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Contents

Contributors Preface Foreword 1. Physical C o n s i d e r a t i o n s of S u r g i c a l Lasers
Terry A. Fuller

ix xi xiii 1

2.

P r a c t i c a l Laser Safety i n O r a l a n d M a x i l l o f a c i a l Surgery . . . .
Lawrence M. Elson

11

3.

Specific G u i d e t o t h e Use o f Lasers
Lewis dayman, Richard Reid

19

4.

Preneoplasia of the O r a l Cavity
Lewis dayman

37

5.

Papillomas and H u m a n Papillomavirus
Richard Reid. Myron Slrasser

55

6.

Soft Tissue Excision T e c h n i q u e s
Lewis dayman. Paul Kuo

63

7.

Transoral R e s e c t i o n o f O r a l C a n c e r
Lewis dayman

85

8.

O u t p a t i e n t T r e a t m e n t o f S n o r i n g a n d Sleep A p n e a S y n d r o m e w i t h C 0 Laser: Laser-Assisted U v u l o p a l a t o p l a s t y
2

111

Yves-Victor Kamami. James W. Woolen

9.

T h e C a r b o n D i o x i d e Laser i n Laryngeal Surgery
Robert J. Meleca

121

10.

Uses o f Lasers i n D e n t i s t r y
Harvey Wigdor

127

viii

Contents 11. P h o t o t h e r a p y w i t h Lasers a n d D y e s
Dan J. Castro. Romaine E. Saxlon, Jacques Soudanl

137

12.

Laser P h o t o t h e r m a l T h e r a p y f o r Cancer T r e a t m e n t
Dan J. Castro. Romaine E. Saxlon. Jacques Soudant

143

13.

Laser-Assisted T e m p o r o m a n d i b u l a r Joint Surgery
Steven J. Butler

151

14.

E n d o s c o p i c Sinus S u r g e r y : A S i g n i f i c a n t A d j u n c t to M a x i l l o f a c i a l Surgery
Jeffrey J. Moses. Claus R. l^ange

157

15.

Laser B i o s t i m u l a t i o n : P h o t o b i o a c t i v a t i o n , a M o d u l a t i o n o f B i o l o g i c Processes by L o w - I n t e n s i t y Laser R a d i a t i o n
Joseph S. Rosenshein

165

16.

Laser Tissue Fusion
PaulKuo

175

17.

Laser A p p l i c a t i o n i n M i c r o g r a v i t y , A e r o s p a c e , a n d Military Operations
I'aul Kuo. Michael D. Colvard

179

Appendix Glossary Index

181 183 185

This chapter presents the fundamentals of laser physics and introduces the reader to the interactions between light and tissue. has transformed lasers into versatile and valuable surgical instruments. coherent (synchronous waves). colored from passing through a filter. or gas. High-energy radiation is pumped into the active medium by means of a pump source. or as discrete (and the smallest) parcels of energy called photons. is a device for generating a high-intensity. an acronym lor light amplification by stimulated emission of radiation. Such light emanates in all directions from its source. Atoms (ions or molecules) at their lowest energy or ground state possess an intrinsic amount of energy.1 • Physical Considerations of Surgical Lasers f Terry A. In recent years improved understanding of light-tissue interactions and. The absorbed energy is subsequently and spontaneously released (spontaneous emission) in the form of a quantum of energy corresponding to the difference between the ground and excited states (E. carbon dioxide ( C 0 ) . and wavelength (\). or other forms of energy. 2 the radiation in the visible region of the spectrum (Fig. except in the fields of ophthalmology and dermatology. and collimated (parallel rays). however. Early applications of lasers in oral and maxillofacial surgery began to appear in the mid. — E = E ) . When excited through the process of absorption by the input of thermal. 2 a A 2 LIGHT THE LASER Electromagnetic radiation is energy transmitted through space. The spontaneous emission of photons from an excited atom may occur at any time and in any direction. 1-1) defines the color of the light. All particles making the transition between the same two energy levels will emit light of identical energy and wavelength (Fig. In 1963 the ruby laser was employed in the treatment of pigmented dermatologic lesions and for photocoagulation of the retina. it stimulates the emission of a second photon of light. As discussed below. Maiman created the first operational laser in 1960. The pump source is energy generally provided by an intense optical or electrical discharge. An active lasing medium. unreliability. liquid. represents a broad spectrum of many wavelengths. It can be viewed either as propagated waves of characteristic energies.to late 1970s. This was followed within 3 years by the development of the argon. expressed in metric units of length. ostensibly parallel beam of monochromatic (single wavelength) electromagnetic radiation. The intensity diminishes as the inverse square of the distance from the source. This second photon has precisely the same energy or wavelength and is spatially and temporally synchronous with and traveling in exactly the same direction as the initial photon. limitations. and operational complexity of the early machines greatly limited the actual use of lasers. The wavelength of Lasers consist of a small number of basic components as shown in Figure 1-3. Ordinary sunlight or lamplight consists of many wavelengths. a laser uses the principle of stimulated emission to produce light of a markedly different quality. The possibility of stimulated emission was predicted by Einstein in I9I7. is enclosed within a laser cavity bounded by two perfectly parallel reflectors (mirrors). Fuller HISTORY A laser. they are raised to one of several distinct higher energy levels. which remain the most widely used lasers in medicine. and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers. which can be a solid. based on the work of Gordon in 1955 and Schawlow and Townes in 1958. 1-2). Which units are employed in any particular application is largely a matter of convention. new technologies for delivering laser light to (he tissue. but the cost. The energy from the pump source is absorbed by the active 1 . even light. Full appreciation of the uses. and risks of surgical lasers requires a basic understanding of laser physics and the biologic action of light. Potential advantages of surgical lasers were clear from the beginning. electromagnetic. benefits. they will yield an amplifying cascade of photons—laser light—that is monochromatic (a single wavelength). Electromagnetic radiation is quantified in terms of two reciprocal forms of measurement: frequency (v). a photon of E strikes an atom already in an upper energy stale E . of greatest importance to the surgeon. a ruby laser emitting a brilliant red beam of light. If these two photons strike additional atoms in the excited state E-j. expressed in Hertz (Hz) or cycles per second. until the past 15 to 18 years. If.

molecular. The gases are either sealed in a tube or are circulated from a tank. Figure 1-2. This is a condition known as a population inversion and is a necessary condition to generate laser light. medium until the majority of atoms. Electromagnetic spectrum.6(H) nm 2 . enabling some of the light to escape the cavity as a beam of laser light. The excited C 0 molecule spontaneously decays and emits mid-infrared photons at a wavelength of 10. ions. CO? Laser Carbon dioxide lasers employ carbon dioxide gas (in addition to other gases required for sustained stimulated emission of radiation) as a lasing or active medium. The properties of the most common surgical lasers are listed in Table 1-1. Thus. light of characteristic wavelengths. emit Energy slate diagram.2 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry Figure 1-1. The two parallel reflectors are situated at the ends of the laser cavity and act to constrain the light along and within the axis of the cavity. or molecules are raised to their upper energy state. Light traveling in other directions escapes the cavity and is lost as heal. Different lasing media. the carbon dioxide absorbs a portion of this energy and raises the CO> molecule to an upper energy state. One of the mirrors is only partially reflective. the light is repeatedly bounced between the reflectors. or ionic structure and energy levels. This will stimulate the emission of even more photons (amplification) in that axial direction. because of their particular atomic. When excited by direct current (DC) or radio-frequency (RF) voltage.

000 W in a repeating train of pulses. (10. Power (measured in units of watts. Table 1-1. 20W SSOmJ 250mJ LASER TYPE C0 Holmium Nd:YAG Diode KTP/KDP Argon Excimer ArF -XcCI Erbium: YAG(Er: YAG) 2 WAVELENGTH 10. In contrast to CW surgical lasers.100 nm 1. W) is the lime function of energy (measured in joules. rapidly repeating pulses typically referred to as superpulses.064 nm 800-890 nm 532 nm 488/514 nm.A. which generate power up to 100 W.. Characteristics of Surgical Lasers SPECTRAL REGION Mid-Infrared Near Infrared Near Infrared Near Infrared Visible Visible Ultraviolet Ultraviolet MODE CW & Gated & Superpulsed Pulsed CW & Pulsed CW Pulsed CW Pulsed Pulsed TYPICAL MAX POWER I00W CW l5Wavg. The carbon dioxide laser can be pulsed in a manner thai results in high energy. The delivery system used to carry Ihe laser light to the lissue is of critical importance to the surgeon. a second low-power visible laser [typically a red beam from a helium-neon (HeNe) laser or visible diode laser) beam is precisely aligned and coaxial with the C 0 laser beam for aiming purposes. the superpulsed C 0 laser generates power up to 10. This is in contrast to very thin. 1992. continu2 2 . conventional pulsing. Therefore. J) and can be delivered either continuously (continuous wave. 190 nm 308 nm Reproduced with permission of T. 2 Infrared light is in a region of the electromagnetic spectrum that is not visible to the human eye. modified from Fuller TA.Physical Considerations of Surgical Lasers 3 Figure 1-3. The C 0 laser generally uses an articulated arm as its principal delivery system. Inc. CW) or in a train of pulses. IO0W CW > 50W 25Wavg. Philadelphia: Surgical Laser Technologies. There are substantial differences in clinical effect between CW. An articulated arm is a series of hollow tubes connected together through a series of six to eight articulating mirrors. Basic laser components.600 nm 2. Thermal Surgical Lasers.6 pm). and superpulsed modes of operation (see Chapter 3)..F.

aluminum. Both commercial and prototype surgical diode laser systems are able to deliver 20 to 50 W. To gain useful power from the laser. Currently. The Q-switched laser emits pulses of pico. The result is a beam of green light at 530 nm. Due to its inherently inefficient operation and certain thermal design considerations. They are operated in a manner similar to a transistor in which an electric potential is applied to dissimilar semiconductor materials. no secondary aiming beam is required. and have no required moving parts. Additionally. The Nd:YAG portion of this laser system generates a wavelength of 1064-nm energy whose frequency is doubled (wavelength is halved) on passing through the KTP crystal. The C O laser is primarily used for cutting and vaporizing tissue in open procedures or in procedures where rigid endoscopy is acceptable. glass (fused silica) fiber optics generally used for near infrared and visible lasers. the Nd:YAG laser requires an aiming beam similar to that used by C 0 lasers. although technologically very different from each other. the Nd:YAG laser can be configured to operate in a special pulsed mode referred to as Q-switched. solid state. this laser requires an aiming beam. The active medium of this laser is the neodymium atoms doped into a matrix of yttrium. This mode is often 2 In contrast to the gas and solid-state lasers discussed thus far. multiple devices must be used in concert. W/cnr) is intimately related to the tissue effect. The argon laser employs an electrically excited ionized argon gas as a lasing medium. In addition to the CW mode of operation. Glass is opaque to 10. In contrast to gas. this laser is pulsed. and liquid lasers. The holmium:YAG laser is technologically associated with the Nd:YAG laser. energy) can be practically delivered to tissue and the means by which the power can be conveyed to tissue. Since the light is visible.YAG Laser The neodymium. ously flexible. and garnet.YAG Lasers Argon and frequency-doubled Nd:YAG laser (also referred to as a KTP laser). glasses used for the green lasers necessarily block green light and thus tend to obscure the overall visualization of the surgical field. Individual "highpower" laser diodes typically generate only 1 to 1^ W per diode. Safety glasses for this laser are transparent to visible light and do not obscure the surgeon's surgical view. This relatively efficient laser generates a wavelength of 1064 nm and is outside the visible region of the spectrum. ganging individual diodes in various optical configurations are being explored: each approach carries its own benefits and drawbacks. Like the NdiYAG laser. The power density can be altered by changing either the power of the laser or spot size . This laser emits bluegreen light at 488 and 514 nm. aluminum. no arc lamps or optical pump sources.4 Lasers in M a x i l l o f a c i a l Surgery and Dentistry used in ophthalmology to disrupt the posterior capsule in secondary cataracts or in shock-wave lithotripsy. They are very efficient (typically >30—35%).600 nm light and thus is not suitable for C O laser transmission. However. The high heat transfer requires a water-jacketed cooling system. Diode Laser Nd. the most popular diode lasers emit light in the 800to 890-nm range. but arc capable of generating only relatively low power levels. The emission from both the argon and KTP lasers can be transmitted through flexible glass fiber optics thai can carry the light to the surgical site. The KTP laser uses a Nd:YAG laser in combination with a potassium titanyl sulfate (KTP) crystal. The neodymium atoms are optically excited by way of a bright arc lamp. diode lasers are in a category of devices that emit light from semiconductor materials. The technological specifications of a given laser type and model indicate how much power (or in the case of a pulsed laser. Safety glasses are required to protect the patient and operating room personnel from the therapeutic beam of all surgical lasers. This solid-state laser uses holmium as its active medium doped into a matrix of yttrium.to nanoseconds in duration. The holmium:YAG beam can be delivered through fiber optics. Lasers in the shorter wavelength range provide biologic effects similar to those of the Nd:YAG lasers. are devices that generate laser energy in the green region of the electromagnetic spectrum. : : Holmium: YAG Argon and Frequency-Doubled Nd. However. The surgical Nd:YAG lasers commonly deliver continuous (CW) power up to KM) W and can be passed easily through inexpensive flexible fiber optics. This distribution or power density or fluence (power/area. There are currently severe fiber optic size and maximum power limitations as well as diode and system warranty and lifetime issues. It emits rapid pulses of energy at 2100 nm in the mid-infrared part of the spectrum. which permits power outputs of up to 25 W. such fibers must be made of low OH (hydroxyl radical) glass due to the high absorption of this wavelength to water. When laser energy interacts with tissue its output power is distributed over the area of an illuminated spot. semiconductor lasers require no high voltages or currents. and garnet. More portable. Longer wavelengths have higher tissue absorption characteristics. air-cooled units arc limited to power outputs of 5 to 10 W.yttrium-aluminum-garnet (Nd:YAG) laser is a solid-state device that generates light in the near infrared region of the spectrum at 1064 nm. Therefore. Linear (one-dimensional) arrays or two-dimensional arrays are being developed to gain sufficient power for surgery.

excise. Light that is transmitted through or reflected from tissue yields no effect until and unless it is absorbed. if desired. The extent of the area of vaporization.1 Figure 1 -4. duration of exposure. 1-5). resect or ablate tissue. and include blanching and shrinkage as well as puckering due to dehydration. Thus. scattered. The effect that a particular laser emission has on tissue. This section presents an outline of the principal variables affecting the clinical end point. These so-called thermal lasers represent the majority of all applications of lasers in medicine. Coagulation provides hemostasis and. Temperature gradients in tissue. lasers that are Q-switched or lasers that operate at low powers for biostimulation or photodynamic therapy (PDT) interactions are excluded herein from discussion. and method of delivery of laser energy as well as tissue parameters. wavelength. vaporization of liquid and solid components occur. The goal of laser surgery is thus to create a temperature gradient (Fig. and coagulation (as well as a heat-affected zone surrounding the coagulation. char. incise. When the temperature is elevated near and above the boiling point of water (100°C). 1-4) or profile in tissue that will result in coagulation or vaporization of tissue. The utility of the thermal laser resides with its capability of providing the surgeon the ability to accurately predict the nature and extent of a thermally induced laser lesion in tissue. There are several variables that determine the gradient. 5 THERMAL LASER—TISSUE EFFECTS The focus of this book is on the interactions of laser energy and tissue that result in an elevation of the tissue temperature. and thus the surgeon's ability to effectively utilize that emission. the surgical effect can be altered. Only by matching the characteristics of the laser beam and the tissue can one begin to accurately predict the effect that the laser will have in surgery. transmitted. Thus. Vaporization (the conversion of solid and liquid phase tissue components into gaseous phase components) provides the ability to cut. Coagulation generally occurs when the temperature is elevated from 60°C to <100°C. Light can be absorbed. a (measured in units of c m ) . as a result of the combustion of tissue) surrounded by coagulated tissue. depends upon power density and other specifications as well as the characteristics of tissue. Coagulation and vaporization are two different effects created by the same process: heating of tissue. The measure of the degree to which tissue absorbs light is the absorption coefficient. which can cause edema) is defined by the temperature gradient. necrosis of tissue. It is a measure of the amount of energy ab.Physical Considerations of Surgical Lasers of the laser beam. by altering the gradient. or reflected by tissue (Fig. . Obvious changes occur in the tissue at these temperatures resulting from the thermal denaturation of tissue protein. Only light that has been absorbed can yield a therapeutic result. They include the laser parameters such as power density. A frank defect is left that includes a zone of char (carbon.

heavily pigmented skin or vascular areas such as a hemangioma will result in high absorption (low penetration). B./T. The intense thermal response quickly evaporates the water and vaporizes tissue. The more highly absorbed the light (high a). and therefore results in intense surface heat. In some instances scatter is an attribute desired by the surgeon.0 mm of the tissue surface.YAG lasers would create high surface temperature and very steep temperature gradients in the tissue. The method of delivering the laser light to the tissue also acts as a variable affecting the tissue response. The scatter of the green lasers are greater than that of the C 0 laser. In general terms this delivery of energy falls into two broad classes: free-beam lasers and lasers lor use in contact with tissue. The y-axis indicates greater absorption (less penetration) and thus higher resulting temperatures. Both the C 0 and EnYAG laser beams are preferentially absorbed by water. A tissue with a high « will create a steep temperature gradient. It can be readily seen that the C 0 and erbium (Er). when Nd:YAG laser energy is used to thermally destroy a tumor. techniques exist to diminish coagulation necrosis. the deep penetration of the laser beam coupled with the high scatter coefficient affects a deep and wide volume of tissue. Scatter of light by tissue spreads the laser beam in a diffuse pattern defined by the tissue's scatter coefficient. The duration of exposure is another key variable in determining the extent of a laser-induced lesion. The result of application of the superpulsed laser is the reduction of coagulation necrosis by 50% over the CW laser operating at the same average power. high peak power pulses with pulse energy 2 2 : . The superpulse C O laser is one such example. By way of contrast. For example. Long exposure times result in conduction of heat into surrounding lissue and thus improve hemostasis and increase coagulation necrosis. and because water is by far the largest component of most tissue.r Figure 1-5. The penetration depth of the laser in a given tissue is proportional to the inverse of the absorption coefficient «. this results in the light energy being converted to heat energy within a shallow layer of tissue.INC. The green light from the argon and KTP lasers is both scattered and absorbed by tissue. Thus.6 . Once the light is scattered. This laser uses rapidly repeating. it will affect a volume of tissue larger than Ihe laser's optical spot size. this results in the rapid transformation of light into heal within about 0. Ihe Nd:YAG laser will penelrate deeply in tissue with a relatively low surface temperature and shallow temperature gradient. if it is absorbed.A. scatter can also be detrimental if one is attempting to localize the effect of the laser. The temperature gradient is so steep that it has relatively poor coagulation properties. In contrast.6 Lasers in M a x i l l o f a c i a l Surgery and Dentistry OW?3SLT. Interactions of light and tissue. 2 sorbed through a distance of the absorbing material. Figure 1-7 illustrates the absorption of light by tissue at different wavelengths. As can be seen in Figure I .2 to 1. The degree of absorption is heavily dependent on the concentration of the chromophores hemoglobin and melanin. In contrast. in the range of 50 to 120 mJ/pulse. the shallower the penetration.

Power/depth and temperature/deplh.Physical Considerations of Surgical Lasers 7 Figure 1-6. Figure 1-7. . Light absorption by composite tissue.

Consider the laser beam exiting a laser delivery system used in a free-beam mode (Fig. Noncontact vs. The tips have several different sizes and shapes and can be easily affixed to the end of fiber optics. rather than by alteration in wavelength. 1-8. This is typically what occurs when there is no contact between the fiber optic end of the delivery device and the target tissue. left). contact laser surgery. A decade ago researchers developed a delivery system in which an optical device is placed in direct contact with the tissue during laser surgery to increase the delivered power density and reduce changes in power density due to changes in distance to the tissue. Contact Laser surgery has been developed to augment and overcome this and other fundamental deficiencies in free-beam surgery. micromanipulators used in conjunction with surgical microscopes. . : Modification of Free-Beam Laser Contact Laser Surgery Surgery: Despite the benefits of free-beam laser surgery. This is accomplished by use of interchangeable contact laser probes and scalpels (tips) made from synthetic sapphire or fused silica. The techniques for learning and using the freebeam laser are substantially different from those of conven- tional instruments. the power density at the tissue will change. Several benefits result from the use of these tips (Fig. and conventional fiber optics. Substantial energy is reflected (Qf) or lost as heat and in smoke (Q»)The free-beam method of delivery provides certain advantages over conventional surgery by providing a method for "non-touch" surgery.8 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry FREE-BEAM LASERS Free-beam (sometimes referred to as noncontact) lasers are devices that permit laser energy alone (without influence by the delivery device) to interact with tissue. In addition to providing the Figure 1-8. causing the final clinical result. Typical free-beam delivery systems include articulating arms. Nd:YAG for coagulation and hembstasis and CO for incision and excision. Perhaps the most limiting feature of the free-beam laser is that different laser sources are required for different surgical maneuvers. The beam will converge (or diverge) as it exits the focusing lens and some portion of the energy will be reflected from the tissue on impact. e. an expensive and intraoperatively difficult task. but suffers from the loss of tactile feedback. They result from interactions between the native laser wavelength and tissue alone. 1-8. The interactions between laser light and tissue described above are specific for free-beam lasers.g. certain limitations and drawbacks exist.. right). Characteristic of these devices is that the effect on tissue is principally that of the laser emission alone. one must choose different laser sources. changing the clinical effect. Contact Laser surgery works by altering the tissue temperature gradient through changes in the laser delivery system. Should the distance from the fiber to the tissue be altered. Perhaps the most significant is that to substantially change the tissue's temperature gradient (clinical effect).

By placing a small amount of light ab- . A frustroconical tip. The Contact Laser attributes thus far described. but the angle of divergence of the beam. a sense lost in free-beam surgery. it will elevate the temperature of the tissue by thermal combustion in addition to the radiation heating caused by the native wavelength. the ends of fiber optics themselves can also be shaped. as can be seen in Figure 1-9. The improved efficiency in coupling of light into the tissue results in the requirement of less power. surgeon with tactile feedback. This means. Alterations in the tip's shape can result in a low divergence angle. Altering the tip configuration of a probe and scalpel makes it possible to change not only the spot size (and thus power density). The wavelength conversion effect does not result in changing the wavelength of the laser. By adjusting the Wavelength Conversion Effect material on the probe tip. Thus. Since the absorbing material is in contact with the probe and the tissue. Changes in temperature gradient and tissue effect by wavelength conversion effect surface treatments. sorbing material integrally between the contact tip and the tissue. still result in a tissue effect that is solely dependent on the absorption of the laser emission by the tissue to generate the temperature gradient. This event is referred to as the Wavelength Conversion Effect. In addition to placing tips onto the ends of fiber optics. Depending upon the quantity and distribution of the absorbing material the contact tip can mimic the effect of other laser wavelengths. can mimic the tissue temperature profile and effect of various lasers. creating a region of high power density that drops rapidly with distance. one can titrate the amount of laser light exiting the tip in comparison to the amount of heat generated by absorption at the tip. 1-8. right). concentrates the laser light on a small. it changes the effect the wavelength has in the surgical situation. The energy absorbed will be converted to heat and will result in a very high temperature. the reflection of light from the tissue is significantly reduced. in most cases a reduction of 40 to 50% (Fig. It is a major attribute of Contact Laser surgery to have the temperature gradient altered by the Contact Laser tip. a portion of the energy will be absorbed by that material. in essence. although they lack the mechanical strength and thermal resistance required for extended and precision use. by use of this absorbing material the tissue temperature gradient induced by the laser emission has been altered. for example. that a single laser in combination with different interchangeable tips. and controlling power density. rather.Physical Considerations of Surgical Lasers 9 Figure 1-9. precisely defined distal area from which light splays out at a wide angle.

spot size contour. depending on its spot size. etc. Each different type of laser produces a different wavelength (color) of light that is absorbed by specific target chromophores within tissues. 2-1). time of application. which determines the rate at which energy is delivered to the tissue.). However. Of the several types of judgment errors. which is determined by the intensity of the focused beam. and the energy density (joules/cm ).2 Practical Laser Safety in Oral and Maxillofacial Surgery Lawrence M. After having appropriately decided to use a laser. depending on the energy density used. the carbon dioxide laser (10. HAZARDS OF LASER SURGERY Judgment Errors As is the case with surgery. can photovaporize or coagulate tissue with up to several millimeters of thermal damage adjacent to the zone of clinical laser treatment. Ultimately. helium-neon (HeNe). and mode of operation [continuous wave (CW) or pulsed|.g. 1 1 2 2 The argon laser emits a blue-green light of 488 and 514 nm. This radiation must be clearly differentiated from ionizing radiation exemplified by x-rays and gamma rays. the depth of this laser's photovaporization or photocoagulation effect is directly dependent on the power density (watts/cm ). lasers have been studied in oral and maxillofacial surgery for the treatment of soft tissue lesions and occasionally for the cutting of bone. This powerful laser is delivered to the surgical site by an optical fiber or contact probe. power. This mandates that the surgeon understand the applied laser physics and laser-tissue interactions at the selected wavelength.). Hazards of the carbon dioxide laser in oral and maxillofacial surgery (OMFS) include corneal. energy level of the beam. it becomes necessary to match the wavelength. oxyhemoglobin at 488 and 540/577 nm (double absorption peak). The technical skill to manipulate the laser delivery system safely to protect patient. judgment error may be as harmful as the use of inappropriate surgical technique. the most severe is misdiagnosis or misinterpretion of the disease state being treated. power. Therefore. carbon dioxide (CO. when this same light comes into contact with shiny surgical instruments. Since human tissue is mostly water. scleral. medical personnel and particularly pregnant women working with or around lasers may do so without the risks.. and operating room personnel must be acquired through instructional courses resulting in proper credentialing for each wavelength used. highly parallel beam of coherent light. The thermal damage produced adjacent to the surgical site by diffusion of heal can be reduced to a range of micrometers. Optical hazards of this laser are similar to that of the argon laser and include retinal and skin hazards (Fig. For example. surgeon. and resulting energy density. In tissue. power. This laser. each surgeon should be proctored by a properly credentialed laser clinician at (he hospital in which the surgeon practices for each type of procedure for which privileges are desired. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser emits an invisible 1060-nm (near-infrared) light that is heavily absorbed by pigmented tissue. reflection will occur. Both the patient and the medical personnel are at risk for these injuries. it absorbs virtually all of the laser energy without significant reflection or backscatter from the surgical site. and cutaneous injury ranging from transient pain to severe burns. It can photovaporize or photocoagulate almost all biologic tissue with which it comes in contact. which is selectively absorbed by the red chromophore. argon (Ar). El son A laser is a device thai produces an intense. Since the late 1970s. The optical hazards of the argon laser include retinal and skin burns.associated with x-rays. It is delivered to the target tissue by an optical fiber.600 nm—middle infrared) light is absorbed heavily by water. It is named after the composition of the excitable medium from which the laser beam emanates [e. In some cases. Irreversible thermal damage adjacent to (he zone of photovaporization is minimized by using the highest controllable power density for the shortest amount of application time. Light emitted by these surgical lasers is generally in the visible and infrared regions of the electromagnetic spectrum and is nonionizing. The zone of thermal damage of the Nd:YAG laser may extend as much as I cm beyond the surgical target site consequent to a deep penetrating effect that is not observable at the time of treatment. which may produce deleterious effects on living tissue. and absorption characteristics of the tissue receiving this energy. and energy densities to the target tissue absorptive characteristics to best eradicate the lesion. patients. Prior to patient use a "test spot" is made on a moistened wooden tongue blade to assess the coaxial HeNe aiming beam. residency training may substitute for a laser 11 . The biologic effect of this light on tissue is dependent upon wavelength.

or eyelid and have the potential to burn or damage these areas. Skin Hazards Even though.e. Wet drapes or gauze sponges should also be placed over the patient's skin and teeth outside of the surgical site. and patients. i. and head and neck surgery photovaporize or photocoagulate tissue..(KM) times! The eye must always be protected to prevent visual field defects or blindness. This happens when the laser is either misfired during the course of surgery or when an assistant carelessly places a hand in contact with the laser beam. Optical Hazards Since the clinical lasers utilized in oral. the laser technician must be ready to change the laser to the "standby" mode whenever an interruption in laser use is encountered. Simultaneously. from a laser usage standpoint. pulsed dye.]. scleral epithelium. it is imperative that all individuals in the operating room. Failing to limit the extent of the laser's lateral heat conduction by the untrained clinician may produce a conduction burn that extends well beyond the laser surgical site. 2-3) or glasses with side shields to be worn by all personnel whenever the laser is : operating. This will protect their eyes from direct exposure to misaimed laser light as well as from specular reflections from instruments or tissues at the surgical site. and the near-infrared Nd:YAG laser's energy will easily be transmitted through the eye directly into the retina where absorption may produce a burn (Fig. depending upon the procedure (i. Depending on the laser's wavelength. etc. and . but the preceplorship credentialing program is still required. All facilities using lasers must therefore have available appropriate wavelength-specific goggles (Fig. It is therefore most important for the clinician to keep his foot off the foot pedal until ready to fire the laser. Therefore. Other important locations at risk of exposure in oral and maxillofacial surgery include the patient's facial skin. they are painful and may be damaging. and soft tissues. The resulting injury may potentially be substantial. Other near-infrared lasers [erbium (Br):YAG and holmium (Ho):YAG[ and middle infrared lasers such as the C O laser are absorbed by the water in the cornea. wear adequate eye protection while the laser is being used. This might well prove disastrous. potassium titanyl phosphate (KTP). and must warn them to keep their hands away from the surgical site when the laser is in operation. they all have the potential to damage the eye. preventing damage to the eye. A laser impact on a tooth has the potential to damage the enamel. teeth. technicians.12 Lasers in M a x i l l o f a c i a l Surgery and Dentistry Figure 2 .1 . Nd:YAG laser procedures).e. Laser light that is focused through the lens of the eye will increase its effective power up to l(K). in addition to wavelength-specific glasses or goggles. course. penetrate into the pulp chamber.. skin hazards are regarded as a minor nuisance. For protecting the patient. nurses. gold vapor. it is also acceptable to place wet gauze or eye pads across the closed eyelids and. It is also very important to remember that improper use converts the laser into an expensive electro cautery unit. HeNe. The most common mishap occurs when the laser operator's or assistant's hands pass in front of the working laser beam causing a burn. different tissue effects will occur. These laser protection devices should have an optical density (OD) stamped or imprinted on them along with the wavelength and/or name of the laser for which they arc to be used. Visible light laser radiation [argon. Nd:YAG-induced relinal burns in a rabbit retina. Nd:YAG-induced retinal burns in a rabbit retina. 2-2) and partial loss of vision or even blindness. The material coating the lenses of these goggles or glasses absorbs and disperses the incident laser energy. Figure 2 . The clinician should also inform the support staff of the danger of laser injuries to tissue. surgeons. an aluminum-metal type of eye shield should be placed over the gauze or pads. maxillofacial.1 .

) . (C) and nearultraviolet radiation.Practical Laser Safety in O r a l and M a x i l l o f a c i a l Surgery 13 Figure 2-2. ( B ) middle. Absorption site of (A) visible and near-infrared radiation. (Reproduced from Laser Institute of America*s Laser Safety Guide. far-infrared radiation and middle ultraviolet radiation.

Examples of these combustible materials include disposable drapes made from wood pulp. and rubber glove. and plastic instruments (Fig. wooden tongue blade. The greatest source of danger in surgery of the oral cavity is the endotracheal tube itself. . To reduce the potential for igniting the draping material by the laser. gauze sponges. Other safety-enhancing techniques to reduce tire risk include reducing the oxygen content of the anesthetic mixture Figure 2—4. this author advocates the use of polypropylene surgical drapes because in my experience when hit by an incident laser beam they melt rather than burst into flame. The stainless steel body of the armored endotracheal tubes will resist perforation by the laser. It is important to have an airtight endotracheal tube with a metal reflective exterior. A tooth damaged by the laser is caries resistant but unsightly. Goggles that are wavelength specific. The cuff at the distal end of the tube should be tilled with a saline and methylene blue dye. Foilwrapped endotracheal tubes are not recommended because of the possibility that hand wrapping may leave an uncovered area that is susceptible to a laser burn. Special care must be taken to prevent the tube from coming into contact with the laser during surgery because ignition of the endotracheal tube produces a tire with a blowtorch effect inside the patient's airway (Figs. causing ignition.14 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry shatter the tooth. All lasers used in the operating suite have the potential to ignite materials on the surgical site and produce a fire hazard. indicating to the surgeon and anes thesiologist that a laser-related puncture of the cuff has occurred. the blue solution will spill. tipped applicators. dry cotton swabs. Fire Hazards Figure 2-3. New "laser safe" endotracheal devices are available for use during laser surgery. 2-4). cotton. If the laser beam penetrates the cuff during surgery. 2-5 and 2-6). Laser burns in combustible materials present at surgery: gauze. wooden tongue blades.

The following protocol is recommended for an airway fire: simultaneously stop lasing. anesthesiologist.Practical Laser Safety in O r a l and M a x i l l o f a c i a l Surgery 15 Figure 2-5. "Is the pack removed?" The anesthesiologist must understand the surgical procedure being performed as if he himself were performing the operation. However. Figure 2-6. deflate the cuff. assess the airway for burns and foreign bodies (e. Methylene blue liquid lilling cuff escapes. cease ventilation. extinguish flames using saline solution from a nearby basin. and insertion of wet cottonoids or gauze sponges as a hypopharyngeal throat pack.. anesthesiologist. rapid planned intervention may be lifesaving. he should ask the surgeon. ventilate the patient's lungs with l(K)% oxygen by bag and mask. it may be possible to continue with the proce- . Covered foot pedal. These serve as additional protection for the endotracheal tube by absorbing laser light and ensuring greater protection for the patient. and operating room staff must always be prepared and have a written plan of action should an airway fire occur. laser technician. and remove the endotracheal tube. the anesthesiologist should record the time of placement and removal of the pack. Next. In the event of this dramatic and frightening complication. The surgeon. If the damage is minimal.g. turn off all anesthetic gases. Ignition of oxygen-filled endotracheal tube results in ignition and creation of a blowtorch-like effect. As always. and nursing staff in a safety-oriented environment is essential for successful and safe surgery. to 30%. the surgeon must know of any potential anesthetic problems so that both the surgeon and anesthesiologist may foresee and avoid mishaps. it should also be remembered that the surgeon must remove these wet packs from the patient's throat upon completion of the procedure. Simultaneously. tracheal tube and packing materials) by using a bronchoscope. communication between surgeon. Cuff of endotracheal tube penetrated by C O 2 laser beam. At the end of the case. including oxygen. As for all throat packs. Make sure the entire tube is removed.

Consequently. the laser should be turned off and a service representative should be called in immediately to evaluate the extent of the problem. 6 7 dure. etc. If the damage is extensive. they should be kept in a locked room to maintain equipment safety and security. medical staff..3 u. and serves as the resource person for the education of hospital staff. podiatrists. However. and nursing staff.. ADDITIONAL LASER SAFETY INFORMATION Each institution that uses lasers clinically should appoint a laser safety officer (LSO) to oversee and ensure the safe use of lasers in its facility. Contact with the fully charged capacitor located inside the laser cabinet may result in electrical shock or even death by electrocution. should be wiped with a hospital-approved sterilizing solution after each laser procedure. it may be necessary to control airway ventilation by inserting an endotracheal tube or performing a tracheostomy. extreme caution is advised in regard to proceeding even in the case of minimal observed damage. As a result of the uncertainty surrounding the seeding ability of this plume material in humans. The LSO evaluates all laser use policies and procedures.. and repair of electrical components in these specialized lasers be performed only by factory-trained technicians. Antibiotics and large dose steroids should also be given. electrical hazards have the greatest potential to be lethal. Laser safety warning signs should be placed on the door of any operating room using lasers prior to usage. Most surgical lasers use high voltage and high current electricity. operating room tables. therefore. The initial observers of this phenomenon cau5 . Currently. Once approved by the laser committee. The laser plume is primarily composed of vaporized water (steam). Use of a high-volume laser smoke evacuation apparatus that filters smoke particles to 0. etc. evaluation. Maintaining the suction wand within 4 cm of the surgical site to remove as much of the plume as possible is recommended. It has also been reported that laser smoke contains many toxic substances. and answers questions regarding laser capabilities. Jn 1993 these researchers reported the first transmission of laser plume-related disease in cows. which are treated as hazardous waste and disposed of in biohazard bags.1 u. e. and should be followed. This smoke has been found to be irritating to those operating room personnel who come in contact with it. which combine to produce a malodorous scent.g. as well as to the laser companies and fiber-optic manufacturers.m. such as formaldehyde. These signs should include the type and power of the laser being used. dentists. Lastly. if possible. and other airborne mutagens. physicians. remain a reservoir of lethal electrical current. additional research is being conducted nationally regarding this issue. goggles and face masks should be worn to prevent the splattering of tissue from the surgical site onto the eyes and noses of those performing or assisting during the procedure. All operating room windows should be covered with Plume Hazards One of the few negative aspects of using lasers in surgery is the resulting smoke or laser plume—a by-product of laser surgery. It is mandatory that inspection. When working with infected patients or those at high risk for HIV/hepatitis.. If a service representative is not available. etc. ventilation proceeds using humidified gases. the laser aspect of the procedure must be immediately terminated (unless a standby laser is available). Lastly. this information should be disseminated to the employees of the operating room staff and to all laser surgeons. and cellular products. all surgical instruments. These incidents have occurred as a result of either untrained and/or unauthorized individuals opening the closed laser cabinet or by technicians who did not follow prescribed electrical safety procedures. a proactive stance should be adopted. if the electrical malfunction indicator light goes on during a procedure. hydrocarbons. All lasers must have their keys removed when not in use and. The laser's direct current (DC) capacitors also have the ability to remain charged for hours after the laser has been turned off and unplugged and. 4 Unfortunately. The particles have an average size of slightly larger than 0. the laser safety officer and the surgeon must report the incident to the appropriate hospital quality improvement and risk management departments. Only LSOapproved personnel should have access to operate the laser equipment. and a report must be filed with the Food and Drug Administration.m is recommended. hydrogen cyanide.16 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry tioned against overreaction because it could not be proven that these particles could seed themselves in unsuspecting human hosts. with several fatalities having been reported since the initiation of the use of lasers in surgery. carbon particles. microscopes. It is recommended that a laser safety policy and procedure be written in each institution using laser to treat patients. human papilloma virus DNA has been identified in the plume during the surgery for removal of papillomas. Disposable gloves and sterile technique should be used to change evacuation filters. 4 Electrical Hazards Of all the laser surgical-related hazards. identifies potential laser-related hazards. The LSO should attend a laser safety officer course to assist in the proper performance of his/her duties. as written. The laser-charred material should be wiped from the surgical site and the cloth and paper products used during the laser procedure disposed of using proper biohazard handling.

