Advanced Laser Surgery in Dentistry

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Advanced Laser Surgery in 

Dentistry
Advanced Laser Surgery in Dentistry

Georgios E. Romanos

D.D.S., Ph.D., PROF. DR. MED. DENT.


Stony Brook University
School of Dental Medicine
Stony Brook, NY, USA
and
Johann Wolfgang Goethe University
School of Dentistry - Carolinum
Frankfurt, Germany
This edition first published 2021
© 2021 John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Romanos, Georgios, author.


  Title: Advanced Laser Surgery in Dentistry / Georgios E. Romanos.
Description: First edition. | Hoboken, NJ : Wiley-Blackwell, 2021. |
  Includes bibliographical references and index.
Identifiers: LCCN 2020028457 (print) | LCCN 2020028458 (ebook) | ISBN
  9781119583301 (hardback) | ISBN 9781119583356 (adobe pdf) | ISBN
  9781119583349 (epub)
Subjects: MESH: Oral Surgical Procedures | Laser Therapy
Classification: LCC RK501  (print) | LCC RK501 (ebook) | NLM WU 600  | DDC
  617.6/05  dc23
LC record available at https://lccn.loc.gov/2020028457
LC ebook record available at https://lccn.loc.gov/2020028458

Cover Design: Wiley


Cover Images: Courtesy of Georgios E. Romanos, © MIKHAIL GRACHIKOV/Shutterstock

Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India

10  9  8  7  6  5  4  3  2  1
To my focused beam, little star, my daughter Stella
vii

Contents

About the Author  xi


List of Contributors   xiii
Preface  xv
Acknowledgement  xvii

1 Laser Fundamental Principles  1


Georgios E. Romanos
1.1 Historical Background  3
1.2 Energy Levels and Stimulated Emission  3
1.3 Properties of the Laser Light  3
1.4 The Laser Cavity  4
1.4.1 Active Medium  4
1.4.2 Pumping Mechanism  5
1.4.3 Lenses – Resonator  5
1.5 Laser Application Modes  5
1.5.1 Beam Profiles  7
1.6 Delivery Systems  7
1.6.1 Direct Coupling  7
1.6.2 Articulated Arms  7
1.6.3 Fiber Systems and Flexible Hollow Guides  8
1.7 Applicators  9
1.7.1 Handpieces  9
1.7.2 Fiber Applicators  10
1.8 Laser Types Based on the Active Medium  11
1.8.1 Gas Lasers  11
1.8.2 Crystal Lasers  14
1.8.3 Liquid (Dye) Lasers  17
1.8.4 Semiconductor (Diode) Lasers  17
1.8.5 New Developments in Laser Technology  19
1.8.6 Lasers for Research Applications  24
1.9 Laser and Biological Tissue Interactions  24
1.9.1 Photochemical Effects  27
1.9.2 Photothermal Effects  29
1.9.3 Ionizing or Nonlinear Effects  33

2 Lasers and Wound Healing  41


Georgios E. Romanos
2.1 Introduction  41
2.2 Wound Healing and Low Power Lasers  42
2.3 Wound Healing and High-Power Lasers  44
2.3.1 Wound Healing and CO2 Laser  44
2.3.2 Wound Healing and the Nd:YAG Laser  47
viii Contents

2.3.3 Wound Healing and Other Laser Wavelengths  50


2.4 Lasers and Bone Healing  51

3 Lasers in Oral Surgery  57


Georgios E. Romanos
3.1 Introduction  57
3.2 Basic Principles  57
3.3 Excision Biopsies  58
3.4 Removal of Benign Soft Tissue Tumors  59
3.4.1 Surgical Protocol for Removal of Small Tumors  59
3.4.2 Surgical Protocol for Removal of Larger Soft Tissue Tumors  62
3.5 Removal of Drug-Induced Gingival Hyperplasias and Epulides  80
3.5.1 Removal of Drug-Induced Gingival Hyperplasias  80
3.5.2 Removal of Epulides  81
3.6 Removal of Soft Tissue Cysts  83
3.7 Frenectomies and Vestibuloplasties  87
3.7.1 Frenectomies  87
3.7.2 Vestibuloplasties  92
3.8 Removal of Precancerous Lesions (Leukoplakia)  99
3.9 Surgical Removal of Malignant Soft Tissue Tumors  106
3.10 Laser Coagulation  106
3.11 Lasers in Vascular and Pigmented Lesions  107
3.11.1 Laser Types  107
3.11.2 Removal of Vascular Alterations with the “Ice Cube” Method  108
3.12 Exposure of Impacted, Unerupted Teeth  121
3.12.1 Exposure of an Unerupted Teeth for Orthodontic Reasons  122
3.13 Removal of Sialoliths Using the Laser  123

