Advanced Laser Surgery in Dentistry
Advanced Laser Surgery in Dentistry
Advanced Laser Surgery in Dentistry
Dentistry
Advanced Laser Surgery in Dentistry
Georgios E. Romanos
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10 9 8 7 6 5 4 3 2 1
To my focused beam, little star, my daughter Stella
vii
Contents
Index 231
xi
List of Contributors
Vangie Dennis, MSN, RN, CNOR, CMLSO Anton Sculean, DDS, MS, PhD, Dr hc, Prof Dr med dent
Executive Director Perioperative Services Executive Director and Chairman
Atlanta Medical Center Department of Periodontology
Downtown Campus School of Dentistry
Atlanta Berne
Georgia Switzerland
USA
Preface
Lasers are novel and innovative technologies with many For instance, the use of laser light to excise or coagu-
benefits for clinicians, patients, and applications in sur- late tumors, the impact of lasers on periodontal surgical
gical dentistry. It is a significant contribution to the procedures, as well as in implant dentistry, from the
modern medical field that laser light can be used effec- implant uncovering to the treatment of peri-implant
tively in clinical dentistry based on present scientific diseases, are discussed. The highlights of the book for
developments and technological advances. the new decade are the modification of traditional con-
Scientific evaluation of this technology presents a lack of cepts of treatment and using a patient friendlier method
strong evidence in specific areas of dentistry, but there is leading to less postoperative complications and excel-
no doubt that lasers are beneficial as clinical tools in a vari- lent wound healing.
ety of clinical scenarios based on the appropriate laser- The book explains systematically the protocols of
tissue interactions and the challenges in daily practice. treatment with clinical cases and illustrates the way of
The first part of the book will provide the fundamental thinking and treatment methodology in the different
and advanced uses of lasers as surgical tools for improve- surgical fields. It is an excellent resource for clinicians
ment of clinical outcomes and is focused on the intraoral who want to improve their experience in surgical den-
applications of a variety of laser wavelengths and devices. tistry and advance their practice. In addition, the book is
The book presents the clinical impact of the use of a strong foundation for the specialist who wants to learn
lasers on the different fields of surgical dentistry in a more about this novel technology and how it can fit in
modern way with clinical photographs and step-by-step their practice.
documentation. The strength of the book is the discus- Enjoy reading but also practice, and you will recog-
sions of the use of different lasers and novel fiber-optics nize the pearls and jewels in Advanced Laser Surgery in
in the treatment of a variety of clinical problems and the Dentistry.
contribution of top specialists in the field of antimicro-
bial, photodynamic therapy, and laser safety. Georgios E. Romanos, DDS, PhD, Prof Dr med dent
xvii
Acknowledgement
Special thanks and appreciation to Mr. Hammaad R. Shah for the preparation of the schematical drawings presented
in the Figures 3.1, 5.5, 5.6 and 5.8.
1
LASER is an acronym of “Light Amplification by The power of lasers can range from milliwatts to almost
Stimulated Emission of Radiation.” Laser is light with 20 W for commercial lasers. In addition, higher levels of
specific properties and may interact with tissues and power in megawatts may be used for military purposes.
materials. Light is an electromagnetic wave, which is a The sizes of lasers can have dimensions larger than
coupling of electric and magnetic fields, traveling as 100 m. Lasers in this size can be used for nuclear experi-
waves at a speed equal to the known speed of light ments using laser beams to squeeze hydrogen atoms in
(velocity, c). Both fields oscillate at the same frequency, order to release a high amount of energy (laser fusion).
with a number of oscillations per second, which is well The biggest facilities in the world so far are the NIF
known as frequency ( f ). The speed of light is a universal (National Ignition Facility) in California and the Laser
constant, which is about 300 000 km/s. Megajoule (LMJ) in France, near Bordeaux.
Since medical professionals are interested in the applica- In contrast to large lasers, the smallest lasers today are
tions of laser devices and not the internal physics, here we 5000 times smaller than the tip of a pen. Scientists have cre-
describe fundamental information, which is foundation ated the world’s smallest laser after they squeezed light into
knowledge, before the use of lasers in clinical settings. a space smaller than a protein molecule. The so-called
A laser light is a monochromatic, coherent light in the “spacer” generates stimulated emission of surface plasmons
visible and nonvisible (infrared or ultraviolet [UV]) (oscillations of free electrons in metallic nanostructures) in
parts on the electromagnetic spectrum. Laser light is resonating metallic nanostructures adjacent to an active
optical radiation and is termed non-ionizing radiation medium. It is anticipated that, at least experimentally, the
to be differentiated from ionizing radiation, such as spacer (wavelength of 531 nm) will advance our fundamen-
gamma- and X-rays, which may cause biological effects tal understanding of nano-plasmonics and the development
in the cells and tissues. The human eye associates a of new opportunities due to the photothermal properties in
color to a group of specific wavelengths from violet, the therapy of malignant lesions (Chon et al. 2014).
blue, green, yellow, orange, red based on the increase of In general, there is a broad diversity in laser applica-
the wavelengths. Invisible wavelengths for the human tions, which can be used for industrial, commercial,
eye are wavelengths of radios and television (infrared) research, and military interests.
or in the UV parts of the spectrum, the gamma- and Some areas where lasers can be used are:
x-rays (Figure 1.1).