Practical Laser Safety in O r a l and M a x i l l o f a c i a l Surgery an opaque material while lasers are being used so no laser light can escape and harm an unsuspecting bystander. This is not necessary during C O | laser procedures because its emission is absorbed by plastic and glass. An extra pair of laser goggles should also be placed on the door handle of the operating room so that a person entering the room will have adequate eye protection. All clinical lasers should be examined weekly and their power output should be monitored regularly with a power meter. This data should be recorded for the LSO's monthly quality assurance reports and for medical/legal record-keeping. Remember foot pedal safety: When the laser is not in use, the clinician's foot should be removed from the pedal. If the laser is not being used for a substantial period of time, the laser should be placed in the standby mode with the approval of the clinician. The covered design of the foot pedal helps prevent accidental activation of the laser. A basin of saline should be available to be utilized in the event of fire for each laser procedure. Remember: In Case of fire, use the laser fire safety protocol and act quickly. Do not use water to extinguish fires on electrical equipment.

17

All operating room personnel should know where and how to use the fire extinguishers located near the operating room. Remember: P.A.S.S.—pull, aim, squeeze, sweep.

REFERENCES
1. dayman L, Fuller T. Bcckman H. Healing of continuous-wave rapid superpulsed. carbon dioxide, laser-induced bone defects.
J Oral Surg 1978:36:932-937.

2. Reid R. Elson L, Absten G. A practical guide to laser safety.
Colposc Gynecol Laser Surg 1986:2(3): 121 -132.

3. Rontal M. Rontal E. Wenokur M. Elson L. Anesthetic management for tracheobronchial laser surgery. Ann Owl Rhinol Laryngol 1986:95:556-560.
4. Sosis MB. ed. Problems in Anesthesia: Anesthesia for Laser

Surgery. Philadelphia: J.B. Lippincott; 1993. 5. Intact viruses in C 0 laser plume spur safety concern. Clin Laser Month I987;5(9): 101-103. 6. New research confirms laser plume can transmit disease. Clin Laser Month 1993;! l(6):8l-84. 7. Recommended practices for laser safety in the practice setting. AORNJ 1989:155-158. 8. American National Standard: For the safe use of lasers in health care facilities. ANSI 2136.3. 1988.
2

3

specific guide to the Use of Lasers
Lewis dayman, Richard Reid

CARBON DIOXIDE LASER
2

Why Use a Co2 Laser? The C 0 laser emits a coherent light beam in the mid-IR region at 10,600 nm which is near a major spectroscopic absorption peak for water. Because the target chromophore is water and all tissues contain water, all tissues have the capability of interacting with the C 0 beam. The extent to which this interaction will occur, and therefore the extent to which it may be controlled, is determined by the water content of the tissue and the irradiance, fluence, and geometry of the C 0 laser beam (also see Chapter 1). This laser has unique application in the evaporative ablation (photovaporization) of superficial mucosal disease of the oral cavity. It can also function as a precise thermal knife for the excision of soft tissue lesions affecting mucosa or skin (Chapter 6). Properly used, the C 0 laser will produce results either superior to or not achievable with a scalpel or electrocautery. The following are the advantages and disadvantages of the C 0 laser.
2 2 2 2

The carbon dioxide ( C 0 ) laser, which is the workhorse of contemporary laser surgery, is a molecular gas laser emitting in the mid-infrared (IR) range configured in either flowing gas or sealed tube form. In the former, the continuously degrading active medium is replenished with fresh gas and the laser consistently produces power outputs of up to 100 watts (W). It is noisy but reliable. The sealed tube laser is of smaller size and lower output power. Its lower maintenance requirements make it suitable for office use. To bring the laser light to the target tissue, two basic delivery systems have been developed: an articulated ann and a waveguide. At present, there is no commercially available fiber-optic delivery system, although feasibility for one was demonstrated when a prototype was developed by Terry A. Fuller in 1982. The articulated arm consists of a series of metal tubes, linked by freely movable joints containing precisely aligned mirrors that maintain the laser beam in the center of each segment of the arm. This prevents degradation of beam integrity within the articulated arm. The distal end of the articulated arm is attached to a handpiece containing a focusing lens, or to a micromanipulator attached to an operating microscope (Figs. 3-1 and 3-2). A flexible hollow waveguide, consisting of a small diameter metal tube coated with a highly reflective material applied to its interior, is available for some C 0 lasers, generally with maximum power outputs of less than 20 W. The laser beam bounces from point to point within the waveguide to reach the handpiece. The greater flexibility of this delivery system permits increased freedom of movement, allowing the operator to reach less accessible areas of the oral cavity and oropharynx. Additional flexibility is achieved by outfitting the waveguide with curved or contraangled lips. In contradistinction to the articulated arm system that attaches to either a handpiece containing a focusing lens or a microscope, the waveguide system does not transmit the laser beam through a lens system. The beam, as it emerges from the latter, immediately begins to diverge. Therefore, the focal point is considered to be at the tip of the waveguide. Divergence is rapid, resulting in a more rapid decrease in power density than is the case for an articulated arm-focusing handpiece system.
2 2

Advantages 1. Improved operating conditions: • Rapid incision or ablation (evaporative photovaporization of tissue). • Minimal damage to normal tissue adjacent to the area of treatment. • Preservation of histologically readable "margins." • Good intraoperative hemostasis. • "Quiet field" secondary to lack of muscle contraction of the target tissue during laser surgery. • Sterilizing action of the beam at its point of application to the tissue. • No need for elaborate "prep" of the operative field. • "No touch" technique permits surgery in difficult to reach locations (vocal cords, esophagus, paranasal sinuses). 2. Improved patient benefits: • Minimal postoperative swelling. • Very low infection rates. • Minimal scar formation. • Elimination of the need for skin grafting in floor of mouth surgery. • Healed tissue is supple and maintains normal healing capability if repeat surgery is required. 19

20

Lasers in M a x i l l o f a c i a l Surgery and Dentistry • Possible source of unexpected injury to patient, staff, or surgeon. • Laser-specific education and credentialling required for surgeons. • High cost of equipment.

Rational Basis for the

Use of the

C0 Laser
2

Figure 3 - 1 .

Handpiece and articulated arm.

Figure 3-2.

Microslad.

• Healing is more rapid than for other thermal instruments (diathermy, cryoprobe " ). • Minimal tissue handling is required.
1 2 4

Electromagnetic radiation reaching the target tissue is reflected, transmitted, scattered, or absorbed. Ultimately, absorption determines the effect of the laser on the tissue. For the C 0 laser, absorption is proportional to water content. Therefore, tissues with high aqueous content like epithelium, connective tissue, or muscle readily absorb the incident beam. This is especially true for corneal epithelium, which, because of its high water content, completely absorbs the laser energy within 50 |xm of the epithelial surface. Therefore, the corneal thermal lesion is very superficial.' Tissues like muscle and skin, which have less water content, suffer greater thermal damage of respective depths of 0.055 mm and 0.25 mm in response to continuous wave (CW) C 0 at low power density (PD). In comparison, nonaqueous tissues like bone, tendon, or fat are poor absorbers that may sustain more heat damage. Using a rapid superpulsed (RSP) beam instead of CW will minimize the heat effects. In addition, bone will rapidly melt thereby becoming even more anhydrous, resulting in excessive heating even to the point of incandescence followed by actual flaming with continued application of the beam. For anhydrous tissue like bone, one must use a shorter wavelength laser like the erbium:yttrium-aluminum-garnet (Er:YAG) (2.92 |xm) or the holmium (Ho):YAG (2.127 u.m) to avoid the excessive heating occurring with C 0 . The other commonly used lasers in head and neck surgery, neodymium (Nd): YAG and argon, respectively, have pigmented chromophores for targets. Argon has affinity for the red pigment of hemoglobin, whereas Nd.YAG is selective for the dark pigments of melanin and protein. Nd:YAG is usually used for excision as a contact laser with a sapphire or silica tip. Argon, on the other hand, is used for photocoagulation of vascular lesions with a fiberoptic or handpiece deliver)' system. The intensity of the tissue interaction also depends on the energy of the incident beam.
2 S 2 2 7

Disadvantages Operative: • Loss of tactile sense with which surgeon is most familiar and comfortable. • Additional safety requirements for use in the operating theater. • Laser safety personnel (laser technician) required in operating theater. • Anterior floor of mouth surgery is complicated by microstomia, limited mouth opening, or other anatomic abnormalities. • Special attention required to avoid contact with the endotracheal tube.
5 6

Beam energy is inversely proportional to wavelength. Hence, wavelength determines whether a laser beam will produce ionization (excimer lasers) or thermal interactions (dye. argon, potassium titanyl sulfate (KTP), Nd:YAG, EnYAG, Ho:YAG, and C 0 lasers). In addition, wavelength also determines whether absorption will be color dependent (dye and Nd:YAG) or color independent (excimer and C 0 ) . Thermal damage is a function of the optical properties of the incident energy as well as of effects induced by the absorbed irradiation.
2 2 7,9

As the incident beam is absorbed, some heat is generated within the medium unless the application time is so short and the fluence is so low that there is no useful effect on the target tissue. Therefore, some heat effects must be accepted

Recent studies have shown that even a single pulse will change the absorption coefficient of water."' This effect is further exaggerated if the tissue has become charred. the pulse width for CO. so does the depth of absorption. which radically alters its optical and absorptive properties. The damaged tissue zone adjacent to the vaporization crater represents a thickness of only 50 to 200 L U I I measured from the histologic tissue specimen. Using a superpulsed laser of adequate fluence. in turn.m. the volume of tissue injury is approximately 40 to 50 times greater than that for C 0 . For a free-beam Nd:YAG delivered by optical fiber in the same water model the absorption depth was 4 to 6 m m .''" It is this extremely high absorption of the thermal energy of the laser beam within a small volume of tissue lhat permits the laser to selectively remove the target tissue while having minimal heal effects on the surrounding tissue. whereas Nd:YAG is absorbed in a much larger volume of water but with less vaporization. so it is very difficult to estimate the true extent of thermal necrosis. 3-4). ' ' ' " ' ' In addition. This becomes more pronounced with repeated laser "hits" particularly at the base of the vaporization crater. To minimize lateral heat conduction. and therefore potentially reversible. The resultant crater consists of a vaporized area surrounded by a zone of carbonization (charring). as the temperature increases during the pulse. This extreme containment of the energy within a small volume of tissue results in instantaneous boiling of water within the tissue. sharply defined zone at the crater margin. For mid-IR lasers. with an intense heating effect in a small volume of water. laser in water demonstrate an intense heating effect that is restricted to a small volume of water. thermal injury "" (Fig. now becomes reduced to 10% of its initial intensity.5 to 2. crater depth conforms closely to the true level of thermal destruction. the critical volume of tissue required to absorb 90% of the incident radiation is defined by the reciprocal of the absorption coefficient. Argon effects arc intermediate. which causes the formation of steam. The C O . in which. which results in a slightly greater depth of penetration than was predicted. This is the fraction of the incident light absorbed by (he tissue. = / / 1 0 . The effect is more pronounced for the C 0 laser at 10. H & F. must be less than approximately 1 ms. this advantage for C 0 may readily be lost 2 2 16 2 I1 = I0 • 10-A* This equation may be simplified by setting tissue thickness {X) equal to 1/ot so that /. Studies of laser-target interactions for the C O .' ) o r / . However. with YAG there is no immediately visible change in the tissue surrounding the zone of vaporization. The clinical significance of the above property is that the amount of tissue removed under direct visual observation represents nearly the entire amount of vaporized and damaged tissue actually removed. coagulation necrosis is limited to a narrow. because of extensive scatter. This is somewhat greater than the volume of absorption of water in laboratory studies. as the temperature increases the absorption coefficient decreases. How is it possible for a thermal instrument to remove the target tissue without having excessive heating cause destruction of the surrounding normal tissue? Tissue interaction with a laser beam is defined by the volume of absorption of the laser beam by the target tissue. what you sec is what you get! This is its great difference compared with the Nd:YAG laser. the absorption peak decreases.0 m m . in which energy levels do not reach the vaporization threshold (Fig. For water. results in explosive disruption of tissue at the impact site. Under these circumstances. with a depth of absorption of 0. basically. which is in turn bordered by a zone of sublethal. thus: 2 21 Figure 3-3. 0 0 The incident transmission /. beam is complc(ely absorbed. The entire energy of the impact beam was absorbed in a depth of water of only 39 to 90 u. Therefore. " This great differential in the water absorption model predicts events occurring in soil (issue. which emit near the 1940-nm absorption peak for water. 3-3). During healing the optical properties of the target tissue do change. thermal damage extends progressively deeper into the tissue.. 12 13 . as the energy from repeated laser pulses accumulates. This. This becomes understandable by considering Beer's law according to which the incident light transmitted through the target tissue (I1) is inversely proportional to the absorption coefficient (u) and the thickness of the irradiated tissue (X). Zones of damage. Using a contact tip converts Nd:YAG into a predominantly thermal instrument with reduced depth of absorption compared with free-beam Nd:YAG. = / ( 1 0 . Therefore.Specific Guide to the Use of Lasers in the course of the performance of useful work by most lasers. With the superpulsed C 0 laser.600 nm. At conditions of vaporization the absorption coefficient may change by a factor of 10\ Therefore.

120 X 5/6).\ 22 Lasers in M a x i l l o f a c i a l Surgery and Dentistry Figure 3-4. Conversely. On the other hand. Hence. 120 X 1/10). In addition. Consequently. the electrical pulsing of a 120-W laser tube. but not by lateral heat conduction from the laser crater. rapid superpulse has one major disadvantage: the choice of a short duty cycle will reduce power output accordingly. During this time. optimization of tissue effects must occur. the C 0 laser. which may also contribute to reduced wound contraction and scarring." (Courtesy T.) if used inexpertly. as previously discussed. Healing postoperatively will not occur until the damaged tissue is repaired. This is accomplished by using high-power densities at pulse widths shorter than the thermal relaxation time of the target tissue. " '' There are also fewer myofibroblasts in the healing laser wound than in the conventional wound. Unfortunately. For conventional thermal instruments to work. Fig. Fuller. This is partly a function of the duty cycle in the pulsed mode of operation. an interpulse interval at least twice as long as the pulse width permits significant. Ph. in practice. selecting a 1:9 duty cycle would produce an output of only 12 W (i. Gaussian distribution curve.e. rapid superpulse is generally reserved for situations in which small tissue volumes need to be treated with maximal precision. which is a slow process.. governed such that the ratio of on/off time (duty cycle) will never exceed 5:1. A short pulse duration is chosen to permit photovaporization effects to predominate over photocoagulation thereby minimizing lateral heat transfer. Because the peak power of each pulse is not amplified. maximal output would be 100 W (i.m wide. for example. in which the laser tube is electrically pulsed to emit broader. but not complete. see Chapter 4. In short. When used at the highest duty cycle. can be administered as a series of pulses that remove tissue through explosive vaporization by the direct thermal effects of the laser radiation. one must understand that the COi laser is an instrument that works by thermal destruction (Table 3—3) as do conventional instruments like the electrocautery or the Shaw scalpel. However. Hence. to achieve the desired wound characteristics listed above. an electronically pulsed laser tube does not have a refractory phase when used in the chopped mode. Tissue removed occurs within the area delined by the "vaporization threshold. ''" 2 17 1 1 1 21 Irradiance (Power Density) Once again. which slows down the rate of tissue removal. Consider. Therefore. repetition rate can be increased to virtually any frequency. healing begins quickly after laser surgery and reepithelialization occurs before excessive collagen (scar) is deposited. heat-damage adjacent to the vaporization crater is generally restricted to a zone less than 100 to 200 u. flatter pulses with a shortened interval between pulses. the tissue is burned. Therefore.e. as pulse frequency approaches a duty cycle of . A handy compromise between the high precision of rapid superpulse and the high power of continuous wave is obtained from the chopped mode (actually chopped CW mode. The actual volume of heat necrosis is largely dependent on the application time of the laser.. tissue cooling between pulses. lateral heat conduction results in absorption of heat in a progressively larger area of tissue. 4-15). D.A. they must maintain contact with the tissue during a lag phase until the target tissue is heated to the necessary temperature.

minimal carbonization.^ 3 . 0. changing the spot size will affect PD exponentially. whereas changing the inline laser power output will affect PD only linearly. which is the rate at which energy is delivered. of the exit beam. As experience was gained. carbonization (carbon appears as target tissue temperature reaches approximately 150°C) Photovaporization (ablation). Consequently. in which the beam is interrupted by a shutter.Specific Guide to the Use of Lasers 2:1. The pulses themselves may be delivered in two different modes: superpulse. With a superpulsed laser of adequate fluence emitting pulses shorter than the thermal relaxation lime of the target tissue. and the clinical effects will resemble those of a continuous wave laser. Physical cooling of the tissue with iced saline also helps reduce unwanted heat transfer during lasing. denaturation.1-second pulse on a moistened wooden tongue depressor. Fluence (Energy Density) 23 3. thermal damage becomes a function of the optical properties of the incident energy. Use of low irradiance by excessively defocusing the beam. cooling the operative field with iced saline before lasing and prior to each raster is helpful in reducing unwanted heat damage. Thus. This provides excellent control of a cool beam. the best compromise is a duty cycle of about 1:1 producing 60 W of power output. approximately same rate of cutting as for a scalpel Plasma formation. superficial hemostasis. There is a wide distribution of power densities used for photovaporization. as it became apparent that there was a specific relationship between PD and clinical effect. Power Density (PD) (W/cm ) 2 In addition to power density.000 W/cm >50. Failure to remove carbonized debris from the wound before using the laser for its second application. target tissue temperatures may reach 3(X)°C Ultrarapid photovaporization. Irradiating a bleeding point at low PD. However. succumbing at 47°C. 2 2 To calculate PD.000 W/cm > 10* W/cm 2 2 2 . This results in the loss of the major benefit of laser use: selective tissue removal. which heals the blood at the surface but does not coagulate the cut blood vessel. A typical pulse duration is 150 to 300 u. not by changing power output at the beam source (Table 3-1). In contrast. one may now select the appropriate PD for 2 Table 3-1. and d is the measured diameter in millimeters of the imprint left by a 10-W. RSP lasers may produce peak pulse powers of individual pulses that exceed 500 W. 22 23 Consequently. acoustic shock waves: tissue destruction by mechanical disruption rather than thermal denaturation > 10. This causes cooking.s at approximately 50 to 150 mJ/pulse with an intcrpulse interval of several milliseconds. thermal incision Incision of tissue. the very short duration of the pulse reduces power output compared with continuous wave function. POWER DENSITY < 100 W/cm > 100 W/cm 2 2 Power Density and Tissue Effects EFFECT 17 25 600-2500 W/cm 2 Desiccation. 2. warming Photovaporization. 2 2 Curve Table 3-2 represents the early experience of the section of oral and maxillofacial surgery during the first year of C 0 laser use at Sinai Hospital of Detroit in 1979-1980. The actual average power output for a pulsed laser corresponds with the duty cycle during which the pulse is actually occurring. Since the inverse square law of light applies here. which will ablate small volumes of tissue very precisely. PD clustered around several restricted ranges. the greatest control by the operator on laser effects will be by altering power density through changes in focus and beam geometry. 24 Learner's Energy Energy (joules) = Power (watts) X Time/(sec) A given amount of energy will destroy the same volume of tissue independent of the rate at which that energy is delivered. a reasonable approximation is given by PD = . It is this technique error of prolonged time of application that causes thermal damage. in watts. The fluence may be delivered in continuous or pulsed modes. in which pulsing occurs within the laser tube (rapid superpulse. It must exceed the vaporization (ablation) threshold for mucosa (4 J/cm per pulse) or skin (5 J/cm per pulse).^ = 100 W/cm 2 where VV is power. The same applies for nonkeratinized oral mucosa • at PD < 350-400 W/cm . measured by the laser power meter. RSP) or "chopped" (gated) continuous wave. resulting in PD <50O-60() W/cm for keratinized tissue. not coagulation! Remember that soft tissues suffer coagulation necrosis at temperatures above 58°C and bone is even more sensitive. when pulse duration exceeds thermal relaxation time. heat accumulates at the surface of the impact crater and lateral heat conduction begins. The following errors most commonly lead to unwanted heat damage: 1. one must also consider the fluence (energy density). However. while preserving about half of the intcrpulse cooling. Therefore. the effects on the target tissue as well as on the surrounding tissue differ greatly depending upon the rate of energy delivery. heat will accumulate at the impact site.

Learner's curve. Fuller. temperatures at the impact crater may increase Figure 3-5.) . A.D. Ph. denaturation and subthreshold heating. thereby contributing to thermal conduction. However. ablative vaporization or incision and rapidly learn how quickly to move the beam across the target tissue to achieve the desired effect. Anhydrous conditions can cause excessive heating. (Courtesy T.24 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry Table 3-2. Irradiance (PD) must be kept high enough to vaporize tissue quickly because low irradiance results in desiccation. the peripheral 14% still heats the tissue. Beam Geometry: Gaussian Distribution of Energy The energy within the laser beam follows a Gaussian distribution pattern with the usable component occupying the central 86% of the beam. and even flaming. Beam profile: transverse and cross section. This is the working "spot size" of the beam. carbonization. Consequently.

or even worse than. (2) enhanced visual resolution increases both beam control and monitoring of direct tissue effects. which ruptures the epithelium at the level of attachment of keratinocytes to the basement membrane. Each pass of the C 0 laser beam will cause a bubbling effect at the surface wherein the target tissue becomes opalescent. This is accompanied by a crackling sound similar to that of pulmonary rales. Both spot size and depth of field at any given wavelength will vary with the focal length of the objective lens. 3-6). particularly after being modified by the lenses within a handpiece. MD and Carlo Clauser. providing high PD that is suitable for incision.' ' Recall that the exit beam. that caused by electrocautery. There is variation within the beam profile that follows a Gaussian distribution and is readily seen at the target site where the shape of the impact crater replicates 1 16 The objective of ablation is to selectively remove part or all of the mucosa according to the operator's choice. The maximum power density is higher. and the beam geometry is therefore sharper for the handpiece compared with the microscope at maximum power densities. Defocusing the beam either by moving the handpiece away from the tissue or by adjusting the microslad device on the microscope by rotating its tuning dial to alter spot size will flatten out the beam. The operating microscope of long focal length objective (300-400 mm) produces a relatively large minimum spot size (approximately 0. To achieve proper depth. The presumed mechanism is that flash boiling of both intra. overlapping by about one third.3 mm) with a shallow depth of field. The characteristics of the beam are also modified by the delivery system. which is similar to. (Courtesy L. the vaporization crater is placed deep in the parabasal layer of mucosa or skin. or by the microscope's objective lenses. Destruction of the first plane removes only the surface epithelium. while the handpiece objective (125 mm) produces a very small spot (0. This is the intrinsic difference that makes the handpiece the instrument of choice for rapid incision. One wishes to flatten the beam profile until the amplitude of the beam is about half that of the spot diameter (Fig. so that at the tissue the beam is slightly divergent. Amplitude beam » 5 spot diameter.and extracellular water occurs. will produce a beam contour as seen in (Fig. dayman. This first layer of removal is also referred to as the first raster. and actual bubbles occur on its surface (Fig. or to the sound of Rice Krispies in milk. DMD. the microscope is most suitable for ablation if target anatomy permits its use because it provides these advantages: (1) keeping the beam normal to the tissue maintains a circular spot size of constant PD (using the defocused handpiece in a "pencil grip" is more likely to permit obliquity and an oval spot size of nonuniform PD). MD. However. the laser spot is manipulated to describe a series of parallel lines.6 mm) with excellent depth of field. 3-8). 3-7). This increased heating causes a burn. Beam profile in bone: cross section of C 0 beam: RSP mode. does not contain energy of uniform density. 3-5). Both systems destroy collimation.Specific G u i d e to the Use of Lasers 25 the energy profile of the incident beam (Fig. Therefore. in focus at high PD (left and center) and lower PD (right) (frozen ox femur).) 2 THE PLANES OF TISSUE DESTRUCTION IN ABLATION First Plane Figure 3-7. Figure 3-6. from 100°C to >600°C. Removal stops at about the level of the basement membrane. Either of these two distinctive signs (opalescence and bubbling) can be lost if deep penetration beyond 2 . A highly focused beam.

Third Plane Figure 3-9. Magnified view (I6X) of collagen network deep to ablated epithelium after wiping away epithelial debris. Second Plane Thermal destruction to the second plane removes all of the epithelium and some of the upper submucosa. for removing cutaneous scars or keloids. shining. or for skin the papillary dermis. It is somewhat delayed because the heat-damaged tissue must be removed by phagocytosis before reepithelialization begins. at the same PD as the first but perpendicular in direction. following which there will be delayed healing and some scar formation. Visual end point: appearance of treatment area after second and linal raster has been applied perpendicular to the initial raster. but predictable zone of coagulation necrosis. which allows one to recognize these landmarks in skin: (1) coarse collagen bundles appearing as gray-white fibers after epithelial ablation: and (2) a network of arterioles and venules running parallel to the epithelial surface (Fig. This is achieved by applying a second raster. this will be limited in use to removal or recontouring of intraoral skin grafts. 3-10). the surgical site will show a roughened surface of yellow color. There will be no bleeding. There is minimal heat damage to the deeper submucosa (or reticular dermis for skin). Surface bubbling and opalescence after treatment of buccal mucosa. a slightly Plane III is rarely used for mucosa since it will obliterate the entire submucosa. 3-9). Wiping away the altered tissue will expose the pink. Correct depth control is most likely obtained with use of the microscope. 3-11). and there will be no scar contracture. Regeneration of mucosa starts from the mucosal edge and from minor salivary gland epithelium. No scarring occurs. the basement membrane occurs. There will also be drops of blood from transected blood vessels in either the reticular dermis or the deep submucosa. In ablative oral and maxillofacial surgery. The extent of necrosis is directly proportional to the duration of irradiation. This delay occurs consequent to thermal damage. Therefore.26 Lasers in M a x i l l o f a c i a l Surgery and Dentistry Figure 3-8. If thermal relaxation time is exceeded. Healing is rapid but slightly delayed compared with plane I. or for debulking nonresectable cancers. Excess heat may cause . Figure 3-10. but some bubbling will still occur (Fig. Alternatively. higher PD may be used initially and the first raster will penetrate directly to plane II. The sublethal zone of thermal injury remains small. smooth intact surface of the basement membrane overlying the submucosa (Fig. this type of lesion extends deeply enough to create a burn. which elevates tissue temperature above 55°C. Healing is complete by reepithelialization in less than 14 days for moderate-sized lesions and in approximately 3 weeks for large lesions. This time there will be no opalescence. Good surgical technique requires slower movement of the beam guided by visual recognition of a "fibrous grain" within the crater base. then deeper transmission and wider scattering of the incident laser beam causes a larger. After wiping away debris.

On the other hand. or for postablation care of the vermilion border of the lips. particularly when strict hemostasis is required (e. as expected. The clinical consequence of this is that the volume of tissue destruction greatly exceeds the volume of visible laser effect between the beam and the tissue. hepatic resection).g. Postoperative Care For oral mucosa. C 0 will be most useful for superficial ablation of surface disease or for incision where the need for hemostasis is moderate. The volume of tissue destruction is 40 to 50 times greater than for a similar exposure to an equal diameter incident beam from a C 0 laser. Skin lesions are occluded for the first 24 to 48 hours. After that. the YAG laser is most useful for ablation of large volumes of tissue. where it further delays healing and promotes fibrosis. the saline is mixed 1:1 with 3% hydrogen peroxide and used as a rinse until the mouth feels comfortable. No antibiotics are used and nonsteroidal anti-inflammatory agents are given orally to control pain. For skin. Reticular dermis: collagen fibrils exposed. The patient uses warm dilute saline rinses four to six times per day on the first day. This is the deepest plane from which optimal healing may occur. thereby producing a deep coagulation effect that increases with power and time of application. (Energy is inversely proportional to wavelength. This is a more highly energetic beam than that of the C 0 laser because of its shorter wavelength.. deeply sited vascular tumors. particularly when the underlying tissue can tolerate thermal damage. As a consequence. absorption length for water is 2 to 4 mm in a large volume of fluid' compared with <90 u-m for Co . less well absorbed by intracellular water than is the C 0 beam. care is very simple. Consequently. blood vessels visible. free-beam Nd:YAG energy causes more extensive scattering and transmission of the incident beam through the target tissue. as in larger. the Nd:YAG laser is useful in situations where coagulation is essential.Specific G u i d e to the Use of Lasers 27 Figure 3—11. As mentioned above. which can be used to excise small capillary hemangiomas. is not suitable as a 2 6 2 2 25 2 26 2 2 "mummification" of collagen within the submucosa (or dermis). The C 0 laser. an antibiotic cream or ointment is applied three times a day. Nd:YAG Neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are solid-state devices emitting at 1060 nm in the infrared region of the electromagnetic spectrum. hemoglobin. and other proteins) and it is 2 . The YAG laser's ability to seal large blood vessels greatly enhances its utility for treatment of vascular lesions. Therefore.) Its target chromophores are pigmented molecules (melanin. Precise control of tissue effects is therefore difficult. More heating of tissue occurs at lower contact temperatures than for the C 0 laser.

The noncontact C 0 laser consistently minimizes collateral heat damage when used properly. linear gradient. In considering treatment of cavernous hemangiomas and vascular malformations (AVMs) using the Nd:YAG laser. The resultant photocoagulation necrosis obliterates the pigmented or vascular lesion with preservation of normal tissue. Patients are usually reevaluated in 4 to 6 weeks for further treatment.85-6.6 urn Spot size: 2—6mm.> 15 J/cm" Cycle = approx. and the cryosurgical probe. The laser spots are placed 2 to 3 mm apart from one another to avoid overlapping of scattered laser energy. Typical Laser Use CO. Figure 3-12. Laser (10. The most recent development permitting an increase in the range of applications of the NdrYAG laser has been the development of contact probe tips (Fig. . which might result in tissue sloughing and compromised healing.28 Lasers in M a x i l l o f a c i a l Surgery and Dentistry Table 3-3. Varied by handpiece P: < 20 W E: 200-500 mJ/pulse Fluence = 5 .000 w/cm Pulsed average power: up to 25 W Duty cycle: up to 15% Fluence: 120-600 mJ/pulse Pulse width: 0. 3-12). leading to resolution of bleeding and swelling as well as improved function. lateral heal propagation declines along a slow. A conservative approach is to employ a target spot technique using a 2-mm spot size free beam in single pulses at 20 to 25 W and 0.600nm) Handpiece: Spot: 0. 0. Argon laser: end point is "whitening" of lesion.3 mm at focal point A = 10. where it acts to delay healing and promote cicatrization.2 sec PRR set by computer with limits defined by length Of cycle 2 Note: 2-4 "passes" are required to ablate skin wrinkles Pulse width < I msec Note: All lasers require protective eyewear and high-speed laser suction to evacuate plume particles. Figure 3-13. 2 27 2 2 Contact Nd-. With conventional devices. which may cause aesthetic and functional disabilities.YAG (1060nm) Silica tips: varied Typical power (a) to mark tumor periphery: up to 10 W (b) to incise: 12-20 W Argon Laser (488 to 514 nm) Handpiece or fiber: 2-4 W CW mode. nor is scalpel excision. the electrodiathermy. Staged treatment helps to reduce overenthusiaslic single-stage therapy.4 ms Maximum peak power: 500 w/pulse CW: Same as output power at exit lube For both: PD *» IOO(W)/spot (cm) 2 2 surgical instrument to treat these larger lesions. which may lead to rupture and hemorrhage of the lesions.000 to >50.5 sec pulse width. C 0 : Scanner Handpiece X = 10. One expects retreatment to be necessary to ablate residual tumor. in that all are instruments of thermal destruction. Adjacent tissues must recover from the ill effects of a diffuse conduction burn from thermal instruments or frostbite from cryoprobes before the healing response can begin. The C 0 laser resembles the electrocautery unit.6 (j-m Output power: 5-80 watts Ablation: PD: 475-750 w/cm Incision: PD: 10. one must be cognizant of potential overtreatment. which control and also limit thermal injury. The Nd:YAG contact lasers act similarly and also provide tactile feedback through tissue contact. Moreover. Nd:YAG contact laser probe tip. collagen damaged by inept laser surgery can remain "mummified" in the dermis for many months. This alters laser-tissue interactions without changing wavelength of the incident beam (see Chapter I). ILP-fiber: 2-4 W CW mode.

a higher dose of argon may be used either to reduce the size of the lesion and devasculari/e the ensuing scar prior to surgery or as definitive treatment. This vesicle itself may form from the vaporization of water into steam. 3-13) followed by blanching (whitening). The depth of absorption is a function both of power density and heating effects. For extensive telangiectasias. The spot size and power is adjusted and the application time in CW is prolonged until the test target tissue turns white.5 to 2.0 second absorption peak of 577 nm should be used. other lasers like flashlamp-pumped dye lasers or copper vapor lasers emitting closer to the H b .2-mm spot size and a 10-ms pulse width will be absorbed to a depth less than 1.0 mm and the energy is absorbed mainly by hemoglobin. During the procedure. liventually. For intramucosal vascular malformations or for those thicker malformations involving critical anatomic regions like the vermilion border of the lip. the epithelial surface elevates.Specific G u i d e to the Use of Lasers Argon laser The argon laser is a continuous wave laser emitting bluegreen light between 488 and 514 nm (Table 3-3). The effect on soft tissue is to create an initial pallor (Fig. averaging between four and five in number. 26 2 29 Figurc 3-14. Completion of treatment: entire lesion is white. 3-14) one may employ physical adjuncts to convert a thick lesion to a thin one with a reduced rate of blood How. the glass slide is maintained in constant position under finger presFigure 3-16. . and a vesicle forms that then ruptures to reveal the effect of the laser on the subjacent deeper tissue. Using such a low irradiance it is possible to treat cutaneous telangiectasias without topical anesthesia by using a spot target technique of single-spot applications to the target vessels. Up to 500 vessels may be treated in a single 20minute session this way. Argon laser applied by liber to glass slide compressing the lesion. Its depth of penetration is 0. At this point the argon laser is applied to the surface of a glass slide placed over the lesion to compress it (diascopy). are required. For superficial coagulation a pulsed argon laser beam at 2-W output power with a 0. However. Therefore.0 mm. This may be achieved by reducing the local blood How by the application of ice to the lesion and by infiltration of local anesthetic containing vasoconstrictor around the lesion. The sessions are repealed at 3 to 4-week intervals. Slightly longer pulse duration at higher power densities will permit photocoagulation to occur to a deeper level in thicker vascular lesions. Laser beam may be used al its focal point or defocused. Figure 3-15. multiple sessions. This results in elevation of the epithelium away from the subepithelial plane due to dispersion and absorption of the beam within this deeper plane. TECHNIQUE To maximize the effectiveness of the argon laser for the treatment of thicker vascular lesions (Fig. The optical fiber is now used to trace a series of decreasing concentric circles from the periphery to the center of the lesion until the entire field turns white (Figs. which takes about 1 minute. 3-15 and 3-16). Vascular malformation of labiobuccal vestibule. at higher outputs some cutaneous absorption will occur and the probability of scarring increases. for superficial cutaneous vascular lesions like port-wine stains or telangiectasias.

The size of the acute lesion increases over 48 to 72 hours. the fiber is advanced into the substance of the vascular malformation. The patient is seen at 5 to 7 days to monitor wound healing followed by monthly reevaluations. For this technique to be effective one depends on both selective photoabsorption by the H b . Two or three treatment sessions may be required until the lesion is eradicated (Fig. First. Wound healing. Using only gentle pressure. '' Analgesics. which is delayed initially. the slide is removed and blood flow through the lesion is visually assessed. 2 Figure 3-18. Using diascopy technique the lesion is compressed and photocoagulated (Figs.'" the lesion is entered. Figure 3-17.0 chromophore and a nonspecific heat effect. The optical fiber is then activated usually starting at 3 W. thereby diminishing the capability of a well-vascularized lesion to function as a heat sink. Mucosa stable at 18 months recall. The healed wound is generally 20 to 30% larger than is the vascular lesion. If the lesion is still quite red. ALTERNATE TECHNIQUE: INTRALESIONAL PHOTOCOAGULATION For thicker vascular lesions. 2 Figure 3-19. is apparent at the end of the first week. Antibiotic ointment is applied and the patient is given wound care instructions. Similar case of vascular malformation of buccal mucosa eliminated. usually in the form of nonsteroidal anti-inflammatory agents.30 Lasers in M a x i l l o f a c i a l Surgery and Dentistry sure. For intralesional photocoagulation the fiber tip is introduced into the lesion. are prescribed. After the tip is heated it is brought into contact with the mucosal surface of the lesion (Fig. Lesion outlined with argon in C'W mode. Edema peaks at 72 hours and persists for several days. After anesthetizing the lesion with local anesthetic containing vasoconstrictor. 3-18 and 3-19). Note that entry is almost completely bloodless. the lesion is retreated after 2 months. Swelling and discoloration at the operative site are to be anticipated. particularly for intraoral hemangiomata a more aggressive technique for photocoagulation is intralesional photocoagulation (ILP). Figure 3-20. ice is applied to help reduce blood How. Center of lesion "filled in'" with argon applied in decreasing concentric circles. 3-17). At the conclusion of the initial treatment. ice is reapplied and the treatment is repeated. 3-20). Care is taken to ensure that the tip does not enter the surrounding normal tissue. the laser is activated and then using very gentle finger pressure so that the fiber is introduced "on its own weight. Diascopy: mucosa compressed. . If resolution is incomplete.

Moderate edema is expected but the amount of postoperative pain is unpredictable. There is no vascular malformation present and the tongue has a full range of motion. If gentle pressure is not adequate to control bleeding.Specific G u i d e to the Use of Lasers 31 Figure 3-21. the lesion should be iced for 3 to 5 minutes between ILPs. Figure 3-22. Patient acceptance is generally quite high and significant improvement is usually seen within two treatment sessions (Fig. four to six such passes are required. 3-21). With the laser in active mode the fiber tip is advanced to the periphery of the lesion opposite the point of entry and is then withdrawn to a point just deep to the mucosa but still within the lesion. and the patient is instructed to rinse with dilute warm saline four to six times per day. then retreatment is suggested. Postoperatively a nonsteroidal analgesic is given for pain. is occurring. The power should be adjusted so that with each pass one hears a gentle crackling sound. If more than three treatments are required. After the last pass the lesion should have become depressed and there should be little or no venous oozing from the lesion. 3-22). With the laser activated the fiber is brought back and forth across the lesion in a series of passes in the same manner as performance of a fine needle aspiration biopsy. If regression is incomplete or progression occurs at the monthly recalls. Thirty-four days after surgery healing has been complete. indicating that absorption and some heating . another series of ILP passes will be required. Generally. It is then redirected and the same action is repeated. then another treatment option should be chosen. The patient is recalled in 5 to 7 days for interim reexamination and then at monthly intervals to assess regression. If a second ILP is required. It is the same technique used for fine needle aspiration technique to sample a mass for cytologic assessment (Fig.

Superficial vascular malformation of free border Figure 3—26. Six months postoperative. In the following case of superficial vascular malformations of the lateral tongue border the argon laser was used at a power output of 2. . of tongue. Figure 3-24. 3-23 to 3-26).5 W and a spot size of 2.0 mm in continuous wave function (Figs. CW: 2. No recurrence and no tear.32 Lasers in M a x i l l o f a c i a l Surgery and Dentistry ARGON: NONCONTACT For very small lesions. the handpiece may be used to provide adequate energy to photocoagulate superficial lesions.5 W. tongue. Figure 3-25. Full range of motion of Figure 3-23. Handpiece delivery system: dcfocused.

coagulation. Fiber approached skin surface too closely during subcutaneous and submucosal photocoagulation. skin injury. Figure 3-27.Specific G u i d e to the Use of Lasers 33 ARGON: COMPLICATIONS COMPLICATION I: INADVERTENT SKIN PENETRATION Figure 3-30. Patient properly protected with goggles. Figure 3-28. site in skin. Lesion photocoagulated using intralesional photo- Figure 3-32. Vascular malformation of labiobuccal sulcus. Eschar forming at burn Figure 3-29. First postoperative day. Thirteen months: depressed scar present at site of . Skin damage. Figure 3-31.

