Lasers Role in Implant Dentistry: An Exclusive Interview
Lasers and Dental Implants: An Interview with Dr. Robert J. Miller
Introduction
Dr. Robert J. Miller is a graduate of the New York University College of Dentistry and completed a general practice residency at Flushing Hospital and Medical Center. Prior to attending dental school, Dr. Miller earned Bachelor of Arts and Master of Arts degrees in biology. He is a board certified Diplomate of the American Board of Oral Implantology/Implant Dentistry and is in private practice in Delray Beach at The Center for Advanced Aesthetic and Implant Dentistry. Dr. Miller serves as chairman of the Department of Oral Implantology at the Atlantic Coast Dental Research Clinic in Palm Beach, Florida. You can find out more about Dr. Miller at: http://www.robertmillerdds.com/
Interview
Osseonews: Dr. Miller, do you believe that lasers have a place in implant dentistry?
Dr. Miller: If we compare the use of lasers to the traditional surgical approach using “cold surgical steelâ€, lasers clearly are the better choice. Using a laser to perform implant surgery enables us to prepare the implant site with minimal trauma to the hard and soft tissue. In fact, I would more properly characterize this approach to surgery as atraumatic.
Osseonews: Could you explain that a little further.
Dr. Miller: With a laser, I can target the tissue to be removed. I will not disrupt or damage the surrounding tissue. The removal of both soft and hard tissue is precise and minimally invasive. You cannot achieve the same results with a scalpel blade.
Osseonews: Do you use a surgical guide stent to guide your laser?
Dr. Miller: The patient gets a Cone Beam Volumetric Tomograhic scan. I use this to generate a highly accurate surgical stent to precisely guide the laser beam. This procedure is accurate to one tenth of a millimemter (0.10 mm). This is minimally invasive dentistry at its best.
Osseonews: How does the surgerized tissue respond?
Dr. Miller: Another great benefit of laser surgery is that it completely re-engineers the wound healing process. We ablate only the target tissue. We do not unnecessarily damage adjacent tissue. This reduces the complications of wound healing. Laser surgery dramatically reduces or eliminates the inflammatory response. It also promotes the release of enzymatic inhibitors of the inflammatory process. Lasers have bactericidal properties which virtually eliminate the problems of infection. Finally it stimulates the healing of hard and soft tissue. The end result of this type of surgery is stellar wound healing. There is nothing else in this league.
Osseonews: What is the potential for complications?
Dr. Miller: Every surgical modality has the potential for complications. But with this kind of laser surgery, complications are minimal because we target specific tissue and sites with great accuracy.
For example, suppose I am doing an osteoplasty around the cervical area of a tooth. If I inadvertantly point the laser at the tooth, I may affect the root surface. I prevent this by carefully directing the laser energy. As in the use of a high speed handpiece, if you point the laser at non-target tissue, you will direct laser energy where you do not want it to go. With careful planning and judicious use, this just does not happen.
Osseonews: What types of lasers do you use?
Dr. Miller: I currently use three lasers:
- 810 nm Diode Laser
- 940 nm Diode Laser
- 2780nm Er,Cr;YSGG laser [Erbium,Chromium;Yttrium,Scandium,Gallium,Garnet]
The Er,Cr:YSGG laser (Biolase Technologies) cuts hard and soft tissue. It primarily targets tissue that contains water or hydroxyapatite. You can use this for many purposes including soft/hard tissue surgery, preparing teeth for restorations, endodontics, and treatment of periodontal pockets. This accounts for about 80% of the market share for high level lasers.
Diode lasers target pigmented tissue or tissue containing hemoglobin or oxyhemoglobin. It has little effect on hard tissue. The 940 nm Diode laser cuts soft tissue like a scalpel blade and can be used without an anaesthetic. The 810 nm Diode laser is also a soft tissue laser and can be used to biostimulate soft and hard tissue. In published studies, laser treated osteotomies heal more quickly and demonstrate a greater percentage of bone to implant contact.
Osseonews: Dr. Miller, can you give us an idea of some of the more important uses of lasers in dentistry?