The spectrum is divided into two major zones: the short ●● Material cutting and welding
wavelength ionizing radiation (nonvisible to the human ●● Measurements
eye) and the non-ionizing radiation (visible light and non- ●● Communications
visible infrared radiation) with longer wavelengths. The ●● Entertaining and performing arts
ionizing radiation can penetrate tissue and damage cells. ●● Holography
In low doses it can be used for diagnostic purposes (i.e. ●● Spectroscopy and atomic physics
X-rays). The non-ionizing range of radiation can be used ●● Environment protection
for superficial heating of tissues, and for treatment of skin ●● Plasma diagnostics
disorders and musculoskeletal injuries. ●● Medical applications
Shortwave
γ-rays X-rays UV rays Infrared Radar FM TV AM
rays
Visible light
time. This relatively new technology is very helpful ●● Electrons can jump only from orbit to orbit and
today in biomedical and clinical sciences. Especially in deliver energy in the form of radiation, as for example
ophthalmology, it provides treatment guidance for glau- light (emission of radiation), or take up energy
coma and diseases of the retina, including age-related (absorption of radiation).
macular degeneration (AMD) and diabetic eye disease
Therefore, in the interaction between light and matter
(Fujimoto et al. 2000).
three different optical concepts may occur: absorption,
spontaneous emission, and stimulated emission.
Absorption is the process when electrons transfer
1.1 Historical Background from a low energy level (E1) (stable) to a higher energy
level (E1) (unstable). Energy levels E1 are called the
The precursor of the laser, namely the “Maser,” was
ground state and E2 called the excited state.
developed in the United States by the physicist
Spontaneous emission is the process, when electrons
Theodore H. Maiman (1960). It consisted of an one-
transit from a higher energy level (E2) to a lower energy
crystal-rod from artificial ruby and could emit red light
level (E1). When E2 > E1, the energy difference satisfies the
with a wavelength of 694 nm in the microwave band.
relation E2-E1 = h ν. The constant h (= 6.63 × 10−34 J/s) is
The Maser, an acronym for Microwave Amplification
known as Planck’s constant, and ν is the radiation
by Stimulated Emission of Radiation, is today gener-
frequency. Spontaneous emission is responsible for the
ally known under the name laser. In its name is sum-
production of conventional visible sunlight.
marized the basic principle after which all laser
Stimulated emission is the process when atoms ini-
systems work. Charles H. Townes (1964) received the
tially from the excited stage fall down to the ground
Nobel Prize for the development of the laser; Townes
state emitting photons. An atom can be stimulated
was the first to achieve, due to stimulated emission,
(excited stage) by an external source, so that its elec-
the fortification of the radiation in the microwave
trons of a low energy can jump to a higher energy orbit.
band.
This source can be of an electric kind, e.g. a flashbulb,
Moreover, Albert Einstein (1917) had already argued
and serves as “a pumping mechanism.” Other pumping
in his thesis “Quantum Theory of Radiation,” that parts
methods can be also chemical or optical, depending on
of the electromagnetic field can be stimulated in such a
the energy source (Figure 1.3).
way that through it fortified light originates. The first
lasers were called optical masers.
1.3 Properties of the Laser Light
1.2 Energy Levels and Stimulated
With the term laser is identified a physical principle
Emission
leading to the production of electromagnetic radiation,
which differs from the usual light in the following
Based on Niels Bohr and the Planck-quantum hypothe-
properties (Figure 1.4):
sis, the following two postulates were formulated:
Coherence: Wave streaks remain parallel and well-
Electrons move only on certain, firm orbits around
●●
●●
defined even in large distances. The light has spatially
the nuclear core
the same phase (the waves are “in tune”).