One year later (Fig. Figure 3-33. COMPLICATION 2: SCARRING AFTER T R E A T M E N T OF TELANGIECTASIAS The argon laser has been used to treat superficial telangiectasias of the skin. 3-35). 3-36) there was slight skin surface scarring. Application of energy was continued until the lesion blanched (Fig. central part of telangiectasia has been blanched. Figure 3-35. although the vascularity of the telangiectasia was significantly diminished. In this illustrative case facial telangiectasias (Fig. Argon at 2 W CW was used at the focal point of the laser fiber. Posttreatment: feeding vessels and. but because of a high rate of unfavorable scarring postoperatively. Ilashlamp pumped dye lasers and copper vapor lasers have largely replaced argon for this use. . Figure 3-36.34 Lasers in M a x i l l o f a c i a l Surgery and Dentistry. Lesion compressed (diascopy) and treated to end point of blanching. Facial telangiectasias. vascularity of the telangiectasia has been greatly reduced but some skin scarring has occurred. 3-33) occurring along with intraoral hemangiomata in a young girl were treated by direct "tracing" by the argon fiber over the telangiectasia that was compressed by a glass slide (Fig. especially. 3-34). Figure 3-34. One year later.

1989. C o n s e q u e n t l y E r : Y A G h a s potential suitability for laser-assisted s u r g e r y of hard tissues. Lasers Surg Med 1994. 2 1 . A comparative histologic study on the healing process after tissue transection. Jako GJ. Absten GT. 19:96-104. Ine/.3(5):l-35. Borst C. Ann Oiol Rhinol iMryngol 1986. Majno G. Hall RR. Reid R. Presence of modified fibroblasts in granulation (issue and their possible role in wound contraction. Marchctta Marchetta FC. Parrish K. 2nd ed. Motamedi M. laser tissue ablation: effect of tissue type and pulse duration on thermal damage. J Prosthet Dent 1983. et al. Sugar S. J Invest Dermatol 1986:87:268-271. Physics of light and lasers. During a r t h r o s c o p i c s u r g e r y of the T M J this laser is used at low power to m a k e releasing incisions in the rctro-discal tissue.93( 1 ):75-77.160(5. Strong MS. 3. Filmar S. usually < 2 0 H z P= P = <ISW <1SW chromophore: water. Cutaneous (issue repair following C O . Cryotherapy of intraoral leukoplakia.in H. van Lecuwen TO.ng 1985. Hayes RL. FC. Eriksson RA.scar formation to power density.e J. Otolaryngol Clin North Am 1983. Arndt KA. In Baggish M. 11. Barraco R. Obstet Gynecol Clin North Am 199l. 20.267:263-294. it is rare to require p o w e r greater than 10 W. Cryosurgery and electrosurgery compared in the treatment of experimentally induced oral carcinomas. Br Dent J 1971. Medical Lasers: How they work and how they affect tissue. Hunt WC. In general.4I(4):203-211. I. Br J Oral Surg 1981. J Invest Dermatol 1989. Zirkin RM. 5. h a s p r o v e n most useful for intraarticular surgery of the t e m p o r o m a n d i b u l a r j o i n t ( T M J ) . Carbon dioxide laser resection of superficial carcinoma: indications.220:524-527. 27.72(2):393-402. 18. Not only is it highly a b s o r b e d by water. The healing of (issues incised by a carbon dioxide laser. or N d : Y A G lasers.18(3):407-427. Elfont GA. Pulsed C O .0 J/pulse at 8-12 Hz: Avg P = 6-12 W.MIUM:YTRIUM-ALUMINUM-GARNi: IT (HO: YAG) H o l m i u m : Y A G laser. Carbon dioxide laser vaporization: relationship of. Cancer Bull I989.58(3):222-225. Am J Ohstet Gynecol 1985. et al. Temperature threshold levels for heat-induced bone tissue injury: a vital microscopic study in the rabbit. Guerry TL. 24.107:286-290.14:258-268. 26. Basic and Advanced Ixiser Surgery and Gynecology: New York: Appleton-CemuryCrof(s. Mem man JH. Sako K. Deutsch T. : 2 Er:YAG X = 2. but it is also m o d e r a t e l y well a b s o r b e d by h y d r o x y a p atite. Dorsey JH.Specific Guide to the Use of Lasers H()I. Blau R. 8. The anatomic and biophysical principles permitting accurate control of (hernial destruction with carbon dioxide laser. Superficial laser vulvectomy II. Tattersall MHN. Cancer Bull I989.91nm 2. Laser tissue interaction. Thomson S. At higher p o w e r it is c a p a b l e of resecting fibrocartilage or bone. Flotte TJ. In: Coppleson M. Gillis TM. Kamat BR. l i c k in. Fuller TA. a n d enamel. Tabic 3 . Experientia l97l. Gaynes E. Useful characteristics of the Ho:YAG pulsed T M J laser a r e listed in T a b l e 3 . 7. 17. Reid R. Mihashi S. Am J Obstet Gynecol 1989:160(5. 13. h y d r o x y a p a t i t e REFERENCES 1. MacDonald DG. ERBIUERBILM:YTRIUM-ALUMINUM-GARNETT (ER:YAG) The E r b i u m : Y A G laser e m i t s at 2 . Laser physics: medical applications. Loumanen M. Dobry MM. part 1): 1063-1067. Myofibroblasts in healing laser wounds of rat tongue mucosa. 25. pulse repetition rates (PRR) of less than 10 W are sufficient. 9 4 n m and b e c a u s e of its shorter w a v e l e n g t h it is a laser of inherently h i g h e r e n e r g y than C O . Anderson R. London: Churchill-Livingstone. Reid R. Am J Ophthomal 1971 . 14. Ann NY Acad Sci 1976. I-ascr irridectomies. Carbon dioxide laser and clectromicrosurgery. 131 (8):347-352.14:513-535. Laser surgery in otolaryngology interactions of C0 laser and soft tissue."l985. 9. laser irradiation. techniques and results. Laufcr G.8:108-118. 124:482-484. Anderson RR.152:261-271. leaser technology in oral and maxillofacial surgery. Morrow C P . Arch Oral Biol 1988:33(1): 17-23. Temperature dependence of the absorption coefficient of water for incident infrared radiation. being c l o s e r to t h e h i g h e s t a b s o r p t i o n p e a k than than is C 0 . d e n t i n . Carney JM.27(5):549-550. Otolaryngol Clin North Am 1983:16(4):775-784. Ryan G B . 35 Table 3-4. McComb P. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiaiion. Walsh JT.95:547-555. 16. Suitable energy levels for the Ho: YAG pulsed TMJ unit Average power—actual use in TMJ arthroscopic surgery: Aiming Beam—0. Polanyi TG. 1992:1087-1132! 23. The tumor potentiating effect of cryosurgery on carcinogen treated hamster cheek pouch. Lehto V-P. Catone G. Gabbiani G. Pennino RP. Am J Surg 1972. 16:753-774. Selected Readings Oral Maxillofac Surg l994.50:101-107. Physical and surgical principles governing expertise wild (he carbon dioxide laser. Jacques SL. 6. Dedo HH. Jetha N. Lasers Surg Med 1988. clectromierosurgery. Peak Power—|up to 5 J/pulse: Surgilase Ho:YAG].41(4):211-218. Physical and surgical principles of carbon dioxide laser surgery in the lower genital tract. which is a major m a j o r constituent of b o n e . Welch AJ.6-1. Fuller TA. Silverman S Jr. Albrektsson T. Poswillo DE. Padilla RS.1 . cd. Armon E. 22. 2 2 . 4. The response of living tissue to pulse of a surgical C 0 laser: transections of the ASME. Laser tissue interaction: (he influence of power density. Gynecologic Oncology. Monaghan JM. by virtue of its ability to vaporize tissue within a Quid m e d i u m . Pospisil OA. Br J Surg 1971 . Part II: Applications. Jansen ED.9lnm E= 125-625mJ/pulse PRR = Variable. Surgical lasers and soft tissue interactions. et al. 10. 19. Obstet Gynecol Clin North Am 1987. H o w e v e r . cds. 12. J Biomech F. 15. Gomel V.4 . 2. Science 1983.

and the sensitivity ranges from 96 to 1 0 0 % . possibly by alteration of one or more tumor suppressor genes. Also worrisome are leukoplakias located on the anterior floor of the mouth covering the orifice of Wharton's duct. which is a particularly notorious site for malignant transformation. The specificity of vital staining with 1% toluidine blue dye ranges from 87 to 100%. VITAL STAINING 14 Toluidine blue (TN). 4-4). 4-11) positive. The carbon dioxide laser does not impart magical properties to the tissues. 4-7). 4-5). " False-positive rates are usually reported as being approximately 2. multicentricity. The principle is similar to that supporting the use of vital staining of the uterine cervix as a method for detecting an abnormal transformation zone in cervical intraepithelial neoplasia (C1N). and lip v e r m i l i o n . soft palate/anterior tonsillar pillar. In this location both dysplasia and invasive carcinoma have the capability of invading directly into the lumen of the salivary ducts.13 to 28% with cancer being detected on average 2. When the oral mucosal surface is dried with a gauze sponge. because this proclivity is still uncertain. The buccal mucosa and the 2 1 6 4-7 1 3912 13 mandibular labiobuccal vestibule are the areas most likely to be affected (Fig. and may include microinvasive cancer at the time of detection. Dysplasias are sharply demarcated from adjacent zones of normal mucosa and they tend to be velvety in appearance. or speckled (Fig. the transformation rate ranges from 0. Most commonly it is found on the area of mucosa with which the smokeless tobacco product is placed in contact. 4-6). 4-10). The latter occurs on the buccal mucosa adjacent to the oral commissure. buccal mucosa. with 85% of the preneoplasias being accounted for by leukoplakia.5%. nodular (Fig. High risk of malignant transformation is associated with dysplasia. the dysplastic leukoplakia. Because it is the transformed (premalignant or malignant) epithelial cell that has escaped regulation by feedback inhibition of its replication. 4-1). the alteration in the reflective surface of the oral mucosa becomes readily apparent (Fig. 4—8). Different varieties of leukoplakia may also occur simultaneously in the same patient (Fig. 4-9). The clinical diagnosis of the subset of lesions at high risk. are often severely dysplastic. The TN is applied with cotton-tipped applicators and is allowed to remain in situ for 60 seconds (Fig. 4-2). ' " Overall. this rapidly dividing cell. moderately (Fig. The snuff dipper's lesion is usually homogeneous but may include areas of nodularity.5 years after the diagnosis of the index leukoplakia. tongue. Erythroplakias are erythematous. and anatomic site of the leukoplakias. which accepts the stain. The area is now rinsed with acetic acid followed by a water rinse (Fig. a directed (by the stain) biopsy of the lesion is 1 5 37 . or strongly (Fig." The areas at highest risk for transformation are the floor of the mouth. is an abnormal cell. a metachromatic vital dye. selectively stains cytoplasmic sulfated mucopolysaccharides and nuclear DNA and RNA in rapidly dividing cells.0% and false-negatives as 2. 4-9). " In regard to dysplasia the risk of malignant transformation is related to its presence but not necessarily its grade. Leukoplakias are categorized as homogeneous (Fig. The erosive variant of lichen planus has stimulated a great deal of debate in regard to its malignant potential. and oral submucous fibrosis. erythroplakia. The basic technique for vital staining requires removal of saliva from the area to be examined by washing with saline or dilute (3%) acetic acid followed by drying of the suspicious mucosa with a gauze sponge (Fig. is facilitated by the application of a vital dye to the mucosal surface. but it does provide a selective therapeutic advantage for the treatment of intramucosal preneoplasia by avoiding damage to subjacent tissue. 4-3). Any remaining blue stain is subjectively ranked as being mildly (Fig. Preneoplastic lesions of the oral mucosa include leukoplakia. The most recent World Health Organization (WHO) classification of leukoplakia will now include dysplasia as an indicator of risk of transformation. particularly as C 0 laser treatment of lichen planus does not alter its natural history and is therefore ineffective. thereby eliminating scar formation and the creation of oral deformities. In this way. erosive lichen planus will not be considered. however.4 Lewis Preneoplasia of the Oral Cavity dayman Successful treatment of superficial mucosal disease of the oral cavity mandates selective ablation of the abnormal epithelium including the parabasal layer attached to the basement membrane. The examiner is now guided directly to the site of most heavy staining as being representative of the "worst" area of the lesion. which is the gynecologic equivalent of leukoplakia with severe dysplasia or erythroplakia.

In Scandinavia. Speckled leukoplakia occurring at its most common location. Simultaneous occurrence of leukoplakia on the floor of mouth. Figure 4-4. This patient also had leukoplakia of the hard and soft palate. the oral commissure. . Typical snuff dippers leukoplakia at site of application of the tobacco product. slightly raised and sharply demarcated from surrounding normal mucosa. but in the United States. these lesions rarely. if ever. Nodular luekoplakia of Ihe buccal mucosa. Figure 4-6. and buccal mucosa. This is frequently accompanied by Colonization with Candida albicans. Figure 4-3. Homogeneous leukoplakia of ihe ventral tongue and floor of mouth. which is also typical. Note staining of the teeth. The lesion is red.38 Lasers in M a x i l l o f a c i a l Surgery and Dentistry Figure 4-1. where snuff is formulated differently.rythroplakia of the ventral tongue. maxillary alveolar ridge. they frequently do become malignant after a very long latency period. ventral tongue and mandibular alveolar ridge. F. Figure 4—5. Multicentricity. Figure 4-2. progress to cancer.

performed. A new oral cancer of the alveolar ridge-buccal mucosa arising in a field of dysplasia 41 months after removal of a primary tumor at the same site.Preneoplasia of the O r a l Cavity 39 Figure 4-7. it is wisest to stain in this way all of Ihe high-risk mucosa of the tongue. retromolar pad. subsequent to which a definitive treatment plan is formulated. when the patient is sedated or anesthetized. Because the multicentric nature of precancer (the condemned mucosa concept) manifests itself as multifocal disease by occurring at multiple sites in the oral cavity and oropharynx. is successful and adequate for limited local disease. After washing with saline. Strongly positive stain with toluidine blue. which consists of excision with a scalpel. The literature reports control rates of around 90%. Failure becomes likely when this local treatment is applied to extensive disease. Conventional surgical treatment. Moderately positive stain with toluidine blue: buccal mucosa. Because oral precancer and cancer is frequently multicentric. and the buccal mucosa. and anterior tonsillar pillar. Ihe residual blue slain demarcates ihe area at the periphery of the lesion. soft palate-retromolar pad area. Alter application of 1% toluidine blue. a more global treatment concept than local excision is required. which is most likely to contain areas of dysplasia. Figure 4-8. Figure 4-10. SURGICAL TREATMENT: C 0 LASER 2 Figure 4-9. Failure rates 6 1 8 1 9 . This is a mildly positive stain. floor of mouth. Figure 4—11. there is dense staining of the cancer as well as the peripheral tissue. Staining of the more posterior area of the mouth may be carried out at the time of planned surgery of the index lesion.

1 to 0. glandular obstruction. is easily managed with oral analgesics. and the grafted skin covers remaining elements of regenerated mucosa that may be unstable. there is little postoperative swelling and patients may take oral fluids immediately after surgery. Fig. Tongue blade: spot size. divided by the square of the spot size (in cm ). and application time for each of the pulses to be used during surgery are "calibrated" on a wooden tongue blade. 4-14). Extensive areas of mucosa may be ablated without skin grafting because epithelium is regenerated from normal tissue at the wound periphery in no more than 5 weeks for lesions as large as 40 c m .1 2 . Both scarring and incomplete epithelial regeneration OCCIir.40 Lasers in M a x i l l o f a c i a l Surgery and Dentistry 4 following local surgical excision are as high as 3 3 % . the mucosa al risk is still observable by direct visual inspection during recall examination. 3-2) delivery system. is an unsatisfactory solution because skin dews not function as well as mucosa. RSP is most desirable because the 19 21 2 2 Figure 4 .1 4 . and there is usually no bleeding or swelling. This. which is highly variable. power.2 mm of reversible thermal injury to the submucosa.1 3 . Lesion over duct. The power density is approximately equal to the exit power of the laser (generally 15 to 40 W). however. The graft ultimately contracts as time passes. laser beam itself is delivered either by a handpiece (Chapter 3. . Figure 4 . 4-15). Excision of large lesions at the oral commissure causes deformity of the oral stoma. Lastly. Of equal importance. The power density is controlled by enlarging the spot size (defocusing the beam) either by direct observation of the coaxial red helium-neon (HeNe) laser aiming beam or by direct observation of the tissue effect. For ablation. site-specific consequences may dictate against locally invasive surgery that induces scarring. the minimum thickness of tissue removed with a scalpel results in exposure and removal of the submucosa. and only occasionally shows a secondary in2 2 crease in intensity on days 3 to 5. Precise control of thermal damage makes it possible to remove even the epithelium directly over the salivary duct orifices without inducing sialodochitis and glandular obstruction (Figs. 3-1) or a microscope (Chapter 3. the denudation of large areas of oral mucosae results in scarring and wound contraction as well as postoperative pain. even for local treatment. However. Muliicentricity demands excision of topographically large areas of mucosa. and nutritional depletion. The advantage of replacing traditional excisional techniques with C 0 laser photoablation is that the laser permits removal of the damaged epithelium with as little as 0. removal of the thinnest layer of mucosa over the opening of Wharton's or Stensen's duct may cause scarring. Fig. Pain. Vaporization of tissue over duct without damaging duct. No sclerosis or submandibular gland obstruction occurred postoperatively. and infection. These patients may be operated upon as outpatients. Using this rough approximation. Despite the greatest care. An estimation of the laser effect is gauged by a pretest in which a wooden tongue blade is exposed to individual pulses from the laser and then the spot size is directly measured (Fig. one can achieve a power density of 500 to 1250 W/cm for ablation by evaporative vaporization (ablative vaporization). rarely lasts more than a few days. " The CO. These latter may be gated or "chopped" CW or. the spot size. Modes of application include continuous wave (CW) or variations of a pulsed mode. The traditional solution to this problem is to replace the mucosa with a split-thickness skin graft. preferably. which then abruptly terminates. edema. In this way. For example. Figure 4 . rapid superpulsed (RSP) (Fig. 4—12 and 4—13). After healing.

22 2 4 23 2 I8 24 25 2 Figure 4 . The amount of collagen found in the wound is diminished and epithelial regeneration is somewhat delayed and irregular. tissues remain soft and pliable. The face is protected with wet surgical drapes and the eyes are covered. Laser wound: soft tissue. No pre. During the entire healing process.1 6 . but may be as brief as 2 weeks in cases having ablation of less than 2 c m of mucosa.In vivo. As the pulse width lengthens beyond I msec..Preneoplasia of the O r a l Cavity 41 Figure 4—17. but this is not uniformly consistent. and using the pulsed mode at 50 to 250 pps. Fibrin coagulum day I. but nerve endings are "rounded off.m. with a peak pulse power of 500 to 1000 W per pulse. ) From the viewpoint of the microscopist.s. and compared with scalpel or cautery wounds." This latter may account for some of the diminution in postoperative pain anecdotally reported. Interspersed in the zone of thermal damage are "boiled away vesicles. there is minimal damage to adjacent tissue across an area of potentially reversible thermal injury of 150 to 300 u-m. . CW (chopped or gated) and RSP profiles. the vital staining is repeated. which is slowly replaced without the occurrence of significant wound contraction. the region of lateral thermal damage exceeds 200 u-m. However. At the time of laser surgery. (Courtesy of Lara d a y m a n . If endotracheal intubation is utilized. the laser wound (Fig. there are fewer myofibroblasts and very little wound contraction. 4-16) has the following c h a r a c t e r i s t i c s . At these power densities of 500 to 1250 W/cm . 2 SURGICAL TECHNIQUE The oral mucosa is assessed and the requisite biopsies are obtained in the manner previously described. pulse width may be designed to be as brief as 250 to 950 u. Denatured protein is found in the form of a coagulum near the wound surface. the hypopharynx is packed with a wet gauze. in the range of 120 to 600 mJ/pulse the fluence actually applied to the target tissues is adequate to ablate them while limiting thermal injury to the subjacent normal tissue to less than 200 p. ." The deeper layers of epithelial cells show intercellular voids as a sign of thermal damage. Local anesthesia is used unless the patient receives a general anesthetic. " However. A fibrin coagulum forms in the first 24 hours (Fig. Not only are small blood vessels and lymphatics sealed by the laser. reepithelialization occurs within 4 to 6 weeks. TIME (msec) Figure 4-15. ' The superficial epithelium is homogeneously carbonized. 4-17).or perioperative antibiotics are given and no antiseptic preparation solution is used for the mouth. thereby exceeding the thermal relaxation time of the target tissue. 712 8. during healing there is minimal inflammatory response. which is shorter than the thermal relaxation time of oral soft tissues.

which results in removal of the entire thickness of the epithelium (Figs. The spot size will vary between 2 and 3 mm in diameter. This is called rastering. The submucosal layer is identified both by the appearance of blood vessels and by the appearance of tissue of granular appearance and yellow color. After completion of this first layer of lasing. Second raster (16X). If the depth of penetration is too superficial. there has been excessive heat conduction because of prolonged contact between the laser beam and the tissue as a result of excessively slow hand speed in moving the handpiece or microscope joystick-directed laser beam across the lesion. then the superficial aspect of the submucosal plane has been breached. several layers of rastering may be required. 4-19)." The lesion (Fig. laser. 4-21 and 4-22). Figure 4-18. In areas of thick hyperplasia as for nicotine stomatitis or fibroepithelial hyperplasia of the palate (see Chapter 6). The more heat conducted. First layer of treated tissue wiped away with a moistened gauze sponge (16X). A moist gauze is now used to wipe away the treated area of mucosa. there should be almost no carbonization. A pale pink base that does not bleed indicates removal of the epithelium at the level of the basement membrane (Fig. 4-18) is outlined with a suitable margin of several millimeters and then parallel lines of application of the laser are placed within the marginal outline (Fig. the laser is set at an average power of 20 to 30 W for pulsed modes. At the conclusion of surgery the abnormal (issue has been removed and there should be no bleeding except where it was necessary to extend tissue removal into the submucosa.42 Lasers i n M a x i l l o f a c i a l S u r g e r y a n d D e n t i s t r y After identifying the extent of the pathology. This allows one to assess the depth of penetration of the laser. CO. 4-20). The clinical end point for ablation of the mucosa is to cause a "rapid bubbling of the epithelium which is opalescent in color and is accompanied by a crackling noise. 21 Figure 4-19. Figure 4-21. . the greater the desiccation occurring at surgery. as may be required in this case of papillary hyperplasia of the palate where four rasters are needed for complete tissue removal. 4—24). Outline of lesion with RSP. Figure 4-20. and 15 to 20 W for CW mode. If there are scattered droplets of blood. 4-23). Complete mucosal reepithelialization and healing has occurred within 5 weeks (Fig. If the wound appears blackened. Lesion: papillary hyperplasia of the palate (I0X). a second raster is applied to reach the required depth. The fibrin coagulum that formed within the first 24 hours is still present at one week (Fig.

This will retard healing." In the treatment of 148 leukoplakias by ablation technique in the series from Sinai Hospital of Detroit. Therefore. which is progressively replaced by epithelium originating from the wound edge. One report reported recurrence in five of seven cases of leukoplakia. "' ' 2 5 1 5 1 8 2 6 26 27 2 1 4 1 8 1 2 6 2 7 Figure 4-23. The ideal treatment is by free-beam C 0 laser because ablation will completely remove the lesion. There are no reports in the literature that laser treatment enhances malignant trans formation of oral preneoplasia. . Repeated application of the laser without removing the char from the previous exposure will dramatically increase heat transfer to the nontarget tissue. Larger mucosal ablations (5. in one patient. There were no serious complications. Reepithelialization commencing from wound periphery. LEUKOPLAKIA The most important subset of oral preneoplasia (precancer) is leukoplakia. This occurs as a function of time of contact of the laser beam with the target tissue.5 to 22% at 3-year follow-up to 10 to 22% at 37. The major cause for delayed healing is from the creation of charring (carbonization) of the tissue. lips. however. even an extensive insult of more than 60 c m still required only 6 weeks for complete resurfacing.. and to which no other specific diagnostic category may be assigned.to 55-month f o l l o w . a frequency that is not substantiated by reports of series with significant numbers o f c a s e s . Condition remained stable for the next 28 months when the patient was lost to recall examination. Ablation of less than 2. Reepithelialization complete after 5 weeks. Series with less than 2year follow-up may report spectacular results of lack of recurrence.Preneoplasia of the O r a l Cavity 43 HEALING Epithelial resurfacing is rapid. the mucosa will almost always reepithelialize in less than 4 to 6 weeks. A fibrinous coagulum tonus within the first 24 hours. infection and damage to teeth. range from 4.u p . with no scar2 Figure 4-24. there were three cases of inadvertent single pulse laser hits to teeth (1) and lip (2). Residual lesion after wiping away tissue treated by second raster* I6X). Histologically leukoplakias may range from simple hyperkeratosis to intramucosal dysplasia or neoplasia. these patients require long-term surveillance.0 c m or more) require between 4 and 5 weeks. etc. Fibrin coagulum still present after one week. RESULTS Reports from the literature on the subject of recurrence alter laser ablation of leukoplakia (dysplasia not specified). 2 2 2 Figure 4-22. Furthermore. Postoperative complications potentially include bleeding. particularly if they continue to smoke and drink.0 c m of mucosa uniformly results in complete epithelial resurfacing in less than 3 weeks. or ignition of the endotracheal tube by laser "mishaps. this attenuates with time. However. a clinical term describing a white lesion of the oral cavity that cannot be removed by wiping the mucosa with a gauze sponge.

generally between days 3 and 5.3% relapsed as leukoplakias. From the point of view of the individual lesions rather than patients. This suggests that there is certainly no enhancement of malignant transformation by laser treatment during the early postoperative observation period." My own series of 114 mucosal precancers occurring in 70 patients included 41 simple leukoplakias and 73 dysplasias that were treated by laser vaporization and followed for a minimum of 2 years to a maximum of 8 years. with eight relapsing as leukoplakias and nine transforming into cancer. with 64% of all the index leukoplakias being dysplastic.44 Lasers in M a x i l l o f a c i a l Surgery and Dentistry areas of previous dysplasias. A recurrence rate of only 10% in 103 leukoplakias observed from 7 to 55 months after ablation was reported. Of the dysplasias. Seventeen lesions in 70 patients escaped control after laser treatment. one must be mindful of the fact that most of the recurrences. although soreness occasionally interfered with food intake. Narcotics are rarely required. Although a recurrence rate of zero was reported from Scmmelweis University in Budapest for a selected group of 126 patients with leukoplakias treated by ablative vaporization at 10 to 15 W |power density (PD) not specified] or by excision at 20 to 25 W (PD not specified). which compares favorably with laser success rates of 10 to 22% reported in the literature after 37 to 55 months' surveillance. This is particularly important because leukoplakia may affect many different locations within the oral cavity. . and retromolar pad. Of the cancer occurrences. progression. may well recur.6% (11/114) during the first 6 years of observation. at only 16 to 28 months.'"' followed 70 patients with 103 leukoplakias. won't appear for about 30 months after identification of the index leukoplakia. anterior tonsillar pillar. 2 : Five case reports demonstrate the technique. eight of the nine (88. and by the need to use the microscope. had a 22 to 28% recurrence rate for lesions treated by ablation with a handpiece. the overall failure rate (relapse. there was an unpredictable subset of patients that required no analgesics immediately after surgery. Therefore. it is a great advantage to have the mucosa return to an undamaged state because retrcatment may be necessary. and may ultimately affect a large surface area of mucosa. by patient emotional needs. the failure rate was only 9. with nonsteroidal analgesics being the drug of choice.2% of which 12. using local or general anesthesia or intravenous sedation. Laser ablation was carried out using the microscopic technique al 10 to 15 W output (PD unspecified but probably approximately 375 w/cnr). 68% were located in the most dangerous sites for malignant transformation: floor of mouth. in all scries listed above (over 700 patients) reepithelialization occurred within 3 weeks for all lesions smaller than 2 c m and within 5 weeks for larger lesions. There is no reduction of oral opening and the oral mucosa remains soft. 33 of which were dysplastic and therefore probably at higher risk for recurrence or malignant transformation. and only the rare patient required analgesics after day 5* However.9% (9/70) developed cancer and 11. About one third of patients required analgesics for the first 24 hours after surgery. moist. and pliable. However. Postoperatively. There was no scarring and no postoperative swelling. which also may include progression to carcinoma. This series is very heavily skewed toward high-risk leukoplakias. All patients were treated as outpatients. tongue. Therefore. 5 ls ring. but that later required two or three days' use of analgesics. Roodcnburg et al. clinical followup had been quite brief. as dictated by site and extent of lesions. or development of new lesions) during the 8-year period was 24. There was no degeneration of any case into cancer and recurrence could not be correlated with degree of dysplasia. soft palate.9%) arose from Horch et al.

Figure 4-25. Figure 4-26. wiping away the treated mucosa (Fig. Any residual area requiring biopsy for assessment may be excised with the scalpel (Fig. Dysplastic leukoplakia of lower lip. Moving the tip away from the target tissue results in reduction of the power density. 4-35) reepithelialization has been completed and maturation is occurring. First raster at PD = 460 W/cm (2. Vital staining with TN (Fig.21 mm. 4-29) one may judge the thickness of tissue removal by observing the border of the untreated mucosa. 4-31) demonstrates that heat artifact is restricted to a thickness of approximately 0. At the conclusion of surgery. 4-26) resulted in a mildly positive stain.8-mm vaporization spot). 2 . 4-25). P = 20 W. which indicates that the laser is at its focal point at the tip of the handpiece. 4-30) and bleeding from the base of the biopsy site may be controlled with the laser. The slightly yellow color of the base of the treated area indi2 0 0 cates that tissue removal has included the basement membrane. 4-32) demonstrates a clear demarcation between the normal epithelial border and the de-epithelialized treatment region. After wiping away the treated mucosa (Fig. average power of 20W. 1. A biopsy from an area of laser treatment at a magnification of I00X (Fig. Note that the epithelium has been completely removed as was desired.Preneoplasia o f the O r a l Cavity 45 CASE 1: LIP LEUKOPLAKIA WITH DYSPLASIA A 59-year-old white man with a leukoplakia containing areas of dysplasia of the lower lip was referred for removal of his lesion (Fig. By 22 days (Fig. At 13 days postoperative (Fig. PD = 617 W/cm .5 mm (1.8-mm vaporization spot. The handpiece delivery system (Fig. The initial raster (Fig. 4—33) fibrin is present covering the wound surface and there are some signs of reepithelialization occurring.l-ms pulse width with 125-mm handpiece). 4-27) was chosen using a spot size of 2. 92 PPS superpulsed mode. Laser handpiece in position to start treatment. 4-36). Note the guide tip extension of the handpiece. Figure 4-28. 4-34) healing is about 50% complete and by one month (Fig.5 mm HeNe guide spot. 216 mJ/pulse l. The dark brown area on the left of the illustration shows the discoloration secondary to the heat effect from application of the laser to control bleeding at the base of the area excised by the scalpel. 92 PPS superpulsed. Vital staining with TN is mildly positive. T E M (transverse electromagnetic mode). 4-28) results in crackling and bubbling of the epithelium with slight brown discoloration of the treated mucosa. 216 mJ/pulse. Figure 4-27. At 5 months the lip looks normal (Fig. superpulsed by the 125-mm handpiece.

Figure 4 .21 mm. Note sharp border of untreated mucosa. Fibrin still covers wound. TN stained tissue sampled by excisional Figure 4 .3 3 . Figure 4-30. Healing ai 22 days.46 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry Figure 4-29. Full thickness of mucosa has been removed. Completion of treatment.3 4 .3 1 . Heat effect at base of treated area at edge of biopsy sample: depth of thermal damage is 0. Selected. Dark color on right from coagulation of base of biopsy area with laser. Tissue treated by first raster removed by wiping with wet gauze. nent. Healing at 13 days. biopsy. Reepitheliali/ation is promi- .3 2 . Figure 4 . Figure 4 .

Mucosa has been stable for 12 months. Five months. Maturation completed during second month. . Figure 4-36.Preneoplasia of the O r a l Cavity 47 Figure 4-35. Thirty-three days. Reepithelialization has been completed and mucosa has started to mature.

and area over ducts ab- Figure 4-38. lated. i. and target tissue. Lingual gingiva.48 Lasers in M a x i l l o f a c i a l Surgery and Dentistry solute absence of charring of the native tissue at the site of ablation after removal of the layer of treated tissue (Fig. Note the ab2 Figure 4-37.5 and 3. Figure 4—39. Six years after treatment. Treatment: The lesion was ablated with a C 0 laser using the handpiece (125 mm focal length). and PD approximately 375 w/cnr. There was no transient obstruction of the submandibular salivary glands. Ablation of the mucosa included the region directly adjacent to the orifices of the submandibular ducts.0 mm. Use of front surface mirror to redirect the beam. with complete epithelial resurfacing having occurred in approximately 30 days. . and no recurrence at 6 years' follow-up examination (Fig. Again. Spot size is enlarged until PD is low enough not to damage the mirror. Note sharp demarcation between normal epithelium and ablated area. sulcus.. Figure 4-40. RSP at 104 PPS. 4-38). an erythroplakia reappeared that was restricted to the lingual frenulum and the same laser vaporization procedure was repeated to remove the second erythroleukoplakia. 4—37). To ablate the lingual gingiva a front surface mirror was used to change the direction of the beam (Fig. there was no long-term damage to the native tissue from the first operation 6 years before. average output power 15 W.e. CASE 2: LEUKOPLAKIA. Staining with TN was mildly positive. 4-44). healing was uncomplicated. ANTERIOR FLOOR OF MOUTH AND LINGUAL GINGIVA A 56-year-old man presented with a very subtle erythroleukoplakia of the anterior floor of the mouth centered on the lingual frenulum and extending onto the lingual gingiva (Fig. no loss of attached gingiva. Subtle erythroleukoplakiu of floor of the mouth originating at the base of the frenulum and extending over the submandibular duct orifices across the lingual sulcus and onto the lingual gingiva. average output power 20 W at 58 PPS. Consequently uncomplicated complete epithelialization occurred within 30 days (Figs. Spot size was between 2. At reoperation the tissue both of the floor of the mouth and of the lingual gingiva was noted to have the same characteristics of plasticity and response to the laser energy as had been the case for treatment of the index lesion. Note absolute absence of charring of base of ablation region. 4-39). The "slower" beam was used to permit easier coordination of energy delivery between the handpiece. mirror. 4—40 to 4-43). Few areas of pinpoint bleeding indicate deeper penetration of beam.

Preneoplasia of the O r a l Cavity

49

Figure 4—41. First postoperative day. Note deposition of fibrin within the wound.

Figure 4 - 4 3 . Postoperative: 30 days. Epithelialization complete.

Figure 4-42 postoperative: 10 days. Reepethilialization well

established.

Figure 4-44. tached gingiva.

Postoperative II months. No loss of lingual al-

50

Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry

CASE 3: BUCCAL MUCOSA
A 54-year-old white woman with a 35-pack-year cigarette smoking habit who did not drink alcohol presented with a leukoplakia of the buccal mucosa. The preoperative biopsy was interpreted as hyperkeratosis with mild atypia. The left buccal mucosa demonstrated a 2 X 3 cm area of leukoplakia that stained mildly positive with toluidine blue (TN). The microscope-guided superpulsed C 0 laser was used
2

with the power density adjusted to achieve the desired e: feet of creating opalescent crackling of the mucosa. This n quired an estimated average power density of approx mately 585 W/cnr (15 W) average beam output powe HcNe aiming beam spot size approximately 2 mm, and true spot size of 1.6 mm. 46 PPS with a pulse width of 4. ms. The worst area of the mucosa was excised for anothe histologic interpretation. The mucosa had completely resui faced in 4 weeks (Figs. 4-45 to 4-48).

Figure 4-45. Buccal mucosa: area of mildly positive staining with TN indicates "worst" area of lesion (I0X).

Figure 4-47. Tissue subject to first raster removed. Note lack of bleeding after ablation of epithelium only. Note sharp demarcation between normal epithelium and treated area ( 1 6 X ) .

Figure 4-46. First raster completed. Mildly stained area saved for excisional biopsy (6X).

F'igure 4-48. Mucosa completely healed at 4 weeks. Patient still is disease free at 4.5 years.

Preneoplasia of the O r a l Cavity

51

CASE 4: BUCCAL MUCOSA
A 58-year-old while man with erosive lichen planus and lichenoid dysplasia of both buccal mucosae. Protocol: Vital staining with TN resulted in a mildly positive result.

Lesion removed in two rasters at an average power of 15 W, true RSP mode, HeNe spot of 2.5 mm (true vaporization spot size of 1.8 mm), giving an estimated PD of 463 W/cm at 150 mJ/pulse at PRR = 118 Hz (Figs. 4 - 4 9 to 4-54).
2

Figure 4-49. Mildly positive staining with TN. Red HeNe aiming beam centered on stained tissue (6X).

Figure 4-52. Second raster halfway completed. Note color change in upper one half of treatment field. The yellow color indicates second plane of ablation has been achieved al the level of the submucosa.

Figure 4-50. First raster completed, Note symmetry of "rows" of tissue ablated. There is no charring. Note distinct boundary between normal mucosa and treated area.

Figure 4-53. Epilhelialization quite pronounced at 7 days. Epithelialization 80 to 90% complete at 13 days. Process complete within 28 days.

Figure 4-51. Rastered area wiped away with moist gauze sponge. A few areas of bleeding noted indicating extension of laser effect into submucosa.

Figure 4-54. norma].