4 Lasers and Bone Surgery  129


Georgios E. Romanos
4.1 Introduction  129
4.2 CO2 Laser  129
4.3 Excimer Laser  130
4.4 Er:YAG and Ho:YAG Lasers  130
4.5 Laser Systems for Clinical Dentistry  131

5 Lasers in Periodontology  139


Georgios E. Romanos
5.1 Introduction  139
5.2 Laser-Assisted Bacteria Reduction in Periodontal Tissues  140
5.3 Removal of Subgingival Calculus  142
5.4 Removal of Pocket Epithelium  144
5.5 Retardation of the Epithelial Downgrowth  149
5.6 Laser Application in Gingivectomy and Gingivoplasty  152
5.7 Laser-Assisted Hemostasis in Periodontics  154
5.8 Photodynamic Therapy in Periodontology  156
5.9 Gingival Troughing for Prosthetic Restorations  165
5.10 Fractional Photothermolysis in Periodontology  165
5.11 Education and Future of Lasers in Periodontal Therapy  178

6 Lasers and Implants  185


Georgios E. Romanos
6.1 Introduction  185
6.2 Laser-Assisted Surgery Before Implant Placement and Implant Exposure  185
Contents ix

6.3 Laser Application During Function  187


6.4 Laser Applications in ­­Peri-implantitis Treatment  188
6.5 Recent Laser Research on Implants  199
6.6 Implant Removal  204
6.7 Laser-Assisted Implant Placement  204
6.8 Future of Laser Dentistry in Oral Implantology  204

7 Photodynamic Therapy in Periodontal and Peri-Implant Treatment  209


Anton Sculean and Georgios E. Romanos
7.1 Biological Rationale  209
7.2 Use of PDT as an Alternative to Systemic or Local Antibiotics  211
7.3 Conclusions  212

8 Understanding Laser Safety in Dentistry  215


Vangie Dennis, Patti Owens and Georgios E. Romanos
8.1 Laser Safety  215
8.2 International Laser Standards  215
8.3 Regulatory Agencies and Nongovernmental Organizations  215
8.3.1 Food and Drug Administration  215
8.3.2 FDA Center for Devices and Radiological Health  216
8.3.3 American National Standards Institute  216
8.3.4 Occupational Safety and Health Administration  216
8.4 State Regulations  218
8.5 Nongovernmental Controls and Professional Organizations  218
8.5.1 American Society for Lasers in Medicine and Surgery  218
8.5.2 Association of periOperative Registered Nurses (AORN)  218
8.6 The Joint Commission (TJC)  218
8.7 Standards and Practice  218
8.7.1 Laser Safety Officer  218
8.8 Hazard Evaluation and Control Measures  219
8.9 Administrative Controls  219
8.10 Procedural and Equipment Controls  219
8.11 Laser Treatment Controlled Area  220
8.12 Maintenance and Service  221
8.13 Beam Hazards  221
8.13.1 Eye Protection  221
8.13.2 Skin Protection  223
8.14 Laser Safety and Training Programs  223
8.15 Medical Surveillance  223
8.16 Nonbeam Hazards  223
8.17 Electrical Hazards  224
8.18 Smoke Plume  224
8.19 Fire and Explosion Hazards  224
8.20 Shared Airway Procedures  225
8.21 Conclusion  226

Appendix A: Suggested Reading   227


Appendix B: Physical Units, Laser Parameters, Physical Parameters, Important Formulas  229