●● Collimation: The laser beam can give a localized spot all directions (Figure 1.4) of space (polychromatic, inco-
when something is in its way. This has the practical herent light).
advantage that the light can be well focused. The concurrent combination from the above-men-
●● Monochromatism: All wave streaks have the same tioned physical properties permits very high capacity
wavelength, the same frequency, and thus the same density. In this way, for example, the sunlight striking
energy. The wavelength of the light plays a critical our earth has power of on an average 0.1 W/cm2; on the
role in medicine and determines today the exact clini- contrary, surgical laser systems easily reach a power of
cal ranges of application. 100 000 W/cm2. Lighting a match produces energy of
200 J. With the energy of only 1 J of coherent light gener-
A high energy density is produced when the gener-
ated by a ruby laser – focused by means of a plane opti-
ated electromagnetic radiation bundles in the narrowest
cal lens – it is possible to cut a hole in a metal plate
space, due to the coherence and the collimation. The
(Frank 1989).
light can be focused precisely and have, because of its
The three basic criteria of light are: brightness (ampli-
high energy density, different effects on the tissues.
tude), color (frequency), and polarization (angle of
Therefore, vaporization, coagulation, and also carboni-
vibration).
zation of tissues are possible. Light with such qualities
does not exist in nature. The photons of usual light
exhibit different wavelengths, and they are emitted in
1.4 The Laser Cavity
Laser System
Focused
surface
Lens
Active
Medium
Focus
Total
reflective
mirror
1.4.2 Pumping Mechanism The type of the operating mode, namely the length or
width of a pulse is dependent on the pumping mecha-
The laser pumping mechanism is the act of energy
nism and the laser medium. The pulsed laser light
transfer from an external source into the active medium
(gated, chopped) can be achieved when a mechanical
of the laser. The pump energy is usually provided in the
shutter opens and closes in front of the beam.
form of light (optic) energy, or electrical current, but
Pulses can be short or ultrashort dependent on the
also other sources have been used, such as chemical or
pulse duration. A superpulse mode is associated with
nuclear reactions.
good ablation and wide residual thermal damage (RTD)
compared to the ultrapulse mode, where the ablation is
precise and the RTD is shallow. The latter may be also
1.4.3 Lenses – Resonator
called char-free mode.
The optical resonator is the reflecting system of the Usually pulses have a pulse duration in the μs-ms
laser device. With the use of two parallel, arranged mir- range. Free-running ( FR ) lasers are pulsed lasers with
rors (mostly concave shaped) at a specific distance, the shorter pulse durations than the conventional pulsed
light will be reflected. The exact radius of curvature lasers. Such lasers can be used in areas when risk of
characterizes the optical resonator. A certain curvature overheating has to be avoided. For instance, a
controls better the light reflections, modifying the distri- FR-Nd:YAG is used for the LANAP protocol in peri-
bution of light within the laser output beam. odontal therapy (see also Chapter 5).
The resonators with a stable reflecting distance are Shorter pulses with pulse duration from microseconds
also called also stable resonators and differentiate (10−6) to nanoseconds (10−9) define the Q-switched lasers
themselves from the unstable ones, which obtain a (Q-switching). Compression or shortening of pulses
variable reflecting distance. According to the distance can be done with this technique. This kind of laser
and shape of the mirrors as well as their position, can be used in industry for metal drilling, cutting, and
there are concentric, confocal, hemi-confocal, and marking with extremely high peak power.
hemispherical resonators. Energy loss can happen if The second compression technique of pulses is to
mirrors (especially output mirrors) do not perfectly create pulses with extremely short duration; some-
reflect light, and this should happen as much as pos- times referred to as ultrashort pulses. These are pulses
sible. Concave mirrors are needed in order to focus with a width in picosecond (10−12 seconds), femtosec-
light transversely. ond (10−15 seconds), or attosecond (10−18 seconds)
The simplest laser cavity is formed by two parallel defining the mode-locking. This can be used for cut-
mirrors facing each other. This is called a Fabry-Perot ting or melting of metals due to the high penetration
Cavity. depth. Pulse repetition rate (frequency) also varies
The laser resonator has two different types of modes: widely.
transverse and longitudinal. Transverse modes can be Pulse modes control the heat transfer to the tissues,
explained by the cross section of the beam profile and providing vaporization without overheating and, as a
represents the intensity pattern. This distribution of consequence, melting. High peak power pulses can cre-
power is also referred to as transverse electromagnetic ate defects with sharp edges in the matter (or tissues)
mode (TEM). without damage.
There is great interest in the pulse duration, also called
pulse width, of the laser beam in order to avoid negative
effects and damage in biological tissues.