Two years. Mucosa is supple. Treated area appears

Note yellow color in central portion where vaporization was deeper especially in center area which had stained positively with TN. Figure 4-55. horizontal. Incisional biopsy of the tongue cancer was inlerpretated as well-differentiated squamous cell carcinoma. Debris removed by wiping with gauze sponge. Figure 4-58. a peak pulse power of 500 W.0-mm diameter. Figure 4-56.0 mm at a fluence of approximately 435 mJ/pulse width.2 ms. 4-55). Reepithelialization of the surface of the tongue was 100% complete at 27 days. average power of 20 W. Note HeNe aiming spot of approximately 2. Three previous biopsies of the "worsf'-appearing areas of her dorsal tongue demonstrated hyperkeratosis with mild atypia. Mature mucosa shown at 9 weeks.52 Lasers in M a x i l l o f a c i a l Surgery and Dentistry CASE 5: LEUKOPLAKIA OF TONGUE This 28-year-old white woman with no risk factors developed a TINOMO squamous cell carcinoma of the left posterolateral tongue border and a dense leukoplakia simplex covering much of the anterior dorsal tongue surface (Fig. . First. This stained only faintly with toluidine blue. Estimated blood loss for the resection was 15 mL. The partial glosscctomy wound was sutured closed. The dorsal tongue lesion was vaporized with a true rapid superpulsed C 0 laser and 46 PPS.ed at 3 weeks. spot size of 2. raster used to remove surface epithelium. There was 2 almost no char and no bleeding (Figs. and an interpulse distance of 19 ms.5 6 to 4-58). 4 . Surface reepitheliali/. No prophylactic antibiotics were administered. The cancer was then removed with the same laser at 30 W average power using the handpiece in focus at 0. Leukoplakia affecting majority of surface area of dorsal tongue. Examination under anesthesia and vital staining also revealed a third white lesion of the left buccal mucosa. Rastering half completed. Figure 4-57. Mild hyperkeratosis was present immediately after healing was completed.3 mm spot size for incision and defocused to control bleeding. at a pulse width of approximately 4. Two rasters were applied with the target tissue being wiped free of debris between applications.

representing about 4 5 % of the viral genome. 20 which migrates more slowly in electrophoresis gels (Fig. while cleavage of both strands at a single site produces a linear molecule form III. 1. form 11 (Fig. The use of the C 0 laser as an alternative instrument for excision is also useful in the resection of oral squamous cell c a n c e r . In essence.900 As previously mentioned. individual papillomaviruses show enormous differences in species specificity. circular. several promoters (sequences needed to initiate viral RNA synthesis). This region contains five ORFs that code for proteins. 1 8 ) . Cleavage of only one DNA strand by bacterial enzymes (restriction endonucleases) results in a relaxed circle.12 w h j t e s p o n g e nevus (HPV I 6 ) . hence.5 Papillomas and Human Papillomavirus Richard Reid. these either induce cell transformation or control viral DNA replication. the viral DNA assumes a supercoiled shape (form I). The "early" or " E " region is the longest segment. The third region of the genome is the upstream regulatory region (URR). site predilection. and degree of oncogenicity. 2 . 2 . and the clinicopathologic consequences of infection.21. and some of these differences have been correlated with changes in virulence and oncogenicity. This is a noncoding segment. Papillomaviruses are small. Myron Strasser Although controversial. I I ) . doublestranded DNA molecule. 1 9 . 5-2C). which comprises about 4 0 % of the viral genome. the actual nucleotide sequences within these ORFs are widely disparate. When the nuclear proteins are stripped away. The possible relationship of HPV to the development of squamous cell cancer (SCC) of the head and neck merits an expanded discussion of HPV in this chapter. The URR is the genetic interval most likely to be divergent among viral types. Virus-specified proteins apparently determine such characteristics as host range. each of these ORFs represents a viral gene.12. Human papillomaviruses compose the largest group. 5-1). The "late" or " L " region.16 lichen planus ( HPV 16 )1. The papillomavirus genome can be subdivided into three functional portions. 1 . 1 7 . known as open reading frames (ORFs). with a molecular length of 7.4 squamous papilloma (HPV 6. verruca vulgaris. carbon dioxide ( C 0 ) laser surgery is gaining increasing acceptance in the treatment of such HPV-associated lesions as condyloma acuminatum. 2 0 2 2 base pairs and a molecular weight of 5200 d. 2 2 However. squamous papilloma. such as ameloblastoma (HPV 16. Viral Genetic Function BASIC VIROLOGY Taxonomy . 6 . Well-established association of HPV with oral cavity disease includes condyloma acuminatum (HPV 45). Supercoiling is visible on electron microscopy and is also detectable by electrophoretic migration because of the relatively rapid mobility of these tight circular molecules. 2 2 55 . 5-2). 6-12 Human papilloma virus has also been detected in diseases that do not show obvious viral stigmata. with more than 50 known t y p e s 3 .2 verruca vulgaris (HPV 6 and 1 6 ) . double-stranded DNA viruses 12. All papillomaviruses exhibit a similar pattern of genetic organization. 1 7 and odontogenic keratocyst (HPV 16) 18 In head and neck surgery as in other specialties. 1 3 . and several enhancers (sequences that increase the rate of RNA transcription). DNA Organization The papillomavirus genome is a closed. alignment of sequenced papillomavirus DNAs revealed a highly conserved pattern of protein-coding potential—the ORFs. 2 5 focal epithelial hyperplasia (HPV 13 and 32) 1 . evidence from immunoperoxidase and DNA hybridization studies have implicated human papillomavirus (HPV) as the etiologic agent for many diseases within the oral cavity.9. are preserved through the genome.2. 2 3 (Fig. It contains the origin of DNA replication. and leukoplakia. 2 1 . representing about 15% of the viral genome. The URR is located between the end of the LI ORF and the beginning of the E5 ORF. DNA sequencing studies have shown that broadly equivalent areas of protein coding potential.22 that manifest qualitatively similar biologic characteristics.1 S leukoplakia (HPV 16)1. The viral DNA is combined with histones (derived from the cellular pool of the natural host) to form a small chromosome of which the viral DNA constitutes only 12% of the virion by weight. contains two ORFs that are essential to vegetative viral replication. tissue tropism. 2 ' 4 and squamous cell carcinoma (HPV 16 and 18) .2.

cottontail rabbit papillomavirus (CRPV). and deer papillomavirus (DPV). is indicated by dotted lines. which was found in four new isolates. 6b. A continuous El. Stippled areas of the genome bar represent coding sequences and black regions stand for so-called noncoding regions. (From reference 35. with permission. In HPV 16 the El frame appeared to be split in the originally published sequence. which could serve as a start point of translation. 16.) 94 35 . bovine papillomavirus (BPV) I. 8.Lasers in M a x i l l o f a c i a l Surgery and Dentistry Figure 5-1. Dotted lines within the frames represent the first methionine codon. Open reading frames were displayed by means of the computer program FRAMES and are indicated by open bars. Genome organization of human papillomaviruses (HPV) la.

Capture of the host cell results in pronounced alteration in cell growth in the basal layers. 5-3). Proteins specified by the early viral genes result in an initial burst of episomal replication.g. viral type.. DNA was extracted by phenol treatment. soft whitish papules on the lower labial mucosa and lateral tongue border (Fig. for example. (A) Structure. a patient presenting with multiple painless. Incubation Phase CLINICAL AND LABORATORY EVALUATION Comprehensive history-taking can help in establishing the diagnosis of HPV-related oral lesions. (From reference 35. When a definitive diagnosis cannot be established by history and clinical examination. termed an episome. VP1 and VP2@ represent structural proteins of the capsid shell. Two basic types of cell-virus interaction are recognized: vegetative (productive) and transforming (nonproductive). thereby producing various virus-specific proteins. where they then shed their outer protein capsid. The viral genome crosses the cell membrane and is then transported to the cell nucleus. HPV virions penetrate to the basal layer of the damaged epidermis. exfoliated superficial cells or keratin fragments) lodge in sites of microtrauma within a susceptible epithelium. 22 may lead to active viral expression. The decision to perform incisional versus excisional biopsy depends on such considerations as lesion size. and viral cytopathic effects in maturing cells. Because these episomal viral plasmids are programmed to replicate with each cell division. in susceptible hosts. however. sessile. there is little dilution of viral copy numbers over the succeeding years. Histones H3. viral colonization . and cofactor activity. H2b. Initially the virus exists as a self-replicating extrachromosomal plasmid. a specimen must be obtained for microscopic and/or other laboratory evaluation. with permission. 22 Active Expression Phase Many exposed individuals will remain in long-term latent infection. Such progression from episomal to productive viral replication depends upon the interplay of cell permissiveness. Patients with high-grade dysplasia and those in whom oncogenic HPV subtypes are identified are at risk for higher recurrence rates after treatment. (B) genomic DNA. while regulatory proteins control viral gene expression. Proteins were separated by polyacrylamide gel electrophoresis after disruption of viral particles by sodium dodecyl sulfate (SDS). increased replication of the viral genome in the middle layers. producing additional viral genomes that will gradually transfect neighboring cells. The molecules appear as supertwisted covalently closed circles (CCC) or open circles (OC).Papillomas a n d H u m a n Papillomavirus 57 Figure 5-2. Transforming proteins induce conducive host cell functions. host susceptibility. H2a. Capsids were stained with phosphotungstic acid. DNA of phage PM2 was included as a size standard (97 kd).) PATHOPHYSIOLOGY OF INFECTION Inoculation Inoculation occurs when material containing relatively large numbers of virus particles (e. Consider. location. There the infecting genome is translated and transcribed. Knowledge that such a patient has an limit ancestry would raise a high degree of suspicion for focal epithelial hyperplasia. and H4 are associated with the viral DNA and appear in preparations of DNA-containing capsids. and possible diagnosis of cancer. and (C) protein pattern of papillomavirus particles.

g. and only 100 to 200 u. thereby decreasing thermal conduction into the adjacent tissue." . In difficult cases. Disadvantages of using the C 0 laser include higher cost for the equipment. CARBON DIOXIDE LASER Excision and vaporization are the two techniques employed in soft tissue surgery. D.m of tissue necrosis adjacent to the points of impact. Larger wounds take 4 to 5 weeks to reepithelialize. limited availability.14 ' 24-27 Greater sensitivity can be achieved by filter hybridization of fresh tissue (e. because this method permits histologic confirmation of the diagnosis and establishment of . being delayed from 2 to 4 days. In the majority of cases.. 8 29 30 7 31 2 2 19 32 2 33 Figure 5-3. D. Although there is lack of consistent proof of the infectivity of these particles. Carbonization produced by vaporization should be wiped away to improve visualization of the lased areas and to decrease crater temperature. (Photo courtesy of Scott Boyd. an oral pathologist will make a firm diagnosis with the light microscope. Laser vaporization (ablation) or painting away of the oral lesions are performed in a layer by layer method (rastering).9. Viral analysis of formalin fixed tissue is done by either polymerase chain reaction or in situ DNA hybridization . Ph. Epithelialization of the laser wound occurs at approximately I week if its surface area is less than 1. slower healing of the laser wound. causing a central /one of tissue vaporization.In contrast. if identification of the specific HPV is needed.D. Conversely. prudence in regard to mask selection is strongly recommended.3. Tissue irradiance of this carbonized material raises the temperature from I00°C (the boiling point of water) to more than 600°C (the temperature of a red-hot coal). Focal epithelial hyperplasia of lateral tongue. incisional biopsy is preferred.58 Lasers in M a x i l l o f a c i a l Surgery and Dentistry margins that are clear of cytopathic changes. during vaporization strategic tissue biopsies need to be obtained prior to vaporization. a cellulose swab or a frozen biopsy sample). It is mandatory to use a high-speed suction system to evacuate the vaporized material. tissue is sent to the pathology laboratory for routine processing. WARNING: If you smell the plume through the mask. ancillary testing is available. 2. Excision is the preferable mode for removal of oral lesions. The pathologist is able to examine the margins of the specimen because the laser destroys tissue in a precise manner. aided by clinical description and historical details. The potential infectivity of virus panicles found in the effluent plume is under intense investigation at present. a carbonized layer should remain to help maintain hemostasis of the small vessels that have been sealed by the laser " if the depth of removal extends into the submucosa. For both cases. Virus testing is still expensive and is not available for routine use. After the surgeon is confident that the lesion has been completelyremoved. and the possibility of the HPV DNA being liberated in the plume of laser vapors.8.0 c m .S. Many authors have noted that laser wounds heal slower than scalpel wounds. A fibrous coagulum replaces the carbonized layer after approximately 24 hours. there is a chance of inhaling particulate matter that may carry virus particles or whole virions. small lesions that appear clinically benign may be excised..) If the area under investigation is large or if one suspects malignancy. There will be slight but pathologically unimportant shrinkage at the base of the specimen being removed for biopsy.

M. Figure 5 . A similar lesion is also noted adjacent to the upper right lateral incisor. These are "kissing" lesions. Figure 5-5.6 . Five-year-old girl with contact papillomas of left mucosal surface of lower lip and left interproximal gingiva between left lower lateral incisor and canine. The first raster removed the superficial mucosa. D. At 14 days. Histopathologic and viral studies demonstrated oral papillomas positive for HPV 6 and 11. the mucosa had completely resurfaced with normal epithelium. Estimated blood loss was nil. Gingival site: no recurrence at one year. the "kissing" lesions of the left lower lip and gingiva had recurred.5 mm. The lip lesion was treated first with a true superpulsed beam with a peak power of 500 W delivering an average power of 10 W at 58 pulses per second with an average power density (PD) of 440 W/cm at a spot size of 1. 5-6). However.M. 2 years later. A clinical diagnosis of oral papillomas is made. Lip site after wiping away char. The lower incisor was protected with a metal matrix band (of the type used for placing interproximal amalgam restorations). . The gingival lesion was now 7 mm in maximum dimension and a 5 X 2 mm plantar papilloma had recurred on the left lower lip. An additional 1 x 3 mm lesion of the left buccal mucosa was similarly ablated. The gingival lesion had not recurred. Part of the lower lip papilloma was excised with 2 2 the laser in a focused mode (PD = 1250 W/cm ) at a spot size of 0.) A 5-year-old African-American girl presents to her family doctor because of recurrent lip biting. 5-7). Figure 5-7. Gingival site after wiping away treated tissue. and the interproximal gingiva was ablated at a power density of 500 W/cm (Fig. even after trauma of eruption of the succedaneous tooth.Papillomas a n d H u m a n Papillomavirus 59 CASE 1: PAPILLOMAS (Courtesy Lewis dayman. These were retreated using the same laser parameters as before.. there was reactivation or reinoculation of the left lower lip lesion. Figure 5-5 illustrates the depth achieved after wiping away the remainder of the treated mucosa. The parents are reported to be free of oral or genital papillomas by report from their family physician. At 3-month follow-up assessment. General anesthesia with oral endotracheal intubation was chosen because of the patient's age. 5-4).4 .D. Examination shows a 5-mm "wart" on the inner aspect of the mucosal surface of her left lower lip. 2 2 Figure 5 . The remainder of the lesion was vaporized using two rasters to ablate just below the basement membrane.D.3 mm. The patient is brought to the operating theater for photoablation by vaporization with the C 0 laser. One year later. With the lip in repose. this abuts a second similar lesion affecting the interproximal papilla between the left lateral incisor and canine teeth (Fig. there was no recurrence (Fig. Lip: no recurrence at one year.

He was HIV negative. lente insulin.0-mm spot size at 90 W average output power at 60 pulses per second. maxillary split-thickness skin grafting and vestibuloplasty had been performed to aid in denture retention. D. and upper and lower lips were treated at an average output power of 20 W superpulsed. potassium iodide. The PD was approximately 1280 W/cm . prednisone. but not involving either the true or false vocal cords. the patient took only two analgesic pills during the first 8 days after treatment.) This 56-year-old African-American man presented with a chief complaint of inability to wear dentures because of "growths" in his mouth (Fig. Maxillary alveolus and palate 19 days after treat- . colchicine. Antibiotic prophylaxis with cephalothin was administered because of the renal transplant. Estimated blood loss was 250 mL for treatment of more than 120 cm of oral mucosae. Following the institution of cyclosporine immunosuppression therapy. Palate and commissures also affected.60 Lasers in M a x i l l o f a c i a l Surgery and Dentistry CASE 2: EXTENSIVE ORAL PAPILLOMATOSIS ON A RENAL TRANSPLANT RECIPIENT (Courtesy Lewis dayman. and palate for a total treatment area of approximately 60 cm (Fig. the PD was 1280 W/cm . progressive maxillary ridge resorption had resulted in the loss of all alveolar bone. ment. Cardizem. Current medications included: cyclosporine. The most uncomfortable area of his mouth was the palate. alveolar ridges. On day 8 there was epithelial resurfacing of about 20 to 30% of the mucosa. The first treatment was performed using general anesthesia and nasoendotracheal intubation. glaucoma. 2 2 Figure 5-8. After first treatment using the microscope delivery system with a defocused beam in the superpulsed mode at an average power output of 90 W delivered at 60 pulses per second at 150 mJ/pulse with a spot size of 3. His list of illnesses active at the time of consultation included diabetes mellitus. The Sharplan 743 C 0 laser with the microscope delivery system was used for the 2 2 maxilla and tongue in a defocused superpulsed mode with a 3. Estimated blood loss was 250 mL and operating time was 130 minutes. Eighteen months before. The entire dorsal tongue was similarly treated over an area of approximately 28 cm . his chronic renal failure had been successfully treated by a cadaver renal transplant. His transplanted kidney was functioning well. and ferrous sulfate. By day 19 there were signs of regrowth of hyperplastic tis2 2 2 2 Figure 5-9. he developed extensive papillary hyperplasia of all of his oral mucosae. Synthroid.6 mm at 120 pulses per second for an average power density of 780 W/cm . Twenty years earlier. 5-8). The histopathologic diagnosis of a representative biopsy of the papillomas of the maxillary alveolar ridge was verruciform hyperplasia. The treatment field included the entire maxillary and mandibular ridge. commissures. 5-9). buccal mucosa. Figure 5-10. The buccal mucosae. which precluded his ability to wear dentures. Extensive papillomatosis and verrucous hyperplasia of maxilla. Imuran.. Zantac. and hypothyroidism. Postoperatively. hypertension.M. and tongue. The anterior nasal spine was now the most prominent feature of the residual ridge. using the handpiece delivery system with a spot size of approximately 1. Since then. This sample was positive for HPV 6 and 11.D. The treatment recommendation for removal of the diseased oral mucosa by C 0 laser in several stages was explained to the patient. Aerodigestive endoscopy demonstrated mucosal changes extending into the pyriform recesses bilaterally.D. and he agreed to therapy. gout. M. No local anesthetics were used. labiobuccal sulci.0 mm.

Eversole L. Recurrent disease 70 days after initial treatment. 2 1991. The areas of recurrence were treated as before. . By day 70 there was approximately 50% recurrence in the maxilla and there were minor areas of recurrence in the retromolar pad bilaterally. 6. Shroycr K. Use of the C 0 laser for malignant disease of the oral cavity. The mandible had recpithelialized to about 60% of normal. Oral Surg Oral Med Oral Pathol 1992:73:155-163. 5-13).18:429-474. Yen C.65:526-532. At this stage the patient developed an attack of Herpes zoster in a left thoracic dermatome. Duncavage J. Using 2 61 Figure 5-13. but there was approximately a 2 0 % recurrence level of mucosal hyperplasia. and scalpel wound in healing. Reid R. oral smokeless tobacco associated leukoplakias.Papillomas and H u m a n Papillomavirus sue in the maxilla (Fig. 5-11).71:708-713.. The patient remained disease free for 3 months. One year later the patient remained disease free in the palate but had a minor recurrence in the lateral tongue and left oral commissure (Fig.39:299-300. 2 REFERENCES 1. J Oral Maxillofac Surg 1990:48:1201 -1205. These areas were completely reepithelialized in 24 days after a third retreatment cycle. Physical and surgical principles of laser surgery in the lower genital tract. 5. Obstet Gynecol Clin North Am Figure 5-12. PRR = 156 PPS with defocused 125-mm handpiece). average output power = 25 w. The utilization of the carbon dioxide laser in the treatment of recurrent papillomatosis: report of the case. The entire retreatment area was about 80% reepithelialized 31 days after treatment. Lasers Surg Med 1986:6:442-444. There was slight scarring at the commissures but none intraorally. Detection of human papillomavirus DNA by in situ DNA hybridization and polymerase chain reaction in premalignant and malignant oral lesions. Pogrel M. and epithelial malignancies. Maitland N. liquid nitrogren cryosurgery. Retreatment again using the microscope delivery system. these two areas were retreated. Viral infections of the head and neck among 2 2 HIV-seropositive patients. 7. One year after treatment and 5 months after maxillary ridge augmentation with corticocancellous block iliac crestal bone. 4. After 2 months.0 mm. 8. Ossoff R. 3. 5-12). 5-I0). Borden G. Scully C. By day 25 epithelialization was 80% complete. Eversole L. the oral commissures. Oral Surg Oral Med Oral Pathol 1991 . 2. which represented approximately half of the surface area of the initial treatment (Fig. and the floor of the mouth (Fig. The total surface area of the treatment field was 53 cm . Pecaro B. small recurrences were observed at the left commissure ( 2 X 7 mm) and the midline of the hard palate (3 X 4 mm). Figure 5-11. at which time minor recurrences were noted at the right mandibular alveolar ridge and left oral commissure. The C 0 laser in oral and maxillofacial surgery. Papillomaviruses: the current status in relation to oral disease. Oral Surg Oral Med Oral Pathol 1990:69:269-273. Crosby L. Examination and palpation under anesthesia did not demonstrate any scarring or loss of resiliency of the oral mucosa. and he was completely pain-free. Sachs S. J Oral Surg 1981 ./ Oral Maxillofac S'urg 1983. Gree R. Prime S. Cox M. superpulsed at a PD of 780 W/cm . local anesthesia and intravenous sedation at a PD of 796 W/cm (parameters: HeNe guide spot size = 2. Detection of human papillomavirus-genomic DNA in oral epithelial dysplasias. Hansen L. Garehim W. 9. Reepithelialization covered approximately 30% of the treatment area by day 14. Greer R.41:725-728. Oral Surg Oral Med Oral Pathol 1988. A comparison of carbon dioxide laser. By day 40 resurfacing was more than 9 0 % complete.

0-mm spot for ablation size can be used. The no-touch technique with a free-beam laser theoretically offers the added advantage of limiting transplantation of malignant or infected cells because in the process of thermovaporization and thermocoagulation. allows precise tissue ablation with minimal lateral thermal damage. At higher power densities the surgeon will have to work rapidly to minimize unwanted thermal damage. such as incisions made in oral mucosa. With the upper lip everted and the frenum stretched taut (Fig. Some controversy may exist on the subject of tumor promotion by C 0 laser since there is a report of seven cases of oral leukoplakia being treated by C 0 laser of which five recurred.4 2 1 USE OF C 0 LASER IN INCISIONAL PROCEDURES 2 To use the C 0 laser as a precise cutting instrument. Be aware of tissue that is in the path of the laser beam beyond the target tissue. Lingual) Maxillary frenectomy can be accomplished using incision and/or ablation. the loss of tactile sensation with which surgeons are so familiar with traditional surgical instruments is easily overcome by visual feedback and a bit of practice." 2 1 2 2 2 3. A focus guide probe. a continuous wave (CW) laser may be used. the depth depends in part on the power set. nor was it found to promote metastases in a mouse adenocarcinoma model. When using the continuous or rapid pulse modes. Paul C.2 to 0. its anatomic location and functional implications after laser treatment. vertical incision is made through the mucosa of the midportion of the frenum. Careful observation of the target tissue is well advised during laser application. risks. the surgeon should work expeditiously and with even strokes. approximately 0. 2 2 2 6-7 Frenectomy (Maxillary. Either CW mode at 3 to 5 W with a 0. In addition. and 2. Protection of the underlying tissue should be provided in anticipation of any laser beam that may "escape" inadvertently after cutting through the target. 6-1). Consideration must be given to ihe nature of the lesion to be treated. Topical anesthetic is usually adequate but infiltration technique may be preferred. along with a coaxial helium-neon (HeNe) guide beam are helpful in acquiring evenness in the cut when a laser handpiece is used. This can best be achieved with a minimum energy of approximately 150 mJ/pulse. Although this is a "no-touch" technique. as well as the benefits. This results in creation of a burn in the target tissue. several passes may be necessary to achieve this. Horizontal releasing incisions are then developed 63 . such as facial skin.2-mm spot size for incision or a pulsed mode at 20 W. However. a short (3-5 mm). A pulsed C 0 laser with a fluence of greater than 4 J/cm delivered with a pulse width shorter than the thermal relaxation time of approximately 950 ms. Where the target tissue can tolerate a wider zone of coagulation necrosis. blood vessels and lymphatics adjacent to a target tumor are also sealed.3 mm. As with a scalpel. or sutures will facilitate precise surgery just as it does for conventional technique. Traction and countertraction of tissue with sponges. Both the power density and the fluence may change with small variations in operative technique and may affect clinical outcome in sensitive areas. This char must be wiped away with wet sponges or cotton swabs as intentional or inadvertent second exposures on the desiccated charred tissue cause severe heat transfer. Recall that the width of the laser cut corresponds to the beam diameter. The target tissue should be examined to see if the desired depth is reached.6 Soft Tissue Excision Techniques Lewis dayman. The beam should be directed perpendicular to the target tissue unless dissection of tissue underlying the lesion is desired. Charring will inevitably occur in inverse relationship to incisional speed. Mandibular. Kuo GENERAL PRINCIPLES OF CLINICAL LASER APPLICATION Surgical lasers are instruments with their own specific indications for applications. particularly with the free-beam C 0 laser where there is no tactile feedback and the depth of penetration is shallow. 50 to 60 pps. and the degree of coagulation necrosis on the duration of laser exposure. and alternate modes of treatment available. this is not supported by more substantial series with longer follow-up where the rate of recurrence or progression of leukoplakia is reported as to be as high as 28%. The C 0 laser was also not found to promote tumor growth in a mouse-melanoma model. the spot size at its focal point should be small. forceps. the heat produced sterilizes the surgical field.

64

Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry through the mucosa on both sides of the frenum, which may extend to the periosteum. A diamond-shaped mucosal wound is developed as the lip-mucosal attachment is released. The fibrous band between the central incisors, if present, is then vaporized. The field should be dry (Fig. 6-2). Any small bleeding vessels encountered can be vaporized or welded closed by withdrawing the handpiece to increase the spot size and decrease the irradiance. Any char that develops should be wiped away with a wet gauze to prevent heat accumulation that may cause excessive lateral thermal damage on reapplication of the laser beam. Warm saline with hydrogen peroxide rinses are prescribed. No dressing is necessary. The wound develops a fibrinous coagulum in 24 hours and reepithelialization occurs in 5 to 3 weeks (Fig. 6-3). Alternatively, a contact Nd:YAG laser using a fine scalpel tip at 8 to 12W CW may be used, following the same surgical technique.

Figure 6-1.

Low attachment of maxillary frenum.

Vestibuloplasty
Other incisional procedures include vestibuloplasty and sulcus extension. Submucous vestibuloplasty is more commonly performed for the atrophic mandible, where denture adherence and stability is problematic. With the lower lip retracted and the mucosa stretched, the junction of the attached gingiva and the alveolar mucosa is noted. Using a focused, small beam spot of 0.2 mm at 6 W CW, an incision is made along the junction from the midline of the mandible posteriorly to the first molar areas bilaterally. Attempts should be made to identify the position of the mental foramen from where the mental nerves emerge. Supraperiosteal dissection can be carried out with the laser to the desired depth. Care should be taken to avoid the mental nerves. Because of the shallow depth of penetration of the laser, the soft tissue overlying these nerves can be dissected precisely, thereby avoiding damage to the mental nerves in their extraosseous course. The use of a split-thickness skin graft to surface the wound and inhibit vestibular loss from upward migration of the mimetic muscles during healing is

Figure 6-2. After 3- to 5-mm vertical incision and superior and inferior horizontal incisions a diamond-shaped dissection is created. Notice absence of char after use of rapid superpulsed C 0 laser.
2

Figure 6-3.

Treatment area healed at 24 days.

Figure 6-4.

High frenal attachment in mandible.

Soft Tissue Excision Techniques

65

advisable. The flanges of the existing denture are extended and relined to use as a surgical stent for 7 to 10 days. Routine oral hygiene is adequate thereafter (Figs. 6-4 to 6-6).

USE OF THE CO, LASER IN EXCISIONAL PROCEDURES
The C 0 laser offers a number of advantages when used as an excisional instrument, particularly for small to moderatesized mucosal, submucosal and cutaneous lesions. The procedure is usually simple and straightforward. The excisional depth can be easily controlled. A good specimen can be obtained with little damage to the margins, although one must include an additional I to 2 mm of marginal tissue more than would otherwise be adequate with conventional scalpel excision, to allow for tissue lost by vaporization or damaged by coagulation necrosis. The surgical wound usually does not need to be sutured. An outline is rapidly made using repeated single pulses (175 mJ/pulse, 0.2-mm spot at 5 W) to circumscribe the desired target tissue. Following this outline, a laser incision is then made to the desired depth using the same method and laser setting as described previously. One edge of the cut margin can then be elevated with forceps and the lesion undermined and harvested at the correct depth of dissection with the laser. With the laser beam defocused. the surgical wound is briskly "painted" over in one pass (raster) to seal off lymphatic vessels and nerve endings and left open to heal by second intention. A fibrinous wound surface results and cellular infiltration begins after 3 days. Larger wounds can be packed with an antiseptic ointment (Balsam of Peru, Bips paste, neomycin, bacitracin, etc.) applied to ribbon gauze for 2 to 7 days.
2

Figure 6-5. Linear dissection using 0.2-mm spot at 6 W CW function. Expanding dissection to compensate lor expected regression after submucosal vestibuloplasty technique.

Figure 6-6. Healed treatment area at 5 weeks. High frenal attachment has been lowered, but as expected without mucosal free grafting, some loss of vestibular depth has occurred.

66

Lasers in M a x i l l o f a c i a l Surgery and Dentistry FIBROMA

Fibromas commonly appear on the buccal mucosae, inner surface of the lip or lateral surfaces of the tongue. Presumably their origin is from trauma, particularly lip or cheek biting, although they may result as the final involutional form of a pyogenic granuloma (Figs. 6-7 to 6-9).

Figure 6-8. Defect left to heal by secondary intention after removing lesion with RSP CO laser at 58 pps, 150 mJ/pulse, 0.2mm spot size delivered with a handpiece at 6 W average output power (PD = 15,000 W/cm ).
: 2

Figure 6-7. Large fibroma of cheek, quite close to commissure, probably initiated by repeat cheek biting.

Figure 6-9. Cheek well healed by the I month recall visit.

: 2 Figure 6-12.e of 0. ture.000 W/cm ]. using general anesthesia delivered by an oral endotracheal tube and without supplemental local anesthesia.1 3 . Transection almost complete. Primary closure of surgical site with resorbable su- . Figure 6-13. cotton swab placed behind target area to prevent unwanted laser contact with adjacent tissue as transection is completed. the polyp was bloodlessly removed in one minute of operating time. Figure 6-10.3 mm. average power output of 10 W [power density (PD) approximately 20.Soft Tissue Excision Techniques 67 FIBROEPITHELIAL POLYP Removal of a libroepilhelial polyp Of the tongue in a neonate is illustrated in Figures 6-10 to 6 . Lesion placed under traction as incision commences across base of lesion. No bleeding occurred during surgery. Figure 6-11. Fibrocpithelial polyp of dorsal midline of tongue. Laser parameters were handheld C O rapid superpulsed laser at 50 pps. At approximately 7 weeks of age the patient was brought to the operating room where. The polyp arising from the dorsal midline of the anterior tongue was both interfering with suckling and causing consternation for the parents and the pediatrician. evaporative spot si/. Note HeNe guiding beam in center of incision.

Then.3-mm spot size using a handpiece at 118 pps. Skin lag along periphery of ihe helix of the right car. 0. A similar case in an adult man from India is illustrated in Figures 6-16 to 6-18. Figure 6-16. which also protected the underlying normal skin. after falling asleep the base of the lesion was inliltrated with 0. Otologic and auditory examinations were normal. Figure 6-18. laser at 6 W average output power. In this illustrative case a consultation was received from the newborn nursery to remove an ear tag. . 0.25 mL of 2% lidocaine. Area was resurfaced in approximately 10 days. Dissection performed after injection of local anesthetic at 6 W. The operation required less than a minute and there was no blood loss (Figs. Figure 6-14. 118 pps in RSP mode. 6-14 to 6-15). Ear lag lifted away from underlying normal skin by a cotton tipped applicator. Surgical site at conclusion of laser surgery. Figure 6-15.3-mm spot size. Base of treatment of area after excision of skin tag. The lesion was then removed with the superpulsed CO. The baby was brought to the laser lab where he was first fed.68 Iasers in M a x i l l o f a c i a l Surgery and Dentistry EAR TAG Skin tags occasionally occur in newborns as well as adults. Skin was completely healed by 17 days. Note complete absence of char. Figure 6-17. Long-term appearance 4 years later.

Rapid identification of the crown permits the operator to avoid inadvertently damaging it by excessive heating from the scalpel tip. less postoperative pain. Mucosa well healed at 3 weeks. Figure 6-19. thereby permitting dissection of the mucosa away from the crown without marring Ihe enamel surface from inadvertent laser strikes at high PD. As dissection proceeds. 6-19 and 6-20). Alternatively. as illustrated in Figures 6-19 and 6-20. Al this point. the mucosal flap is elevated 2 2 2 with tissue forceps until the underlying crown is identified. Crown of impacted tooth exposed.3 mm spot size to incise around the impacted crown of the tooth. Note absence Figure 6-20.YAG laser in contact mode using a short scalpel tip at 5 to 10 W average output power is used to excise the gingival cuff. 10 W average output power and 0. of bleeding. The C 0 laser may be used at PD of approximately 10. Bonded bracket ready to be used to start tooth movement. there is less swelling. the handpiece is moved away from the tissue to diminish PD. and less chance of thermal injury to the exposed tooth if the free beam C 0 or the contact heodymium:yttrium-aluminum-garnet (Nd:YAG) laser is used (Figs. There is no bleeding.000 W/cm at 50 PPS.Soft Tissue Excision Techniques 69 EXPOSURE OF IMPACTED TEETH Although exposure of impacted teeth (soft tissue impaction) is easily accomplished in the dental operatory using local anesthesia and a loop cautery. . the Nd.

2 nun. spot size = 0. 6-23). A completely bloodless and char-free base was obtained (Fig. 2 Figure 6-22. Free palatal graft secured in position. 6-22).2-mm spot size. The graft was readily accepted and the mature graft is demonstrated at 6 weeks recall examination (Fig. A free palatal graft was obtained with scalpel dissection and thinned with scissors to the correct thickness. 0. . This was secured to the recipient site with sutures (Fig. PRR = 50 Hz. Complete "take" at 6 weeks. The donor site was "sealed" to stop bleeding with one raster in the defocused mode. Figure 6-21. pulsed mode. Figure 6-23. Mature graft. Recipient site prepared with RSP CO> laser with P • SW.70 Lasers in M a x i l l o f a c i a l Surgery and Dentistry FREE GINGIVAL GRAFTING Lack of attached gingiva was treated by first dissecting away the alveolar mucosa with the C 0 laser at 5 W average power. 50 pps. 6-21).

Dissection of the lesion itself. Figure 6-26. 150 mJ/pulse. 6-24 to 6-27) a small vascular malformation of the labial sulcus was excised with the C 0 laser. small. which had been left open to heal by secondary intention. higher-flow lesions are occasionally treated with the Nd:YAG laser. However.Soft Tissue Excision Techniques 71 HEMANGIOMAS AND VASCULAR MALFORMATIONS Hemangiomas in the oral cavity are most effectively treated with the argon laser (see Chapter 3) by direct application after compressing the lesion with a glass slide or for larger lesions by intralesional introduction of the liber. In the illustrated case (Figs. 0. 2 Figure 6-27. Small vascular malformation of labial sulcus. Dissection of the inferior mucosal flap. Ten years later there was no recurrence. localized. The surgical site was completely healed in an additional 2 weeks. low-flow lesions may be excised with the C 0 laser. handheld at IIS pps. . 2 2 figure 6-24. the wound was nearly healed with some contraction of the surgical site. An absolutely dry field was achieved with RSP C 0 laser. Large.3-mm spot size which was defocused when necessary to control small bleeding points. Figure 6-25. Two weeks postoperative. at 10 W average output power.

laser is used when ablation of localized. which results in increased thermal damage. In general. A defocused spot size of 1 to 5 mm at the target is used.72 Lasers in Maxillofacial Surgery and Dentistry USE OF THE CO. increases pain and delays healing. see Chapter 4. Usually approximately 100 to 150 mJ/pulse is used. LASER AS A VAPORIZATION INSTRUMENT Vaporization with the C O . especially when multiple passes are performed. depends on the preference and experience of the surgeon. The PD used. which is best adjusted by varying the distance of the incident beam to target tissue. It works in a similar manner to incisional and excisional techniques except that a larger beam size is preferred. This prevents excessive overlapping of laser crater margins. Each treated layer is wiped away with a gauze sponge before applying the next raster. This is because of the Gaussian distribution of the laser energy curve (see Chapter 1) such that a laser crater may be clean in the center but charred at its periphery.) . The target tissue is vaporized with a defocused beam in a "painting" (rastering) fashion. On the other hand. the power can be set from 15 to 30 W average power at 50 to 150 pps at 50 to 650 mJ/pulse. Slow vaporization with lower PD causes greater coagulation necrosis. With deeper lesions it is better to ablate the entire surface of the lesion to the same shallow depth in layers. vaporization can be achieved at a higher PD with little charring and minimal thermal effect on the adjacent tissue but also less photocoagulation for good hemostasis. as can be the case when narrower areas are first vaporized to the desired depth. However. superficial strips of tissue is desired. careful use of the handpiece will usually produce satisfactory results. repeating the process until the desired depth is reached. (For detailed examples of clinical use. This procedure is performed most accurately when the laser is used in conjunction with the microscope and efforts are taken to maintain a perpendicular relationship between the laser and the target tissue.

6-28 to 6-32).0 and 2. Gingiveclomy complete: charred area consequent to defocused beam application to control bleeding.Soft Tissue Excision Techniques 73 GINGIVAL HYPERTROPHY A 34-year-old African-American male recipient of a cadaver renal transplant receiving azathioprine. doxazosin. Patient has not received recommended dental prophylaxis every 3 months. Series of test spots hi assess for suitable I'D to produce opalescent bubbling of lirst layer of tissue to be removed. captopril. Six months follow-up. Figure 6-28. Figure 6-29. Loss of normal interproximal gingival contour. diltiazem. : 2 Figure 6-30. Still on cyclosporine. Figure 6-32. Gingiva removed by each raster is wiped away to remove the carbonization prior to applying additional rasters with the laser (Figs. clonidine.5 mm at 58 pps 600 mJ/pulse at an average power output of 25 W. Note red HeNe aiming beam adjusted to approximately 2.0-mm spot size. prednisone. . Some recurrent hyperplasia present between the lower central incisors. and cyclosporine was treated for hypertrophic gingivae. A matrix band is secured around the cervical margin of the tooth below the free margin of the gingiva to protect the enamel and cementum from injury by the laser beam. Bulbous papillae and hypertrophy of marginal and attached gingiva. Key elements of laser technique for gingivoplasty include the use of a superpulsed C O laser with the handpiece at a PD of 500 to 625 W/cm by varying the spot size between 2. Toftlemire-type metal matrix band applied snugly around tooth at or below cervicoenamel junction. Gingival hypertrophy. Figure 6-31.

with a 2. Healing gingivae at 1 week. Bone exposure was studiously avoided. A superpulsed C 0 laser at 30 W average output power. Note placement of self-retained matrix bands. 2 Figure 6-33. 6-33 to 6-36). Removal of excess gingivae. Two years postoperative.to 3-mm spot size was used. without the use of local anesthetic. Figure 6-36. Blood loss was less than 5 mL and four quadrant gingivectomy. At 2 weeks the wound was 50% epithelialized. Figure 5-34. Figure 6-35. . Gingival hypertrophy was extensive and was much more fibrotic than was the hypertrophy induced by cyclosporine illustrated in the previous case.74 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry SEVERE GINGIVAL HYPERTROPHY A 35-year-old woman with epilepsy has been taking diphenyl hydantoin in a stable dose for many years to control her seizure disorder. required 60 minutes under general anesthesia (Figs. Severe gingival hypertrophy induced by phenytoin (diphenyl hydantoin).

