Laser Technology: Real World Applications

INTRODUCTION
Remember the last time you were thinking about acquiring some new technology for your practice and, even though you wanted to be on the cutting edge, you looked at the price tag and thought, "It will eventually be offered at a price that I would consider buying it." Or, because of the perceived high cost of the new technology, you dismissed it as "not worth it." Then, when patients started to ask you about it, it became clear that you might have to reconsider getting the technology for your practice after all.
Many of us share these inexplicable feelings about purchasing something that is "new" and possibly "just a fad." Lasers have been causing feelings like these for dentists for more than 20 years now; however, not only has the price become more realistic, the very best part of laser technology is its efficacy and value. No longer is laser technology a "new" or "not worth it" investment; with the advent of lasers that are convenient to take from room to room, this has become an indispensible technology that can create a tremendous return on investment.
The use of laser has become an integral part my practice and, frankly, I could not even conceive of practicing dentistry without it. For example, imagine scheduling to insert a beautiful set of anterior restorations, exquisitely constructed, in a dentition with less than ideal oral hygiene. The provisionals you painstakingly constructed are removed in anticipation of the try-ins and hopefully inserts of the finals, yet there interproximally is inflamed tissue. Just cleaning the preparations elicits some bleeding. Does one reschedule the patient, or, consider using medicaments and packing cord to sequester the hemorrhage? Knowing that more potential trauma to the patients' friable tissues occurs with these procedures, a simple low-wattage laser used to gently eliminate bacteria and coagulate these types of "minor that can turn into major" problems becomes an attractive alternative. In my opinion, the convenience, safety, and bactericidal effects of this most vital tool make it a mandatory addition to our armamentarium.
Let's look at some case examples that demonstrate some of the current and clinically predictable uses for modern laser technology.

CASE 1
A 44-year-old woman presented to the office for her routine dental care and we discussed her restricted tongue space due to previous orthodontic treatment, which included extraction of 4 bicuspids. In addition, through the use of a sleep study, she had diagnosed with obstructive sleep apnea (OSA). Upon a closer examination, we noticed the frenum attached almost to the very tip of her tongue (Figure 1), preventing her from being able to protrude it (Figure 2). She was also unable to bring her tongue to a "point" when requested to do so, something that is commonly seen when a patient presents with this condition (Figure 3). We did not notice any problems with her ability to enunciate words; because she had had this condition most likely since birth, she had accommodated for it via development and maturation.

Figure 1. Case 1: Preoperative photo illustrating lingual frenum attached up to the tip of tongue, thus restricting mobility. Figure 2. Lateral view of improperly positioned frenum, preventing
ability for patient to
protrude tongue.
Figure 3. Anterior preoperative view demonstrating the patient's inability to bring tongue to a "point."

Utilizing eutectic mixture of local anesthetic (EMLA) for 2 minutes for adequate anesthesia, and with the laser (NV Microlaser [Discus Dental]) set on continuous wave at 0.9 watts, the tongue was held in place bilaterally with gauze to help lift it to stretch the frenum into a flat shape. A laser incision was initiated at the point right below the estimated desired (projected) tip of the tongue (Figure 4) and was kept perpendicular to the frenum at the base of the tongue. The tip was then carried inferiorly, moving across the frenum from right to left in a downward motion (Figure 5). As the muscle fibers were lased, the tongue was noticeably able to be raised more (Figure 6) as the wound was carried inferiorly to the very base of the tongue (Figure 7). Special attention needs to be paid to Wharton's duct at the floor of the mouth and to carry the incision short of this landmark. Once the incision was completed, the patient was able to raise her tongue much more freely (Figure 8). Also, protrusion, even with the anesthetized feeling, was immediately accomplished with ease (Figures 9a and 9b). Since the frenum release, the patient has undergone treatment to help correct her OSA.

Figure 4. Photo illustrating initial laser incision using the NV Microlaser (Discus Dental) just inferior to the estimated desired (projected) point of tongue. Figure 5. Photo illustrating continuation of the laser incision inferiorly along frenum.
Figure 6. Photo illustrating the patient's increasing ability to raise her tongue as the frenum was being released. Figure 7. Photo illustrating full extent of the incision made for the frenectomy.
Figure 8. Completed postoperative incision for lingual frenectomy.
Figures 9a and 9b. Note the marked improvement in the ability to protrude the tongue immediately following this laser procedure.