1.5 Laser Application Modes Chopped (shuttered) pulses usually have a duration
of 100–500 ms. Superpulses have a shorter width,
The operation mode of a laser can be switched to usually of 60–200 μs and higher peak power. The
pulsed or continuous (Figure 1.6). The pulsed mode is width can be controlled electrically using mechanical
also known as normal mode. A continuous beam is shutters and other devices, like shutters and
referred to as continuous wave (“continuous-wave Q-switches. These devices are placed in the laser
laser”) or CW laser, when light will be constantly cavity.
emitted over an uninterrupted period of time due to The pulse width must be shorter or equal than the
continuous pumping. These lasers have usually low thermal relaxation time ( TRT ) of the target chromo-
peak energy and low power. They are usually gas phore. This time is directly proportional to the square
lasers, i.e. CO2 lasers. size of the chromophore. Therefore, small objects cool
6 1 Laser Fundamental Principles
(a) (b)
7 7
6 6
5 5
Power (W)
Power (W)
Laser Laser
4 4
on off
3 3
2 2
1 1
0 0
0 1 2 3 4 5 0 1 2 3 4 5
Time (s) Time (s)
(c) (d)
Superpulse mode: Ultrapulse mode:
Pulse Interpulse Good ablation with Precise ablation with
width interval comparatively shallow RTD zone
Peak power (MW) wide RTD zone “char-free”
106 106
104 104
Power (W)
Power (W)
102 102
Average
power
0 0
Time (ms, μs) Time (ms) Time (μs)
Figure 1.6 Continuous (CW) and pulsed (chopped, gated) laser application modes compared to pulsed, superpulse, and
ultrapulse mode.
Ppeak : E/ t
1.6 Delivery Systems
Average Power is the energy flow over one full time
period. The laser beam is used as a handpiece by means of dif-
ferent guide systems (the so-called beam guide systems),
Pavg E/T allowing the surgeon to perform a perfect, with minimal
complications, and practical, laser application. A direct
Therefore:
coupling, an articulated arm, a flexible hollow guide as
Ppeak t Pavg T an optical fiber, or a fiber system are currently available
for this purpose.
Also, Duty Cycle is the fractional amount of time the
laser is “on” during a specific given period.
1.6.1 Direct Coupling
Therefore:
A direct coupling is possible only in extremely compact
Duty Cycle t/t Pavg/Ppeak systems (e.g. He:Ne target lasers, soft lasers, laser point-
ers). In such systems the laser unit corresponds to the
handpiece of the system.
Figure 1.8 Articulated arm for a CO2 laser application in Figure 1.9 Hollow guide of a CO2 laser presenting
the modern CO2 laser (Denta 2, Lutronic, GPT dental, Fairfield, the flexible delivery system for oral applications.
NE, USA). Source: Dr. Georgios E Romanos.
relatively inflexible operation, and the relatively expen- beam is needed. The handpiece is autoclavable, and the
sive reconstruction. To reduce the heavy weight, a tech- latest designs use no disposable tips.
nical modification is needed. A weight balance with gas The optical fiber (Figure 1.10) works by a total inter-
pressure springs or counterweights can also positively nal reflection in which the index of reflection inside the
affect the clinical use of endoscopes, surgical micro- core of the fiber is higher than the index of reflection of
scopes, or handpieces. the cladding (Ghatak and Thyagarajan 1998). They are
currently used in many laser systems, because they are
reasonably priced. These light pipes can be quite long,
1.6.3 Fiber Systems and Flexible Hollow
so that the laser unit and the surgical area can be physi-
Guides
cally separated.
These fiber systems are flexible light guides made of They have a broad clinical application possibility,
glass fibers (high-purity fused quartz glass) coated with among others in gastroenterology, vascular surgery,
transparent plastic or piping systems, the so-called gynecology, and also in dentistry.
waveguides (Figure 1.9). A disadvantage of these waveguides is the relative
Flexible hollow guides are also used in the construc- loss of power at high deflection of the fiber and the
tion of CO2 lasers, instead of more expensive and rela- limitations in focusing. Of particular clinical impor-
tively inflexible articulated arms. The flexible hollow tance is the intracorporeal application of the fiber, due
fiber for CO2 laser wavelength was developed in the to the high quartz fiber flexibility. Flexible fibers can
1990s; it features an unprecedented reach and accessi- nowadays be inserted, by means of endoscopy, in dif-
bility unattainable with articulated arm lasers. A pen- ficult to access areas, and there they can be therapeu-
size, scalpel-like handpiece is held very close to the tically used.
target tissue. It focuses the CO2 laser beam 1–3 mm For intracorporeal clinical use an optical fiber is essential.
away from handpiece’s distal end; no aiming of the Waveguides are not currently used intracorporeally, as
1.7 Applicator 9
1.7.1 Handpieces
Handpieces are primarily used for mirror swivel arms
and make possible the transmission and focusing of the
beam on a tissue area without contact (noncontact).