Postoperatively. Fibroepithelial hyperplasia of palate. and the estimated blood loss. There was no recurrence when she was discharged from follow-up observation 28 months after surgery (Figs. The area ablated measured just over 15 cm". 2. Figure 6-38. . is reported to be representative of fibroepithelial hyperplasia of the palate. She is treated under general anesthesia with nasoendotrachcal intubation. reddish. Observation for 10 minutes by the clock at the conclusion of surgery shows no bleeding. a single diflunisal tablet was taken for pain control on the evening of surgery. She smoked two packs of cigarettes per day. with 300 mg of codeine on the evening of day 3. She had a family history of an undefined "bleeding disease. on days I. and none thereafter. measured prospectively. Last raster (third application of laser). CO\ laser in CW mode at 20 to 30 W.5-cm raised." Her coagulation profile was normal. and colon resection for adenocarcinoma presented with a complaint of a sore mouth under her upper denture. First raster after wiping away the char. Surgical treatment requires two rasters at 750 W/cm to remove all of the abnormal tissue followed by a third exposure at 500 W/cm to coagulate the base of the lesion. of 500 W/cm and 750 W/cm . was 18 mL. respectively. and the surgical site is not prepared with antiseptic solutions. Consequent to her medical history. Figure 6-40. She required similar analgesics for the next 4 days. 6-37 to 6-46).5 g of aspirin per day. at average PDs.0 mm. emphysema. and took 2. Completion of tirst raster. By day 21. The parameters for the laser treatment are spot size 2. irregular midline palatal lesion that. and 3 the patient required four analgesics (Synalgos) per day and a single dose of acetaminophen (500 mg). Total surgical time including the period of observation is 27 minutes. Figure 6-39. power output 20 and 30 W. She has a 1. 2 2 2 2 Figure 6-37. Local anesthetic with vasoconstrictor is administered for postoperative pain relief. the operative site was 90% resurfaced with epithelium despite the heavy charring created at the base of the lesion by the coagulation of the base with the 30 W beam. the C O laser is used in the CW mode specifically 2 : to induce a greater than customary amount of lateral heat conduction to minimize bleeding. no prophylactic antibiotics are used. CW function. this patient is admitted to the hospital on the morning of surgery and discharged the following day. when biopsied. At surgery. Ablation by vaporization with the C 0 laser is chosen as the treatment of choice. having completed a full course of gold therapy for her rheumatoid arthritis 8 months ago. However.Soft Tissue Excision Techniques 75 FIBROEPITHELIAL HYPERPLASIA OF PALATE A 65-year-old while woman with a history of rheumatoid arthritis. Epithelialization was complete on day 26.

Note general yellow color as submucosa deep to minor salivary glands has been excised. Day 19. Day 6. . Figure 6 . Figure 6-44. First postoperative day. Characteristic appearance of fibrin covering the wound. Last raster after wiping away the char.76 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry Figure 6-41.4 3 .4 2 . Figure 6 .

Soft Tissue Excision Techniques 77 Figure 6-45. Long-term results. Day 26. 15 months postoperatively mucosa has been stable. Treatment area has become completely reepithelialized. . Figure 6-46.

After two rasters at PD = 450 W/cm .0 mm at an output power of 15 W and a PD of approximately 450 W/cm . . RSP CO. Facial nevus. 2 2 2 Figure 6-48. 6-47). Very minor depression. Two rasters were administered under 10X magnification and the surface of the target tissue was debrided with a wet gauze sponge after the first and second raster (Fig. Treatment of nevus. Laser parameters: RSP C 0 laser (110 mJ/pulse) at 108 pps using the microscopic and microslad system. 6-48).78 Lasers in M a x i l l o f a c i a l Surgery and Dentistry FACIAL NEVI A 38-year-old white woman sought consultation for removal of a nodular facial nevus present for the past 10 years. 2 Figure 6-47. The target site was anesthetized by infiltration of 1% lidocaine local anesthetic. One year later there was only a faint depression at the treatment site and there was no change in skin color (Fig. with microscope at I OX magnification. Figure 6-49. 6—49). The laser spot size was 2. No skin preparation was performed (Fig. Perfect skin color at treatment site. Result at one year. Vaporization technique with rapid superpulsed (RSP) C 0 laser was chosen to reduce scarring.

The subjacent papillary and reticular dermis receives no 3 thermal damage. the target tissue is removed with a saline moistened gauze sponge (Figs. or rhylidcs from excessive sun exposure. This microprocessor controlled device creates char-free ablation by moving a high-irradiance beam at a rapid rate. post surgery. 6-50 to 6-57). 18-yearold male with small area of burn scar. Figure 6-52. and is capable of removing very shallow skin craters whose penetration level is restricted to the epidermis and upper dermis. CO. The wrinkle is treated by ablating the area adjacent to the deepest point of the wrinkle fold with the laser set at 7 W average output power in the pulsed mode at 0. collimated beam. This permits assessment of the laser effect after completion of a single cycle (one complete revolution of the flash scanner within its target circle). laser resurfacing with the Coherent Ultrapulse 5000C CPG scanner at 300 ml. thereby preventing the dwelling time at any one point scanned to be greater than the thermal relaxation time of the skin. I (WW with 2 passes at moderate density. 60W. 2 Figure 6-50. Benign cutaneous growths and atrophic scars and pits can be treated similarly (see chapter 4. particularly those occurring on and around the lips and eyes. may be reduced by treatment with the COs laser using an automated scanner such as the SilkTouch flash-scanner (Sharplan Lasers). White Lesions of the Lip. Figure 6-53. I week Figure 6-57. 2 months post surgery. The scanner can be attached to any C 0 laser that provides a CW. Figure 6-56. which is expected to improve in time. 6 months post surgery.) Postoperative results are consistently good.2-s cycles. figure 6-51. mildly raised. Pending the area to be treated. . a second and third pass may be necessary to penetrate into or through the papillary dermis. Figure 6-54. 62-year-old female with line wrinkles in lower lid.Skin wrinkles. 3 weeks post surgery Note resolving edema and erythema. with one pass at moderate density over lower lid and 2-3 passes over lateral and infraorbital/malar areas. a Computer Pattern Generator (Coherent Lasers) can be used with an ultrapulse C 0 laser at 175 to 300 mJ/pulse and an average power of between 60 and 100 W. Alternatively. lateral and infraorbital areas. sustained 2 years prior. As always. over right temporal area.79 SKIN RESURFACING IN AESTHETIC SURGERY . C02 lasers resurfacing with Coherent Ultrapulse 5000C CPG scanner at 225 ml. Note smoothened area with the slight hypo-pigmentation. Figure 6-55.

The CO. (Fig. As long as laser-tissue interaction principles are understood and adhered to. 6-59). The presence of intact sebaceous glands should be noted on the deep margin to minimize scarring. 2 Rhinophyma Treatment of rhinophyma is an example.80 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry COMBINATION USES A combination of excision and vaporization techniques can be used in the treatment of certain diseases. Postoperative result at 5 weeks. . 6-58) Previous treatment methods with dermabrasion was often incom- plete. Reepithelialization takes place in 3 to 5 weeks (Fig. Recontouring with a scalpel is complicated and also difficult because of excessive hemorrhage. (Courtesy of Dr. whereas electrocautery would leave significant scars. and ablate by simply moving the laser handpiece into and out of focus is a major advantage of the instrument in its medical applications. laser allows good precision and a dry field for easier sculpting. Figure 6-58. In fact. Thermal damage using the CW beam should be avoided. Excision with a small spot size at 5 W of power can be used in combination with vaporization in the defocused mode with multiple passes for recontouring.) Figure 6-59. the versatility of the C 0 laser in its ability to incise. Andrew Van Hassel. the desired tissue effect can be obtained. coagulate. Rhinophyma.

Three weeks. The existing denture is relined with soft denture liner. . a defo- cused beam at 5 to 10 W CW is used to aid hemostasis and promote a dry field. handpiece. Figure 6-63.0 to 3. The wound re-epithelializes in about 3 weeks with little loss or no loss of sulcus depth (Figs. 6-60 to 6-63).0-mm spot size may be used. which consists of hyperplastic mucogingival folds from fibroepithelial proliferation secondary to ill-fitting dentures. CO. It responds well to laser excision with minimal postoperative discomfort and swelling. Figure 6-60. a pulsed waveform at 20 W.Soft Tissue Excision Techniques 81 EPULIS FISSURATUM Epulis fissuratum. Stability was maintained at a 6 month recall visit. Focus mode used to excise much of the redundant tissue. prevents proper denture seating on a stable base. Fpulis fissuratum secondary to a poorly fitting Figure 6-62. Sulcus deepened approximately 5 mm after frenectomy. Alternatively. In this case. After treatment and wiping away treated area. maxillary denture. PRR = 50-200 pps at 2. Figure 6-61.

Similarly.82 Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry MUCOCELE Mucoceles can be excised after mucoepidermoid carcinoma has been ruled out. Hene guide beam beyond periphery of "roof" of mucocele. ulcerative lesions can be removed and treated palliatively. The periphery A similar technique with the C 0 laser can be used to primarily desensitize oral wounds. . CW and defocused mode using a char and wipe technique is adequate here. Figure 6-65. The wound margin is then sealed with a defocused beam. Three months. Large ranulae are marsupialized by having the " r o o f excised. The lesion heals in 2 to 3 weeks without pain.5-mm spot size can then be used to "paint" over the surgical wound to a slightly grayish color. Aphthous and traumatic ulcers are first painted over with topical anesthetic. as occasional minimal scarring can be well tolerated. the lesion is first unroofed. Skin moles can be excised sharply with a scalpel flush to the skin. The center of the wound may become slightly concave due to contraction of collagen fibers. the central portion of the lesion is lifted with a forceps. it can be left alone until such pigment rises to the surface of the dermis during healing. F'igure 6-67. Aphthous Stomatitis 2 Benign 2 Pigmented Lesions The C 0 laser used in combination with scalpel surgery facilitates wound management and healing. 6-64 to 6-67). Reepithelialization is complete in 2 or 3 weeks depending on the size of the wounds (Figs. A lower power.to 2. A pulsed laser at 3 W of power output with 200 mJ/pulse of energy using a 1. No submandibular gland obstruction. Recurrent mucocele of floor of mouth. defocused C 0 beam is then passed over the entire lesion including the red halo rim. At 6 to 8 W CW. The area can then be resurfaced again. Slight scar at surgical site. If residual pigment is present in the deep dermis. Part of sublingual gland ablated. or rim of the wound is then recontoured with the larger spot size and adequate energy/pulse to level raised areas. Likewise. Mucosal donor sites in the palate can be glazed over to provide a thin layer of fibrinous coagulation. The gland is then propped up and excised in toto to prevent recurrence. lichen planus that causes burning and itching sensations can be treated with passes of C 0 laser beam at lower power settings in 2 2 Figure 6-64. painful. F'igure 6-66.

In general.6(3):431^143. Roodenburg JL. Larger oral wounds may be covered initially with gauze packing impregnated with a topical agent like Balsam of Peru. Oosterhuis JW. 7. Sun exposure should be avoided for 6 to 12 months. Management of mucosal premalignant lesions. J Surg Oncol 1989. Many of the laser procedures are minor and can be performed under local or topical anesthesia. It can also be helpful in infected surgical sites as it theoretically sterilizes during application. The advantage of C O laser usage is evident.and hyperpigmentation. 1977:1 II. and vascular tissues. Goldschmidt RA. Dental. wound contracture. This includes granulation tissue. Supplemental 0 should be avoided unless delivered through an endotracheal tube. It is useful as a surgical instrument in patients with bleeding disorders. patients in whom the use of epinephrine vasoconstriction is contraindicated. provide patient comfort. Parrish JA. 5. Clinical evaluation of tumor promotion by C 0 laser. which is the intermediate zone of coagulation necrosis. 83 WOUND CARE The objective of postoperative wound care is to protect the wound. Whitehead's varnish. 4. 1991:138-144.18(3):407-427. Science 1983. Laser. however. Ammirati M. The ultimate late of the lesion. Bips paste. 2 surgery of oral leukoplakia. Prevention of their formation by choosing the proper wavelength and parameters is paramount. . and in those patients who are on monitoring or pacemaker devices.41:153-159. Rao LN. will be determined by the natural history of lichen planus. Warm saline rinses four to six times daily and general oral hygiene care should be instituted. or an antibiotic ointment. This tissue can be peeled away with a hemostat and the underlying tissue assessed. and promote healing. 2. Long-term complications are related to regeneration of wound tissue. both edema and pain will increase if poor technique results in excessive heating of the tissues during surgery. dayman L. Skin wounds should be cleansed gently twice daily with a mild soap solution and topical antibiotic ointment applied. care should be taken to monitor the pain tolerance of the patient and prevent patient movement. patients who arc on anticoagulants. Extra protection with a dressing such as Duoderm is advisable until new epithelium is formed in 4 to 6 weeks. hypertrophic scar.220:524-527. and Veterinary Medicine. Postoperative edema is usually minimal. Oral Surg Oral Med Oral Pathol 1991:71:670-674. Charring is expected with laser burn. bloody procedures. Obstet Gynecol Clin North Am l99I. The coagulation necrosis widens in the first few postoperative days and sloughs. Smaller oral and pharyngeal wounds are left open. 6. particularly in treatment of widespread. REFERENCES 1. Panders AK. Braun RE.Soft Tissue Excision Techniques the defocused mode until the mucosal tissue begins to blister and turn white. Carbon dioxide laser COMPLICATIONS Laser-related complications in the orofacial area are minimal if proper precautions are taken. Buchmann T. superficial diseases. Rox Anderson R. Vermey A. Nether- lands: Rijksuniversiteit. 2 3. Wound care ideally should be simple such that the patient can perform the tasks at home. . Physics of light and lasers. accounting for the delay in initial wound healing and possibly some increase in patient discomfort at thai time. Scanlon BF. Carbonized eschar (char) should be wiped and removed. The degree of thermal damage tolerance of the target tissue should be understood. In: SPIE vol 1424: Lasers in Orthopedic. Improvement of symptoms varies from patient to patient. Studies with the Cloudman S9I Mouse Melanoma. covered only with coagulum. Oral Maxillofac Clin North Am I994. Charring promotes hemostasis but also can act as a heat sink and mask the depth of laser effect on tissues. However. Groningen. Partial nephrectomy in mice with milliwatt carbon dioxide laser and its influence on experimental metastasis. Unintentional burns should be diligently avoided. With the latter. Morthy Ms. some improvements can be expected with smaller lesions. Any remaining disease can be treated with a second pass. Selective photolhermolysis: precise microsurgery by selective absorption of pulsed radiation. Absten GT. Leibow C. Tumor Surgery with the CO. and hypo. Management of these complications is similar to those resulting from scalpel or electrocautery surgery.

106 p a t i e n t s h a v e been treated by transoral resection with the free-beam C 0 laser. there is a r e d u c e d likelihood of i n d u c i n g t u m o r m i c r o e m b o l i d u r i n g surgical extirpation of the t u m o r . 4 3 patients with 5 1 stage I or II oral c a n c e r s h a v e been u n d e r surveillance for m o r e than 5 y e a r s . node. 9 % . O n e o f the q u e s t i o n s t o c o n s i d e r that c o u l d t h e o r e t i c a l l y h a v e a n e g a t i v e effect on local r e c u r r e n c e is t h e p o s sibility that c a n c e r c e l l s t h a t a r e n o t c l i n i c a l l y a p p a r e n t d u r i n g s u r g e r y c o u l d b e c o m e b u r i e d and m a i n t a i n their v i a b i l i t y after l o s i n g c o n t i n u i t y with t h e e p i t h e l i a l s u r f a c e from w h i c h t h e y a r o s e . s t a g e II: T 2 N 0 M 0 ) a t 7 8 . I n c o n c o r d a n c e w i t h t h e N a t i o n a l C a n c e r Institute data individual studies from the literature reporting c u r e r a t e s for c o n v e n t i o n a l s u r g e r y o f p r e v i o u s l y u n 2 2 7 2 2 8 2 9 85 . T h i s q u e s t i o n w a s c o n s i d e r e d and i n v e s t i g a t e d d u r i n g s t u d i e s o f C 0 l a s e r a b l a t i o n o f the transformation z o n e in c a s e s of cervical intraepithelial neoplasia. The rate of n e w c a s e formation is a p p r o x i m a t e l y 3 0 .3-6 r e g a r d i n g survival after transoral resection o f localized oral c a v i t y c a n c e r using the C 0 laser q u o t e r e l a t i v e survival rates of 81 to 8 9 % for previo u s l y untreated l e s i o n s . As reported later in this c h a p ter. a n d elimination of the need for s p l i t .t h i c k n e s s skin grafting. 3 % . it is noted that for T glottic c a n cer.y e a r r e l a t i v e s u r v i v a l rate for oral cavity a n d p h a r y n x i s 5 2 . in t h e o r y . life-threatening d i s e a s e o r i g i n a t i n g from the oral cavity is s q u a m o u s cell c a r c i n o m a . Of those p e o p l e e v e r h a v i n g been e x a m i n e d for oral c a n c e r 5 4 . metastasis tumor staging—stage I: T 1 N 0 M 0 . the sur- vival is w o r s e for r e g i o n a l d i s e a s e ( p r i m a r y and neck inv o l v e m e n t ) at 4 1 . 5-year s u r v i v a l for local d i s e a s e ( s t a g e I or II) must equal or e x ceed 7 8 . Despite the p o tential for early detection. C u r e rates a c h i e v a b l e with the surgical laser match those attributed to scalpel or e l e c t r o s u r g e r y . in my o w n e x p e r i e n c e at Sinai Hospital of Detroit. less p o s t o p e r a t i v e e d e m a . of w h o m 22 w e r e m o n i t o r e d for 2 years and 156 w e r e m o n i t o r e d for 5 y e a r s . SURVIVAL T h e most r e c e n t survival statistics a p p l i c a b l e t o oral c a n c e r a r e those p u b l i s h e d in 1994 by t h e N a t i o n a l C a n c e r Institute of t h e United S t a t e s N a t i o n a l Institutes of Health for the period 1973 to 1 9 9 1 . M o r b i d i t y and late detection remain high largely b e cause of the l o w rate of clinical e x a m i n a t i o n by health care workers. d i m i n i s h e d infection rates. A n y o t h e r t e c h nique such as e l e c t r o s u r g e r y . R e p o r t s in t h e literature. A s e x p e c t e d . c r y o s u r g e r y ." 1 Transoral resection of stages I and II oral c a n c e r is a well-accepted treatment m e t h o d in o n c o l o g i c s u r g e r y . a n o n o r a l head and neck site. or laser s u r g e r y must p r o d u c e c o m p a r a b l e o r i m p r o v e d c u r e r a t e s . 4 % had received this e x a m i n a t i o n as part of a dental e x amination and 3 5 % as part of a r o u t i n e p h y s i c a l e x a m i n a tion. T h e C e n t e r s for D i s e a s e C o n t r o l (Atlanta. shorter hospital stay. the laser-treated cases d i d not s h o w i n c r e a s e d local r e c u r r e n c e o r r e g i o n a l m e t a s t a s e s . During colposcopic and histopathologic assessment it was noted that recurrent lesions did maintain c o n t a c t with t h e s u r f a c e e p i t h e l i u m . T h e y d i d not lie d o r m a n t a s b u r i e d c r y p t s o f a b n o r m a l e p i t h e l i u m that w o u l d t h e n h a v e t h e p o t e n t i a l t o g r o w into n e o p l a s m s later. 9 % . 0 0 0 per year. T h e r e f o r e . S e r e n d i p i t o u s l y . 178 patients w e r e studied. for transoral r e s e c tion w i t h t h e s u r g i c a l laser t o b e c o m e a c c e p t a b l e . In addition. e n d o s c o p i c e x c i s i o n with the free-beam C 0 laser resulted in a 5-year local control rate of 9 4 % with a 5 . 3 % of adults had e v e r had any t y p e of s i m p l e s c r e e n i n g e x a m i n a t i o n for oral c a n c e r . O f this g r o u p . T h e d e t e r m i n a t e 5 .y e a r survival rate of 7 8 % with deaths attributable to e i t h e r a s e c o n d p r i m a r y c a n c e r or intercurrent disease. b e c a u s e of t h e l a s e r ' s ability to seal small blood vessels and l y m p h a t i c s . G A ) e s timates that in 1993 less than 1 4 . w h i c h in turn r e d u c e s the c h a n c e s of " s e e d i n g " the surgical site or the v a s c u l a r or the l y m p h a t i c system. 3 % . T h e gold s t a n d a r d for o u t c o m e is the result a c h i e v e d by scalpel resection.y e a r survival rate is 9 2 . C o l l e c t i v e l y . 5 % a n d it is better for local d i s e a s e (tumor.7 Transoral Resection of Oral Cancer Lewis dayman The most s e r i o u s . In the United States this results in a p p r o x i m a t e l y 8 0 0 0 d e a t h s per y e a r . T h e specific surgical t e c h n i q u e is less important than is t h e sound application of o n c o l o g i c p r i n c i p l e s to a c h i e v e adequate resection of the tumor. ' F o r the m o s t r e c e n t interval in this series ( 1 9 8 3 to 1990) t h e 5 . C o m p a r e d with p a t i e n t s h a v i n g s t a g e s I and II oral c a v ity t u m o r s that w e r e t r e a t e d b y c o n v e n t i o n a l s u r g e r y using transoral resection technique. m o s t oral c a n c e r s are still d i s c o v ered in their late s t a g e s (stages III and I V ) . and also p r o v i d e the significant a d v a n t a g e s of better h e m o s t a s i s .

W h e n used a s a n a l t e r n a t i v e o r a s a n a d j u n c t t o c o n v e n tional s u r g e r y for larger T a n d T l e s i o n s .g a r n e t ( N d : Y A G ) laser scalpel had l o w e r local r e c u r r e n c e rates c o m p a r e d with c o n ventional resection with a steel scalpel. It is well advised to wait 5 to 7 m i n u t e s for m a x i m u m vasoconstriction to o c c u r prior . T h i s can be achieved by u s i n g a c h o p p e d c o n t i n u o u s w a v e ( C W ) m o d e rather than rapid s u p e r p u l s e d ( R S P ) . 0 u n i t s / m L ) . Both t h e h a n d h e l d p r o b e and the j o y stick m i c r o m a n i p u l a t o r result in safe excisional surgery. 2 2 14 3 4 2 2 2 T h e transoral resection of oral c a n c e r w a s first reported by S t r o n g et a l . transoral resection with elective neck dissect i o n . 0 m J / c m 2 (see C h a p t e r 15). T h i s e x t e n t of heat d a m a g e of tissue adjacent to the b e a m in c a n c e r resection is quite a c c e p t a b l e . respectively. t h e m i c r o s c o p e e n h a n c e s control b y magnifying t h e surgical field a n d thereby a d d i n g precision to the m e t h o d o f tissue r e m o v a l .6-u.0 mm. T h e c h o p p e d m o d e provides a r e a s o n a b l e c o m p r o m i s e b e t w e e n a " c o o l " b e a m and the heat transfer to t i s s u e required for h e m o s t a s i s . 21 C a r c i n o m a s in a rat liver m o d e l w e r e not subject to increased m e t a s t a s e s w h e n e x p o s e d t o milliwatt C 0 l a s e r s . in fact. 1 7-1 9 A p r o s p e c t i v e c l i n i c a l trial t o e v a l u a t e s u c h a n effect for T . In v i v o .h e l d probe and j o y s t i c k m i c r o m a n i p u l a t o r c o u p l e d to an o p e r a t i n g mic r o s c o p e . 3 . floor o f m o u t h c a n c e r fell t o 6 7 t o 9 6 % d e p e n d i n g on whether the patients had originally been treated b y r a d i o t h e r a p y o r s u r g e r y . U s i n g a s u p e r p u l s e d C 0 laser with a fluence of approximately 3 J / c m 2 at 2 Hz an e s t i m a t e d z o n e of tissue d a m a g e of nonablated t i s s u e of 40 to 50 u. B e c a u s e the b e a m i s a p p l i e d o n l y t o c l i n i c a l l y n o r m a l t i s s u e at t h e resection m a r g i n and not on t h e t u m o r itself. T w o t e c h n i q u e s w e r e e m p l o y e d : h a n d . 2 2 M o u s e m a m m a r y c a r c i n o m a s treated b y c o n t a c t n e o d y m i u m : y t t r i u m .3. t h e literature d o e s not s u p p o r t s u c h a n e g a t i v e o u t c o m e i n s u r g i c a l l a s e r t r e a t m e n t o f h u m a n oral m a l i g n a n c i e s . T h i s c o n c e p t received further support by t h e early 1980s. T h e former is a timed e p e n d e n t function o f e n e r g y a b s o r p t i o n and thermal c o n d u c t i o n . and therefore h e m o s t a s i s i s e n h a n c e d b y C W o r c h o p p e d C W free-beam lasers c o m p a r e d with R S P lasers.4 4 ) . S u c h a study h a s n e v e r b e e n d o n e . with no significant d i f f e r e n c e r e p o r t e d for t r a n s o r a l r e s e c t i o n alone vs. 0 0 0 ) e p i n e p h rine or Pitressin ( 1 . 1 0 . 2 3 4 2 2 2 6 DRY FIELD M a i n t e n a n c e of a dry field d e p e n d s on laser-tissue interactions as well as o t h e r tissue factors. and C a r r u t h .0 t o 4 .l5.16 T h e most i m p o r t a n t n e g a t i v e a s p e c t t o c o n s i d e r i n e v a l u a t i n g l a s e r s u r g e r y i s w h e t h e r t h e l a s e r b e a m itself m i g h t h a v e a n y t u m o r .8 ) . r e s p e c t i v e l y .p r o m o t i n g effects that m i g h t e n h a n c e r e c u r r e n c e o r s p r e a d t o l o c o . 7 . D e t r o i t ) . A n i m a l solid t u m o r m o d e l s h a v e d e m o n s t r a t e d conflicting results with h a m s t e r c h e e k pouch c a r c i n o m a r e s p o n d i n g b y increasing t u m o r s p r e a d 2 0 and m o u s e m e l a n o m a s not b e i n g affected b y laser light.86 Lasers in Maxillofacial Surgery and Dentistry FREE-BEAM C0 2 treated l o c a l i z e d t o n g u e a n d floor o f m o u t h c a n c e r r a n g e d from 8 6 % t o a s h i g h a s 9 4 % for 2 y e a r s for T j l e s i o n s a n d 6 9 t o 8 6 % for T l e s i o n s . particularly from Panjer et a l . t h e s u r v i v a l rate for T .000 to 10.1 2 A t 5 y e a r s . at m o r e realistic ablation rates of 50 to 150 pulses per s e c o n d it is consistently noted that t h e z o n e of d a m a g e is less than 2 0 0 u-m (see Fig. h o w e v e r . S i m i l a r l y .2 9 laser i m p r o v e s h e m o s t a s i s significantly w h i l e still a v o i d i n g e x c e s s i v e heat d a m a g e (see Fig.m width is o b t a i n a b l e in a g u i n e a pig skin m o d e l . any e n h a n c e m e n t of s p r e a d w o u l d be e x p e c t e d to be a c o n s e q u e n c e o f direct h a n d l i n g o f t h e n e o p l a s t i c t i s s u e b y retraction i n s t r u m e n t s . 1 1 . Sinai H o s p i t a l . T h e issue r e g a r d i n g t u m o r p r o m o t i o n b y direct a p p l i c a tion of laser light to t h e t u m o r itself is m o r e c o n t r o v e r s i a l . R e v i e w of t h e literature of t h e b i o s t i m u l a t o r y effects of low-level laser light on fibroblasts and epithelial cells in tissue c u l t u r e generally s h o w s s t i m u l a t o r y effects at e n e r g y d e n s i t i e s b e l o w 3.a l u m i n u m . 7 . T h i s usually m e a n s a c c e p t a n c e of a z o n e of heat d a m a g e at the depth of t h e crater as well as a l o n g its side walls of about 0. E n h a n c i n g h e m o s t a s i s in tissue is a b e t t e d by the use of local a n e s t h e t i c solution c o n t a i n i n g d i l u t e ( 1 : 2 0 0 . In addition.1 3 F o r T | and T oral t o n g u e c a n c e r t r e a t e d b y r e s e c t i o n t h e 5 year survival was 7 7 % and 6 5 % . T h e s e s u r v i v a l s t a t i s t i c s s u p p o r t t h e u s e o f t h e surg i c a l laser for t r a n s o r a l r e s e c t i o n of l o c a l i z e d ( s t a g e s I and II) oral c a n c e r w i t h o u t i n c r e a s i n g t h e risk o f local recurrence or regional spread.000 W / c m . t h e r e w e r e n o a d v e r s e effects o n e i t h e r w o u n d h e a l i n g o r t u m o r c o n trol. o n e w o u l d not e x p e c t to find a d i m i n i s h e d c o n t r o l r a t e with l a s e r u s e a n d . l e s i o n s w h e r e t h e l a s e r c u r e rate e x c e e d s 9 0 % w o u l d r e q u i r e 3 4 2 c a s e s in e a c h a r m of a s t u d y ( c o n v e n tional and laser) to d e t e c t a 5% s u r v i v a l d i f f e r e n c e at a p < . 1 ' 5 . N d : Y A G delivered by c o n v e n t i o n a l sapphire tip or by the silica c o n t a c t p r o b e of the Surgical Laser T e c h n o l o g i e s ( S L T ) 2 7 . 0 5 (at 8 0 % p o w e r ) ( p e r s o n a l c o m m u n i c a t i o n : Y D a o u d .5 to 1.m laser light ( C 0 ) . b i o s t a t i s t i c i a n . H e m o s t a s i s requires a l o n g e r duty cycle than d o e s ablation as d i s c u s s e d in the p r e c e d i n g c h a p t e r bec a u s e a m o d e r a t e a m o u n t of lateral thermal c o n d u c t i o n is required to seal t h e m i c r o v a s c u l a t u r e . 0 m J / c m a n d inhibitory effects a b o v e 4 . T h e y e s t a b l i s h e d the safety of mic r o s c o p e . T h i s b e i n g t h e c a s e .g u i d e d C 0 laser surgery c o u p l e d with the use o f vital s t a i n i n g with t o l u i d i n e b l u e and the use of frozen sections to control m a r g i n s . 2 4 ' 2 5 in 1979. F o r both t e c h n i q u e s i r r a d i a n c e must exceed 5.r e g i o n a l o r distant s i t e s . 23 T h e r e a r e no a n i mal data on s q u a m o u s cell c a r c i n o m a r e s p o n s e to irradiation with 10. its extent is m u c h m o r e c o n t r o l l a b l e than is heat d a m a g e associated with e l e c t r o s u r g e r y .

T h e laser-treated g r o u p c o n s i s t e d o f five p a t i e n t s w h o : 2 CONSEQUENCES P o s t o p e r a t i v e l y there w a s a high level of patient accept a n c e . T h e s e latter adjuncts add the benefit of intraoperative and p o s t o p e r a t i v e analgesia in addition to the vasoconstriction that facilitates a c c u r a t e surgery by maintaining a dry field. N o n e of these p a t i e n t s required p o s t o p e r a t i v e ICU for surgical site m a n a g e m e n t and n o n e of t h e m required hospitalization for m o r e than 48 hours. B e c a u s e operating in the oral cavity u n d e r these c o n d i t i o n s places the airway at risk for obstruction from b l e e d i n g during surgery.0 unitvmL) w a s also added to the local a n e s t h e t i c . T h e average blood loss for the c o n v e n t i o n a l g r o u p w a s 122 mL and that for the laser-treated g r o u p w a s 6 0 m L . In no c a s e w a s it necessary to excessively d e e p e n sedation to meet the n e e d s of patient comfort. or T mal c a r c i n o m a s . 5 % and e p i n e p h r i n e 1:200. T h e result is that the target tissue lies passively during e n e r g y application. T h e drapes w e r e then a p p l i e d and a h y p o p h a r y n g e a l g a u z e pack w a s inserted. A p r o s p e c t i v e study of t h e u s e of f r e e . there h a v e been 13 patients with T. s e v e n of w h i c h w e r e floor of mouth ami t o n g u e . w h i c h w e r e treated by laser resection using local a n e s t h e t i c and i n t r a v e n o u s sedation. ( S e e c a s e reports for details. 87 did not r e c e i v e v a s o c o n s t r i c t o r w h o s e b l o o d loss w a s 9 0 m L and three w h o did r e c e i v e v a s o c o n s t r i c t o r w h o s e avera g e b l o o d loss w a s 3 8 m L for t h e s a m e o p e r a t i o n . During f o l l o w . T h i s is most a p p a r e n t during surgery on the t o n g u e . No " p r e p " solutions w e r e used and no preoperative or intraoperative antibiotics w e r e given unless they w e r e required for p r o p h y laxis b e c a u s e of c a r d i a c v a l v u l a r d i s e a s e or the presence of metallic o r t h o p e d i c i m p l a n t s . AVOIDING GENERAL ANESTHESIA Surgical CO. Both g r o u p s received local infiltration a n e s t h e s i a with l i d o c a i n e 0 .1 . m a i n t a i n i n g a dry field b e c o m e s essential to the maintenance of a patent a i r w a y . Pitressin (1. and the v a r i o u s c o n t a c t N d : Y A G lasers.s t a g e oral c a n c e r that had been previously treated by radiation it w a s e v e n found to reduce infectious c o m p l i c a t i o n s .000. Most of these patients h a v e significant intercurrent d i s e a s e s . I n c o m p a r i s o n with the role o f free-beam C 0 the contact N d : Y A G laser w h e n used at 15 to 25 W output power with an 8 0 0 . and distant flap complications. N e i t h e r systemic nor locally a p p l i e d steroids w e r e g i v e n .u p e x a m i n a t i o n s the use of postoperative a n a l g e s i c s w a s r e c o r d e d . and c e r e b r o v a s c u l a r . F o r B o o r o f m o u t h c a n c e r . the 10 p a t i e n t s treated c o n v e n t i o n a l l y all had local a n e s t h e t i c with v a s o c o n s t r i c t o r . Unfavorable airway incidents did not o c c u r during surgery and no c a s e required a c h a n g e in a n e s t h e t i c m a n a g e m e n t to control the airway during surgery.p m conical tip w a s found to reduce bleeding and not to i m p a i r w o u n d healing. T h e application of the laser e n e r g y to the tissue d o e s not c a u s e any m o v e m e n t of the tissue. T h e trend w a s t o w a r d r e d u c e d b l o o d loss for t h e laser-treated p a t i e n t s . and their a v e r a g e b l o o d loss w a s 190 m L . T r a c t i o n using sutures or ins t r u m e n t s to aid visibility d u r i n g s u r g e r y w a s applied as n e c e s s a r y . a g a u z e pack w a s placed as a throat screen rather than as a h y p o p h a r y n g e a l pack. pulmonary. which m a k e it preferable to perform their surgery using local a n d / o r regional a n e s t h e s i a techniques a c c o m p a n i e d by i n t r a v e n o u s s e d a t i o n . Both the C O and the Y A G lasers permit the safe c o n d u c t of surgery u n d e r these circumstances. As noted in the literature" " and 1. particularly m u s c l e . W h e n used for the resection of a d v a n c e d . : 2 29 Protocol T h e a n a t o m i c site w a s injected with lidocaine or bupivacaine c o n t a i n i n g e p i n e p h r i n e 1:200.b e a m C O in t h e D e p a r t m e n t o f D e n t i s t r y / O r a l and M a x i l l o f a c i a l S u r g e r y at Sinai H o s p i t a l w a s initiated in 1988 to e v a l u a t e its efficacy for the transoral resection of s t a g e s I a n d II oral c a n cer. they had m u c h less e d e m a and also res u m e d oral feedings m o r e rapidly than did those patients with similar lesions w h o w e r e treated by c o n v e n t i o n a l s u r g e r y . T h e Boor of m o u t h r e s e c t i o n s for both g r o u p s did not i n c l u d e r e m o v a l of b o n e .Transoral Resection of Oral Cancer to Operating. T h e i r utility b e c o m e s progressively m o r e important as m o r e a g e d patients c o m e to surgery for r e s e c tion of their oral c a n c e r s . For floor of mouth c a s e s .000. fistula formation. as is the c a s e with e l e c t r o c a u t e r y w h o s e application induces strong m u s c l e c o n t r a c t i o n s . For o p e r a t i o n s p e r f o r m e d using sedation instead of g e n e r a l a n e s t h e s i a . T h e first p a r a m e t e r to be e x a m i n e d w a s b l o o d loss resulting from partial g l o s s e c t o m y and floor of m o u t h resection. the t w o lasers of greatest value are the free-beam C O . AND CONTACT Nd:YAG For transoral c a n c e r resection.) S i n c e 1988. particularly with electrocautery. T h e c a n c e r itself w a s not m a n i p u l a t e d but the area a r o u n d t h e t u m o r that would later constitute the margin w a s intiltrated with the a n e s t h e t i c solution. particularly c a r d i o v a s c u l a r . which e n h a n c e s t h e precision of resection. O b j e c t i v e l y . T h e r e w e r e 12 t o n g u e l e s i o n s treated with the free-beam C 0 laser ( s t u d y g r o u p ) and 1 0 treated with scalpel o r e l e c t r o s u r g e r y ( c o n v e n t i o n a l g r o u p ) . All o p e r a t i o n s for t o n g u e and floor of m o u t h w e r e p e r f o r m e d on p a t i e n t s having g e n e r a l a n e s t h e s i a with t h e a i r w a y m a i n t a i n e d b y n a s o e n dotrachcal intubation. O p e r a t i n g c o n d i t i o n s a r e further i m p r o v e d by using t h e laser.