Most patients who are tongue-tied have no idea what it feels like to have the lingual frenum released and a more mobile tongue. The tongue, as an organ, is used not only for deglutination, but also for aiding in mastication, speech, and for sexual expression. The tongue is a very strong muscle, only connected at one end. When this connection is too close to the tip of the tongue, mobility and function are reduced. The diode laser is a superb tool to give the patient more freedom of movement, and many patients that have this procedure performed, make comments regarding improved speech, less food retention in the vestibular areas, and even improved kissing ability.

CASE 2
This patient noticed a "space" developing between her "lower front teeth" (Figure 10). Upon closer examination, it became apparent that over time her labial frenum was beginning to "tug" at the interproximal papilla between these teeth (Figure 11). It was apparent that this frenum could be lased in order to prevent the papilla from being pulled away from the gingival attachment.

Figure 10. Case 2: Preoperative anterior view of "space" between lower centrals due to "high" frenum attachment.
Figures 11 and 12. Close-up preoperative views of the offending frenum.
Figure 13. Anterior view of laser incision illustrating how frenum is pulled taut with outward pressure. Figure 14. View illustrating full depth of laser incision into vestibule.
Figure 15. Final view of laser frenectomy illustrating triangular wound that is characteristic of this treatment. Figure 16. One-week postoperative photo of the surgical site. Note that the papilla had already begun to fill the interdental space at this time.
Figure 17. Case 3: Anterior preoperative view of edentulous ridge prior to implant placement.

Utilizing EMLA 2 minutes prior to procedure for adequate anesthesia, the frenum was pulled taut with pressure outward and forward on the lower lip (Figure 13). Then, an incision was carried inferiorly (Figure 14) to the depth of the attachment into the vestibule to release all the offending muscle fibers. Notice the triangular wound created from the surgery in Figure 15. The patient was instructed to leave a cotton roll in the vestibule over the surgical site for approximately 24 hours. After just one week of healing (Figure 16), it became apparent that the papillary tissue between the central incisors was beginning to "creep" back up to the contact point, producing a very desirable outcome (Figure 17).

Practice Management Ramifications of Laser Technology

Amy Morgan
When deciding on introducing new technology, it is essential that the leader have a clear idea of the vision, goals, and strategies for implementation and integration so that the upgrade can be a success. It can be very frustrating to purchase new innovations, only to see them gather dust in the corner for lack of use.
In this article, we are looking at enhancing dental care with lasers.
If part of your practice's vision is to incorporate modern, precision technology that expands the dentist's (and hygienist's) ability to perform a wide variety of procedures, then lasers can be a viable addition to your dental care tool chest. Once you know your vision supports innovation, the next question the dentist needs to ask is, "What do I want to use the laser for?" Your choice of laser and the ensuing cost is intimately connected to the answer to that question. Lasers are being used in a variety of treatments for hard tissue, soft tissue, teeth whitening, sleep apnea, and temporomandibular disorder, to mention a few.
In all of these, lasers can allow for greater precision, while minimizing pain and healing time. As the use of lasers in dentistry is relatively new and evolving, there is not general consensus in the community on all the pros and cons of implementing the different laser usages, so dentists must educate themselves thoroughly on the clinical benefits.
Because lasers can range in cost from $3,000 to $12,000 for applications in the continuing care department, to $35,000 to $45,000 for more advanced procedures, a perceived obstacle has been cost, as well as limited procedures as compared to traditional correctional therapies; It is vital that discussions about fees and insurance coding take place with the team so that profitability is supported.
The potential benefits for patients include:
• Less pain/minimized bleeding
• Less anesthesia
• Decreased anxiety
• Preservation of healthy teeth
• Reduced healing times
•"One stop shop" access to all dental procedures.
These benefits can anchor a strong marketing message that excites existing patients and attracts new ones. The equipment and service itself cannot get the message out. A huge part of the integration plan must be how the message will be featured, ie, Web site, newsletters, articles, direct mail pieces, etc.
The entire team needs to learn new skills to integrate and support lasers in the practice culture. Everyone needs to learn how to educate patients about the new technology and make sure that scheduling and financial arrangements support the new upgrade.
The dentist, dental assistants, and hygienists will all need to learn new clinical skills to support the utilization of lasers with competence and confidence.There is a definite learning curve, and a big concern has been that with the technology continuously evolving, the individuals who are using the lasers are truly qualified to get the best results. The dentist will need to ensure that the training is extensive enough to get the best benefits.
The implementation of lasers affects every area of the office.
• Customized time has to be scheduled for laser procedures.
• The cost has to be added to the fees, therefore financial arrangements and insurance discussions.
• Marketing and education strategies to create buzz, excitement, and commitment.
• Decisions on what clinical uses will be optimal per the practice's vision for care.
Lasers will continue to evolve and more practices will be attracted to their use. Plan well and a laser can be an asset—something patients truly appreciate.