They can shrink the irradiated area considerably,
depending on the manufacturer and by means of special
tips made of ceramic or metal (Figures 1.11–1.14). Bent
Figures 1.12–1.14 Special tips for direct connection with the hand piece (left) for Er:YAG laser made by sapphire or glass fiber
for Er:YAG or diode lasers (middle) and for Er,Cr:YSGG laser (right). Source: Dr. Georgios E Romanos.
10 1 Laser Fundamental Principles
metal spikes can be also used for less accessible regions Laser manufacturers have special tools (Figure 1.17)
of the oral cavity. Likewise, there are handpieces with for cutting the glass fibers after removal of the plastic
beam deflection. coating (clearing).
With new laser developments, the industry grows,
and laser devices become smaller and more powerful
1.7.2 Fiber Applicators
every day. An example is the growth of the Er,Cr:YSGG
Fiber applicators are straight or curved tubes that allow lasers (Biolase Inc.) over the last 20 years demonstrating
contact of the flexible fibers with the tissues. The fiber a significant reduction of the size of the devices.
can be fixed in the applicator by a simple screw. During The spot size is very important since smaller spot
a contact application, the fiber tip is worn out over time, sizes are associated with higher fluence. Thermal trans-
which reduces the beam profile and decreases the avail- fer in small spot sizes can be more effective without
able power density (Figures 1.15 and 1.16). Thus, an damage to the surrounding tissues. In contrast to this, a
optimal ablation is prevented. larger spot size requires higher energy levels or longer
A fiber cable consists of the main core (8 μm), the clad- irradiation periods, which may have side effects to the
ding (125 μm) covered by the coating (approx. 250 μm), and surrounding tissues (i.e. carbonization or overheating).
the jacket (400 μm), which protects the entire fiber optic. In this case, when clinicians try to avoid overheating
Figures 1.15 and 1.16 Diode laser irradiation during frenectomy and partial vestibuloplasty using a contact of the fiber tip
with the tissues (left). This may allow damage of the tip, decrease of the power density, and, due to overheating, potential scar
tissue formation. For this specific indication, initiated tips are strongly recommended (right). Source: Dr. Georgios E Romanos.
Figure 1.17 Special tools to remove plastic coating around glass fiber without damaging the fiberoptic. Source: Dr. Georgios E
Romanos.
1.8 Laser Types Based on the Active Mediu 11
tissues, the therapeutic energy level cannot be achieved Physically seen, the change of energy levels of elec-
and, therefore, the final outcome is insufficient. trons in an atom produces the laser radiation. With the
gas and solid-state lasers, the atoms are stimulated by
electron collisions. On the contrary, in the excimer, or in
1.8 Laser Types Based on the the dye lasers, a transition of electrons to molecules
Active Medium takes place.
All lasers used in medicine, including their wave-
The currently known laser systems are, according to lengths, are in the Table 1.2.
their active medium, divided into the following types Below are described those types of lasers, which are
(Table 1.2): primarily used in surgical dentistry.
lasers for general surgery especially the carbon dioxide With a wavelength of 10 600 nm (invisible infrared
laser. However, the bulky size of these devices and the range), the beam can be well absorbed by the enamel, so
fragile construction make these lasers not the first that at first it was considered to use this type of laser in
choice of application in private practices. the cavity preparation, the conditioning of dental
enamel, and treatment of caries (Lobene and Fine 1966;
1.8.1.1 CO2 Laser (10 600 nm) Lobene et al. 1968; Stern et al. 1972). Significant
This type of laser was developed in the US between the increases in temperature on the tooth surface strongly
early 1960s and the early 1980s. The active medium con- limited the use of conventional CO2 lasers (CW or
sists of carbon dioxide (CO2), nitrogen, and helium. The pulsed) at the processing of hard tissues (Stewart
mixing ratio of the laser medium is 4.5% CO2, 13.5% N2, et al. 1985). On the contrary, Melcer et al. (1984) demon-
and 82% He and represents a nontoxic gas mixture. strated in a clinical trial with 1000 patients positive
Nitrogen molecules are pumped by an external energy observations in the removal of caries. In an animal
source, which by its energy activates the molecules of study Melcer et al. (1987) histologically confirmed the
the active medium (CO2). For this reason, this type of formation of secondary dentin and the sterilization of
laser is also called a molecular laser. dentin and pulp during the application of CO2 laser.