Index  231
xi

About the Author

●● Board Certified in Oral Surgery and Implant Dentistry


in Germany
●● Diplomate by the American Board of Periodontology
●● Certified Medical Laser Safety officer (CMLSO) by the
Board of Laser Safety (BLS)
●● former Associate Dean for Clinical Affairs at SBU
●● former Professor of Clinical Dentistry at the Univ. of
Rochester/NY and Professor and Director of Laser
Sciences at NYU
●● Past President of the Academy of Osseointegration
Foundation and the Implantology Research Group of
the IADR
●● Fellow of the American Association for Dental
Research, the Academy of Osseointegration, Int.
College of Dentists, ICOI, ITI Foundation, Pierre
Fauchard Academy, American Society for Laser
Medicine and Surgery, Great of NY Academy of
Prosthodontics, Int. Academy for Dental Facial
Esthetics, American College of Dentists
●● Editorial Board Membership in various peer-reviewed
journals
●● More than 400 publications (h-Index: 66; over 14,000
citations, 6 books)
Georgios E. Romanos, D.D.S., Ph.D., Prof. Dr. med. dent. ●● Over 700 presentations worldwide; International sci-
entific collaborations and teaching activities globally
●● Professor of Periodontology and Director of Laser ●● Lecturer in more than 50 countries
Education at Stony Brook University (SBU), School of
Dental Medicine 2016 Award Recipient for Excellence in Dental Laser
●● Professor (Prof. Dr. med. dent.) of Oral Surgery/ Research (T.H. Maiman) by the Academy of Laser
Implant Dentistry in Frankfurt/Germany Dentistry
●● Fully trained in Periodontics, Prosthodontics and
Oral Surgery in Germany and in USA
xiii

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

Patti Owens, BSN, MHA, RN, CNOR, CMLSO


President of Aesthetic Med Consulting International,
LLC
Laser Training
Rancho Mirage
California
USA
xv

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 Fundamental Principles


Georgios E. Romanos
Stony Brook University, School of Dental Medicine, Stony Brook, NY, USA

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

Advanced Laser Surgery in Dentistry, First Edition. Georgios E. Romanos.


© 2021 John Wiley & Sons, Inc. Published 2021 by John Wiley & Sons, Inc.
2 1  Laser Fundamental Principles

Shortwave
γ-rays X-rays UV rays Infrared Radar FM TV AM
rays

10–14 10–12 10–10 10–8 10–6 10–4 10–2 1 102 104


Wavelength (m)

Visible light

400 500 600 700


Wavelength (nm)

Figure 1.1  Electromagnetic spectrum and the different wavelengths.

There is no way to think about modern life without


the internet, mobile phones, and technology. Therefore,
lasers are everywhere in our lives since lasers are funda-
mental in all these technological advances.
Lasers can do a lot, for example measuring distances,
such as the depth of oceans and in aerospace, based on
the principle that laser light is sent to a target, which
will then be reflected and sent backward. For instance,
laser light can be sent to the moon, collecting a few pho-
tons reflected back by mirrors placed on the lunar sur-
face (such as during the Apollo missions), and then we
know the distance between the moon and the Earth.
The coherent properties of laser light will be used in
ring laser gyroscopes allowing distance measurement in
aircrafts, helicopters, missiles, ships, etc. Bar code read-
ers and scanners exist only in conjunction with diode
lasers. Also, optical storage capacity from compact discs
(CDs) to digital video discs (DVDs) and today Blu-ray
discs depends on the density of coding elements (pits)
and the laser spot after focusing. The shorter the wave-
length, the smaller the laser spot and the engraved sur-
face of the disc. In addition, partial or complete
absorption of the light can be at resonance with the
material medium and create distinguished resonance
frequencies (signals), characterizing the medium com- Figure 1.2  OCT device for clinical and diagnostic
position (spectroscopy). applications. Source: Dr. Georgios E Romanos.
In medicine, cornea surgery, removal of wrinkles, and
coagulation of blood vessels in abdominal surgery
accommodate lasers in daily practice. Also, other appli- high-resolution cross-sectional imaging compared to
cations in laser medical imaging, like the phenomena of the conventional diagnostics due to the reflected light
scattering and absorption of light by tissues, have been by a mirror and by measuring backscattered or back-
used extensively the last few years establishing excellent reflected light.
opportunities in the field of diagnostics. Specifically, OCT (Figure 1.2) can provide cross-sectional images
optical coherence tomography (OCT) today allows a of tissue structure on the micron scale in situ and in real
1.3  ­Properties of the Laser Ligh 3

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”).

