
Laser induced da4age to s0in and others non target tissues can result
fro4 the ther4al interaction of radiant energy )ith tissue proteins.
6e4perature ele-ation of 21SC ao-e nor4al ody te4p F3(SCG can produce
cell destruction y denaturation of cellular en1y4es and structural proteins.
6issue da4age can also occur due to cu4ulati-e effects of radiant e!posure.
%lthough there ha-e een no reports of laser induced caroinogenesis to date5
the potential for 4utagenic changes5 possily y the direct alteration of
cellular 8"% through reathing of 4olecular onds5 has een Iuestioned.
6he ter4s photodisruption and photoplas4olysis ha-e een applied to
descrie these type of tissue da4age.
3' 2espiratory:
%nother class of ha1ards in-ol-es the potential inhalation of airorne
ioha1ardous 4aterials that 4ay e released as a result of the surgical
application of lasers. 6o!ic gases and che4ical used in lasers are also
responsile to so4e e!tent.
8uring alation or incision of oral soft tissue5 cellular products are
-apori1ed due to the rapid heating of the liIuid co4ponent in the tissue. In the
36
process5 e!tre4ely s4all frag4ents of caroni1ed5 partially caroni1ed5 and
relati-ely intact tissue ele4ents are -iolently proJected into the area5 creating
airorne conta4inants that are oser-ed clinically as s4o0e or )hat is
co44only called the ?laser plu4e@. /tandard surgical 4as0s are ale to filter
out particles do)n to 5 4 in si1e. ,article fro4 laser plu4e ho)e-er 4ay e
as s4all as ..3 4 in dia4eters. 6herefore5 e-acuation of laser plu4e is
al)ays indicated.
;' )ire and E!posion
Fla44ale solids5 liIuids and gases used )ithin the clinical setting can
e easily ignited if e!posed to the laser ea4. 6he use of fla4e-resistant
4aterials and other precautions therefore is reco44ended.
Fla44ale 4aterials found in dental treat4ent areas.
Soids Li<%ids *ases
Clothing
,aper products
,lastics
7a!es and resins
'thanol
%cetone
9ethyl4ethacrylate
/ol-ents
C!ygen
"itrous o!ide
&eneral anesthetics
%ro4atic -apors
.' Eectrica Ha9ards:
6hese can e#
- 'lectrical shoc0 ha1ards
- 'lectrical fire or e!plosion ha1ards
S%mmary of aser safey contro meas%res recommended by $NS-
En"ineerin" contros:
- ,rotecti-e housing
- Interloc0s
- Aea4 enclosures
- /hutters
- /er-ice panels
3(
- 'Iuip4ent tales
- 7arning syste4s
- Ley s)itch
$dministrati&e contros:
- Laser safety officer
- /tandard operating procedures
- Cutput li4itations
- 6raining and education
- 9edical sur-eillance
Persona protecti&e e<%ipment:
- 'ye )ear
- Clothing
- /creens and curtains
Specia contros:
- Fire and e!plosion
- 2epair and 4aintenance
Conc%sion:
Laser has eco4e a ray of hope in dentistry. 7hen used efficaciously
and ethically5 lasers are an e!ceptional 4odality of treat4ent for 4any clinical
conditions that dentists treat on daily asis. Aut laser has ne-er een the
<4agic )and> that 4any people ha-e hoped for. It has got its o)n li4itations.
Ho)e-er5 the futures of 4a!illofacial surgery )ith the laser is right )ith
so4e of the ne)est ongoing researches.
3*
2E)E2ENCES-
1. Chrysi0opoulos5 Laser assisted oral 3 4a!illofacial surgery for the patients
on the anticoagulant therapy in daily practice5 E Cral Laser applications
6F2..6G no 2.
2. 8ent Clin "orth %4 2... octD 44F4G# *51-(3
3.8esiate %5 Cantore /5 6ullo 85 ,rofeta &5 &rassi Fr5 Aallini %. +*. n4 diode
lasers in oral and facial practice# current state of the science and art5 .Int J Med
Sci 2..+D 6:358-364.
4. Hendler AH. Ciatcno E. 9ooar ,. et al. Hol4iuin#$%& laser arthroscopy of
the te4poro4andiular Joint. J Oral Ma!llo"a# S$r% 1++2#5.#+31-+34.
5. E.Can1ona5 Caron-di-o!ide laser in oral 3 4a!illofacial surgery EC9/.-ol
4(5 issue *5 pg 52-54.
6.E Ishii L FuJita 5 6 Lo4ori 5 Laser surgery as a treat4ent for oral leu0opla0ia.
Cral oncology5:olu4e 3+5 Issue *5 ,ages (5+-(6+ F8ece4er 2..3G
(. Eunnosu0e Ishii5 Lunio FuJita5 /achi0o 9une4oto5 6a0ahide Lo4ori.
Eournal of Clinical Laser 9edicine 3 /urgery. Feruary 2..45 22F1G# 2(-33
*. Loslin 9&. 9artin EC. 6he use of the hol4iu4 laser for
te4poro4andiular
Joint arthroscopic surgery. J Oral Ma!llo"a# S$r% 1++3#51#122-123
+. Laser artifacts 3 diagnostic iopsy . Cral /urg Cral 4ed Cral path Cral
radiol 3 'ndond -ol *35issue65pg 63+-64..
1.. Le)is clay4an5 ,aul Luo5 6e!t oo0 on Lasers in 4a!illofacial surgery 3
dentistry.
11. Cral 3 9a!illofacial surgery clinics -ol.165 issue 25 9ay 2..45 pg no 143-
3.*
12. 2oodenurg EL. ,anders %L. :er4ey %. Caron dio!ide laser surgery of
oral leu0opla0ia. Oral S$r% Oral Med Oral Pathol 1++1#(1#6(.-6(4.
3+
13. /hinichi 6a0euchi5 'ffect of the caron-di-o!ide laser -apourisation on
oral precancerous lesions-pro4ptional effects for 4alignant transfor4ation.
%sian E Cral 9a!illofac /urg 2..5D1(#21(-222
.
4.