Depending on the type of discharge, they are cur- The absorption of the laser beam increases by water.
rently operated as continuous (CW) or pulsed systems. Since its penetration depth is low (ca. 0.1–0.3 mm) and
During the production of the laser light, an excessive the surrounding tissue is hardly heated, modern CO2
overheating of the optical resonator is prevented by the lasers can be primarily used in the superficial manipu-
cooling effect of helium. Optical materials for the CO2 lating of soft tissues (Figure 1.19). The coagulating
laser are, among others used, germanium, zinc selenide, effect on small blood vessels allows a blood-free and
and gallium arsenide. Even the slightest dirt on the clear surgical field.
lenses can cause destruction.
In terms of CO2 laser construction characteristics, 1.8.1.2 CO2 Laser (9300 nm)
there are different types of CO2 lasers including glass This is a relatively new development of the CO2
tubes dating back to the 1960s; this technology features (9300 nm) laser with applications in hard and soft tis-
a relatively short lifetime and high maintenance costs; it sues in dentistry. Due to the relatively high absorption
requires up to 20 000 volts and flowing liquid coolant, by hydroxyapatite, this wavelength can be used for
both of which are expensive in service. Innovative tech- removal of enamel and dentin.
nology with all-metal tubes was developed in 1990s; it The first laser with FDA clearance for soft and hard
features rugged an all-metal air-cooled resonator design, tissue applications in dentistry is the SOLEA
long lifetime (up to 45 000 hours), low cost, low voltage (Convergent Dental). Compared to the conventional
RF transistor-operated power supplies, and excellent CO2 lasers and the Er:YAG lasers, which vaporize water
laser pulsing capabilities (Figure 1.18). and enamel, this new laser uses an oxygen-18 isotope
Figure 1.18 Innovative all metal-tube compared to the classic old glass tube of CO2 laser systems (courtesy:
LightScalpel, Inc.).
1.8 Laser Types Based on the Active Mediu 13
Figure 1.19 Development of CO2 lasers over time by LightScalpel, Inc. demonstrates the modern and robust design for
surgical applications using hollow guide technology. Luxar (MegaPulse, Lightscalpel)
1.8.1.3 Argon-Laser
The argon laser is an ion laser and is currently not popu-
lar in dentistry. Its wavelength is in the visible range of
light (488 nm blue or 514.5 nm green light) and its capac-
ity is up to 30 W. Almost all its power is converted into Figure 1.20 Argon laser device (Premier, Irvine, CA).
heat, which is why adequate water cooling is necessary.
Initially in the 1960s the argon laser was introduced intra- and extraoral, a complication-free hemostasis of
in gynecology, dermatology, ENT, and ophthalmology. strongly vascular tissues, and the removal of pigmented
In dentistry, it is useful for caries diagnosis; it reduces lesions (Dixon et al. 1986; Hohenleutner and
the polymerizing time in the therapy with hybrid or Landthaler 1990; Kutsch and Blankenau 1995; Poetke
micro-filled composite fillings (Kelsey et al. 1989; et al. 1996). Vessels up to a diameter of 1 mm can be
Powell et al. 1989; Severin and Maquin 1989; Blankenau coagulated. The optical penetration depth of the argon
et al. 1991a, 1991b; Powell et al. 1995) and can also be laser is limited to about 1 mm. The superficial water
used in surgery for the removal of vascular lesions cooling allows a doubling of the thermal impact depth
(White et al. 1993) (Figure 1.20). by about 2 mm. Thermal damage to the skin can be min-
The high absorption of the argon laser light from imized by the use of saline solution and pressing with a
hemoglobin, hemosiderin, and melanin allows both glass spatula (Poetke et al. 1996).
14 1 Laser Fundamental Principles
1.8.1.4 He:Ne Laser 50 J, and has as a continuous beam (CW laser) and an
This laser is a neutral atom laser. It contains neon as the output power up to 150 W. It is also used as an industrial
active medium and helium as pumping gas at a ratio of laser for material processing (Abdurrochman
1 : 10. The light is emitted at a wavelength of 633 nm. et al. 2014). However, in dentistry the Nd:YAG laser can
He:Ne lasers operate in continuous wave mode. The be used only in pulsed mode due to the high risk of tis-
output power is at 0.5 to 50 mW relatively low. Reliability, sue overheating and deep tissue penetration. The laser
manageability, and a relatively low price compensate for beam is absorbed from only a small amount of water
the low working efficiency of this laser. The He:Ne laser and works in contact with the tissue. The heat effect
is currently used as a target (the so-called pilot laser), as occurs deep in the tissue of the irradiated area and has a
well as a laser light pointer in holography. In medicine, strong coagulation effect. This leads to the shrinkage of
it belongs to the group of soft lasers that are used to sup- the tissue, and vessels up to a diameter of 2– 3 mm can
port wound healing and pain reduction. Further possi- be closed. This hemostatic effect of the Nd:YAG laser is
ble applications are found in the counting of cells and used in many ways in clinical surgery. Its biological
measuring of the eye in ophthalmology. effects are coagulation, carbonization, and vaporization
(Frank 1989).