Absorption Spontaneous Emission Stimulated Emission

Figure 1.3  Spontaneous and stimulated emission principles.


4 1  Laser Fundamental Principles

●● 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

From the practical standpoint, a laser device (Figure 1.5)


Conventional contains the following components:
light source
●● The laser medium (active medium), which generates
the laser light (this is the “brain” of the system).
●● The optical resonator (reflecting system)
●● The laser pumping mechanism

Laser 1.4.1  Active Medium


Atoms are stimulated to the production of the laser radia-
tion. These atoms are components of the so-called
“active (gain) medium.” This can be a gas, a solid body
Figure 1.4  Collimated light of the laser versus non-collimated (crystal), a liquid, or a semiconductor. Different lasers
light of the conventional light source systems can be classified based on the active medium.

Laser System

Focused
surface
Lens

Active
Medium
Focus
Total
reflective
mirror

Figure 1.5  Schematic demonstration of a laser device.


1.5 ­Laser Application Mode 5

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.

faster than large ones, while larger chromophores have Also:


a longer TRT than smaller chromophores. meanP = Pmax × tpulse × frequency
The TRT is defined as the time needed for the Pmax is the maximum power (watt)
­target chromophore to dissipate 63% of its peak tem- tpulse is pulse duration (second)
perature. Bogdan Allemann and Kaufman (2011) frequency (Hz)
showed different TRTs of importance based on the
chromophore size in dermatology (see Table 1.1). Table 1.1  Thermal relaxation times for different
chromophores of various size.
Contact and non-contact laser modes can be defined
dependent on the position of the optic fiber or tip in
Thermal relaxation
relation to the tissue or material.
Size, μm times (approx.)
Important parameters, when continuous lasers are
used, are the irradiation period, power, and spot size. In Tattoo ink particle 0.5–4 10 ns
contrast, for pulsed lasers maximum energy per pulse, Melanosome 0.5–1 1 μs
pulse duration, frequency, and spot size are fundamen-
Erythrocyte 7 2 μs
tal. Power (in watts) is defined by the transmitted energy
Blood vessel 50 1 ms
(in joules) per unit time.
Blood vessel 100 5 ms
Therefore,
Blood vessel 200 20 ms

P E/t (Frequency 1/t, in Hz) Hair follicle 200 10–100 ms


1.6 ­Delivery System 7

The energy per area is the power density (PD, or fluence)


and expressed in joules/cm2
PD = meanP/S
PD is Power Density (watt/cm2); mean power (watt);
S is the irradiated surface (cm2)
r is the radius of the glass fiber; (S = π . r2), π = 3.14
All parameters that must be included in different
TEMoo TEMxx
laser studies should be: power density, energy of the
laser beam, pulse width and frequency, irradiation Figure 1.7  Transverse electromagnetic modes with regular,
period, diameter of the glass fiber (or tip), beam profile, high concentrated beam (TEM00) and irregular (TEMxx)
pattern with less concentration of the maximum energy in
distance to the irradiation object, and tip angulation. the beam.
Peak Power is the energy flow in every pulse

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.

1.5.1  Beam Profiles


1.6.2  Articulated Arms
The energy distribution across the beam (transverse
electromagnetic mode) determines the nature of laser The laser beam can be used as a handpiece by means of
focus (focal spot size). This focus can have a circular, articulated arms (Figure  1.8) at specific wavelengths
clean pattern (TEM00), or an irregular pattern (multi- (e.g. in the UV range and the wavelength of the CO2
mode, TEMxx). The circular spot is the fundamental laser). In such systems, mirrors are used for beam
mode, with Gaussian (normal distribution) in the deflection. For this reason, such articulated arms are
beam profile, which has the highest concentration of also called transmission arms.
power and can be focused into the smallest, most con- Articulated arm beam delivery dates back to the
centrated focal spot (Figure  1.7). The TEM00 mode is 1970s; it features a cumbersome four-elbow, seven-
the most desirable beam. The fundamental mode with mirror articulation, which can rotate to different
the maximum intensity peak at the center of the beam angles for the transmission of the laser beam, but it
is the TEM00 and contains roughly 86% of the power in can have limitations in accessibility. A lens in the base
the spot. of the handpiece focuses the laser beam 2–3 cm from
Longitudinal modes correspond to different reso- the exit aperture of the handpiece. An articulated arm
nances along the length of the laser cavity which occur is unusable without an aiming beam – the only visible
at different frequencies or wavelengths. The transverse indicator of the focused CO2 laser beam location on
modes are classified according to the number of nulls the target tissue.
that appear across the beam cross-section. However, Although, the beam quality can be described as a very
multimode beams can have high power but lower good one, disadvantages are the large weight of the
quality. articulated arm and thus the entire laser unit, the
8 1  Laser Fundamental Principles