Dr. Miller: My pleasure to do so. I hope that I can give your readers some idea of how useful lasers are in many areas of dentistry.
- Uncovering implants in Stage II surgery. This procedure is atraumatic and helps to prevent crestal bone remodeling
- Recontouring gingival tissue and sculpting emergence profile for prosthetic components
- Raising surgical flaps
- Osseous recontouring
- Creating parabolic tissue architecture. This can be done pre-operatively or post-operatively after implant placement
- Bone harvesting for block grafts
- Lateral wall sinus graft windows
- Ridge splitting for expansion
- Distraction osteogenesis
- Debriding extraction sites for immediate implant placement. Since laser surgery is bactericidal, infected implant sites can be relieved of pathogenic bacterial load and apical granulomas
- Ablating diseased junctional epithelium
- Biostimulation for soft and hard tissue healing
- Removing calculus and plaque from implant surfaces without damaging the implant fixture or components.
- Treatment of peri-implantitis
Osseonews: Can the laser be used to remove failing implants?
Dr. Miller: This is a very important use for lasers. In cases like this we want to remove the implant with minimal damage to the adjacent soft and hard tissues. This is far better than using the traditional approach of trephining the implant body.
It is important to note that the laser approach will be atraumatic. We will not damage the adjacent bone or soft tissue. We will not overheat the surrounding bone which would cause problems postoperatively. The site will not be contaminated with titanium fragments or filings because we are not going to cut the implant or grind it. The laser energy has bactericidal properties which will eliminate pathogenic bacteria from the site. After removing the implant and debriding the site, we can stimulate the healing of the soft and hard tissues. The laser confers ultimate control of the operating field which is critical in cases like this.
Osseonews: What is the best source of training in laser dentistry?
Dr. Miller: I recommend the World Clinical Laser Institute (WCLI) at http://www.learnlasers.com/. This is the largest laser training institute in the United States. I would also recommend the Academy of Laser Dentistry at http://www.laserdentistry.org/. It is important that you learn how to use the laser before you start using it in clinical practice. These both offer excellent training programs.
In Europe I recommend the International Society for Oral Laser Applications http://www.sola-int.org/. I am a member of the SOLA Executive Board.
OsseoNews: Dr. Miller, thanks for your time.
Interview conducted by:
Gary J. Kaplowitz, DDS, MA, M Ed, ABGD
Editor-in-Chief, www.osseonews.com
34 Comments on Lasers Role in Implant Dentistry: An Exclusive Interview
New comments are currently closed for this post.
Javier Higuera
7/31/2007
I use lasers since 1999. I use Er:YAG for hard tissues and Surgical Diode for soft tissues.
I ussually make the incission with the Diode Laser without flap, no pain, no infection and atraumatic.
I also use a Therapeutic Laser after implant surgery to minimize postoperative pain and stimulate osseointegration
The future of dentistry is in Lasers.
Best Regards to everyone at Osseonews!
Johndds
7/31/2007
I am a Periolase owner. I can't say it has been good for my implant side of my practice since we now are helpng people keep their teeth. I have posted some X-rays of 3 of my cases here. These are just X-rays but the Perio Probings are even more incredible :-)
http://ddsgadget.com/implantcases/?cat=79
I LOVE the Periolase :-)
Dr. Mehdi Jafari
8/2/2007
Titanium as a metal exhibits reflectivity to incident light energy. With regard to the wavelengths of current lasers, the reflectivity is lowest in the range 780-900 nm, rising as the wavelength increases towards 10,600 nm (Rechmann P, Sadegh H, Goldin D, Hennig T. Surface morphology of implants after laser irradiation. Dtsch Zahnärztl Z 2000; 55: 371–376).This would suggest that shorter wavelengths are most damaging, as the low reflectivity would allow greater heat effects to build up. However, there is evidence to suggest that the diode wavelength group delivered in low power CW values (1-2 Watts average power), cause minimal damage to the implant or surrounding bone. This is explained by the fact that the Nd: YAG, Er,Cr:YSGG and Er:YAG emission modes (FRP), result in high peak power values and heat production more than several hundred degrees Celsius. Laser use in implantology has been historically controversial. Whilst there is a general acceptance that lasers are capable of accurate cutting of materials and tissue, there is no evidence-based advocacy as to the use of any laser wavelength in producing a fully-prepared osteotomy site for the placement of root-form dental implants. However, there are some reports of the use of erbium YAG and erbium YSGG lasers to establish a controlled incision of overlying gingival tissue and to initiate a breach of the cortical bone plate, prior to the use of conventional implant drills. Such techniques, although intrinsically correctly based on predictable laser-tissue interaction, run the risk of skepticism amongst practitioners more allied to a conventional surgical approach to implant placement. With all other predisposing factors addressed, the fundamental key to success in implant surgery is the apposition of normal healing bone onto the implant surface. While using a laser beam around an implant, demands a technique whereby the local temperature does not exceed 47 degrees centigrade, which is clinically hard to prove. Any therapeutic use of lasers in implant dentistry must address this fact that the prime interaction in laser use results in the conversion of incident electromagnetic energy into heat energy. As far as the clinician is concerned, the possibility of implant surface damage arising from incident laser light must be avoided by any means, and the soft and hard tissues around it as well.