The application of Nd:YAG laser in medicine was
1.8.2 Crystal Lasers
tested by extensive clinical studies and is scientifically
Crystal lasers (usually named as “solid-state” lasers) are validated. One can currently use it in hepatectomy and
lasers with a crystal as an active medium. Usually, the in the removal of hemorrhoids and highly vascularized
YAG (yttrium-aluminum-garnet) crystal is used in these tissues, as hemangiomas, without major complications
lasers. Approximately 1% of the yttrium atoms is in contact with the tissue used in a fiber optic system
replaced (“doped”) with neodymium, to have the (Kiefhaber et al. 1977; Iwasaki et al. 1985; Joffe 1986;
Nd:YAG (Neodymium: yttrium, aluminum, garnet) laser, Joffe et al. 1986; Poetke et al. 1996).
which is the most known laser type of this group. The The first studies in dentistry were carried out by
invisible 1064 nm wavelength penetrates deeply into Myers and Myers (1985), and their purpose was the
biological tissues, compared to the 532 nm (half of removal of dental caries, concluding that superficial
1064 nm) which penetrates far less and is visible. Such carious enamel lesions can be removed with the Nd:YAG
crystals are KTP (potassium triphosphate), producing laser. The fine fiber of the Nd:YAG laser system can be
the frequency-doubled Nd:YAG (KTP) lasers (green used both in the excision of soft tissue, as well as for
output) with many applications in the treatment of coagulation (Figures 1.21 and 1.22). In endodontics the
vascularized tissues due to the high absorption by positive effect of the laser was shown by means of
hemoglobin. bacterial reduction in the root canal (Dederich
Similarly, there are Er:YAG (erbium: yttrium, alu- et al. 1984, 1985; Melcer et al. 1987; Hardee et al. 1994;
minum, garnet), Er,Cr:YSGG (erbium, chromium:yttrium, Gutknecht et al. 1996). In various clinical articles it was
scandium, gallium, garnet) and the alexandrite lasers. shown that the application of the Nd:YAG laser is also
Less popular crystal dental lasers and some no longer possible in the surgical excision of the labial frenulum
commercially available are the Ho:YAG (holmium: (frenectomy) in periodontology and in the excision of
yttrium, aluminum, garnet; 2120 nm), the ruby (694.3 nm), benign tumors in the oral cavity (Romanos 1994;
the Nd:CGSGG (neodymium: chromium, gadolinium, Goldstein et al. 1995).
scandium, gallium, garnet; 1061 nm) and the Nd:YAP
(neodymium: yttrium, aluminum, perovskite; 1340 nm) 1.8.2.2 Er:YAG Laser
laser. The Er:YAG laser with a wavelength of 2940 nm plays an
These lasers or any glass lasers cannot operate in a important role in medicine and dentistry. Its active
CW mode in order to avoid risks of overheating and medium is as for the Nd:YAG laser, a crystal, although
damage of the laser crystal. the Er:YAG laser with 30–40 wt% is relatively high doped,
and yttrium atoms are replaced by erbium atoms. In total
1.8.2.1 Nd:YAG Laser the Er:YAG system, including the pumping mechanism
The Nd:YAG laser was used in dentistry for the first time (using a pulsed linear xenon flash lamp), is similar to the
in 1977 in animal studies in order to test its effect on the Nd:YAG laser system (Figures 1.23 and 1.24).
pulp (Adrian 1977). Nowadays, it is the most important The penetration depth of the radiation in the tissue is
known solid-state laser with a wavelength of 1064 nm. only approx. 1 μm (10−3 mm), so that a selective photoa-
In the normal pulse mode, it provides energies up to blation occurs, and the tissue is removed layer by layer.
1.8 Laser Types Based on the Active Mediu 15
Figures 1.25–1.27 Different Er,Cr:YSGG laser devices developed in the last 20 years by Biolase, Inc. The size of the device
has been decreased, providing innovative opportunities for clinical settings. Source: Biolase, Inc.