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

combustion products in the case of not-with-window- 1.7 ­Applicators


closed waveguides can contaminate the inner surfaces.
Technological efforts for the optimization of beam con- Applicators are technical devices of the laser unit,
trol systems are intensively carried out in the various which allow direct transmission of the laser beam in the
fields of clinical medicine. tissue. They have the shape of a handpiece or a tube
(fiber applicator).

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

Figure 1.11  Irradiation of soft tissues in the lamb vestibule


using a ceramic tip and CO2 laser (left) and a glass flexible
fiber of a diode laser (right). Observe the superficial
carbonization of the CO2 laser excision compared to the
diode ablation. Different diameter applicators were used
Figure 1.10  Flexible optical fibers for medical and dental (ceramic cylindrical tip for the CO2 and narrow glass fiber for
applications. Source: Dr. Georgios E Romanos. the diode laser). Source: Dr. Georgios E Romanos.

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.

●● Gas lasers (He:Ne, CO2, excimer [ArF or KrF] or


argon laser)
1.8.1  Gas Lasers
●● Solid state lasers (Nd:YAG, Ho:YAG, Er:YAG,
Er,Cr:YSGG, rubin, alexandrite laser) Such lasers use gas as the active medium. These lasers
●● Liquid (dye) lasers (containing liquid colorant as the are relatively inexpensive and can achieve high power
medium, e.g. Rhodamine G6, Coumarin, etc.) in continuous wave mode. Known systems are the CO2,
●● Semiconductor (diode) lasers, so-called GaAs, the argon, the He:Ne, and the excimer laser. In these
GaAlAs lasers (containing semiconductor as the types of lasers, the active medium is stimulated by an
medium) optical pumping mechanism or by electrical discharge.
●● “Free-electron” lasers (using an electron accelerator, Flowing gas is required, and usually there is no need for
not available for dentistry) gas refill for a long lifetime. Such lasers are the main

Table 1.2  Laser systems with applications in medicine.

Wavelength (nm) Laser Active Medium Mode Application

193 Argon fluoride ArF Pulsed Ophthalmology


Excimer
308 Xenon chloride XeCl Pulsed Vascular surgery
Excimer
488 Argon ion Ar CW Various surgeries
511 Copper vapor Cu ions Pulsed Dermatology
514 Argon Ar CW Various surgeries
532 KTP (frequency Nd:YAG Pulsed Various surgeries
doubled Nd:YAG) KTP crystal
627.3 Gold vapor Au ions Pulsed PDT
632.8 Helium‑neon Neon gas CW Biostimulation
647 Krypton Ionized Kr gas CW Retinal coagulation
3+
694.3 Ruby Cr :Al2O3 Pulsed Dermatology
500–800 Dye Dyes CW/pulsed PDT, Dermatology
670–1550 Diode Ga-As CW/pulsed various surgeries
798 Alexandrite Crystal Pulsed Research
1064 Neodymium:YAG Crystal Pulsed Various surgeries
1070 Ytterbium:YAG Crystal Pulsed Dermatology
2010 Thulium Tm:YAG crystal Pulsed Urology
2140 Holmium ThHoCr:YAG crystal Pulsed Cartilage surgery
2940 Er:YAG Er:YAG crystal Pulsed Ophthalmology
10 600 (or 9300) CO2 CO2 CW/pulsed Various surgeries
12 1  Laser Fundamental Principles

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

LightScalpel 2013 Luxar 1991


Luxar (MegaPulse, Lightscalpel)

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)

and other modifications to emit 9.3 μm, matching the


peak absorption of hydroxyapatite. Therefore, it can be
used for removal of decay and also soft tissue excisions
with controlled bleeding. Since this wavelength is rela-
tively new in dentistry, more case series and clinical
applications are needed to demonstrate the long-term
effects of this wavelength on the tissues.