Bret Dyer
8/8/2007
Dr. Miller I enjoyed your interview. On the question of erbium lasers creating thermal damage on implants and the adjacent tissue, that has been evaluated. A pubmed search will reveal articles by Schwarz, Matsuyama, and others that demonstrate in vitro that erbium lasers create a biocompatable surface on implants for fibroblasts and osteoblast. In vivo studies have also demonstrated no thermal effect to the implant or the adjacent tissues. Rather any solid instrument contaminates and alters the implant surface negatively. Chemical treatments have not been shown to create predictable debridement or biocompatibility. To date, the most effective and the safest way to treat an ailing/failing implant is with an erbium laser. Dr. Miller's study demonstrated that laser exposure of implants before restoration prevents future bone loss around the neck of the implant. Contouring the sulcus around an implant before final seating of the abutment and restoration prevents pressure necrosis and preserves the papillae.
Indeed using conventional drills creates a concern for temperature rising in the bone during implantation. Using a drill or disk for bony expansion procedures is much more likely to damage adjacent cortical bone than a laser incision through bone. This has also been shown in the literature (look up Kimura, Wang, and a host of others).
I would be concerned about creating an osteotomy with a laser. Not from a thermal standpoint. More from a precision point of view.
Robert J. Miller
8/8/2007
In a recent published study, I compared the traditional chemotherapeutic modality of treating the ailing implant to laser debridement ("Treatment of the Contaminated Implant Surface Using the Er,Cr;YSGG Laser", Implant Dentistry 2004;4,165-170. Erbium based lasers are demonstrably superior to citric acid as proposed by Roland Meffert for the past decade. We have shown that the Er,Cr laser can be safely used directly on the implant surface, and has the capability to remove any adherent material, including appositional plasma sprayed surfaces because of its high absorption spectrum in HA. In other studies, including one presented at the recent SOLA conference in Belgium, researchers at the University of Vienna (Beer, Schoop, Moritz), showed that erbium lasers actually DECREASE the temperature of the surface of the implant over time. On the other hand, Nd;YAG is contraindicated on the implant surface because of its high thermal coefficient - it melts the implant surface and can fuse cover screws. Reflectivity is NOT a valid measure of temperature coefficient, but rather the pulse mode and wave shape of the laser energy.
With regard to preparation of the osteotomy, in thin ridges, where drills may fracture thin facial plates, the laser is an ideal modality for protecting thin boney plates and preparing them for implant placement or further expansion with chisels/osteotomes.