3 2 3 0 30 2 U s i n g these t e c h n i q u e s to r e m o v e 106 c a n c e r s d u r i n g the past 5 y e a r s . S i m i l a r f i n d i n g s h a v e also b e e n reported for u s e of the c o n t a c t N d : Y A G (sapphire t i p ) . D u r i n g this initial period n o n e of these patients required intubation of t h e gastrointestinal tract to maintain their nutrition. a s u b g r o u p will e x p e r i e n c e a 2. b e c a u s e of the consistent m i n i m a l p o s t o p e r a t i v e e d e m a . w h o " o o z e d " for 2 to 3 d a y s after s u r g e r y . a p p r o x i m a t e l y o n e third o f patients will h a v e less p o s t o p e r a t i v e pain w h i l e a n o t h e r third will h a v e m o r e p o s t o p e r a t i v e pain than do t h o s e patients h a v i n g c o n v e n t i o n a l s u r g e r y . T w o o c c u r r e d in patients with c i r r h o s i s of t h e liver. After day 5. we h a v e not had any patients stay in t h e hospital l o n g e r than 2 d a y s . G a s p a r and S z a b o reported o n 5 4 8 o p e r a t i o n s o f different types in the oral cavity and found that only 3 1 . n o n e o f these 9 0 patients from w h o m 106 t u m o r s w e r e r e m o v e d required o v e r n i g h t intubation or a d m i s s i o n to an intensive care unit after s u r g e r y . For larger T lesions and those with p o s t e r i o r defects r e q u i r i n g insertion of a surgical pack. all patients w e r e c o m p l e t e l y h e a l e d by t h e fifth p o s t o p e r a tive w e e k . In fact.m i n u t e (by t h e clock) h e m o s t a s i s c h e c k prior to terminating the operation. T h e r e w a s also o n e c a s e o f d e l a y e d h e m a t o m a d e v e l o p i n g 10 d a y s after resection of the ventral t o n g u e and floor of m o u t h in a patient with c i r r h o s i s of t h e liver. vital s t a i n i n g with toluidine b l u e . a n d m a n d i b u l a r a l v e o l u s a l o n g with s u p r a o m o h y o i d n e c k diss e c t i o n had a mild s p e e c h i m p e d i m e n t for w h i c h he d i d not seek t r e a t m e n t . A m o n g the 106 p a t i e n t s treated by transoral resection with t h e free-beam C 0 laser. 2 3 TIME AT OPERATION COMPLICATIONS N o s p l i t . A m o n g those with less pain. they are c o m pletely i g n o r e d . H o w e v e r . P o s t o p e r a t i v e l y the rate of significant s u b m a n d i b u l a r gland e n l a r g e m e n t s e c o n d a r y to obstruction requiring removal of the g l a n d i s 4 % i n o u r s e r i e s . No sialodochoplasty of t h e part of t h e p r o x i m a l duct r e m a i n i n g in situ is performed. In addition. w e did not specifically m o n i t o r s w a l l o w i n g difficulties. 2 c o n f i r m e d i n o u r o w n p r o s p e c t i v e and o n g o i n g a s s e s s m e n t of p o s t o p e r a t i v e pain. both o c c u r r i n g on the first p o s t o p e r a t i v e e v e n i n g . the d e g r e e of pain to be anticipated is unpredictable. laser c a s e s go quite quickly. T h e r e 2 O n c e the " l e a r n i n g c u r v e " delay is o v e r c o m e by clinical exp e r i e n c e . In fact.t h i c k n e s s skin grafts w e r e p l a c e d for a n y lasertreated c a s e s . reported s w a l l o w i n g difficulties in 2 1 % o f their c a s e s treated b y transoral resection with the C 0 laser. 2 THE SUBMANDIBULAR DUCT F o r anterior floor of m o u t h resection. 3 3 T h e laser is used to transect the duct if this is required to " c l e a r the field" of cancer. all s t a y e d an a v e r a g e of 2 d a y s . although t w o p a t i e n t s from a m o n g 2 6 p a t i e n t s with floor o f m o u t h o r ventral t o n g u e r e s e c t i o n r e q u i r e d s c a r r e l e a s e ( 7 . F u r t h e r m o r e . no special care is taken in regard to W h a r t o n ' s duct. and a m a n d a t o r y 5 .88 Lasers in Maxillofacial Surgery and Dentistry w e r e t w o c a s e s o f p o s t o p e r a t i v e infection requiring treatm e n t with s y s t e m i c antibiotics. but there w e r e no cases of significantly d e l a y e d h e a l i n g . T h e r e w e r e t w o c a s e s o f d e l a y e d b l e e d ing necessitating r e a d m i s s i o n to the o p e r a t i n g r o o m to c o n trol b l e e d i n g . . ' s 2 4 ' 2 5 original 1979 study of 57 oral canc e r s o f unspecified stage r e m o v e d using m i c r o s c o p i c control b y C W C 0 laser did not report any postoperative infections. and there w a s o n e patient w h o bled a t t h e c o n c l u sion of s u r g e r y d u r i n g e m e r g e n c e from a n e s t h e s i a w h i l e still intubated. 11 1 8 All of o u r patients w e r e seen on a w e e k l y basis until h e a l i n g w a s c o m p l e t e . a n d after m a t u r a t i o n w e r e indistinguishable from n o r m a l m u c o s a . t h e average t i m e d u r i n g t h e past 5 y e a r s for resection of T. floor of the m o u t h . 2 A l t h o u g h Panje et a l . I n d e p e n d e n t o f oral a n a t o m i c r e g i o n . as in d o g s . 3 4 it is w i s e to be q u i t e liberal in regard to t h e indications for r e m o v i n g the duct as part of t h e en b l o c resection. T h e s e treatment areas in h u m a n s . the healed oral m u c o s a p r e s e r v e s its elastic properties. 2 9 S t r o n g et a l . P o s t o p e r a t i v e s c a r r i n g w a s m i n i m a l . only t w o patients required a n a l g e s i c s b e c a u s e of pain from e x p o s e d b o n e . B e c a u s e of the k n o w n possibility of d o w n g r o w t h into the duct of oral s q u a m o u s cell c a n c e r located o v e r the d u c t . or T oral les i o n s is less than 45 to 50 m i n u t e s including injection of local a n e s t h e t i c .or 3-day interval of s u d d e n l y increasing pain starting on p o s t o p e r a t i v e day 4 or 5 . w h o required r e c o a g u l a t i o n of t h e floor of the m o u t h . T h i s m a y be related to the m i n i m a l increase in m u c o s a l t h i c k n e s s after C 0 laser treatment c o m p a r e d with scalpel i n c i s i o n s or it could be related to d i m i n i s h e d activity of m y o f i b r o blasts i n t h e h e a l i n g w o u n d . w e r e a l m o s t t h e s a m e c o l o r and t e x t u r e within 4 to 5 w e e k s . 7 % ) t o i m p r o v e t o n g u e m o b i l i t y a n d o n e patient with w i d e local e x c i s i o n of t h e t o n g u e . 2 % of their patients required a n a l g e s i c s o n t h e d a y o f s u r g e r y . p o s t o p e r a t i v e b l e e d i n g w h i l e in hospital w a s limited to five e v e n t s . All patients c o u l d eat a soft or n o r m a l diet by the t i m e epithelial resurfacing w a s c o m p l e t e at 4 to 5 w e e k s . T h i s consistent epithelialization of t h e laser-ind u c e d w o u n d i n h u m a n s c o n f i r m s t h e results o f a n i m a l e x p e r i m e n t s in which reepithelialization from t h e peripheral b o r d e r of a laser w o u n d took place within 4 w e e k s .

B l o o d loss is m i n imized. T h i s r e q u i r e s a bit of practice for surg e o n s w i t h o u t dental training.3 m m . particularly of the t o n g u e . T h e free-beam C 0 laser i n c h o p p e d C W o r R S P m o d e s c a u s e s t h e least s c a r r i n g b e c a u s e it c a u s e s t h e least heat d a m a g e . but heat d a m a g e m a y e x c e e d 3.Transoral Resection of Oral Cancer SURGICAL CASES General Comments: Free-Beam C0 Contact Nd: YAG 2 89 2 vs. T h e C 0 laser d o e s not p r o v i d e tactile sensation t o t h e operator. P o s t o p e r a t i v e scar contraction is mild and persistent restricted oral o p e n i n g following resection of posteriorly located lesions of t h e buccal m u c o s a . w h i c h is usually but not a l w a y s less than that e n c o u n t e r e d with e l e c t r o s u r g e r y . T h e return rate to the o p e r a t i n g theater to c o n t r o l d e l a y e d bleeding is about 4 % .b e a m C 0 w o u n d s heal slightly faster but this is not clinically significant. a dry o p e r a t i v e f i e l d . The major a d v a n t a g e s for t h e u s e of lasers a r e m i n i m a l postoperative e d e m a . F r e e . T h e c o n t a c t N d : Y A G pro2 2 2 vides tactile sensation and better h e m o s t a s i s . a n d for u s e in t h e area of t h e lingual anterior m a n d i b u l a r g i n g i v a o n e m u s t use a front surface d e n t a l m i r r o r to c h a n g e t h e b e a m d i r e c t i o n . r e m e m b e r t o rapidly c l a m p and tie o r c o agulate vessels if t h e laser d o e s not s t o p t h e b l e e d i n g .6 m m w h e r e a s R S P C 0 heat d a m a g e i s usually less than 0. Reconstruction after floor of m o u t h resection is particu- larly simplified by the lack of need for split-thickness skin grafts. and either g e n e r a l a n e s t h e s i a or s e d a t i o n t e c h n i q u e s may be used a l o n g with local a n e s t h e s i a . retromolar pad. Surgery itself g o e s q u i c k l y . usually lasting less than I hour. As a corollary it is also less h e m o s t a t i c than either C W C 0 o r c o n t a c t N d : Y A G . S o m e patients will lose a b o u t 1 0 t o 2 0 % o f their m a x i m a l incisal o p e n i n g . Both the free-beam C 0 laser and t h e c o n t a c t N d : Y A G laser a r e a p p l i c a b l e to t h e transoral resection of oral c a n c e r . or anter i o r tonsillar pillar is u n c o m m o n . O n t h e o t h e r hand. and a b s e n c e o f m u s c u l a r fasciculations. H o w e v e r . these latter t w o o p t i o n s c r e a t e m o r e u n w a n t e d heat effects both to the m a r g i n o f t h e s p e c i m e n and t o t h e native tissue. w h i c h p r o v i d e s a " q u i e t " o p e r a t i v e field. 2 2 . Most patients are d i s c h a r g e d within 2 4 t o 4 8 h o u r s a n d patient a c c e p t a n c e is very high.

TECHNIQUE Figure 7 .3 .3 ) and the peripheral resection margin is m a r k e d with t h e laser in the d e f o c u s e d m o d e ( F i g .2 . Figure 7 . Defocused spots to mark resection margin. the oral m u c o s a is stained with toluidine blue. After the c o m p l e t i o n of a e r o d i g e s t i v e e n d o s c o p y with the patient r e c e i v i n g a general a n e s t h e t i c .) T h i s is very helpful in a s s e s s i n g subclinical extent of spread of t h e m u c o s a l t u m o r . 2 . tongue properly retracted.y c a r . S h e i s also noted to h a v e mild von W i l l e b r a n d ' s disease. Bloodless markings are made with single pulses (PD <500 W / c m ) . HeNe guide beam placed into contact with tissue ai focal point of probe demonstrating 0. c h r o n i c obstructive lung d i s e a s e .m o n t h history of an "irritation u n d e r m y t o n g u e . T h e laser is adjusted s o that i n c h o p p e d C W o r R S P m o d e a n a v e r a g e p o w e r o u t p u t of 20 to 30 W is d e l i v e r e d .3-mm guide spot size foi incision. W h i l e a w a i t i n g m a x i m u m vasoconstrictor effect..90 Lasers in Maxillofacial Surgery a n d Dentistry TRANSORAL CASE 1: FLOOR OF MOUTH A 5 4 . 7 .n e o n ( H e N e ) g u i d e b e a m spot size is varied from 0 . T h e h a n d p i e c e for the free-beam C O 2 laser is n o w placed in c o n t a c t (i.1 . the areas retaining the stain a r e noted (Fig. presents with a 2 .1 a n d 7 . " E x a m i n a t i o n . and insulin-controlled d i a b e t e s mellitus. and the h y p o p h a r y n x is packed with a wet throat pack. Figure 7-4. and s y s t e m i c e v a l u a t i o n d e m o n s t r a t e a T | N ( ) M ( ) m o d e r a t e l y well-differentiated s q u a m o u s cell c a r c i n o m a o f the anterior floor of m o u t h ( F O M ) that e n c r o a c h e s upon t h e t e r m i n u s o f W h a r t o n ' s duct ( F i g s . By v a r y i n g the h a n d p i e c e distance from the tissue h e l i u m . Lesion retains toluidine blue vital slain after aectk acid rinse. T h e tip of the t o n g u e is g r a s p e d with a towel clip to facilitate retraction. T h e face is protected with moist saline e y e p a t c h e s and facial d r a p e s . 3 to 3. Handpiece is moved away from focal point until 2. 7 .2 ) . During operation. T h e free-beam CC»2 laser is c h o s e n as the instrument of c h o i c e for r e m o v a l of her tumor. After w a s h i n g the field with saline.o l d A f r i c a n . 7 . T | N()M() SCC of anterior floor of mouth.4 ) .A m e r i c a n w o m a n . ( S e e C h a p t e r 4. stable c o r o n a r y artery d i s e a s e . at the focal point) with the tissue to be e x c i s e d to start the e x c i s i o n .0 U / m L is injected along t h e p l a n n e d lines of resection into t h e d e p t h of the w o u n d .000 e p i n e p h r i n e and Pitressin 1.e. the a i r w a y is secured with a n a s o e n d o t r a c h e a l t u b e . Local a n e s t h e t i c solution c o n t a i n i n g 1:200.0 m m . with a 2 5 . incisional b i o p s y . T h e true Figure 7 .to 3-mm spot size is obtained.y e a r history of daily s m o k i n g of t w o p a c k s of cigarettes and of drinking four b e e r s .

Dissection made to base of deep resection margin. Specimen mobilized.1 7 ) speech. Figure 7 .5 ) and c a u t e r y or suture ligatures are used liberally to q u i c k l y s t o p b l e e d i n g . F'igure 7 .8 ) . the p o w e r d e n s i t y ( P D ) will range from 3 5 . (If used. N o t e that t h e extent of the thermal d a m a g e on t h e d e e p side of the resection m a r g i n w a s only 0. T h e s p e c i m e n w a s oriented and pinned on a w o o d e n t o n g u e blade to be s e n t to the p a t h o l ogy laboratory (Fig.16 m m (Fig.16 mm (100X). . T h e r e f o r e . At 1-year recall ( F i g s . and r a n g e o f motion o f t h e t o n g u e were all n o r m a l . 91 Figure 7 .0 m L and operating t i m e w a s 4 0 m i n u t e s . an oral p a c k is r e m o v e d either at bedside prior to d i s c h a r g e . pathologist. P r o g r e s s of h e a l i n g w a s checked a p p r o x i m a t e l y w e e k l y ( F i g s . 0 0 0 W / c m 2 t o 5 2 5 W / c m 2 a t 3 0 . Histology: Note zone of thermal necrosis on base of specimen is only 0. 7 . t h e b a s e o f t h e w o u n d w a s f i b rin covered. 7 . 7 . Specimen oriented and pinned for transfer to the Figure 7 .5 .6 ) . 7 .W o u t p u t and from 5 2 . The patient w a s d i s c h a r g e d in the m o r n i n g with a p r e scription for a narcotic and a nonsteroidal anti-inflammatory analgesic. s w a l l o w i n g .) T h e day after s u r g e r y . Note that both resection and coagulation violate the submandibular ducts. T h e b a s e of the resection w a s free of c h a r e x c e p t w h e r e d e l i b e r a t e c o a g ulation w a s used (Fig. T h e posterior dissection w a s then m a d e from the m u c o s a to the d e p t h of t h e r e s e c t i o n . 7 . defocused for maximum hemostasis. or in t h e office on the f o l l o w i n g day. The former values a r e used for e x c i s i o n and t h e latter for coagulation.1 4 ) until reepithelialization w a s c o m p l e t e . 7 . at which t i m e p o s t o p e r a tive observation w a s m a i n t a i n e d a c c o r d i n g to the c a n c e r surveillance protocol.6 . Note instruments retracting both tongue and specimen to provide traction-countertraction for good surgical exposure.7 ) . E s t i m a t e d b l o o d loss w a s 5.7 .Transoral Resection of Oral Cancer vaporization spot size a v e r a g e s a p p r o x i m a t e l y 8 0 % o f the HeNe spot size. T h e s u b mandibular ducts are transected at will at high PD in the pulsed m o d e . d i s s e c tion w a s c o n t i n u e d posteriorly until an a d e q u a t e m a r g i n was established.W output. T h e patient rinsed twice a d a y with c h l o r h e x i dine for t h e next 7 to 10 d a y s . Surgical principles of traction-countertraction a r e used to facilitate dissection (Fig.1 5 to 7 . and n o s i a l o d o c h o p l a s t i e s a r e p e r f o r m e d .9 t o 7 .8 . Base coagulated in CW mode al 30 to 40 W. After d e t e r m i n i n g the d e p t h of resection anteriorly. T h e r e w a s no e v i d e n c e of recurrent d i s e a s e at 3 years. 0 0 0 W / c m 2 t o 3 5 0 W / c m 2 a t 2 0 .

Note that reepithelialization occurs from the periphery. . one will expect squestrum. Completely healed. Twenty-two days. Figure 7-11. still present at 1 week. Figure 7-13. The patient has received no antibiotics.92 Lasers in Maxillofacial Surgery and Dentistry Figure 7-9. Figure 7-10. Most of the surgical site has reepithelialized. but not progressive osteomyelitis to develop. Note that most of oral floor is covered by new epithelium. Figure 7-12 twenty-two days. Thirty-two days. mirror demonestrate area of exposed bone. Two weeks. Note the exposed area of lingual plate of mandible on the patient's left side. Figure 7-14. Fibrinous coagulum appears within the first 24 hours. Forty-six days. Bone is still exposed.

(From another patient) Note that a front surface mirror may be used to reflect the laser beam to reach the lingual aspect of the mucosa or gingiva lining the lingual surface of the mandible.2 0 ) .94 Lasers in Maxillofacial Surgery and Dentistry TRANSORAL CASE 2: FOM d e l i b e r a t e c o a g u l a t i o n w a s used. w h e r e it is often important to r e m o v e t h e soft tissue lining t h e lingual surface of the m a n d i b l e in a s u p r a p e r i o s t e a l p l a n e . PROBLEM AREA: LINGUAL ANTERIOR MANDIBULAR GINGIVA T h e most difficult area to a d e q u a t e l y control is the region of the lingual g i n g i v a . 7 . m a r g i n s w e r e harvested from the patient for frozen section. s o m e o f the s u p r a p e r i o s t e a l dissection m a y be p e r f o r m e d with a periosteal e l e v a t o r . and s y s t e m i c evaluation d e m o n strate a T | N M well-differentiated m i c r o i n v a s i v e s q u a m o u s cell c a r c i n o m a o f t h e anterior floor o f m o u t h ( F O M ) that e n c r o a c h e s upon the t e r m i n u s of W h a r t o n ' s d u c t ( F i g . s h o u l d t h e latter o c c u r to a mild d e g r e e . 0 Figure 7 .o l d w h i t e m a n with a 2 5 .1 8 .y e a r . T h e tube is then c h a n g e d to a nas o e n d o t r a c h e a l t u b e . T h e patient is e x t u b a t e d in t h e recovery r o o m w h e n fully a w a k e . A l t e r n a t i v e l y . T h i s latter m a n e u v e r r e q u i r e s the u s e of an a d j u s t a b l e front surface m i r r o r ( F i g . u n c o m m o n for a s m a l l . H e i s also noted t o h a v e c h r o n i c o b s t r u c t i v e lung disease and c o r o n a r y artery d i s e a s e w i t h o u t recent anginal chest pain. Or. a c o n t r a .0 U / m L ( 1 . After r e m o v i n g t h e s p e c i m e n (Fig. and no s i a l o d o c h o p l a s t i e s a r e performed. N o p r e p a ration solution is used and neither p r o p h y l a c t i c antibiotics n o r steroids a r e g i v e n . On (he o t h e r hand. thin seq u e s t r u m of part of the lingual plate of the m a n d i b l e to be formed. T h e free-beam C 0 laser i s c h o s e n a s t h e instrument of c h o i c e for r e m o v a l of h i s t u m o r . T h i s m a y be d o n e in several w a y s . the oral m u c o s a is stained with t o l u i d i n e b l u e (see C h a p t e r 4 ) t o assess a n y subclinical m u c o s a l s p r e a d o f the t u m o r . " E x a m i nation. T h e s u b m a n d i b u l a r d u c t s are t r a n s e c t e d at will at high PD in the p u l s e d m o d e . After d e t e r m i n i n g the d e p t h of resection a n t e r i o r l y . If hemostasis is satisfactory after 5 to 10 m i n u t e s of observation. E s t i m a t e d blood loss w a s 15 mL and o p e r a t i n g t i m e w a s 20 m i n u t e s . T h e b a s e of the resection should be free of c h a r e x c e p t w h e r e Figure 7 . Microinvasive T|N M„ squamous cell carcinoma of anterior oral floor arising in proximity to Wharton's duct. if h e m o s t a s i s is imperfect. 5 % b u p i v a c a i n e c o n t a i n i n g 1:200. 0 n 2 TECHNIQUE After i n d u c i n g general a n e s t h e s i a and s e c u r i n g t h e airw a y with a n oral e n d o t r a c h e a l t u b e . H o w e v e r . A 5 6 . w h i c h u n f o r t u n a t e l y c a u s e s b l e e d i n g . h o w e v e r . o r t h e laser must b e redirected a n t e r i o r l y s o t h e incision can b e carried d o w n t o t h e p e r i o s t e u m . and the h y p o p h a r y n x is p a c k e d with a wet throat pack. T h e vertical c o m p o n e n t o f t h e resection from m u cosa to the depth of the resection is then c o m p l e t e d .1 9 . a e r o d i g e s t i v e e n d o s c o p y is p e r f o r m e d . T h e final incision of p e r i o s t e u m is best p e r f o r m e d with a scalpel to a v o i d d a m a g i n g t h e b o n e with the laser i m p a c t s .1 9 ) to redirect the b e a m . incisional biopsy. if using t h e laser. T h e face i s p r o t e c t e d with moist s a l i n e e y e p a t c h e s and facial d r a p e s . W h i l e a w a i t i n g m a x i m u m v a s o c o n strictor effect. dissection c o n t i n u e s posteriorly until an a d e q u a t e margin guided by the initial m a r k i n g out of t h e resection is e s t a b lished. E i t h e r t h e scalpel is used to incise to b o n e . a b o v i n e c o l l a g e n pad is placed o v e r the resection bed a n d an iodoform g a u z e pack is secured for o v e r n i g h t insertion.1 8 ) . 7 . T h e defect w a s p a c k e d with i o d o f o r m g a u z e and a n antibacterial ointment. It is not. e p i t h e l i u m will still c o m p l e t e l y c o v e r l a s e r d a m a g e d b o n e in about 4 w e e k s .000 e p i n e p h r i n e and Pitressin 1.m o n t h history o f a n "irritation u n d e r m y t o n g u e . Local a n e s t h e t i c solution of 0 . t h e patient is b r o u g h t to t h e recovery r o o m .a n g l e h a n d p i e c e m a y be used instead of a front surface m i r r o r d e p e n d i n g on availability.y e a r history of daily smoking of two packs of cigarettes and drinking four w h i s k e y e q u i v a l e n t s of b e e r p e r d a y p r e s e n t s with a 2 . T h e patient w a s transferred to the recovery r o o m w h e r e e x t u b a t i o n w a s p e r f o r m e d only w h e n h e w a s fully awake. 7 . . 0 m L o f Pitressin a d d e d t o 3 0 m L o f b u p i v a c a i n e ) is injected a l o n g the p l a n n e d lines of resection t o t h e depth o f t h e m u s c u l a t u r e o f t h e oral floor.

2 1 ) . Figure 7 . S p e e c h usually returns t o normal within 2 to 3 m o n t h s and is a c c o m p a n i e d by a n o r m a l r a n g e o f m o t i o n o f t h e t o n g u e .2 3 . Oral floor well healed.2 3 ) . Wound was reepithelialized in 25 days. T h e patient rinses twice a day with c h l o r h e x i d i n e for the n e x t 7 to 10 days.2 2 and 7 . Frozen sections are obtained from the palient as required. a t w h i c h t i m e p o s t o p e r a t i v e observation i s m a i n tained a c c o r d i n g t o t h e c a n c e r s u r v e i l l a n c e protocol.Transoral Resection of Oral Cancer AFTER CARE Oral fluids are a d m i n i s t e r e d that night and narcotics a r e prescribed i n t r a m u s c u l a r l y or i n t r a v e n o u s l y that night. Fibrin coagulum still present at floor of resection.2 1 . postoperative day 10. marked for orientation and demonstrated to the pathologist in the operating room. R e s e c t i o n s o f t h e posterolateral floor of the m o u t h a r e m o r e likely to be associated with minor speech impediments.2 2 . At this t i m e . Figure 7 . Recover)' of tongue range of motion was complete. pliable mucosa present (10 weeks). P r o g r e s s of healing is c h e c k e d w e e k l y until reepithelialization is c o m p l e t e ( F i g s . 7 . T h e patient is discharged in the m o r n i n g with a prescription for a narcotic and a nonsteroidal anti-inflammatory a n a l g e s i c . . Lingual gingiva stripped at surgery has recovered completely (10 weeks). 7 . Figure 7 . For a n terior floor of m o u t h r e s e c t i o n s . The oral p a c k is r e m o v e d either at b e d s i d e p r i o r to discharge. or in the office on t h e following d a y . there is no interference with n o r m a l s w a l l o w i n g . (he base of the w o u n d is fibrin c o v e r e d ( F i g . Figure 7-20. The specimen is pinned onto a wooden tongue blade. H y d r o g e n peroxide/salt w a t e r rinses m i x e d 1:1 a r e 95 used e v e r y few h o u r s . Mature.

5 cm.2 4 ) . 7 . inferior a l v e o l a r and long b u c c a l b l o c k s as well as by direct infiltration in the m i d l i n e of t h e t o n g u e and in the lateral oral floor with 0 . 7 . T h e p e r i p h e r y of the p l a n n e d resection w a s m a r k e d using the laser h a n d p i e c e in t h e d e f o c u s e d m o d e at a PD of about 5 0 0 W / c m .96 Lasers in Maxillofacial Surgery a n d Dentistry period of 4 to 5 m i n u t e s lo m i n i m i z e t h e h y p e r t e n s i v e effect C A S E 3: T O N G U E — F R E E . After a s s e s s i n g for a d e q u a c y of m a r g i n s .000 W/cm for resection. (PD approximately 52.000 e p i n e p h r i n e . then p r o c e e d i n g o b l i q u e l y to reach the midline (Fig. Oral side of specimen. defocused handpiece. E x t e n s i v e p r e o p e r a t i v e c o u n s e l ing in regard to risks as well as the details of t r e a t m e n t s e cured her c o n s e n t to r e m o v e the t u m o r u s i n g local a n e s t h e sia with s u p p l e m e n t a l i n t r a v e n o u s s e d a t i o n .) 2 . the resection c o m m e n c e d at an a p p r o x i m a t e PD of > 5 0 .3 m m .c m a b d o m i n a l aortic a n e u r y s m p r e s e n t e d with a T 2 N 0 M 0 m o d e r a t e l y well-differentiated c a r c i n o m a of the right lateral t o n g u e (Fig.9 m s . after p r o v i d i n g s e d a t i o n . 0 0 0 W / c m 2 ( A v g . H e N e spot = 0.2 7 . 5 % b u p i v a c a i n e with 1:200. intcrpulsc d i s t a n c e = 9. Approximately 5 mm of additional "marginal" tissue was vaporized at the depth of resection. Figure 7-26. the t o n g u e w a s anesthetized by lingual. Deep resection margin of specimen. Specimen measured 4. the entire right lower lip and oral c a v i t y w a s anesthetized to p r o v i d e comfort d u r i n g retraction as well as pain p r e v e n l i o n for the actual a r e a s of incision. At s u r g e r y . 2 T h i s 8 2 . Figure 7 . N o w d i s s e c t i o n w a s c o n t i n u e d posteriorly i n the relatively b l o o d l e s s p l a n e of the m i d l i n e of the tongue. T N„M . PD = 450 W / e n r .3 X 1.o l d w h i t e w o m a n with h y p e r t e n s i o n and a 9 .2 5 .B E A M C 0 2 of the e p i n e p h r i n e . . Superpulsed mode. Note relative lack of charring. Essentially. pulse w i d t h = 2 .2 5 ) . p p s = 1 1 8 .7 X Figure 7 . 11 ue n c e = 2 9 0 m J / p u l s e ) starting lateral to the m i d l i n e to pres e r v e the m a x i m u m a m o u n t of u s a b l e t o n g u e tip with the incision. After r e v i e w b y t h e head and n e c k c a n cer t e a m .y e a r . P = 3 0 W .i moderately well-differentialed squamous cell carcinoma of mobile tongue. Margins marked. T h i s w a s given slowly o v e r a Figure 7-24. 4. 4 m s . surgical r e m o v a l o f the t u m o r w a s r e c o m m e n d e d as the t r e a t m e n t of c h o i c e .

F u n c t i o n a l l y . T h e patient started a c l e a r liquid diet on t h e day of s u r g e r y and full liquids on t h e first p o s t o p e r a t i v e d a y . Fibrin covering of laser wound left to heal by second intention. T h e b a s e w a s c o a g u l a t e d at 30 W in CW m o d e with a 3 . T h e s e q u e n c e of healing from the first p o s t o p e r a t i v e visit to c o m p l e t e reepithelialization is d e m o n strated i n F i g u r e s 7 . and s h e w a s discharged o n p o s t o p e r a t i v e day 2. This forms during the first 24 to 48 hours after wounding and is gradually replaced by epithelial tissue. and o p e r a t i n g 2 97 t i m e i n c l u d i n g a d m i n i s t r a t i o n of local a n e s t h e t i c w a s 48 minutes. 7 . A s i m p l e g a u z e s p o n g e w a s placed o v e r the w o u n d and t h e patient w a s a s k e d to bite on it.2 8 ) . F'igure 7 . Day 10. T h e r e w a s n o postoperative s u b m a n d i b u l a r g l a n d o b s t r u c t i o n .3 3 . 7 . This latter w a s n o w joined by the anterior resection line at the level of t h e floor of t h e m o u t h and t h e s p e c i m e n w a s delivered (Figs. narcotic a n a l g e s i c s w e r e required for 4 d a y s . CW effect causing char left in situ to inhibit bleeding. the incision w a s e x tended laterally to j o i n t h e line of resection at the oral floor. Figure 7 .3 1 . . T h e b a s e w a s d e l i b e r a t e l y left slightly c h a r r e d to r e d u c e the likelihood of p o s t o p e r a t i v e bleeding (Fig. N o t e the contrast to F i g u r e 7 . Some wound contraction has occurred and most of wound is covered by new epithelium. Figure 7 .2 7 ) . Most of fibrin has been replaced by immature epithelium. P o s t o p e r a t i v e l y . Day 18.Transoral Resection of Oral Cancer At the p o s t e r i o r limit of t h e resection.2 7 in which the d e e p surface of t h e s p e c i m e n r e m o v e d by the laser in s u p e r p u l s e d m o d e s h o w s a l m o s t no c h a r and t h e r e fore minimal heat effects.3 0 . and the patient r e m a i n e d dise a s e free for 3 years until s h e died from a m y o c a r d i a l infarction. T h e r e w a s n o p o s t o p e r a t i v e b l e e d i n g . Estimated blood loss w a s less than 50 m L . Figure 7-28. Base of resection. d e f o c u s e d to provide a PD = 4 2 5 W / c m . speech and s w a l l o w i n g w e r e c o m p l e t e l y n o r m a l within 9 w e e k s of the c o m p l e t i o n o f s u r g e r y .2 6 and 7 .2 9 .m m spot s i z e . Day 4.2 9 t o 7 .

Day 25.3 2 . All except one small area representing less than 10% of the total surface area of the wound has been replaced by new epithelium. Figure 7 . Eight weeks. .3 3 . 24 days later the surface is unchanged and the range of motion of the tongue is very good but slightly restricted. Complete epithelialization occurred by day 3 1 .98 Lasers in Maxillofacial Surgery and Dentistry Figure 7 .

Primary closure of wound. 7 . 99 Figure 7 . superpulsed mode.3 7 ) . Patient had no evidence of disease at 8 years. tongue. PD approximately 30. Starting the incision with the laser handpiece tip adjacent the tissue at the focal point. . T.(X)0 W. Note HeNe aiming beam just below tip within incision. Figure 7-34. Normal tongue protrusion at 33 months. Figure 7-35.Transoral Resection of Oral Cancer CASE 4: T O N G U E CANCER—PRIMARY CLOSURE A 53-year-old w h i t e w o m a n with a T 1 N 0 M 0 well-differentiated s q u a m o u s cell c a r c i n o m a of t h e m i d d l e third of the lateral border of the m o b i l e t o n g u e ( F i g s .N M n u squamous cell carcinoma of mobile Figure 7-37. Field is dry.3 6 .3 4 to 7 .

T h e c o n t a c t N d : Y A G l a s e r ( S L T ) w a s c h o s e n as t h e instrument of c h o i c e b e c a u s e of the need to e x t e n d the posterior limit of t h e resection a l o n g t h e lingual 0 ( ) gutter into the u p p e r h y p o p h a r y n x . Figure 7 . At operation. Note proximity of high-speed laser suction to laser probe tip. Silica scalpel tips for the contact Nd:YAG laser. T h e silica c o n t a c t scalpel p r o b e s (Fig.3 9 . T h e h y p o p h a r y n x w a s o c c l u d e d with a wet g a u z e throat pack.4 1 .100 Lasers in Maxillofacial Surgery a n d Dentistry C A S E 5: T O N G U E — C O N T A C T ND:YAG LASER SCALPEL T h i s 8 3 . 7 . Posterolateral aspect of tongue adjacent to tongue base retracted laterally to demonstrate extent of posterior element of the excision.000 w a s a d m i n i s t e r e d w i t h i n the s u b s t a n c e of the t o n g u e both to e n h a n c e h e m o s t a s i s and t o p r o v i d e p o s t o p e r a t i v e a n a l g e s i a . Note absence of bleeding. 2 2 F'igure 7 . it is gently stroked along the path of incision. an area w h e r e control of the free-beam C 0 b e c o m e s a bit difficult e v e n with the u s e of a front surface m i r r o r to alter t h e incident a n g l e of t h e b e a m .4 0 . H e had d i s c o n t i n u e d s m o k i n g cigarettes after the t r e a t m e n t of h i s index c a n c e r . . the increased h e m o s t a s i s of the c o n t a c t Y A G w a s c o n s i d e r e d t o b e o f a d e q u a t e benefit t o a c c e p t the slight increase in thermal n e c r o s i s a t t e n d a n t to t h e c o n t a c t laser c o m p a r e d with t h e free-beam C 0 . 5 % with e p i n e p h r i n e 1:200. g e n e r a l a n e s t h e s i a with n a s o e n d o t r a c h e a l intubation t o secure t h e a i r w a y w a s c h o s e n . Dissection proceeding into depth of tongue. but c o n t i n u e d to c o n s u m e four w h i s k e y e q u i v a l e n t s of gin per d a y . Tactile sense regulates rate and depth of incision. Depth of resection in residual mobile tongue. Laser is activated prior to touching probe against tissue.3 8 ) w e r e selected b a s e d upon their g e o m e t r y for tissue e x c i s i o n in this highly v a s c u l a r area. W i t h the c o n t a c t Y A G l a s e r set at an Figure 7 . T h e c o l l e c t i v e r e c o m m e n d a t i o n of the head and neck t u m o r c o n f e r e n c e w a s to resect the t u m o r . T h e f i e l d w a s stained with toluidinc blue to assess for areas of subclinical n e o p l a sia a n d / o r areas o f p r e n e o p l a s t i c c h a n g e ( d y s p l a s i a ) . (Scalpel tip number 6 used for incision at 15 W.o l d w h i t e m a n p r e s e n t e d with a well-differentiated T 1 N 0 M 0 s q u a m o u s cell c a r c i n o m a o f the posterior third of the m o b i l e t o n g u e located along its ventrolateral surface.) Figure 7 . In addition. B u p i v a c a i n e 0 . When probe tip reaches operating temperature. S e v e n t e e n years before he had had a w i d e local e x cision of the m i d p o r t i o n of t h e left lateral t o n g u e for a w e l l differentiated T | N M s q u a m o u s cell c a r c i n o m a .3 8 . Liver function s t u d i e s a n d q u a n titative platelet c o u n t s w e r e n o r m a l . An Allis c l a m p w a s p l a c e d in t h e left anterolateral t o n g u e to facilitate retraction.y e a r .

At 18 weeks. Normal swallowing. Histology of resection margin. At 18 w e e k s the r a n g e of motion of the t o n g u e w a s n o r m a l . He r e s u m e d oral intake the next m o r n i n g . Bovine collagen dressing sutured in place lo facilitate hemostasis (from a similar case). G e n t l e pressure on t h e hand p r o b e p e r m i t t e d unforced penetration of t h e tiss u e s . Note that depth of coagulation necrosis from the contact YAG tip is only 0. and it returned to n o r m a l d u r i n g p o s t o p e r a t i v e w e e k 5 (Fig. w h i c h w a s only then inserted into t h e t i s s u e to begin the e x c i s i o n . T h i s p r e v e n t e d e x c e s s i v e b u i l d u p of c h a r r e d tissue on t h e p r o b e tip. Figure 7 . and p o s t o p e r a t i v e h e m o s t a s i s w a s e n h a n c e d by a p p l y i n g a b o v i n e c o l l a g e n patch to t h e surface of the t o n g u e . W i t h slight c h a r r i n g of the tip o c c u r r i n g .4 1 ) u s i n g tactile c u e s very similar t o those used for e l e c t r o c a u t e r y in " c u t " m o d e . and using the n u m b e r 6 scalpel tip probe. At t h e c o n c l u s i o n of this subtotal posterolateral g l o s s e c t o m y . Mild speech impediment.) Figure 7 .Transoral Resection of Oral Cancer 101 Figure 7 . the p r o b e tip w a s c h a n g e d to a n u m b e r 8 scalpel tip. 7 . H i s s p e e c h w a s intelligible on t h e d a y after surgery. T h e s p e c i m e n (Fig. e s t i m a t e d blood loss w a s 125 m L and operation time w a s 4 0 m i n u t e s . (Depending upon area examined it ranged from 0. P o s t o p e r a t i v e n a r c o t i c a n a l g e s i c s w e r e required for 6 d a y s after s u r g e r y . o u t p u t p o w e r of 15 W.4 3 ) . and h e w a s d i s c h a r g e d t h e following d a y . T h e entire t o n g u e w o u n d w a s left to heal by s e c o n d a r y intention. 1-AA). H o w e v e r . the dissection w a s c o m p l e t e d ( F i g s .3 9 t o 7 . a n d the pedal w a s d e p r e s s e d to permit h e a t i n g of the p r o b e tip.4 3 . 7 .7 m m .)(H&E200X. which w a s sutured a l o n g its p e r i p h e r y (Fig.67 mm. Figure 7-44. After s u r g e r y . there w a s m i n i m a l postoperative e d e m a and there w a s n o p o s t o p e r a t i v e bleeding. as w a s s w a l l o w i n g (Fig.22 mm to 0.22 mm. 3 to 0. the prospective margin was gently scribed approximately 1 cm b e y o n d the visible a n d / o r p a l p a b l e t u m o r e d g e . T h e histologic s p e c i m e n (Fig.4 5 . In this w a y . 7—45). 7 . Specimen. the patient applied p r e s s u r e until t h e f o l l o w i n g m o r n i n g . Range of motion of tongue good. . t h e laser t u r n e d o n . heat transfer w a s n o w kept constant by periodically w i p i n g the p r o b e tip to m a i n t a i n a consistent level of c a r b o n i z a t i o n . M e t a s t a t i c d i s e a s e a p p e a r e d in the ipsilateral neck d u r i n g the fifth m o n t h after s u r g e r y . w h i c h w o u l d o t h e r w i s e h a v e c h a n g e d t h e output p o w e r (heat) a n d b e a m g e o m e t r y .4 2 ) w a s reviewed with t h e p a t h o l o g i s t in the o p e r a t i n g r o o m . N o w . 7 ^ 1 4 ) s h o w e d t h e r m a l n e c r o s i s limited t o 0 . S w a l l o w ing w a s n o r m a l by w e e k 8.4 2 .