1.8 Laser Types Based on the Active Mediu 17
the application of two different wavelengths possible. A 1.8.3 Liquid (Dye) Lasers
Ho:YAG (2090 nm) and a Nd:YAG (1064 nm) laser can
Liquid (dye) laser systems have a dye as the active
be adjusted for use, depending on the therapeutic
medium. They need other lasers or intense light for
requirements, at the touch of a button. The Ho:YAG
optical pumping. The laser light has a wavelength rang-
laser (formerly DuoPulse®) system can achieve up to 4 W
ing from UV, through the visible, to infrared spectral
output power, and it also allows easier handling through
range. A medium is used, usually rhodamine 6G, which
a flexible silica fiber. This type of laser is in used in the
flows at high velocity through the pump beam. In this
fields of vascular surgery (Mehmet et al. 1989; Hardee
way heating during the operation is avoided. The con-
et al. 1994), ophthalmology (Iwasaki and Inomata 1986),
centration of the dye is 10−4 mol/I. Another laser (e.g.
urology (Johnson et al. 1992), ENT (Shapshay et al. 1990;
an excimer laser) or a flash lamp is used as the pumping
April et al. 1991; Oswald and Bingham 1992), gastroen-
mechanism. This allows a pulse mode, and the corre-
terology (Nishioka et al. 1989; Bass et al. 1991;
sponding output power ranges from a few mW to 106 W.
Rubio 1991), gynecology (Rosenberg et al. 1990), and
When an argon or krypton laser is used as a pump laser,
orthopedics, especially for arthroscopy (Trauner
a continuous laser beam (CW) with a capacity of up to
et al. 1990; Shi et al. 1993).
1 W is possible. The wavelength of the laser beam is then
In the arthroscopic surgery of the TMJ, the use of this
in the range of 570–620 nm.
laser type was tested and clinically studied by Hendler
In medicine, such laser systems are used in the field
et al. (1992) and Koslin and Martin (1993). It has been
of ophthalmology (for surgeries of the retina, for
proven that the Ho:YAG laser is currently a low-invasive
instance, coagulation of the retina) and in dermatology
treatment alternative in arthroscopic surgical proce-
(e.g. in pigmentation and tattoo removal).
dures. Examinations of the irradiated tissue and the
adjacent areas showed only a slight thermal effect.
In dentistry, the Ho:YAG laser is used for the condi-
1.8.4 Semiconductor (Diode) Lasers
tioning of dentine, the removal of the dentin surface
(White et al. 1993), the effective ablation of dentine Laser dentistry has specific, sometimes unique, other
from the root canal (Stevens et al. 1994), and for in vitro times rather standard requirements for laser parameters
root apex resections (Komori et al. 1997). Under certain and design of laser systems. Common desired features
circumstances it can remove enamel, dentin, and calcu- of laser systems for such widespread procedures as hard
lus (Mani 1992). and soft tissue microsurgery, bacteria reduction, tissue
Physically seen, the Ho:YAG laser beam is very well regeneration, and tooth whitening are small size and
absorbed by water, although its absorption coefficient is low cost of ownership. These demands stimulated the
about 19 times lower in comparison to the CO2 laser. growth in popularity of semiconductor (diode) lasers
Due to the high amount of water in enamel and dentin, due to their high efficiency, small package size, conveni-
the removal of hard tissue is minimally possible. One ent ergonomics, high reliability, and reasonable costs.
can achieve with it an efficient management of soft tis- Such lasers fulfill the needs of the vast majority of den-
sue without complications, either highly pigmented or tal practices very well.
white (with or without contact with the tissue). In A semiconductor (diode) is a crystal in which the
regard to the coagulation of vessels, the coagulation individual atoms are arranged periodically and has an
zone is in comparison to CO2 laser bigger, but smaller electrical conductivity, which stands between insulators
than the one of Nd:YAG laser. and metals. Semiconductor lasers are relatively small,
compact, and practice-friendly devices (Figure 1.28)
1.8.2.5 Alexandrite Laser and have as the active medium semiconductors (diodes).
The design principle of the frequency-doubled alexan- This diode can be a GaAlAs (gallium aluminum arse-
drite laser (comprised of a Cr:BeAl2O4 crystal) corre- nide) or GaAs (gallium arsenide) diode. Such lasers are
sponds to the Nd:YAG laser. The alexandrite laser has a relatively small, but relatively high-energy densities can
fundamental wavelength between 720 and 800 nm (typi- be achieved. Therefore, they can also be used for medi-
cally 755 nm). The frequency-doubled Alexandrite laser cal purposes. Diode lasers have been used widely out-
corresponds to ca. 578 nm. Its application, which was side the United States as therapeutic devices for pain
previously only experimental, takes place in the salivary control with controversial efficacy.
duct stone lithotripsy. Its advantages are the high stone The GaAs diode lasers generate pulses with an aver-
fragmentation rate and the low trauma, as it is a mini- age power of 10–20 mW and are used for biostimulation.
mally invasive procedure (Gundlach et al. 1995). The GaAlAs diodes can be modulated and pulsed as