DR Stewart Rosenberg
8/9/2007
I read with interest the excellent interview with Dr. Robert Miller and was about to comment last night when we had a power outage. I was pleasantly surprised this morning to see the posts by Dr. Dyer and Miller describing the literature relating to the use or Erbium lasers in implantology that I was about to quote. So I now I need only say that I agree with Dr. Miller's and Dyer's discussions completely. As a pioneer in the use of dental lasers going back to 1985 I have . after using every wavelength available settled on the Er,Cr:YSGG laser as my laser of choice coupled with a diode for biostimulation to yield dramatically faster healing and lack of post operative sequela. Having read Dr.Miller's article on treating failing implants in 2004 I have been using the technique described with remarkable success to save implants I believe would have been lost using any other technique. The Er,Cr:YSGG has been demonstrated in the literature to actually dercrease pulpal temperature by 2 degrees when used for cavity preparations and anecdotally in numerous incidences in our practice over the last few years I have seen only positive results clinically on implants. That would not be the case with "hot" cutting lasers such as CO2, Nd:YAG, Argon. or diodes in a cutting mode.
I have also witnessed personally Dr. Norberto Berna, of Rome, Italy, perform a complete osteotomy and immediate implant placement using an Er,Cr:YSGG laser and a series of patented jigs or guides . And he did it without local anesthesia!!!!
The laser is also wonderful as a laser ostoetome to aid in the atraumatic extraction of anterior teeth prior to implant placement to avoid fracture of the thin buccal plate of bone. I have several case studies using this technique soon to be published.
In closing I applaud Dr. Miller for his innovations in the use of lasers in implantology. HIs efforts have made it much easier, more predictable, and far less uncomfortable to achieve excellence in our implant cases.
johndds
8/9/2007
DR Stewart Rosenberg Said
That would not be the case with “hot†cutting lasers such as CO2, Nd:YAG, Argon. or diodes in a cutting mode.
Even though the Periolase is an Nd:Yag it has a duty cycle of .2% that means that it is off for over 99.8% of the time. This allows the tissue to relax and cool. Periolase owners have found the LANAP protocol helps with peri implantitis.
Robert J. Miller
8/9/2007
Dr. Rosenberg correctly states that in "cutting mode", the Nd:YAG, CO2, Argon and diode lasers are, in fact, high thermal coefficient lasers. This supports my thesis that it is pulse and wave form that determines the thermal coefficient of laser energy, not wavelength. As we become more astute with regard to laser interaction with both hard and soft tissue, we will be able to titrate the affect of targeted monchromatic energy. The body of knowledge with regard to lasers in dentistry and medicine is now 40 years old. Our ability to target specific tissue and to biomodulate metabolic processes has finally matched our enthusiasm in the use of this modality. Control of periodontal disease, true bacteriocidal kill, biostimulation, non-surgical pocket reduction, and a host of parallel procedures will help us to rewrite the textbooks on treatment of dental disease. We meet the requirements for both evidence-based and minimally invasive dental treatment. If you have not yet attended a laser program, it's time to give this modality serious consideration. RJM
Horneman
8/12/2007
I wonder or dr Miller does his whole implantbedpreparation with the laser or just the pilot drilling?. I use the er-yag laser only for pilotdriling, but I like to know in which way you can do the whole preparation with the laser. Is the trick in the template you've let fabricated. I also use the diode laser for cutting the gingiva. They advise me to use a hot tip, because the laserenergy wouldn't travel to deep into the surrounding tissues due to de carbonisation. But most of the clients feel pain ( as a result of the carbonisation) and I have to use anesthetics. I use the diode laser in a continuous wave setting. Is it better not to use a hot tip and use a chopping setting?
T. Horneman
Dr. Mehdi Jafari
8/12/2007
A group of investigators studied the application of Erbium: YAG lasers for second-stage implant surgery. Twenty patients were studied with a total of 50 implants in which osseointegration was complete. The subjects were divided into two groups: a control group (10 patients with 25 implants), subjected to conventional second stage surgery; and a group of 10 subjects (also with 25 implants) treated with the Er: YAG lasers at second stage implant surgery. The use of Er: YAG lasers obviated the need for local anesthesia and minimized postoperative pain and time needed before starting the second stage. With regard to surgical duration, quality of hemostasis, and success in implant treatment, NO DIFFERENCES were reported. In the second stage of implant surgery, different types of laser have been used, taking advantage of their bactericidal effect; disadvantages arise from inducing damage to the implant surface and adverse thermal effects. They concluded that advantages afforded by laser treatment include technical simplicity, the possibility of obviating local anesthesia, absence of postoperative pain and edema, and complete tissue healing, thus facilitating faster prosthetic rehabilitation, but they insisted that the described technique can be used in all cases EXCEPT situations where esthetic considerations prevail in anterior areas, or in the event of a lack of keratinized gingiva surrounding the implant. (Josep Arnabat-DomÃnguez, et al. INT J ORAL MAXILLOFAC IMPLANTS 2003; 18:104–112).