Scrutiny of the oral cavity did not reveal additional m u c o s a l lesions and vital staining with toluidine b l u e w a s positive only for the area of carcinoma. Her past m e d i c a l history w a s significant for insulin-dependent d i a b e t e s mcllitus a n d she was blind as a c o n s e q u e n c e of proliferative diabetic retinopathy.2 cm at its widest d i m e n s i o n w a s p r e s e n t (Fig.102 Lasers in Maxillofacial Surgery and Dentistry CASE 6: BUCCAL M U C O S A the family would not permit a full-thickness cheek resection if indicated at surgery. It o c c u p i e d the most dorsal aspect of the left buccal m u c o s a e x t e n d i n g from the apex of the buccal v e s t i b u l e to the inferior aspect of the buccal m u c o s a . 7-46). a globular e x o p h y t i c m a s s m e a s u r ing 3.5 cm thick but to be freely m o v a b l e and not a d h e r e n t to skin or s u b c u t a n e o u s tissue. T h e surface of the lesion a p p e a r e d to be c o r r u g a t e d .000 e p i n e p h r i n e . Surgical resection w a s the r e c o m m e n d e d treatment by the head and neck t u m o r board. 2 fl An 86-year-old d i v o r c e d A f r i c a n . S h e h a s been c h e w i n g t o b a c c o for 75 years with the quid usually being held in the left buccal p o u c h .m o n t h history of a m a s s in her left buccal m u c o s a p r e sented for e v a l u a t i o n . T h e r e has been no pain or bleeding but the m a s s interfered with her u p p e r d e n t u r e . Thirty-six days.A m e r i c a n w o m a n with a I . R e s e c t i o n w a s p e r f o r m e d with t h e c o n t a c t N d : Y A G laser with a n u m b e r 4 s c a l p e l silica tip at 15-W output p o w e r . 5 % b u p i v a c a i n e containing 1:200. . it was estimated to be 1. (( a Figure 7-48. . On oral e x a m i n a t i o n .0-cm m a r g i n w h e n e v e r p o s s i b l e and the d e p t h of resection was e s t a b l i s h e d bey o n d the b u c c i n a t o r m u s c l e so that the d e p t h of t h e resection w a s w i t h i n t h e s u b c u t a n e o u s fat of the c h e e k . T h e lesion w a s staged as T N „ M m o d e r a t e l y well-differentiated s q u a m o u s cell carcinoma. Buccal fat pad graft is partially epithelialized (6 days). Figure 7 . Development of buccal fat pad for partial coverage of surgical defect. On b i m a n u a l palpation. Completely reepithelialized. R e s e c t i o n i n c l u d e d a 1. The c h e e k w a s infiltrated with 8 mL of 0 . T h e r e w a s no l y m p h a d e n o p a t h y .4 9 . By 15 weeks the wound was mature and maximum oral opening was 50 mm. By 16 days it was approximately 50% reepithelialized. T N M well-differentiated squamous cell cancer. Histologic a s s e s s m e n t o f the r e s e c t i o n s h o w e d t h e z o n e o f t h e r m a l n e c r o s i s at t h e b a s e of the resection s p e c i m e n to Figure 7-46. F i b e r o p t i c n a s e n d o s c o p y w a s n e g a t i v e and R e s e c t i o n w a s p e r f o r m e d with the patient receiving a general a n e s t h e t i c with n a s o e n d o t r a c h e a l intubation. Figure 7-47.

4 7 ) . and had n o p a i n .Transoral Resection of Oral Cancer range from 0 . 7 .34 m m i n t h i c k n e s s . At 103 1 5 d a y s . Partial c l o sure of t h e d e f e c t w a s o b t a i n e d by a d v a n c e m e n t of t h e buccal fat pad ( F i g .4 9 ) . S h e had res u m e d her n o r m a l d i e t . A t 3 6 d a y s . E s t i m a t e d b l o o d loss w a s 150 mL and o p e r a t i v e t i m e r e q u i r e d for this subtotal e x c i s i o n o f the c h e e k w a s 9 0 m i n u t e s . . At e x a m i n a t i o n 6 d a y s after surgery t h e r e w a s significant e p i t h e l i a l c o v e r i n g of t h e buccal fat pad a n d there w a s slight e p i t h e l i a l i z a t i o n of the depth of the u n c o v e r e d part of t h e w o u n d ( F i g . 3 2 t o 0. A t 1 0 w e e k s there w a s slight t r i s m u s with a m a x i m u m interridge o p e n i n g of 42 m m . 7 . h e a l i n g w a s p r o g r e s s i n g with m o d e r a t e s c a r c o n traction o c c u r r i n g and a p p r o x i m a t e l y 5 0 % e p i t h e l i a l i z a tion h a v i n g o c c u r r e d . t h e w o u n d w a s c o m pletely e p i t h e l i a l i z e d ( F i g . w a s m a i n t a i n i n g her w e i g h t . A t 1 5 w e e k s t h e patient o p e n e d 5 0 m m .4 8 ) . 7 .

Specimen. Output p o w e r w a s 12 to 20 W. Resection c o m m e n c e d with the S L T contact N d : Y A G laser silica p r o b e tip. 2 Figure 7 . Case 7: Palate—Postoperative Tonsillar Hypertrophy T h i s 4 9 . Complete reepithelialization and healing at 3 . Outlining the mass: SLT contact YAG: number 6 scalpel tip at 15 W. An u n e x p e c t e d l y e x u b e r a n t host r e s p o n s e to t h e palatal resection o c c u r r e d d u r i n g the s e c o n d m o n t h of observation. N o w using the number 8 scalpel tip at 15 W.5 2 .y e a r . Figure 7 .5 1 . Dissection w a s carried full thickness through the levator veli palatini m u s c l e after first marking the periphery for margins with the n u m b e r 4 scalpel tip used at 20 W. Traction as dissection reaches depth of tonsillar crypt. Note smoke generation.5 0 . hemostasis was excellent and the more e x t e n s i v e heat d a m a g e w a s not clinically significant. just as it is for the free-beam C 0 laser. No bleeding. a T1N0M0 well-differentiated s q u a m o u s cell c a r c i n o m a . and to drink t w o or three beers per d a y . H e c o n t i n u e d t o s m o k e o n e and a half p a c k s of cigarettes per d a y . Figure 7 . the tip w a s angled to maintain proper position in t h e depth of the resection. T h e treatment plan c a l l e d for w i d e local e x c i s i o n o f the n e w p r i m a r y c a n c e r a n d e v a p o r a tive ablation of the leukoplakia after directed b i o p s y g u i d e d by vital s t a i n i n g with t o l u i d i n e b l u e . weeks.5 3 . H o w e v e r . In this c a s e s o m e palatal m u s c l e w a s preserved and there w a s no perforation of the nasopharyngeal m u c o s a . T h e margins w e r e s o m e w h a t affected by heat artifact from the Y A G contact laser with the d e e p margin s h o w i n g 1. T h e index lesion w a s a T 1 N 0 M 0 m o d e r a t e l y well-differentiated s q u a m o u s cell carc i n o m a of the left ventrolateral t o n g u e treated by free-beam laser e x c i s i o n 1 2 m o n t h s p r e v i o u s l y .o l d w h i t e m a n presented with h i s s e c o n d prim a r y s q u a m o u s cell c a r c i n o m a .104 Lasers in Maxillofacial Surgery and Dentistry COMPLICATIONS T h e r e w e r e no unexpected extensions of the palatal cancer. d e veloped on the left soft palate and a n e w l e u k o p l a k i a d e v e l oped on the right soft p a l a t e . A s e c o n d p r i m a r y t u m o r .6 mm of thermal necrosis. The high-speed laser smoke evacuation system still must be used. Figure 7 . Histopathologic assessment of the specimen confirmed adequacy of resection.

.5 1 and 7 . T h e surgical site w a s reepithelialized and c o m p l e t e l y healed in 3 w e e k s ( F i g . T h e tonsillar fossa w a s not b l e e d i n g at the c o n c l u s i o n of surgery and r a w surface a r e a w a s reduced by partially closing the fossa.Transoral Resection of Oral Cancer Unilateral h y p e r t o p h y of tonsillar tissue d e v e l o p e d adjacent to the resection site (Fig. 7 . Significant laser s m o k e w a s g e n e r a t e d by the Y A G tip in c o n t a c t with 105 the tissue. s p e e c h and s w a l l o w i n g w e r e c o m p l e t e l y n o r m a l within 6 w e e k s after s u r g e r y .5 0 ) .5 3 ) . T h e lesion w a s easily delivered from a bloodless field ( F i g s . Postoperatively. T h i s w a s r e m o v e d for histopathologic a s s e s s m e n t using the b l o o d l e s s t e c h n i q u e of the c o n t a c t : Y A G laser.5 2 ) . T h e c o n t a c t : Y A G p r o v i d e d the security of tactile feedback while p e r f o r m i n g surgery at the depth of the tonsillar fossa. As a l w a y s it w a s m a n d a t o r y to u s e the highspeed laser suction. 7 . 7 .

1 Figure 7-54. PD approximately 500 to 6(H) W/cm . RSP. of mouth.106 Lasers in Maxillofacial Surgery a n d Dentistry C A S E 8: FOM C O M P L I C A T I O N RESTRICTED TONGUE MOTION A 72-year-old w h i t e w o m a n with T | N M m o d e r a t e l y well differentiated s q u a m o u s cell c a r c i n o m a . Limitation of r a n g e of motion of t o n g u e o c c u r r e d requiring scar release (Figs. Restricting scar band: Pseudoankyloglossia at 19 months. 118 pps. Release of wide and thick scar band causing pseudoankyloglossia. 0 0 Figure 7 . 7 .5 4 and 7 . A n t e r i o r floor of mouth. T1N0M0 squamous cell carcinoma of anterior floor .5 5 .5 5 ) .

. A maxillary acrylic prosthesis with a buccal flange w a s worn for 1 month to prevent o c c l u s a l trauma to any granulation tissue that might have proliferated at the treatment site. cosa. Within 1 month of e x c i s i o n . It w a s . Maxillary prosthesis to protect cheek. w a s treated by w i d e local e x c i s i o n with the free-beam R S P C 0 laser at an average p o w e r of 25 W.5-cm-diameter mass of granulation tissue persisted at the proxi2 107 mal e d g e of the resection margin. Excised with the RSP C 0 laser. T2N0M0 verrucous carcinoma of righl buccal mu- Figure 7-58. therefore. Figure 7-57. d e f o cused spot size of 2 .m m spot size for incision. 9 months after excision of polyp.5 mm for coagulation at 86 pps. A l t h o u g h . a 1. 3 . T 2 N 0 M 0 of the right buccal m u c o s a . at proximal edge of resection margin. Buccal mucosa.5 9 ) . 2 Figure 7-59. 7 . 0 to 2. 0 . Matured lesion now appeared as a large pedunculated polyp. Figure 7-56. the buccal m u c o s a had healed c o m p l e t e l y and maxim u m incisal o p e n i n g w a s normal. mouth opening and buccal mucosa are both normal.Transoral Resection of Oral Cancer C A S E 9: BUCCAL M U C O S A WITH PROLIFERATIVE GRANULATION TISSUE A 58-year-old w o m a n with a verrucous carcinoma. e x c i s e d using the same parameters described a b o v e . Three years later there is still no recurrence of the polyp or the cancer. m o s t of the treated area reepithelialized normally. 2 9 0 mJ/pulse ( F i g s . S h e has been cancer free and the proliferative lesion has not returned.5 6 t o 7 . Trauma from her m o lars o c c l u d i n g into the proliferative scar prevented its resolution. Proliferative granulation tissue arose. After an additional 2 months of maturation the l e s i o n persisted.

o n e is confronted with the problem of designing compassionate palliative treatment to debulk recurrence at the primary site. Satisfactory palliation should provide pain relief. A 68-year-old man developed recurrent squamous cell carcinoma under his pectoralis major myocutaneous flap that extended into the submental triangle (Figs. The wound remained clean and without an offensive odor until the patient's death 3 months later. and the palliative procedure should be brief. 90 W.6 2 . and surgical resection with immediate soft tissue reconstruction. Free-beam C 0 . The high-powered free-beam C 0 laser serves this purpose well. radiotherapy.to 3-mm spot size. Ablation of recurrent tumor. This provided adequate hemostasis while permitting debulking of the tumor. T 3 N 3 M 0 squamous cell carcinoma of the tongue and his recurrence developed 27 months after treatment of the index tumor by a combined regimen of chemotherapy. Figure 7 .6 1 . 2. and reduce the smell of necrotic tissue. l Figure 7 . Note HeNe aiming beam in upper left comer of wound. The original tumor was a stage IV.0 mm giving an average PD of 3 5 0 0 W / c m to 1560 W / c m .108 Lasers in Maxillofacial Surgery and Dentistry 2 C A S E 10: A D J U N C T I V E U S E O F T H E C 0 LASER—TUMOR DEBULKING When treating patients with head and neck cancer w h o have failed definitive therapy. Tumor bed is clean 3 weeks after treatment.6 0 to 2 7 .6 3 . create a wound that is easy to clean. Significant plume production occurred at this power density.6 3 ) . 2 Figure 7 . The treated area remains quite clean. The C 0 laser with a handheld probe was used in the defocused mode at an output power of 90 W CW with a spot size of 2 . 2 2 2 Figure 7-60. 7 . 0 to 3. A collagen hemostatic dressing w a s applied to the depth of the wound to aid in hemostasis. Three months after treatment just before death. General anesthesia was used and the operation required less than 30 minutes. . Recurrent carcinoma of anterior neck and floor of mouth occurring inferior to a myocutaneous flap 27 months after resection of a T 3 N 3 M 0 squamous cell carcinoma of the tongue.

2 2 2 Further c o n t r a i n d i c a t i o n s t o L A U P a r e s e v e r e m a e r o g l o s sia and morbid obesity with h y p o p h a r y n g e a l o b s t r u c t i o n at the t o n g u e b a s e . In t h e rare c o n d i t i o n of floppy epiglottis. An additional a d v a n tage o f t h e C 0 laser i s its u s e a s a " n o . INDICATIONS It has been d e m o n s t r a t e d that t h e majority of s n o r e r s benefit from L A U P a s d o m a n y p a t i e n t s with O S A S w h o s e r e s p i ratory distress index ( R D I ) is less than 5 0 . and better overall c o n t r o l of s u r g e r y . If s y m p t o m s of snoring or O S A S recur.i n d u c e d w o u n d s is faster than after standard U P P P . the v e l u m . B e c a u s e of the h e m o s t a t i c a c t i o n of the laser. p o s t o p e r a t i v e e d e m a a n d pain are m i n i m a l and healing is rapid. t o b a c c o and a l c o h o l use. a s e c o n d treatment directed at t h e palate may i n d u c e r e m i s s i o n . the d u r a t i o n of p o s t o p e r a t i v e pain is p r o l o n g e d .8 Section 1: Outpatient Treatment of Snoring and Sleep Apnea Syndrome with C 0 Assisted Uvulopalatoplasty 2 Laser: Laser- Yves-Victor Kamami The laser-assisted uvulopalatoplasty ( L A U P ) is a surgical technique d e s i g n e d to correct b r e a t h i n g a b n o r m a l i t i e s d u r i n g sleep that result in snoring or mild to m o d e r a t e obstructive sleep apnea s y n d r o m e ( O S A S ) .t o u c h " t e c h n i q u e . e v e n i n s o m e c a s e s o f s e v e r e O S A S with obstruction at the p h a r y n g e a l level w h o do not r e s p o n d to C P A P . and the superior part of the posterior p h a r y n g e a l pillars. performed in the office using local anesthesia a n d a surgical laser. o b e s i t y . After t r e a t m e n t .h y p n o t i c d r u g s o r tranquilize r s . T h e C 0 laser o r c o n t a c t n e o d y m i u m : y t t r i u m . H o w e v e r . t h e p r o c e d u r e m a y be performed using local a n e s t h e s i a with minimal b l e e d i n g d e s p i t e the highly vascular tissue o f the oral m u c o s a . 1 . L A U P is also not of benefit. e x c e p t in t h e c a s e s of alcohol or t o b a c c o use. uvula. t h e h e a l i n g of t h e l a s e r .a l u m i n u m . T h e objective is to reduce p h a r y n g e a l a i r w a y o b s t r u c tion by reducing tissue v o l u m e in the uvula. especially for the hyp e r s e n s i t i v e individual w h o s e g a g g i n g o c c u r s on a p s y c h o logical basis despite h a v i n g a d e q u a t e a n e s t h e s i a at t h e surgical site. T h e lack o f m o r b i d i t y from L A U P all o w s p a t i e n t s to return to work i m m e d i a t e l y after surgery. L A U P m a y b e o f limited benefit i n i n c r e a s i n g p h a ryngeal a i r w a y c o m p l i a n c e . T h i s p r o p e r t y r e d u c e s g a g g i n g . a n d free 2 111 . a r e required. In all c a s e s .r e l a t e d risks. w h o h a v e s e v e r e m a n d i b u l a r retrognathia or nasal tract o b s t r u c t i o n . p r e d i c t a b l e . e x c e s sive c o n s u m p t i o n o f s e d a t i v e . the L A U P is a limited o p e r a t i o n with l o w m o r b i d i t y that d o e s not req u i r e general a n e s t h e s i a and m a y be performed in an office o r d a y s u r g e r y c e n t e r . particularly c o n t i n u o u s p o s i t i v e a i r w a y p r e s s u r e (CPAP) o r m a n d i b u l a r a d v a n c e m e n t o s t e o t o m y . thereby e l i m i n a t i n g c o n t a c t with t h e palate and p h a r y n g e a l w a l l s . In these c a s e s . 1 of u n c o n t r o l l e d scar f o r m a t i o n . a n d posterior tonsillar pillar to direct s c u l p t ing by t h e laser a l l o w s the o p e r a t o r to selectively r e g u l a t e tissue r e m o v a l . L A U P m a y a l s o b e useful w h e n U P P P h a s failed d u e t o o b s t r u c t i o n of t h e h y p o p h a r y n x from fatty and r e d u n d a n t tissue on t h e p o s t e r o l a t e r a l p h a r y n g e a l walls. T h i s property p r e v e n t s e x c e s s i v e thermal n e c r o s i s o f t h e target tissue. a l t h o u g h this problem is e l i m i n a t e d for c o n t a c t Y A G lasers. COMPARISON TO UVULOPALATOPHARYNGOPLASTY (UPPP) The p r o p e r use o f the t h e r m a l p r o p e r t i e s o f the C 0 laser provides technical a d v a n t a g e s o v e r scalpel t e c h n i q u e s for the surgical treatment of s n o r i n g .g a r n e t ( N d : Y A G ) l a s e r i s preferred t o the u s e of t h e N d : Y A G fiber-delivered laser in this p r o c e d u r e b e c a u s e o f the l o w v o l u m e o f absorption o f the C 0 laser b e a m o r c o n t a c t N d : Y A G i n tissue. T h e L A U P a l l o w s m o r e precise tissue r e m o v a l . F o r t h o s e w i t h severe O S A S ( R D I > 7 5 ) . or untreated h y p o t h y r o i d i s m . U n l i k e U P P P . T h e accessibility of t h e velum. s w e l l i n g . It is m o r e attractive t o s u r g e o n s w h o q u e s t i o n traditional U P P P b e c a u s e of its a n e s t h e t i c risk a n d increased p o s t o p e r a t i v e pain. s n o r i n g and O S A S m a y also r e c u r after L A U P . It is also a g o o d a l t e r n a t i v e for patients w h o present with major surgical a n d a n e s t h e s i a . T h e Y A G laser a l s o d o e s not h a v e a b a c k s t o p . and potential risk of d e v e l o p i n g v e l o p h a r y n g e a l incompetence (VPI). o t h e r t r e a t m e n t m e t h ods. 2 T h i s is a short operation. A s i s t h e c a s e for U P P P . T h i s i s d u e t o v e l o p h a r y n g e a l h y p o t o n i a s e c o n d a r y t o a g e . less tissue l o s s .

u v u l a " is created. to e n l a r g e the aperture. B e a m g u i d a n c e is p r o v i d e d by a coaxial h e l i u m neon ( H e N e ) laser. Usually the surgery is repeated a s e c o n d or a third t i m e . Figure 8 . T h e b a c k s t o p protects the posterior p h a r y n g e a l wall and the s m o k e e v a c u ator m a i n t a i n s clear visibility in the o p e r a t i v e field. Laser-assisted UPPP (LAUP) in four to five sessions. In this w a y the n e o . at the left. Its anterior and p o s t e r i o r sides must be preserved. T h e slightly d e f o c u s e d b e a m w h e n applied to t h e area of incision a d e q u a t e l y c o n t r o l s b l e e d i n g from any discrete area that still bleeds after m a k ing the incision. Bilateral vertical incisions a r c m a d e lateral to the u v u l a . then at the right side of the uvula. T h e e n d point is d e t e r m i n e d w h e n the patient or bed partner stops c o m p l a i n i n g a b o u t snoring.6 to 3. T h i s h a n d p i e c e h a s a focus-defocus ring: focus to cut. Standard C O laser safety p r e c a u t i o n s h a v e to be followed. s p a r i n g the uvula itself. the patient is placed in a scaled position with the m o u t h o p e n . Blood pressure is m o n i t o r e d d u r i n g the operation. 0 g of lidocaine) into the base of the uvula on both sides. B e t w e e n I and 2 mL are infiltrated on e a c h side.1 . and defocus to c o a g u l a t e . " A " n e o . The "Multiple-Stage " Technique T h i s p r o c e d u r e is d e s i g n e d to r e m o v e the minimal a m o u n t of tissue consistent with t h e reduction of snoring. a horizontal section is performed on t h e u p p e r part of the posterior tonsillar pillars. Extending t h e incisions m u c h h i g h e r o n t o t h e soft palate will usually result in increased p o s t o p e r a t i v e pain. In patients with a narrow n a s o p h a r y n g e a l orifice. The patient is p r e m e d i c a t e d with an oral a n a l g e s i c and antiemetic. T h i s r e m o v a l of the upper part of the . At the time of the session. T h e e y e s a r e protected with g o g g l e s or wet g a u z e s p o n g e s . d e p e n d i n g on the thickness of tissue that is to be incised. 8 . leaving the m u c o s a intact to prevent g r a n u l o m a formation and facilitate reepithclialization.u v u l a will gradually a s s u m e a m o r e s u p e r i o r position following each treatment until it reaches t h e level of P a s s a v a n t ' s ridge (Figs. LAUP in multiple sessions: reducing lateral aspect S u b s e q u e n t s e s s i o n s are basically the s a m e as the first o n e . which p r o d u c e s minimal char w h i l e a b l a t i n g the tissue rapidly and bloodlcsslv.1 ) . with further d e b u l k i n g of the inferior and lateral sides of t h e uvula. A h a n d p i e c e specifically d e s i g n e d for this p r o c e d u r e inc o r p o r a t e s a b a c k s t o p and a s m o k e e v a c u a t o r . No s u t u r e s are r e q u i r e d .112 Lasers in Maxillofacial Surgery and Dentistry DESCRIPTION OF THE PROCEDURE L A U P is performed with a free-beam C O . laser with a b a c k s t o p . At e a c h of the p l a n n e d s e s s i o n s .3 ) . Illustration demonstrates the vertical and horizontal incision cutting of the soft palate. T h e uvula is then shortened by a p p r o x i m a t e l y 5 0 % of its length and " r e s h a p e d . : Kinure 8 . 8 . about 5 to 8 mm of the v e l u m is r e m o v e d .2 and 8 .6 m m ) using a pulsed m o d e " S w i f l l a s e " a t t a c h m e n t for t h e S h a p lan laser. A specific s n o r i n g h a n d piece is used with a variable spot size of 0. T h e patient then is given breathing instructions: to take a d e e p breath and very slowly let it out.25 mg in 2 . T h i s c o n servative a p p r o a c h to tissue r e m o v a l essentially e l i m i n a t e s the d e v e l o p m e n t of VPI as a c o m p l i c a t i o n of L A U P . of uvula. T h i s is d o n e by vaporization al the point of focus (0. T h e s e are full-thickness " t r e n c h e s " on either side of the uvula (Fig. Local anesthesia is then a d m i n i s t e r e d using a lidocaine 1 5 % spray followed by an injection of 2% lidocaine with e p i n e p h r i n e (1. laterally to the root of the uvula.2 .51 mm at a focal length of 3 0 0 m m . T h e o u t p u t p o w e r is set at 20 to 30 W a v e r a g e p o w e r in a pulsed m o d e .

u v u l a .u v u l a h a n g s from t h e r e a r of the hard palate. generally s p a c e d at monthly intervals. T h e o p e r a t i o n s are therefore l o n g e r for apneic s n o r e r s than for n o n a p n e i c snorers b e c a u s e of the l o n g e r t i m e n e e d e d to transfix and trim the uvula. b e c a u s e of t h e specific m a k e u p of its m u s c l e fibers ( w h i c h s e e m s to be different from n o n . T h e length and n u m b e r of t h e s e s s i o n s will vary a c c o r d i n g to t h e t h i c k n e s s of the arch and soft palate and t h e h y p e r t r o p h y o f t h e tonsils. 8 .u v u l a are m a d e into a U s h a p e using the Swiftlase a t t a c h m e n t (Fig. t h e u p p e r part of the posterior pillars a r e d e b u l k e d and both t h e s u p e r i o r portion of the vertical incisions and the n e o . a C 0 laser—assisted partial inferior turbinectomy ( L A P T ) or a septoplasty may have to be performed.s p e e d dedicated laser e v a c u a t i o n s y s t e m . LAUP: one-stage vertical incisions and creation of .5 ) . Actually. it is possible to perform a tonsil ablation with e i t h e r a fixed 90° or an adjustable front surface m i r r o r h a n d p i e c e . If there is h y p e r t r o p h y of t h e lingual tonsils.5 ) . LAUP: multiple sessions. tonsillar pillar is usually d o n e in the last s e s s i o n . c a u s i n g an anterior and superior m o t i o n of the n e o .5 mm in d i a m e t e r . In the O S A S p a t i e n t s ." T h e b a s e of t h e uvula is then held with a K o c h e r c l a m p to pull it laterally to facilitate a horizontal inc i s i o n j u s t u n d e r the b a s e of t h e uvula (Fig. " T h i s n e o . R e s h a p i n g of the u v u l a at t h e apex of the soft palate is carried out. Five watts of c o n t i n u o u s p o w e r and a local a n e s t h e t i c spray a r e used.3 . Repeat sessions will gradually result in the "nco-uvula" assuming a more superior and dorsal position. resulting in a s m a l l " n e o . closer to Passavant's ridge. S m o k e is e v a c u a t e d by a h i g h . like a m a i n m a s t s u p p o r t i n g the palatine arch. it is controlled with the defocused b e a m . three to four sessions of 5 m i n u t e s e a c h a r e p e r f o r m e d . as retraction occurs. B l e e d i n g is u s u a l l y m i n i m a l or m o r e likely nonexistent. a " s i n g l e s t a g e " t e c h n i q u e h a s n o w been d e v e l o p e d . p r e v e n t i n g centripetal s c a r fibrosis. 2 Figure 8-4. It c o n t a i n s a portion of the a z y g o s m u s c l e that can still contract and prevent V P I from o c c u r r i n g . If b l e e d i n g c o n t i n u e s . 8 . most patients m a y h a v e a L A P T about 1 m o n t h after the c o m p l e t i o n of the L A U P procedure to ensure better n a s o p h a r y n g e a l air flow. In c a s e s of nasal obstruction c a u s e d by turbinate h y p e r t r o p h y or septal deviation. 3 in O S A S patients. In a d d i t i o n . t h e uvula is u s u a l l y thicker and longer than in p a t i e n t s with s i m p l e s n o r i n g . neo-uvula. a Kigure 8 . T h i s should only be p e r f o r m e d by s u r g e o n s e x p e r i e n c e d in the multistage t e c h n i q u e . it is c o n t r o l l e d with bipolar electrocautery. w h i c h permits o n e to redirect t h e laser b e a m to the p o s t e r i o r third of the t o n g u e . T h e s e incisions a r e lateral to t h e root of the u v u l a and e x t e n d superiorly up to t h e j u n c t i o n of the soft a n d hard palate at the " d i m p l e point.s n o r e r s ) (Fig.4 ) . The "Single-Stage" Technique To facilitate rapidity of t h e c o r r e c t i o n of s n o r i n g . Palatine or lingual tonsillar h y p e r t r o p h y is treated by laser-assisted tonsil ablation ( L A T A ) with t h e " S w i f t l a s e " if tonsillar size is contributing to the O S A S by obstructing the oropharynx. w h i c h c o a g u l a t e s vessels less than 0.u v u l a . Creation of a "neouvula. T w o p a r a m e d i a n vertical incisions o r transfixing " t r e n c h e s " a r e m a d e to a h e i g h t of 2 to 3 c m .Outpatient Treatment of Snoring and Sleep Apnea Syndrome 113 In t h e m u l t i s t a g e t e c h n i q u e . T h e a v e r a g e n u m b e r o f sess i o n s is 3. W h e n there is b l e e d i n g . w h i c h is c o n n e c t e d to the laser h a n d p i e c e ." by debulking of the inferior and the lateral sides of the uvula.77 in n o n a p n e i c snorers and 4 . 8 .

Nasal regurgitation h a s not been reported after t h e laser surgery. topical a n e s t h e t i c throat l o z e n g e s . C P A P i s d i s c o n t i n u e d w h e n t h e p o l y s o m n o g r a m becomes normal. After t r e a t m e n t . T h e m a i n m a s t of the u v u l a is m a d e by t h e p a l a t o s t a p h y l i n u s or uvula a z y g o s m u s c l e . s n o r i n g had reappeared in a few c a s e s . n o s e r i o u s c o m p l i c a t i o n s o c c u r d u r i n g the operation o r d u r i n g the i m m e d i a t e p o s t o p e r a t i v e p h a s e after L A U P . e a t i n g food with vinegar.1 % ( 4 4 patients) s h o w e d no r e s p o n s e after L A U P . OSAS PATIENTS T o e n s u r e p h y s i o l o g i c night ventilation i n s e v e r e O S A S patients. No r e c o r d i n g s of s n o r i n g w e r e carried out.5 . but with m u c h less d i s t u r b a n c e than before. a n d viscous l i d o c a i n e to relieve throat p a i n . Pain intensity r e a c h e s its peak 3 to 5 d a y s p o s t o p e r a t i v e l y . w i t h o u t d i s t u r b i n g t h e s p o u s e . results s h o w e d clinical i m p r o v e m e n t by the second or third L A U P s e s s i o n . as t h e d i a g n o s i n g and treatment indications w e r e based on the s p o u s e ' s c o m p l a i n t and not on a m e a s u r e d level or character of n o i s e . Patients c o m p l a i n only of a m o d e r a t e to s e v e r e " s w a l l o w i n g p a i n " similar to a " s o r e t h r o a t " for a b o u t 10 d a y s . P o s t o p e r a t i v e o b s e r v a t i o n in a medical c a r e unit is F r o m D e c e m b e r 1988 t o July 1994. but longer follow-up s h o w e d reduced success. After several m o n t h s . U s u a l l y . A c l e a r d e c r e a s e of s n o r i n g w a s seen. 1 m o n t h later. vertical m u s c l e is entirely e n c l o s e d in t h e v e l u m .s t a g e t e c h n i q u e . Nonapneic Snorers s t u b m i d d l e pillar s i m i l a r to t h o s e of t h e ribbed vault of a c h u r c h . l e m o n . and 5. a n e s t h e t i c m o u t h s p r a y s . T h e r e w e r e 7 1 5 m e n and 141 w o m e n . with no long-term r e c u r r e n c e . T h i s s m a l l . t h e rare patients who c a m e back again for a n o t h e r session b e c a u s e of snoring re4 . T h e m e a n b o d y m a s s index ( B M I ) w a s 2 5 .2 d a y s . Levin and B e c k e r h a v e s h o w n that s n o r i n g recurred in m o s t patients 6 to 12 m o n t h s after U P P P . 7 0 . RESULTS OF A PERSONAL SERIES Figure 8 . after L A U P . 2 4 . T h e mean duration t i m e of p o s t o p e r a t i v e pain w a s 11. A further study of l o n g . t h e p a t i e n t s a r e g i v e n a prescription inc l u d i n g mild a n a l g e s i c s . s p i n d l e .t e r m results by t e l e p h o n e interview is currently in p r o g r e s s to d e t e r m i n e t h e e x a c t p e r c e n t a g e of snoring r e c u r r e n c e several years after L A U P .1 to 4 5 ) . and this m u s c l e is only attached to t h e posterior side of the hard palate at its u p p e r e d g e .s h a p e d . LAUP: one stage. or w o r k i n g i m m e d i a t e l y afterward. with a m e a n a g e of 4 9 . flanked by t h e t w o lateral p o s t e r i o r pillars. there w e r e only seven patients w h o n e e d e d a s e c o n d s e s s i o n . 3 OPERATIVE OUTCOME After the p r o c e d u r e . Early p o s t o p e r a t i v e results w e r e better than for the classic U P P P . o r spices a n d t a k i n g aspirin a n d nonsteroidal anti-inflammatory d r u g s ( N S A I D s ) for 10 d a y s after t h e o p e r a t i o n . p o l y s o m n o g r a p h y i s rep e a t e d . p e r o x i d e and w a t e r g a r g l e s . its m a i n action is to raise t h e uvula. Of the 6 4 4 p a t i e n t s treated with the m u l t i s t a g e t e c h n i q u e . So it is very important to partially p r e s e r v e this m a i n m a s t as a s u p port of the m i d d l e of the v e l u m . 2 8 % o f patients with initial complete abolition of s n o r i n g had returned to preoperative levels (after U P P P ) .114 Lasers in Maxillofacial Surgery and Dentistry u n n e c e s s a r y . T h e y a r e instructed to avoid d r i n k i n g a l c o h o l . and t h e mean s e s s i o n n u m b e r w a s 3. T h e r e a r e no clinically identifiable c h a n g e s in s p e e c h o r v e l o p h a r y n g e a l function. 4 % of patients ( 6 0 3 patients) had a c o m p l e t e or n e a r e l i m i n a t i o n of s n o r i n g . N o f i b r o s i s c a u s i n g narr o w i n g of the n a s o p h a r y n g e a l a p e r t u r e has been o b s e r v e d as s o m e t i m e s h a s b e e n seen after U P P P . Debulking the superior part of the posterior pillars to create a U shape.C P A P ) is utilized for t h e d u r a t i o n of t h e laser t r e a t m e n t . s p e a k i n g . U s u a l l y . 8 5 6 patients were treated with L A U P b y t h e author. A m o n g t h e 2 1 2 patients cured with t h e o n e . spitting o f b l o o d m a y o c c u r either d u r i n g t h e f i r s t 4 8 h o u r s o r a p p r o x i m a t e l y 8 d a y s after the s e s s i o n . nasal c o n t i n u o u s p o s i t i v e airway p r e s s u r e ( N . Infections w e r e rare e x c e p t for o c c a s i o n a l oral c a n d i d i a s i s . but c a n easily be s t o p p e d in minutes with p e r o x i d e and w a t e r g a r g l e s .77. Following c o m p l e t i o n o f the L A U P t r e a t m e n t . In these "failures" there w a s a l w a y s a d i m i n u t i o n of s n o r i n g but t h e bed partner w a s still u n h a p p y a b o u t the intensity of snoring. but d o e s n ' t inhibit e a t i n g food or d r i n k i n g . 2 years ( r a n g e : 25 to 8 0 ) . 4 % ( 2 0 9 p a t i e n t s ) had i m p r o v e m e n t in their s n o r i n g . 9 (range: 17. R a r e l y .

with at least a 5 0 % reduction in both the p r e o p e r a t i v e o x y g e n d e s a t u r a t i o n index and of the duration of the a p n e a s . 8 t o 17. O n e very significant result is that t h e a p n e a s h a v e been transf o r m e d t o h y p o p n e a s . D a y t i m e s l e e p i n e s s disappeared in 8 2 % of cases. which d e m o n s t r a t e d longer periods spent in stages III to IV and R E M sleep. After L A U P . m o r n i n g tiredness. t h e r e s p i r a t o r y d i s t u r b a n c e index ( R D I ) w a s reduced by m o r e t h a n 5 0 % . In three patients ( 4 . T h e m e a n S a O for t h e 7 0 p a t i e n t s i m p r o v e d from 9 3 . there w a s i m p r o v e m e n t of snoring. 1 % p r e o p e r a t i v e l y t o 9 3 . there w a s also a significant reduction of d a y t i m e s o m n o l e n c e . A m o n g 6 2 p a t i e n t s classified a s successful r e s p o n d e r s . and r e m a i n e d as before L A U P in eight cases. 7 0 adult p a t i e n t s w e r e included in this study as " O S A S s n o r e r s . T h e most frequent c a u s e of r e c u r r e n c e is t o b a c c o s m o k i n g . with a m e a n age of 5 3 . 9 % p o s t o p e r a t i v e l y . 10 w e r e i m p r o v e d .t e r m follow-up e x a m i n a tion and to repeat a full sleep study several m o n t h s after s u r g e r y to confirm the efficacy of the L A U P o p e r a t i o n . these patients had better long-term a c c e p t a n c e of C P A P b e c a u s e of the reduction of the u p p e r respiratory t r a d obstruction.c o m p l e t e elimination of snoring. All had pre. loss of libido). and I failed. As for U P P P . there were 14 c o m p l e t e c u r e s . . this s y m p t o m disappeared in 30 c a s e s . w h i c h are less d a n g e r o u s for these p a t i e n t s . w h i l e the m e a n a p n e a index for t h e n o n r e s p o n d e r s d e c r e a s e d from 2 3 . It is essential to c o n v i n c e our treated patients to maintain l o n g .115 currence h a v e been cured of their d i s c o m f o r t . this s y m p t o m d i s a p p e a r e d in 25 cases. T h e r e w e r e n o c o m p l i c a t i o n s r e p o r t e d . m o r n i n g h e a d a c h e s .6 t o 15. 3 . Of the 25 cases of c o n v e n t i o n a l U P P P failures treated by L A U P . but still a small a m o u n t of occasional noise persisted.5. T h e r e d u c t i o n o f a p n e a length and o f preo p e r a t i v e o x y g e n d e s a t u r a t i o n index w a s greater than 5 0 % . sleep a w a k e n i n g s . 9 ( r a n g e : 2 3 .2 ( r a n g e : 2 2 . M o r n i n g tiredness disappeared in 9 4 % of cases and decreased in 6% of c a s e s . 44 patients noticed a r e a p p e a r a n c e of d r e a m i n g . " 64 m e n and 6 w o m e n . 4 % ) w e r e u n i m p r o v e d .4 0 ) and t h e B M I w a s found t o be m o r e than 30 in 23 c a s e s . d e c r e a s e d in 18 c a s e s . t h e results w e r e t w o c o m p l e t e recoveries and t w o failures. decreased in 1 5 % of cases. A m o n g the 56 patients with frequent sleep a w a k e n i n g s . there w a s c o m p l e t e or n e a r . in 63%> of p a t i e n t s confirmed by nocturnal E E G s t u d i e s . A m o n g the 27 patients w h o suffered sexual p r o b l e m s (erectile dysfunction. and r e m a i n e d u n c h a n g e d in o n e case. T h i r t e e n patients w e r e also cured of nasal o b s t r u c t i o n by laser-assisted partial t u r b i n e c t o m y c o m b i n e d with t h e L A U P . F o u r patients w e r e surgical U P P P failures corrected by L A U P . T h e i r m e a n a p n e a index d e c r e a s e d from 2 3 . : Obstructive Sleep Apnea Syndrome F r o m D e c e m b e r 1988 t o M a y 1994. 3 % t o 8 0 . 23 said that their sex life w a s i m p r o v e d after L A U P . 4 % ) . T h e m e a n l o w e s t S a O c h a n g e d from 7 7 .7. F u r t h e r m o r e . H o w e v e r . For severe O S A S . . and a c l e a r i m p r o v e m e n t of O S A S in 26 p a t i e n t s ( 3 7 . a n d t h e m e a n a p n e a index from 2 3 . 3 t o 7. and sexual p r o b l e m s (erectile dysfunction). A l s o s h o w n w a s an i n c r e a s e in d e e p sleep t i m e (stages III to IV and R E M ) . In the majority of the patients.9.2. S l e e p efficiency (total s l e e p t i m e X 100/total sleep p e riod) w a s i m p r o v e d i n 6 3 % o f patients a m o n g patients with pre. T h e m e a n BMI w a s 29. 3 to 6. P o l y s o m n o g r a p h y w a s carried out before and after L A U P . 1 % ) . and w a s u n c h a n g e d in 3% of cases.and p o s t o p e r a t i v e nocturnal E E G studies. In 11 patients ( 1 5 .and p o s t o p e r a t i v e evaluation by p o l y s o m n o g r a p h y and d e m o n s t r a t e d e v i d e n c e of repeated obstructive respiratory e v e n t s d u r i n g sleep on presurgical p o l y s o m n o g r a p h y . there w a s an i m p r o v e m e n t of sleep efficiency as measured by nocturnal E E C . but the noise w a s still disturbing to the s p o u s e . A m o n g the 26 patients w h o suffered from m o r n i n g h e a d a c h e s . Eight patients ( 1 1 . For all 70 p a t i e n t s . 7 % ) . 5 % p o s t o p eratively. with no recurrence. C P A P w a s initiated before L A U P . A c o m p l e t e c u r e of O S A S w a s a c h i e v e d in 36 patients ( 5 1 . 3 % ) there was a d e c r e a s e in snoring. high RDI and sleep a p n e a indices and morbid o b e s i t y a l s o predicted a p o o r r e s p o n s e to L A U P . T h e m e a n r e s p o n d e r R D I d e c r e a s e d from 37.7 2 ) . t h e m e a n R D I d e c r e a s e d from 3 7 . 8 to 19. After L A U P . In 56 patients ( 8 0 % ) .