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

Er:YAG (Syneron, Israel)

Figure 1.21  Classic Nd:YAG laser (Pulsemaster 1000;


American Dental Technologies, Southfield, MI, USA).
Source: Dr. Georgios E. Romanos.

Er:YAG (KaVo Key III, Germany)

Figures 1.23 and 1.24  Representative Er:YAG laser devices for


dental clinical applications. Source: Dr. Georgios E. Romanos.

This wavelength is used primarily in the field of micro-


surgery and hard tissue surgery. Soft tissue incisions
and removal can be achieved due to the low penetration
depth. Due to the high absorption rate of the laser beam
in water, this wavelength can be used for the ablation of
enamel, dentin, or bone. Discoloration and carbonized
zones appear in the tissue only at the margins of the
Figure 1.22  Nd:YAG laser device (American Dental Technologies, irradiated area. This can be prevented through an inte-
Southfield, MI, USA). Source: Dr. Georgios E. Romanos grated water-cooling (Keller and Hibst 1995).
16 1  Laser Fundamental Principles

Although different experimental animal and clinical 1.8.2.3  Er,Cr:YSGG Laser


studies have been conducted (Keller and Hibst  1990; Great efforts have been made with the development of
Keller et  al.  1990,  1991), the scientific substantiation the Er,Cr:YSGG laser (2780 nm) for bone cutting. This
through a broad clinical application of this system is wavelength has been used in oral surgery for osteoto-
lacking, in contrast to other dental lasers. mies, osteoplasties, and removal of supernumerary teeth
In osteotomies with the Er:YAG laser, Keller et  al. utilizing water and air spray in different ratios. Further
(1991) observed a minimal zone of necrosis, which com- applications in implant dentistry, like the preparation of
pared to the osteotomies made with the CO2 laser, and the lateral maxillary sinus window, the implant uncover-
led to no wound healing delay. In contrast to these stud- ing, and implant site preparation have also been reported
ies, Nelson et al. (1989) found a delay of wound healing (see also Chapter  6). In addition, in pediatric dentistry
(similar to the CO2 laser) after the application of the and orthodontics, for removal of the frenum, gingivecto-
Er:YAG laser, when no water cooling was utilized. mies, and operculectomies, is an opportunity for soft tis-
Regarding the treatment of the soft tissue, the wave- sue excisions with low complication rates. The
length of this laser is recommended for the ablation of Er,Cr:YSGG laser has a lower water absorption coeffi-
oral mucosa (e.g. surgical removal of leukoplakia or cient compared to the Er:YAG laser and therefore a bet-
lichen planus) (Keller et al. 1990). A clinical application ter penetration depth in the soft tissues. Therefore, the
in areas where there is no major bleeding tendency cutting efficiency is better. Furthermore, this wavelength
(Keller et al. 1990) (e.g. in the removal of benign soft tis- can be used in operative dentistry for enamel condition-
sue tumors, gingivoplasty, and extraorally on the skin) is ing before etching and cavity preparation. Due to the
possible without the need of additional suturing increased interest for use, the company Biolase, Inc. has
(Kautzky et  al.  1992). The Er:YAG laser can be also developed numerous devices for different clinical appli-
applied, as shown in in vitro studies in periodontology, cations (Figures 1.25–1.27).
for the removal of calculus from the root surface (Aoki
et al. 1994). 1.8.2.4  Ho:YAG Laser
Experimental tests with this wavelength were also The Ho:YAG laser has a wavelength of 2.1 μm or 2.01 μm
performed successfully in temporomandibular-joint and in the water a penetration depth of 0.3 mm. It is
(TMJ) arthroscopy, as conventional arthroscopy is used for hard and soft tissue excisions. Currently there
highly time consuming and complex and is associated is only the Ho:YAG laser for dental applications in some
with significant trauma (Mordon et al. 1995). countries. This unit contains two laser sources, making

Waterlase MD Waterlase iPlus Waterlase Xpress


1-25 1-26 1-27

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

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