Dr. Mehdi Jafari
8/13/2007
The application of high-energy lasers in dentistry requires special consideration of potential risks of inadvertent tissue and material damage. With regard to the treatment of periimplantitis, the risks relate to possible implant surface alterations and excessive heat generation in the peri-implant bone. The diode laser is the only laser type which, irrespective of the power density, does not adversely influence structural implant surface characteristics (Kreisler, Me t al. (2001) Effect of the Nd: YAG, Ho: YAG, Er: YAG, CO2 and Ga Al As laser irradiation on surface properties of endosseous dental implants. Medical Laser Applications 16: 152). This is not a result of its specific wavelength, as the reflection capacity of titanium for light of 800 nm is even lower than for light of 1064 nm (Nd:YAG), 2100 nm (Ho:YAG), 2940 nm (Er:YAG), and 10 600 nm (CO2), leading to higher energy absorption (Rechmann, P et al. (2000) Zur Oberflächenmorphologie von Implantaten nach Laserbestrahlung. Deutsche Zahnärztliche Zeitschrift 55: 371–376). Pulsed lasers (YAG and CO2 lasers) with considerable energy peaks are capable of generating power densities higher than 106 W/cm2, inducing plasma formation (so-called photoplsmolysis phenomenon) and alteration of light reflection in the superficial layers of metals (0.1–1.0 μm). These extremely high temperatures reached during this process, however, are, to a large extent, restricted to the area of laser–metal interaction. A slow but steady warming of the metal body can be observed and considerable temperature elevations can be recorded even in remote parts of the object. Regarding the biological effects of excessive heat generation, it must be taken into consideration that this process might impair wound healing. Moreover, possible laser effects on implant surfaces with regard to bacterial re-colonization and new cellular attachment require further research.It is feasible that, similar to the influence of different sterilization processes, lasing titanium or hydroxyapatite surfaces might affect new adhesion of periimplantitis-relevant pathogens.
Robert J. Miller
8/13/2007
To Dr. Horneman: We will occasionally use the Er,Cr laser to perform our complete osteotomies in D4 bone to prevent microfracturing of the thin trebeculae. Most of the time, however, we use it to start the ostetomies, preserve the facial plates by doing a "D" shaped preparation with the flat towards the facial and then expanding the ridge. With regard to your diode laser, the reason your patients need anaesthetic is that you are using it in continuous wave mode. With the proper pulsed mode, you will get thermal relaxation, excellent cutting, hemostasis, and a lack of carbonization which allows you to travel deeper in the tissue. Also, the selection of diode wavelength (810, 940, 980nm) will also make a difference with regard to hemoglobin and oxyhemoglobin containing tissues. We use a 940nm for cutting and 810nm for photobiomodulation.
Robert J. Miller
8/13/2007
I am familiar with the studies you quote. Dr. Arnabat is a close personal friend of mine and I was present when he presented his paper on 2nd stage uncovering of implants using lasers. However, the conclusion he reached was flawed. This is because in all cases they ablated the healed attachment apparatus around the necks of the implants. This causes apical reattachment of the junctional epithelium which results in a violation of biological width and resultant crestal bone remodeling. When he looked at our studies and modified his technique to avoid traumatizing the mature hemi-desmosomal attachment, he had BETTER results using the laser. He now lectures on using our technique and is publishing his new study.
With regard to using lasers in the aesthetic zone, it is demonstrably superior to traditional surgical techniques. This is because we dramatically reduce or eliminate the inflammatory response. This prevents the production of matrix-metalloproteanases (collagenase, gelastase, elastase, protease) which break down soft tissue, cause edema/erythema, and have an osteopromotive effect on osteoclasts. Lasers will remove tissue fragments/smear layer, have bacteriocidal properties, and have a biological stimulatory affect of hard/soft tissue (photobiomodulation) which comes from the orthopaedic literature.