CASE 3
One of the most perplexing fears with the use of the laser is the fear of tissue shrinkage. Additionally, the creation of interdental papilla around adjacent dental implants is also a very difficult and time-consuming procedure. However, with judicious use of the proper armamentarium, this can be routinely accomplished. This case for this 50-year-old female phobic patient, who desired a fixed replacement of her maxillary incisors (Figure 17), illustrates how laser treatment can be used to create beautiful gingival symmetry and form.
The patient had been wearing a maxillary removable prosthesis for more than 25 years to replace her incisors; however, the available bone was surprisingly adequate and her soft-tissue conditions lent themselves well to a predictable result. Once the osseointegration of the implants was confirmed (Figure 18), the creation of ovate emergence profiles was initiated. The diode laser was utilized to uncover the healing screw on the implant at the No. 10 position (Figure 19). Subsequently, temporary healing cuffs were placed into each implant (Figure 20) and were trimmed to proper contours (Figure 21). Once properly contoured, the diode laser was used to create the ovate emergence from each temporary abutment (Figures 22 and 23). Floss was utilized to achieve ideal positioning of the vertical height that was desired for each abutment, with the laterals being approximately one mm coronally to the line between the centrals and cuspids (Figure 24). The completed "preps" are seen in Figure 25. Provisional crowns were then fabricated using a Siltex putty matrix (Ivoclar Vivadent) created from a diagnostic wax-up and Luxatemp Automix Plus (DMG America). These, when properly done, were done to facilitate healing of the tissue around the neck of each implant (Figure 26) and to attempt to create interproximal papilla around each temporary crown. Following a healing time of several weeks, the gingival tissue began to heal with the proper architecture around the splinted crowns (Figure 27). The provisionals were removed, impression posts placed, and impressions taken. Then, the case was sent to the dental laboratory team for the fabrication of 4 zirconium oxide abutments (Zimmer) and 4 lithium disilicate crowns (e.max [Ivoclar Vivadent]).

Figure 18. Anterior view of implants with healing caps in place after osseointegration. Figure 19. Anterior view illustrating the use of the laser to help uncover healing cuff on the implant at the No. 10 position.
Figure 20. Anterior view illustrating all 4 temporary abutments in place, prior to preparation for temporary crowns. Figure 21. Anterior view of preparation of temporary abutments for provisionalization.
Figure 22. Use of the diode laser to contour tissues juxtapositioned to prepared temporary abutments for creation of ovate emergence profiles and proper papillary form for each implant. Figure 23. Continuation of creating proper gingival contours with diode laser.
Figure 24. Use of floss to determine proper height of gingival tissues of laterals compared to central incisors (should be 0.5 to 1 mm more apical on lateral incisors). Figure 25. The completed abutments and gingival contours ready for provisionalization.
Figure 26. Properly contoured provisional (splinted) crowns over the temporary abutments immediately after laser contouring and preparation of the abutments. Figure 27. Temporary crowns after several weeks of healing.
Figure 28. Zirconium oxide final implant abutments (Zimmer) in place. Figure 29. Final lithium disilicate (e.max [Ivoclar Vivadent]) crowns over zirconium abutments, several months after final placement. Notice papillary tissue interspersed between the implant retained crowns and the excellent soft-tissue health.

When the patient returned for final delivery, the provisionals were removed and the implant abutments (Figure 28) and final crowns were tried in place. After confirming the fit, the implant abutments were torqued into place, and the lithium disilicate crowns were luted with a resin cement (Anchor Cement [Apex Dental Manufacturing]) to the zirconium oxide abutments. Several months after completion of the case, final photos were obtained. The patient was thrilled with the results (Figure 29).