With regard to peri-implantitis treatment, a high thermal coefficient is not necessarily bad. The first published reports were using a CO2 laser. The high spot energy actually causes a deepening of the titanium oxide layer which, when used in invitro studies, actually increases the wettability of the implant surface, a good thing when trying to "reintegrate" an implant. When an implant surface is "surgically clean", it offers the best interface for bone regrowth. You MUST graft these sites or you will get soft tissue reattachment rather than reintegration. You recreate the "ailing" implant which, if a pathologic process reoccurs, quickly progresses to a "failing" implant. And last, none of the studies you quote include the Er,Cr:YSGG laser. At 2780nm, it is the best combination of power, hertz rate, pulse form, and tip selection for both hard and soft tissue surgery. 80% of the world market for dental lasers after 20 years speaks for itself.
Salam
4/30/2017
When he looked at our studies and modified his technique to avoid traumatizing the mature hemi-desmosomal attachment, he had BETTER results using the laser
Dear Dr Miller
Can you kindly send me a link to your published articles on this topic ,i would like to learn the key technique for using laser in second stage implant uncoverage in esthetic zone
Thanks for your reply
Jason Luchtefeld, DMD
8/14/2007
what were the parameters of Nd:YAG when used to fuse the implant?
thanks.
Robert J. Miller
8/14/2007
The original Nd:YAG studies were done in a continuous wave mode. While this is fine for soft tissue ablation, it has an extremely high thermal coefficient on the implant surface and can fuse cover screws to the implant body (Roland Meffert, WCOI, 2003). Fortunately, the new ND:YAGs have a pulsed mode as well. At the SOLA conference in Bruges, Belgium last year, a paper was presented on using the Nd:YAG for 2nd stage implant recovery. LOW power and pulsed mode to mitigate the thermal effects on the cover screw.
Higuera Javier
8/14/2007
Dr. Miller, I use Diode Laser for 2nd stage implant recovery. It's amazing the way gingival tissue is vaporized without bleeding and without retraction. I have many documentated cases and I have made several experiences which I will publish very soon.
Robert J. Miller
8/16/2007
I refer you to the studies by Dr. Norberto Berna in Rome, Italy. He has patented a cad milled device containing rings of varying dimensions that act as a guide for the laser tip. An appropriate tip length is selected and the tip follows the concentric outline of the ring to depth. It must be noted, however, that laser prepared osteotomies are NOT as accurate as drill prepared. However, laser osteotomies contain no smear layer, so the catabolic phase of bone, mitigated by bone fragments, is less pronounced. It will help to prevent fracture of thin ridges and, as published in the literature (G Romanos, et al), there will be greater bone to implant contact in laser prepared osteotomies.
johndds
8/19/2007
Dr. Miller
I was thoroughly impressed with your lecture at the WCMID. Nice photography. :-)
Lance
9/6/2007
I am concerned with your discussion of treatment of ailing/failing implants. Are you referring to old cylindrical implant types? Hopefully you are not talking about perimplantitis around screw type implants. If so, there is a problem with the implant installation technique,possibly over heating the bone or altering the implant surface. Periimplantitis is really a thing of the past and was related to rough surface bullet shaped implants. This is why they are off the market.
Robert J. Miller
9/8/2007
Virtually all of the peri-implantitis treatment we have performed over the last few years using lasers has been on endosseous screws. The biologic process that leads to the ailing/failing implant can occur regardless of the architecture and surface type. How often do you see several millimeters of crestal bone remodeling around healed implants? This attachment of soft tissue to the roughened body predisposes the implant to further breakdown well after healing. We are starting to see the first big waves of failure of implants 5-7 years after full loading and function. The idea that peri-implantitis is a thing of the past is an absurd notion. For those of us who have been placing implants for an extended period of time, we are starting to see our late failures of our cases. These cases, in the earlier stages, can be ideal candidates for repair. Not addressing this slow,steady progression of bone loss is to considered as supervised neglect.
Robert J. Miller
9/23/2007
Just returned from the International Society for Oral Laser Applications (SOLA) in Great Britain. Our colleagues from the University of Vienna (Moritz, Beer, Schoop) presented a study that definitively shows that lasers are now the number one indication for treatment of peri-implantitis. Their controlled studies and ESEM's are beautifully done and there should be no doubt that ablative laser techniques are demonstrably better than all previous modalities in surgically debriding the implant surface in preparation for grafting.
drs. T
11/11/2007
I thank you for the explanation for the diode 810 nm. I have also an er-yag laser and I am stimulated by your interview to use this for rigde splitting,etc. Till now I just used it to decontaminate implants in case o peri-implantitis, removing third molars and resection of the roottips, with very good woundhealing in even infectiious sites. This is another wellcome treatment modality. In my country lasers aren't much of a choice in treatments, but I love to use them.
Robert J. Miller
11/11/2007
Just returned from the World Clinical Laser Institute conference in London. Outstanding lectures on the use of both Erbium and Diode lasers in endodontics. The 2780nm laser is used to remove the smear layer following instrumentation using their photoacoustic properties, and the 810-980 diodes kill pathogens at depth in hard to obturate accessory canals, including the most hardy ent. faecalis. The indications for surgery, periodontal therapy, restorative, and endodontic disciplines just keeps growing. Time for clinicians to give this modality a very serious look. Over 2500 peer-reviewed publications to date on PubMed.
ElieVictor
11/15/2007
To Dr Robert Miller,
what about the use of laser beam to remove the gingival hyperpigmentations ?
drs. T
11/18/2007
With lasers you can remove the hyperpigmentations. The diodelasers particular react very good withe melanine, but with the correct settings you can use other lasers as well
Robert J. Miller
11/20/2007
I refer you to a the work by Dr. Gizem Berk of Ankara, Turkey. In a published study, the Er,Cr;YSGG laser is used for depigmentation without the need for anaesthesia. You may also use diode lasers, as they have high absorption in pigmented tissue. Be prepared to use anesthesia as they have a relatively high thermal coefficient. You must remove the melanocyte containing epithelial zone or repigmentation may occur. Once this zone has been completely ablated, depigmentaton is permanent. RJM
dr T
11/22/2007
What about post-operative pain? Is the erbiumlaser in this case better then the diodelaser? I agree with RJM in the use of anesthetics when you use a diodelaser, because this is a thermal laser and not a waterlaser where all the energy will beabsorbed by water. In my experience the diodelaser is more ease, because it targets the right cell-line and in the case of ther erbiumlaser you rmeove as much tissue as needed till you remove the right layer of cells. So with the use of the diodelaser I hope I target the right cells more then the other cells. What is you Idea about this?
Dr. Mehdi Jafari
11/23/2007
Excision of benign or atypical pigmentations can leave noticeable scars in cosmetically sensitive and even other sites and a patchwork of evidence in some patients. Both congenital and acquired melanocytic hyperactivities or pigmentations have been treated with argon, ruby, alexandrite, Nd: YAG and very seldom, diode lasers, although the latter remains controversial. The long-term effects of laser irradiation on melanocytes is unknown, as is laser ‘debulking’ of congenital melanocytic naevi (CMN) in relation to the risk of malignant melanoma. Even after multiple treatments of them, most lesions show repigmentation. Subsequent excision for histological examination, frequenyly shows fibrosis and a decrease in melanocytes.Introral pigmentations may be intrepithelial and/or within the Lamina Propria. As with postinflammatory hyperpigmentation, laser therapy is unpredictable and may darken lesions.While using lasers on melanin pigmented oral lesions (especially the heat generating ones), the clinician should always be aware of future meta- or neoplastic cellular activities at that site.