DISCUSSION
The incidence of loss of attachment in many patients can predispose them to eventually experiencing muscle pulls from any neighboring frenum or frena. Most practitioners, conservatively thinking, would try to stave off referral to the periodontist for preventative procedures such as these. Often, innocuous looking situations aren't even brought to the attention of the patient, when a 2-minute procedure with a laser to do a minor frenectomy can preclude the possibility of further loss of attachment or the dreaded "black triangle." Most of the time, procedures like these can be done with laser technology using only topical anesthetic; and they can be easily done during the hygiene visit, right in the hygiene operatory.

Technological Implications of Laser Technology

Leslie Silverman, DDS
If, like me, you spend a good chunk of your free time Googling, Skyping, and/or using a mobile device, then odds are you too are a regular or will become (if not wholly addicted) user of laser technology. Lasers are used today to enable everything from high-speed telecommunications to corrective eye surgery to holography to Roger Waters rock concerts to planetarium light shows to measuring the distance from the earth to the moon. In recent years, advancements in laser devices have had perhaps the most impact in the healthcare industry in particular.
While lasers have been replacing scalpels for many decades, it is really only during the past decade or so that applications have become widely commercially available (and viable) to mainstream dental professionals. In the world of dentistry, practitioners have utilized dental lasers to cut tissue more accurately, decrease the need for anesthesia, kill bacteria, eliminate/minimize bleeding, and reduce patient healing time. Practitioners have discovered as well that the technology comes with its potential challenges and drawbacks.
But I'm getting ahead of myself. Let's first review the basics of dental laser technology in general.

HOW A DENTAL LASER WORKS
LASER is an acronym for light amplification by stimulated emission of radiation. Lasers have an internal center (called active medium) that becomes activated. Once activated, a laser emits various wavelengths of nonionizing radiation that targets a specific tissue and affects a thermal reaction within that tissue. The wavelengths range from approximately 500 nm to 10,600 nm and are either an invisible infrared light or a visible light wavelength.
Depending on the tissue that will be targeted for treatment, the clinician deploying a laser must be aware of the most appropriate wavelength and "emission mode."
Wavelength: Soft-tissue applications can use any wavelength as all dental lasers absorb at least one of the soft-tissue components. Lasers used for hard-tissue treatment need wavelengths that will interact with water and components within the bone and enamel.
Emission mode: Lasers send out a pulsing or continuous beam of light energy. The emission mode will affect the length of time the tissue is exposed and hence the amount of heat that will be incoperated into the tissue.
Due to the different parameters that practioners must consider, a few lasers (for example, Discus Dental portable diode laser the NV MicroLaser) now come with standard power presets per procedure making the lasers easier to operate and with less chance for operator error.

NAMES OF LASERS
Lasers are named for the material contained within the core of the device, referred to as the active medium. Dental laser active mediums are either solid rods of crystal, solid state semiconductor wafers, or gas (such as carbon dioxide). Diode laser is the name used for semiconductor lasers. Nd:YAG or Er:YAG are acronyms for crystal lasers.
Examples of lasers are:
• Erbium, chromium–doped yttrium scandium gallium garnet (Er,Cr:YSGG) laser
• Potassium titanyl phosphate (KTP) laser
• Erbium doped yttrium aluminum garnet (Er:YAG) laser
• Carbon dioxide (CO2) laser.

POTENTIAL BENEFITS OF DENTAL LASER TECHNOLOGY
• Certain soft-tissue laser procedures many not require sutures
• Certain procedures may not require anesthesia
• Tissue regeneration and decreased healing time
• Lasers can significantly impact hemostasis
• Lasers allow the practitioner to target highly specific areas without negatively impacting surrounding tissue
• Lasers can have a bactericidal effect
• Potentially enables the practitioner to better multitask and incorporate several procedures into an one-step appointment.
• The portable laser is a major convenience advancement in that it does not require a fiber-optic line that attaches the clinician to the unit. Older models typically come with a wired footswitch. Many newer lasers come equipped with a keyed wireless version of the footswitch, which adds to its useability. 

POTENTIAL CHALLENGES, DRAWBACKS, AND OTHER CONSIDERATIONS
• Because there is no one laser with appropriate wavelength for all dental applications, the clinician needs to make sure to properly align the right laser with the right procedure.
• Learning curve: Training is required to be able to handle a laser device most effectively. More traditional dental devices, for example, are typically both-side and end-cutting. Dental lasers are only end-cutting.
Dental lasers cannot remove amalgams or crowns efficiently.