Robert J. Miller
11/26/2007
Argon, ruby, and alexandrite lasers are no longer used for soft/hard tissue procedures. The only use today for the Argon laser is for curing of composite. You mention the use of lasers for depigmentation and then mention removal of nevi. These are two definitively different lesions, with pigmentation being a variant of normal tissue, while nevi are considered by many pathologists as pre-malignant. If the melanocyte zone in normal pigmented tissue is ablated, depigmentation is permanent. The only way pigmentation can return is if there is incomplete removal of melanocytes.Diode lasers have an affinity for melanin containing tissue and preferentially ablate them. However, the manner in which the diode tip is brought across the tissue bed leaves a tissue plane that is relatively uneven. This may result in incomplete ablation of the melanocyte zone and repigmentation. Once again, you did not mention the lasers that represent the largest number of instuments being used today; the erbium family and super-pulsed CO2.With regard to the Er.Cr;YSGG laser, there is pure ablation without a thermal coefficient. The formation of a fibrous layer is scarring of the tissue and results from a thermal interaction. The histology of the Erbium treated mucosal zones shows no evidence of scarring and a normal epithelial zone/thickness after healing.
Dr. Mehdi Jafari
11/29/2007
Gingival hyperpigmentation is caused by excessive melanin deposition by the melanocytes mainly located in the basal and suprabasal cell layers of the epithelium. The melanocytes are dendritic cells unattached to the surrounding epithelial cells that behave as unicellular exocrine glands.Activated melanocytes convert tyrosine to melanin, which is transferred to the basal and prickle cell layers. Most of the melanin and melanocytes are concentrated in the basal layer and among the epithelial cells located directly above it, and the laser beam vaporizes the various epithelial levels as far as the basement membrane.Furthermore, the pain and disturbance caused by the procedure, may hinder the complete removal of the pigmented gingiva.Laser ablation of gingival melanin pigmentations may lead to devitalization of the adjacent teeth, gingival recession, damage to the underlying periosteum and bone, delayed wound healing, and loss of enamel. The complications may be due to the thermal effects of the heat generating lasers(e.g. diode laser), which is reported to sometimes extend at tissue depth into the Lamina propria, resulting in a large volume of coagulated tissue.In contrast to the alveolar mucosa, depigmentation of the attached gingiva requires repeated passes of the laser beam over the surface and/or within various treatment sessions.Repigmentation is a major concern in the treatment of gingival melanin pigmentation. The recurrence rate varies with regard to the treatment modalities and the duration of follow-up.Nakamura et al[Y. Nakamura, M. Hossain, K. Hirayama and K. Matsumoto, Lasers Surg Med 25 (1999), pp. 140–147] reported that there was repigmentation in four of their seven cases, almost equal to the preoperative state, at 24 months. To prevent the recurrence, the gingival tissue should be cleared of melanin entirely including free gingiva and interdental papilla since repigmentation starts as a result of migrating melanocytes from free gingiva.Many clinicians believe that adequate tissue removal may not be possible at the gingival margins and interdental papillary region due to close proximity of the adjacent teeth, which may be damaged by the laser beam. These limitations have led to incomplete vaporization of the pigment in such delicate areas, which tend to promote repigmentation.
dr T
12/3/2007
I agree with dr. miller the use of diodlasers in endodontics is great! But you need the right wavelength. The diodlaser with 810 nm will approximately goes to the same depth as the ND-yag and gives you very good results. The 980nm diodlaser will not come very deep into the dentin. See some research done on this topic by dr Guttknecht Germany.
Robert J. Miller
12/25/2007
I am not aware of anyone using the diode laser for gingival depigmentation anymore. The standard for this procedure is an Erbium based laser. This is because pure ablation, rather than coagulation, is far more effective at the lamina propria level than any other wavelength. Vaporization is an older concept, as evidenced by the sources you quote, and results in a grossly uneven tissue plane. This is why previous attempts at depigmentation met with mixed results. Tissue temperature does not mitigate the success of this procedure. Rather, it is the efficacy of melanocyte removal that dictates success. A pubmed check of the current literature indicates this. There is absolutely no evidence of devitalization of teeth subsequent to depigmentation using the Er,Cr;YSGG laser and the success rates are outstanding. Vaporization at any wavelength is no longer an accepted paradigm and indicates a lack of knowledge of the current state of the art. RJM
vaughan dentist
7/15/2010
Lasers are becoming more popular in dental practices and are replacing blades to perform implant and periodontal surgery. Dental lasers provide a cleaner cut and less bleeding.