CLOSING COMMENTS
In short, a dental laser is a more precise medical device which can provide great advantages for both practitioner and patient in many situations. For dentists, lasers help to make procedures more accurate, efficient, and time-effective—the ability to combine previously multistep activities (such as cutting tissue and placing hemostatic agents) into one step is a key example. For patients, dental laser devices have the potential to, among other things, reduce bleeding, bacterial infections, sensitivity and recovery time. At the same time, the adopter must be aware that laser technology is not a solution to every procedural challenge faced in the dental practice.

Many of the most recent procedures involving the use of the laser are not only for soft-tissue alteration, but now also can be utilized to aid in the development of an adequate biologic width to create an area apical to lost tooth structure to establish a new gingival attachment. The laser-assisted new attachment procedure is an excellent example of this. The majority of procedures in most restorative dental practices, however, encompass minor excisional procedures that include but aren't limited to frenectomies, implant exposure, and gingival troughing (versus gingival retraction via cord) for impressions to establish the proper emergence profile for indirect restorations. Dental laboratory technicians are much more able to create a proper contour to allow for ideal gingival health when they can adequately visualize unprepared tooth acreage below the last scratch from the diamond bur.
An added benefit of laser usage for troughing is the inherent ability for the laser to effortlessly destroy potentially pathogenic bacteria in this delicate sulcular area. In my practice, we noticed this originally when 2 adjacent preparations were both exposed, one via gingival retraction with cord, and the other with the laser and gentle troughing. When the provisionals were removed in anticipation of the final inserts, the tissue was noticeably healthier around the tooth that was lased, versus the one that was exposed via retraction cord. We notice anecdotally now, however, that many of the patients who return several weeks after wearing their provisionals, have much improved gingival health due to the benefit of reducing/eliminating bacteria in the sulcular areas that were necessary to expose due to previous decay or missing structure.
The lack of hemorrhage also is a very important added benefit of allowing the operator to actually see what one is doing, providing a much more clean and visible operating field. More defined cuts can be performed as well as creating circular depressions in tissue to allow for the development of ovate pontics with provisionalization over the operating site. Finally, quicker healing with less postoperative sequelae also can be obtained with procedures using lasers, due to the previously mentioned elimination of bacteria in the operating site. Again, anecdotally, our patients seem to complain less about postoperative discomfort with the use of the laser, as compared to the use of conventional surgical intervention using the scalpel.

CLOSING COMMENTS
The use of the laser now is routine in the restorative offices across the country, and after a very short learning curve, most dentists can perform gingival troughing, frenectomy procedures, minor gingivectomy procedures, crown exposures, and the like…all with comparative ease. Numerous adjunctive procedures, such as the use of a laser to remove tooth colored restorations via breaking the bond have recently come to pass, are increasing the dentist's ability to treat all different types of scenarios.
It is the author's opinion that with time, this bloodless and minimally invasive treatment modality (when indicated) will become the standard of care treatment tool for situations like those demonstrated in the case examples presented herein.


Dr. Voller practices in Kittanning and Pittsburgh, Pa. He is a 1980 graduate of the University of Pittsburgh School of Dental Medicine. Dr. Voller attained Fellowship, then mastership in the AGD, and is a Fellow in the Academy of Dentistry International. He also serves on the board of advisors for the Academy of Comprehensive Esthetics (acesthetics.com) in which he also has attained Fellowship status. Dr. Voller has lectured nationally and has authored numerous articles on restorative and laser dentistry, prosthodontics, and orthodontics. He can be reached at (724) 543-4948, at (412) 406-8100, or at vollersmiles.com.

 

Disclosure: Dr. Voller reports no disclosures.

Dr. Silverman serves as a senior consultant at Pride Institute. Drawing on her years in private practice, Dr. Silverman has helped hundreds of dental practices nationwide achieve their clinical, organizational, and business objectives. She lectures frequently on topics that include reducing practice stress, optimizing financial results, and maintaining work/life balance. She can be reached via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Silverman reports no disclosures.

Ms. Morgan serves as the CEO of Pride Institute. She is a dental consultant and international lecturer. Over the years, Ms. Morgan has facilitated the successful revitalization of thousands of dental practices using Pride Management Systems. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Ms. Morgan reports no disclosures.



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