presented with a 3 0 . with an RDI of 2 2 . 8 inches) tall. Laser C 0 for snoring. no d a y t i m e s o m n o l e n c e . i m p r o v e m e n t o f sexual p r o b l e m s and of s l e e p efficiency. T h e patient later com plained of nasal o b s t r u c t i o n . m o r n i n g tiredness. 1. a third o p e r a t i o n w a s performed. although he c o m p l a i n e d of c h r o n i c nasal obstruction.s t a g e L A U P and returned for r e e x a m i n a t i o n I month later at which l i m e there w a s cessation of snoring. He underwent a o n e . with a n R D I o f 6 2 . w a s carried out in two s e s s i o n s .5. T h e right turbinates w e r e treated by L A P T 3 w e e k s later. T h e r e w a s n o m o r e snoring. N o maxillofacial a b n o r m a l i t y w a s found. which found significant i m p r o v e m e n t of the O S A S . LAUP: laser-assisted UPPP results on 46 patients. this technique h a s imp r o v e d or e l i m i n a t e d O S A S in most cases and probably shall be routinely used in O S A S s u r g e r y in a few years if the results are c o n f i r m e d by other investigators.116 Lasers in Maxillofacial Surgery and Dentistry CASE 1 CASE 2 A 5 0 . still a bit d i s t u r b i n g to h i s wife. T h e first and s e c o n d s e s s i o n s performed 2 m o n t h s apart still required c o n t i n u e d use of NC P A P . he had no more m o r n i n g tiredness and there w a s i m p r o v e m e n t of his sexual d y s f u n c t i o n and of s l e e p efficiency with the reappearance o f d r e a m i n g . preliminary results. and a laser-assisted partial turb i n e c t o m y of the left inferior and m i d d l e turbinate w a s performed 14 m o n t h s after initial t r e a t m e n t . T h e patient returned for e x a m i n a t i o n 4 m o n t h s later with no m o r e m o r n i n g tiredness o r d a y t i m e s o m n o l e n c e . P o l y s o m n o g r a p h y w a s r e p e a t e d 3 w e e k s later. a m e a n S a 0 of 9 3 . A strict weight reduction diet w a s started.73 m (5 feet. 8 / h o u r and a sleep a p n e a index of 4 6 . sexual p r o b l e m s . 7 and 8 m o n t h s after initial treatment. Laser-assisted turbinectomy of the left inferior and m i d d l e turbinates. E x a m i n a t i o n of his n o s e d e m o n s t r a t e d a mild septal deviation and hypertrop h y of the turbinates. i n c l u d i n g a reduction of weight to 98 kg ( 2 1 6 p o u n d s ) . This was followed 3 w e e k s later by p o l y s o m n o graphy s h o w i n g an RDI of 13/hour. Nasal C P A P w a s initiated 10 d a y s later at a pressure o f + 1 1 c m o f H 0 . Four m o n t h s after the initial L A U P . which is m o r e difficult to treat b e c a u s e of the thickness of t h e soft palate. 2. In these patients. 6 and an a p n e a index of 12. After 5 years of e x p e r i e n c e with L A U P . P o p u l a r i z a t i o n of t h e L A U P will r e q u i r e serious training of s u r g e o n s and further study with special e m p h a s i s on l o n g .y c a r . 2 2 2 2 2 2 2 CONCLUSION L A U P can lift the d r o o p i n g soft palate on both sides of the uvula. A repeat p o l y s o m n o g r a m 9 m o n t h s after initial treatment c o n f i r m e d the e l i m i n a t i o n of O S A S and the C P A P w a s stopped. and a lowest S a 0 of 6 1 .12:215-219.C P A P and agreed t o u n d e r g o L A U P in several s e s s i o n s . 6 % .C P A P was decreased to 7 cm H 0 . similar to the w a y a theater curtain rises. It would b e c o m e a valuable alternative technique to conventional U P P P . Outpatient treatment of sleep apnea syndrome with C 0 laser. J Clin User Med Surg 1994. The N . 4 8 % of sleep registering t i m e o c c u r r e d in association with a S a 0 of less than 9 5 % . especially in surgery for O S A S . resulting i n R E M positive sleep. 9 . and o n l y o c c a sional soft s n o r i n g . E x a m i n a t i o n r e v e a l e d that the tip of the soft palate e x t e n d e d to the inferior b a s e of the t o n g u e . and a BMI of 24. 9 % and the lowest S a 0 was 7 2 . with its great potential to r e d u c e morbidity and cost to patients. Kamami YV. long-term p o l y s o m n o g r a p h y c o n t r o l s are n e c e s s a r y to study long-term results.3/hour. T h e total d u r a t i o n of a p neas w a s 41 m i n u t e s 12 s e c o n d s . A fourth and fifth session w a s d o n e . 2 2 .o l d medical d o c t o r presented with a 1-year history of snoring. p r e d i s p o s i n g t o p h a r y n g e a l collapse. r e s p e c t i v e l y . REFERENCES 1. and a total duration time of a p n e a s of 126 m i n u t e s 14 s e c o n d s . T h e m e a n S a 0 w a s 9 2 . W h e n reevaluated 4 m o n t h s later. T h e patient noticed a c l e a r i m p r o v e m e n t of clinical s y m p t o m s .44:451-456. 6 / h o u r .6. 5 % . Kamami YV.y e a r history of snoring and m o d e r a t e sleep a p n e a . His initial p o l y s o m n o g r a p h y c o n f i r m e d the d i a g n o s i s o f O S A S .t e r m a s s e s s m e n t . T h e patient w a n t e d t o d i s c o n t i n u e the N . and an a p n e a index of 7. Ada Otorhtnolaryngol Belg 1990. A 55-year-old o b e s e ( 1 0 2 k g . or 2 2 5 lbs) m a n .

) or by a l a s e r e t c h i n g of t h e m u c o s a ( F i g .6 b ) . 8 . T h e operation is c o n ducted using local anesthesia with optional s e d a t i o n in a series of o n e to five surgeries staged 3 to 5 w e e k s apart. (A) Vertical incisions are made on each side of the uvula. H a ! " A d i m p l e will briefly a p p e a r on the oral s u r f a c e of t h e soft palate. 4 % .t e r m s u c c e s s rates a r e high with elimination of snoring being rated as c o m p l e t e in 7 0 . (D) lateral trenches are created on the anterior surface of the posterior pharyngeal pillars. A 3 9 . satisfactory in 2 4 . W A R N I N G : E x t e n s i o n o f t h e vertical i n c i s i o n s a b o v e the level of t h e d i m p l e m a y c a u s e v e l o p h a r y n g e a l i n c o m petence ( V P I ) .y e a r . Ordinarily a less e x t e n s i v e p r o c e d u r e is a c c o m p l i s h e d on repeat L A U P s . t h e u v u l a is g e n e r a l l y reduced b y o n e half ( F i g . thereby giving a c o n s t r i c t e d a p p e a r a n c e to the v e l o p h a r y n g e a l ring. The s u p e r i o r e x t e n t of the incision l e n g t h is m a r k e d by the attachment o f t h e levator veli palatini m u s c l e s . L o n g . then the p r o c e d u r e can be repeated. T h i s must b e a v o i d e d .6 c ) . (C) The uvula is generally reduced the same length as the vertical incisions. R e covery is relatively uneventful. T h i s incision e x tends from the start of the initial vertical palatal incision and e x t e n d s laterally and interiorly to t h e b a s e of t h e p o s t e rior tonsillar pillar (Fig. After t h e vertical incisions a r e p e r f o r m e d b i l a t e r a l l y . If l o w palatal w e b b i n g persists. 8 . . In most cases the laser is next used to create a 2 mm d e e p and 4 mm w i d e trench on the anterior m u c o s a l surface of the posterior tonsillar pillars bilaterally.5-7 Case Report Vertical full-thickness i n c i s i o n s are m a d e bilaterally adjacent to the u v u l a e x t e n d i n g from t h e free e d g e of t h e soft palate s u p e r i o r l y for a p p r o x i m a t e l y 1 to 2 cm ( F i g . T h i s will v a r y a c c o r d i n g to the length of t h e u v u l a . " H a ! . Figure 8-6. M o r e than t w o p r o c e d u r e s are s e l d o m required. 4 % of c a s e s . anterior and s u p e r i o r to the b a s e of the u v u l a .2%. 1 has b e c o m e a low m o r bidity operation that m a y safely be p e r f o r m e d in an a m b u l a tory setting (office or s u r g i c e n t e r ) .8 Section 2: Further Comments on the Laser-Assisted Uvulopalatoplasty lames W. T h e s u p e rior extent of t h e incision is limited by an i m a g i n a r y line located at t h e p o s t e r i o r / i n f e r i o r b o r d e r of t h e l e v a t o r ' s insertion. 8 .2. T h e s e a r e generally less than 3 cm in length. and u n i m p r o v e d in 5. It is r e c o g nized by h a v i n g the patient forcefully s a y . an additional vertical release of 3 to 5 mm is placed laterally to t h e original vertical incisions. T h e p o s i t i o n of its a t t a c h m e n t is in t h e m i d l i n e . (B) Superior extension of incision is detemiined by the position of attachment of the levator palati. Procedure1. O n e p r o c e d u r e is successful a p p r o x i m a t e l y 7 5 % of the time.o l d m a n w a s referred from the sleep laboratory for e v a l u a t i o n of snoring and h y p o x e m i a . If s n o r i n g persists or if the patient can still snort. 8 . Wooten The laser-assisted uvulopalatoplasty ( L A U P ) to e l i m i n a t e snoring first described by K a m a m i . He is 6 feet tall.6 d ) . r e s u l t i n g in nasal reflux of fluids and hypernasal s p e e c h .6 a ) . T h i s d i m p l e i s m a r k e d b y either silver nitrate ( A g N O . 2 Second Procedure T h r e e t o f i v e w e e k s p o s t o p e r a t i v e l y the p a t i e n t ' s snoring status should be reevaluated.

a n d . T h e d i m p l e w a s then m a r k e d with the laser using 10-W p u l s e s to etch the mucosal surface lying directly o v e r t h e d i m p l e m a r k i n g the attachment o f t h e levator palatini ( F i g . S e v e n w e e k s after t h e initial s u r g e r y . U s i n g the s a m e i. w a s g i v e n .3 mL to the right and left sides of t h e a t t a c h m e n t of t h e levator p a l a t i n i . The uvula was shortened the same distance. a 4 mm w i d e . T h e lateral p h a r y n g e a l walls w e r e thickened (Fig. T h i s w a s all a c c o m p l i s h e d w i t h o u t difficulty and w i t h o u t physical discomfort to the patient. s e d a t i o n and a n e s t h e s i a p r o t o c o l . A n a s o p h a r y n g o s c o p y d e m o n s t r a t e d a n a r r o w i n g of t h e a i r w a y from e a c h side and a c l o s u r e of the retropalatal area d u r i n g M i d l e r ' s m a n e u v e r .2 to 0. 2 mm deep. S l e e p studies indicated an a p n e a index of 1 and a n o x y g e n desaturation index o f 3 1 . 9 % t e t r a c y c l i n e or d o x y c y c l i n e s u s p e n s i o n . T h e inferior a s p e c t o f 8 2 Figure 8-7.9 ) . 8 . into the c e n t e r of t h e u v u l a and then bilaterally into t h e m i d position o f the posterior p h a r y n g e a l pillars. A nystatin s u s p e n s i o n was prescribed with 1 mL to be gargled and expectorated q. and 15 mm long trench w a s c r e a t e d on both the right and left sides e x t e n d i n g laterally a n d inferiorly on t h e a n t e r i o r surface of the posterior p h a r y n g e a l pillar (Fig. w h i c h w a s eventually s u p p l e m e n t e d b y three additional 1-mg i n c r e m e n t s . o x y g e n saturation w a s less than 8 0 % . ( 1 1 4 k g ) a n d has a history of s e v e r e c o n t i n u o u s snoring. D u r i n g 1 8 % o f his sleep time. W i t h the s a m e h a n d p i e c e . A lateral c e p h a l o m e t r i c r a d i o g r a p h s h o w e d a d e q u a t e p o s t e r i o r airw a y s p a c e in the h y p o p h a r y n g e a l region.n. . Prcoperatively the patient has a long uvula and a low webbed soft palate. a n d 1% of a 1% b e t a m e t h a s o n e lotion t o b e g a r g l e d a n d e x p e c t o r a t e d four t i m e s a d a y a n d p. 13-mm t h r o u g h . Lateral trenches 4 mm wide.S y n e p h r i n e solution and by s p r a y i n g of t h e o r o p h a r y n x with C e t a c a i n e . the patient could still snort and t h e s e c o n d stage w a s then p l a n n e d . Vertical incisions of 13 mm length were placed on each side of the uvula. and liquid o x y c o d o n e 5 m g / a c e t a minophen 5 0 0 m g . 5 % b u p i v a c a i n e using 0.8 ) . Oral e x a m i n a t i o n r e v e a l e d a low w e b b e d soft palate and a long uvula. and 15 mm long were created on the anterior surface of the posterior pharyngeal pillar.8 ) . t h e patient w a s anxiety and pain-free yet a w a k e and c o o p e r a t i v e .7 ) . T h e s l e e p laboratory w o r k u p included r e c o m m e n d a t i o n s t o use C P A P a n d lose w e i g h t . t h e L A U P w a s r e c o m m e n d e d as a c o n s e r v a t i v e surgical treatment b e c a u s e the n a s o p h a r y n g o s c o p y d e m o n s t r a t e d a retropalatal c l o s u r e .i. D u r i n g the p r o c e d u r e t h e uvula w a s stabilized with a wet w o o d e n t o n g u e blade. 2 mm d e e p . U p o n retesling. At 4 w e e k s t h e patient stated that h i s d o r m i t o r y m a t e s c o m m e n t e d that his s n o r i n g w a s m u c h less severe. but t h e p a tient w a s u n w i l l i n g t o d o either.d. Topical anesthesia o f t h e nasal and o r o p h a r y n g e a l t i s s u e s w a s a c c o m p l i s h e d b y nasal insufflation o f 2 % l i d o c a i n e / 2 % N e o . 8 . the p a tient agreed to h a v e t h e o p e r a t i o n s . a s e c o n d p r o c e d u r e w a s d o n e t o c o m p l e t e l y s t o p t h e snoring. T h e p o s t o p e r a t i v e c o u r s e w a s benign and t h e m u c o s a e w e r e well healed at 3 w e e k s ( F i g .v.t h r o u g h vertical i n c i s i o n s w e r e m a d e o n e a c h side o f t h e uvula.m. T h e patient returned to h i s n o r m a l w o r k on an offshore oil rig 2 d a y s after s u r g e r y . alt h o u g h it still persisted.118 Lasers in Maxillofacial Surgery and Dentistry the uvula w a s shortened 13 mm by e x c i s i n g it with a nonb a c k s t o p p e d h a n d p i e c e . T h e r e f o r e . S e d a t i o n w a s initiated and m a i n t a i n e d with 3 m g m i d a z o l a m .r. A topical anesthetic solution containing a m i x t u r e o f 9 0 % d i p h e n h y d r a m i n e HC1 s y r u p . 8 . 8 . T h e d i m p l e w a s m a r k e d and vertical incisions w e r e m a d e on the right and left sides of the u v u l a e x t e n d i n g vertically 6 to 7 mm w e i g h s 2 4 5 lbs. After c o u n s e l i n g and o b t a i n i n g informed c o n s e n t . Postoperative medications were ketorolac Irimethamine ( T o r a d o l ) 6 0 m g i. Local a n e s t h e s i a w a s o b tained with 0 . Figure 8—8. U s i n g a C 0 laser adjusted to 15 W o u t p u t p o w e r with a b a c k s t o p p e d h a n d p i e c e .

4 . 8 .3 8 ) is chosen for the incisions that are made as recommended by Kamami earlier in this chapter. the patient's lowest o x y g e n saturation was 7 2 % and only 1. The uvula was then shortened 4 mm and lateral trenches 1 cm long. With the patient seated and the mouth open. The postoperative regime was the same as for the first procedure and the recovery was uncomplicated. and 2 mm deep were created on the anterior surface of the posterior pharyngeal arch (Fig. The long contra-angle handpiece is used to provide a z Figure 8 -10. The patient is very satisfied. the patient has a well-contoured soft palate and is sleeping without snoring.Further Comments on the Laser-Assisted Uvulopalatoplasty using 15 W output power.7% of his sleep time was associated with an o x y g e n saturation of less than 80%. 4 mm wide. Figure 8 -11. Additional vertical incisions of 4 to 5 mm in length were placed 3 to 4 mm lateral to the original cuts. Preoperative assessment and the technique for adequately anesthetizing the operative site remain the same. Instructions to lose 15 to 2 0 % body weight were o n c e again given to the patient.1 0 ) . Figure 8-9. final adjustments of contour as well as deepening of the superior part of the incisions may be performed with the rounded CONTACT ND:YAG An alternative technique for L A U P is to use a contact N d : Y A G laser instead of the free-beam C O . Four months after original surgery. The secondary procedure was less extensive when performed at 7 weeks after initial surgery. 8 . Most impressively. the palate has g o o d form with a less constrictive velopharyngeal ring and a shorter uvula (Fig.6 and 8 . a repeat sleep study demonstrated an apnea index of 1 and an o x y g e n desaturation index of 2 3 . 119 clear line of sight along the handpiece. After positioning the high v o l u m e s m o k e evacuator at the corner of the mouth the operation c o m m e n c e s . 8 . Four months after the initial surgery. 8 . Three months after the original surgery. A scalpel-type probe tip (see Fig. 7 . some snoring persisted.1 0 ) . His dormitory mates reported c o m p l e t e cessation of snoring. After creating the general U-shaped form for the neo-uvula as illustrated by Kamami and W o o t e n in Figs. At 3 weeks the mucosa was healed but. a black (nonreflective) metal tongue blade is used to depress the tongue. T h e patient's mouth is conveniently held open by a bite block or side action mouth prop. .1 1 ) .

44:451-456. A n y b l e e d i n g p o i n t s a r e e a s i l y c o a g u l a t e d with the probe. Krespi Y.5(4):235-243. Laser C 0 for snoring. Krespi YP. permit s u b t l e c o n t o u r i n g with only m i n o r t h e r m a l d a m a g e t o n a t i v e tiss u e . 7. 5. Sphrintzen RJ. Levin BC. Operative Tech Otolayrngol Head Neck Surg l994. REFERENCES 1. Cornay WJ III. Kamami YV. 104(9): 1150-1152. . Paris: Pr6lat J. preliminary results. Becker GD. Outpatient treatment of sleep apnea syndrome 2 8. 3. 6. The efficacy of laser assisted uvulopalatoplasty in the management of obstructive sleep apnea and upper airway resistance syndrome. Keidar A.95( 12): 1483-1487. LAUP: laser-assisted UPPP results on 46 patients. Acta Otorhinolaiyngol Belg f99<). Thorpy MJ. 1974. excellent hemostasis. 2 tips that. Spielman AJ.5(4):228-234.120 Lasers in Maxillofacial Surgery and Dentistry with C 0 laser. Kamami YV. el al. O u t p u t p o w e r o f the N d : Y A G s h o u l d b e i n t h e r a n g e o f 12 to 15 W u s i n g a n u m b e r 6 S L T c o n t a c t p r o b e for rapid operating time. Couly G. Predictive value of Muller's maneuver in selection of patient for uvulopalatopharyngoplasty. Laryngoscope 1994. 4. Analomie Maxillo-faciale 25 questions pour la preparation des examens et concours. 12:215-219. by d e l i v e r i n g a flatter b e a m profile. 2. et al. Laser-assisted uvulopalatoplasty for the treatment of snoring. Sher AE. J Clin Laser Med Surg 1994. and predictable results. Operative Tech Otolaryngol Head Neck Surg l994. Personal communication. Laryngoscope 1985. Uvulopalalopharyngoplasty for snoring: long term results.

The glottis is an ideal structure for the use of a C 0 2 laser because of its high tissue w a t e r c o n t e n t . (3) using short pulse d u r a t i o n s in a s u p e r p u l s e m o d e to d e c r e a s e the t i m e o v e r which thermal energy b u i l d u p o c c u r s in the tissues (0.m m w o r k i n g distance. a m o i s t u r i z e d pledget is placed o v e r the cuff to protect t h e cuff and distal tissues. 7 T h e goal of laser va- Laser p a r a m e t e r s and laryngeal surgical t e c h n i q u e s that will d e c r e a s e s u r r o u n d i n g soft tissue thermal injury include ( I ) using a m i c r o m a n i p u l a t o r that p r o d u c e s a spot size of 0. (5) frequently r e m o v i n g c a r b o n a c e o u s debris (char) from the soft tissue laser e x c i s i o n site with laryngeal suction to d e c r e a s e heat transfer. and (6) k e e p i n g tension at the laser e x c i s i o n line by stretching the tissues with microsurgical forceps: this p r o d u c e s a cleaner incision by m i n i m i z i n g c h a r formation.25 mm with a 4 0 0 mm focal length lens. and t h e e y e s and face a r e protected with d a m p e n e d e y e p a d s and a head d r a p e . a l l o w i n g for diffusion of t h e r m a l e n e r g y away from the impact site of the b e a m and resulting in less surrounding tissue injury. S u s p e n s i o n m i c r o l a r y n g o s c o p y is p e r f o r m e d using a l a r g e .0 s e c o n d s 121 . and h e m o r r h a g e (see Chapter 2 for m o r e details). T h e C O 2 laser m a y also b e utilized alone or in c o m b i n a t i o n with c o n v e n t i o n a l surgical techniques for r e m o v a l of vocal fold cysts or t r e a t m e n t of Reinke's edema. respectively (Figs. therefore. 1 2 2 W h e n used properly t h e C O 2 laser is an effective and safe instrument for laryngeal s u r g e r y .1 to 1. especially with the j u v e n i l e onset type. 9 .3 and 9 . T h i s lesion is t h e most c o m m o n benign neoplasm of the larynx. corneal injury. the C 0 2 laser c o m b i n e s surgical m i c r o p r e c i s i o n with capillary h e m o s t a t i c capability and h a s b e c o m e t h e instrument of c h o i c e for a n u m b e r of laryngeal p a t h o l o g i e s . ignition of pledgets or d r a p e s . but d e s p i t e m e t i c u l o u s safety p r e c a u t i o n s c o m p l i c a t i o n s will o c c u r . indications for their r e m o v a l . p n e u mothorax. e n d o t r a c h e a l tube ignition. T h e benefit of m i n i m a l thermal d a m a g e from C 0 laser s u r g e r y results i n less p o s t o p e r a t i v e tissue e d e m a .b o r e l a r y n g o s c o p e with 10X to 2 5 X magnification. b u r n s to t h e skin or m u c o s a of t h e patient or o p e r a t i n g r o o m p e r s o n n e l . 9 . laryngeal c y s t s .5 to 6 W ) . is thought to be only palliative in most cases.2 ) .9 The Carbon Dioxide Laser in Laryngeal Surgery Robert). for all p r o c e d u r e s d e scribed b e l o w the patient is intubated with a small ( 6 . H o w e v e r . or i m p r o v e d . T h e e n d o t r a c h e a l tube cuff is filled with m e t h y l e n e blue to allow for rapid detection of a cuff leak from a m i s d i r e c t e d laser "hit.i n d u c e d soft tissue damage. LARYNGEAL PAPILLOMAS Laryngeal papillomas are cauliflower-like lesions caused by infection with t h e h u m a n papilloma virus ( H P V ) (Figs.6 T h e f o l l o w i n g sections d e s c r i b e the p a t h o p h y s i o l o g y of specific laryngeal lesions. t h u s p r e v e n t i n g h e a t . vocal fold mucosal healing a n d voice q u a l i t y .5 m m i n n e r d i a m e t e r ) laser-resistant e n d o t r a c h e a l tube (jet ventilation m a y be used to avoid p l a c e m e n t of an e n d o tracheal t u b e ) . 0 to 6. m i n i m a l s c a r r i n g ." U s e of o x y g e n concentrations b e t w e e n 3 0 and 4 0 % will d e c r e a s e the c h a n c e o f end o t r a c h e a l tube ignition. s u b c u t a n e o u s e m p h y s e m a . the d e v e l o p m e n t of n e w m i c r o s u r g i c a l instrumentation. although the accepted procedure of choice today. Several e x p e r i m e n t a l studies h a v e d e m o n s t r a t e d d e l a y e d healing and increased s c a r r i n g w h e n the C 0 2 laser i s used. r e d u c e d b e a m spot size. During infancy or adulthood its presenting s y m p t o m s are hoarseness o r airway obstruction. a n d early glottic c a r c i n o m a s . and C O 2 laser t e c h n i q u e s . g r a n u l o m a s . (4) s u c t i o n i n g the v a p o r p l u m e from the o p e r a t i v e field. C O 2 laser vaporization of these lesions. and better o p e r a tor t e c h n i q u e s h a v e led to e q u i v a l e n t .25 mm at a 4 0 0 .1 a n d 9 .4 ) . With the d e v e l o p m e n t of microsurgical i n s t r u m e n t a t i o n a n d a m i c r o m a n i p u l a t o r laser a t t a c h m e n t that p r o d u c e s a reduced spot size d i a m e t e r of 0. w h i c h will limit t h e a m o u n t of heat b u i l d u p a n d d e c r e a s e thermal injury to s u r r o u n d i n g tissues. Multiple recurrences are thought to be caused by persistent g r o w t h of H P V in subclinically infected normal-appearing tissue bordering the area of treatment. G e n e r a l l y . vascular lesions of the larynx such as h e m a n g i o m a s and h e m o r r h a g i c p o l y p s . especially in R e i n k e ' s s p a c e . It is ideally suited for r e m o v a l of recurrent laryngeal papillomas. (2) utilizing l o w power settings (0. Meleca Coupling (he o p e r a t i n g m i c r o s c o p e with the C 0 2 laser launched a n e w era in the field of laryngeal m i c r o s u r g e r y . T h e natural history of this disease is o n e of multiple recurrences. T h e s e m a y include cuff rupture. and rapid w o u n d h e a l i n g . 5 2 1 in a 1 0 % duty c y c l e ) .

M. or mixed c a p i l l a r y / c a v e r n o u s lesions..D. which is exposed using a laryngoscope placed in suspension. The microscope is coupled to a C 0 laser micromanipulator. and 0 . 2 Figure 9 . Preoperative view of a 27-year-old patient with laryngeal papillomas involving both true vocal folds and the anterior false fold on the right.3 . the pediatric form is p r e d o m i n a n t l y capillary in nature and the adult form more often mixed or c a v e r n o u s . 5 . Note that a 4(X)-mm lens on the microscope provides adequate working distance between the microscope and the laryngoscope. Simultaneous removal of papillomas from both sides of the anterior or posterior c o m m i s s u r e should be avoided.to 1.2 . Bastian. 9 .to 3-W power. 2 porization is to eradicate this lesion and establish an adequate airway and functional voice without causing submucosal d a m a g e that m a y result in vocal fold scarring and fibrosis. as this maneuver often results in c o m m i s s u r e w e b formation. Chicago. cave r n o u s . (Photo courtesy of Robert W. 8 Typical C 0 2 laser settings for such a procedure include using a 0 .122 Lasers in Maxillofacial Surgery and Dentistry Figure 9 . 2.1 . T h e y may present in a pediatric or adult form. 2 5 mm spot size at a working distance of 4 0 0 m m . Intraoperative view demonstrating the equipment used for a patient undergoing suspension microlaryngoscopy and C O .0-second pulse durations.1 . 6 T h e pediatric h e m a n g i o m a char- Figure 9 . Loyola University. laser excision of subglottic granulation tissue. This allows for a magnified and binocular view of the lesion. LARYNGEAL AND SUBGLOTTIC HEMANGIOMAS H e m a n g i o m a s are u n c o m m o n n e o p l a s m s that m a y occur a n y w h e r e in the larynx and histologically are capillary. Note the red beam of the C 0 laser located at the inferior boundary of the lesion.) . Iixample of the view obtained through the subglottiscope used for the patient in Fig.

and a 0 . T h e irritating stimuli p r o d u c ing these p a t h o l o g i c c h a n g e s include vocal a b u s e .to 2 .W p o w e r . capillary h e m a n g i o m a s m a y b e effectively t r e a t e d . o r g e n e r a l i z e d . Bastian. 5 . T h e s e l e s i o n s often o c c u r subglottically and m a y p r o g r e s s in size. W i t h l o n g .s e c o n d pulse d u r a t i o n . (Photo courtesy of Robert W. or for p o l y p s d e m o n s t r a t i n g fusiform. Etiologies include p r e v i o u s t r a u m a from e n d o t r a c h e a l intubation.0-second pulse d u r a t i o n s .m m lens. and finally to a p e d u n c u l a t e d m a s s that will e v e n t u a l l y fall off.W p o w e r .t o 0 . Vessels leading to the p o l y p a r e c o a g u l a t e d . T y p i c a l laser s e t t i n g s for r e m o v a l of such lesions include using a 0 . 1 . 2.m m spot size. T h e y characteristically p r e s e n t with s y m p t o m s of h o a r s e n e s s . resulting i n a i r w a y obstruction.m m lens. sore throat. a s well a s s p e e c h therapy. M. 5 .b a s e d g r a n u l o m a . hemorrhagic. 2 REINKE'S EDEMA AND VOCAL FOLD POLYPS R e i n k e ' s e d e m a a n d vocal fold p o l y p s r e p r e s e n t a d i s e a s e process induced by c h r o n i c irritation to t h e vocal folds with resultant fluid a c c u m u l a t i o n in t h e superficial l a y e r of the lamina propria. 1 . h o w e v e r . C o n g e n i t a l sacc u l a r c y s t s or l a r y n g o c e l e s a r e rare and m a y present with voice c h a n g e o r airway c o m p r o m i s e . A p p r o p r i a t e laser settings for such a p r o c e d u r e m i g h t include using a 0 . 10 acteristically p r e s e n t s shortly after birth. C 0 2 laser t r e a t m e n t m a y b e used safely to r e m o v e these lesions w h i l e s i m u l t a n e o u s l y m a i n taining a patent a i r w a y and thereby a v o i d i n g need for a tracheotomy. Effective treatment usually includes rem o v a l o f t h e irritating s o u r c e . 6 2 MALIGNANT NEOPLASMS V o c a l fold h y p e r k e r a t o s i s . 5 to 2 W.m m spot size at a 4 0 0 .m m focal d i s t a n c e . c h r o n i c throat c l e a r i n g or c o u g h . or gastric acid a s sociated with g a s t r o e s o p h a g e a l reflux. h a s a proliferative phase that m a y last up to 1 y e a r followed by an involutional phase o c c u r r i n g from 1 to 7 y e a r s of a g e . 6 GRANULOMA L a r y n g e a l g r a n u l o m a s typically arise in t h e posterior glottis. and 0 . T h e C O 2 laser i s ideal for c o m p l e t e r e m o v a l of these lesions e n d o s c o p i c a l l y .'' W i t h the use of a s u b g l o t t o s c o p e and a laser with increased pulse d u r a t i o n settings to a l l o w for m o r e thermal diffusion and better c o a g u l a t i o n of small v e s s e l s . T h e s e lesions often begin as ulcerations with p r o g r e s s i o n toward granulation formation. or e a r l y i n v a s i v e c a r c i n o m a can all be effectively treated .to 3 . a d m i n i s t e r i n g antibiotics and antireflux m e d i c a t i o n s . 5 . 2 5 . or a g l o b u s s e n s a t i o n . g a s t r o e s o p h a g e a l reflux. 2 5 . 0 .r e t e n t i o n c y s t s m a y o c c u r in the supraglottis w h e r e m u c u s . 2 5 .m m spot size with a 4 0 0 . 5 . 6 A n y r e m a i n ing g r a n u l a t i o n tissue can be spot v a p o r i z e d . r e c u r r e n c e i s not u n c o m m o n . 5 to 1.t e r m c o n s e r v a t i v e therapy most g r a n u l o m a s will resolve in an o r d e r l y fashion by p r o g r e s s i n g from an ulcerative state to a b r o a d .to 2 . W h e n c o n s e r v a t i v e t r e a t m e n t fails. Surgical intervention is r e c o m m e n d e d for i m m a t u r e . LARYNGEAL CYSTS Figure 9-4. t h e r e b y r e q u i r i n g t h e use of o t h e r forms of therapy. T h e s e lesions can be m a n a g e d u s i n g a laser with a 0 ..1 to 0. Loyola University. and a 0 . T h e C 0 laser i s particularly useful for r e m o v a l of p e d u n c u l a t e d . o v e r t h e medial aspect of the vocal p r o c e s s . C a v e r n o u s lesions often present bleeding p r o b l e m s d u r i n g r e m o v a l that a r e not effectively controlled using t h e C 0 2 laser. cigarette s m o k e . soft lesions failing c o n s e r v ative t h e r a p y .D. T h e laser is used to precisely e x c i s e the g r a n u loma w i t h o u t e x p o s i n g u n d e r l y i n g c a r t i l a g e . t h u s p l a c i n g t h e area to be incised under tension. T h i s a l l o w s for less c h a r formation and d e c r e a s e d peripheral thermal tissue d a m a g e . t h e C 0 laser i s ideal for surgical e x c i s i o n . c h r o n i c throat c l e a r i n g . Laser settings for such a p r o c e d u r e include a 0 .s e c o n d pulse d u r a t i o n . 0 .5 s e c o n d .) M u c u s . P o l y p s m a y be fusiform. e r y t h r o p l a s i a . M a r supialization and ablation of the cysts lining m a y be att e m p t e d .The Carbon Dioxide Laser in Laryngeal Surgery 123 2 and the incision site i s then carefully outlined with the C 0 laser. c a r c i n o m a in situ. h e m o r rhagic p o l y p s . p e d u n culated. and pulse durations of 0. Two-week postoperative view demonstrating mild vocal fold edema. but the voice is significantly improved. o r h e m o r r h a g i c c h a r a c t e r i s t i c s . or vocal a b u s e . Chicago. U s i n g microsurgical i n s t r u m e n t a t i o n the lesion is retracted m e d i a l l y . T h i s fluid a c c u m u l a t i o n usually o c c u r s bilaterally and m a y b e diffuse ( R e i n k e ' s e d e m a ) o r localized (vocal fold p o l y p ) .s e c r e t i n g g l a n d s exist in a b u n d a n c e . 2 5 mm spot size with a 4 0 0 . T h e lesion is r e m o v e d at its b a s e with c a r e taken not to induce t h e r m a l d a m a g e d e e p to the superficial l a m i n a propria.W p o w e r . p e d u n c u l a t e d .to 0 . 0 .

Loyola University. squamous cell carcinoma involving the left true vocal fold after biopsy at an outside institute. 1 1 . but w h e n m o r e than 5 0 % o f t h e vocal fold width is resected using t h e laser. t h e cure rates a r e e q u i v a l e n t . This lesion is ideal for laser removal because of its position on the midcord.D.) Figure 9 . erythroplasia.0-second p u l s e duration. c o m b i n e d with o p e r a t o r e x p e r t i s e . After frozen section confirmation of clear margins the final defect included removal of the medial one third of the vocalis muscle. 2 W h e n c o m p a r i n g C 0 laser resection with irradiation for T . without involvement of the anterior commissure or vocal process. vocal fold p o l y p s and g r a n u l o m a s . with a 0. T y p i c a l s e t t i n g s used for laser e x c i sion of T. a n d rapid w o u n d h e a l i n g w h e n c o m p a r e d with o t h e r surgical t e c h n i q u e s . (Photo courtesy of Robert W. c a r c i n o m a s o f t h e glottis.D. Chicago. i n c l u d i n g laryngeal p a p i l l o m a s . 2 using the C O .) Figure 9-6. (Photo courtesy of Robert W. Loyola University. h e m a n g i o m a s and cysts.to 6 . 2 5 . Bastian. and malignant lesions of t h e larynx. Intraoperative view after removal of the lesion.. as well as vocal fold h y p e r k e r a t o s i s . Loyola University. (Photo courtesy of Robert W.m m spot size at 2 2 14 2 2 Figure 9 . M. minimal s c a r r i n g . c a r c i n o m a in situ.124 Lasers in Maxillofacial Surgery and Dentistry a w o r k i n g d i s t a n c e of 4 0 0 m m . p r e m a l i g n a n t . T h e laser m a y be used to treat a n u m b e r of b e n i g n . M. Six-week postoperative view with near complete healing of the left vocal fold. laser ( F i g s ..5to 1. glottic c a r c i n o m a s include a 0 . Bastian. t h e field of m i c r o l a r y n g e a l surgery will c o n t i n u e to e v o l v e at an accelerated p a c e . M.7 . I n s u m m a r y .D. 9 . M. 4. (Photo courtesy of Robert W. Six-month postoperative view with a mucosalized scar band extending across the original excision site.) F i g u r e 9 . Chicago.8 . With the developm e n t of m o r e sophisticated instrumentation. lesions i n v o l v i n g t h e m i d c o r d . w i t h out i n v o l v e m e n t o f t h e a n t e r i o r c o m m i s s u r e o r vocal process o f the arytenoid. Loyola University. S u g g e s t e d criteria for C 0 laser r e m o v a l o f a glottic c a r c i n o m a include T .W power.5 t o 9 . Chicago. C 0 laser excision i s a n e x c e l l e n t alternative to irradiation b e c a u s e it a l l o w s for a s i m u l t a n e o u s staging excisional biopsy and definitive t h e r a p y .to 3-mm margin. Preoperative view of a 57 -year-old patient with a T. voice quality d e t e r i o r a t e s .) . Chicago. c a r c i n o m a s treated with C 0 laser resection e q u a l s that for similarly staged patients treated with radiation t h e r a p y .5 . Bastian.1 3 V o i c e quality in select patients with T .9 ) . t h e C 0 laser c o m b i n e s surgical microprecision with h e m o s t a s i s of capillary size blood vessels.. T h e s e qualities result in less postoperative tissue e d e m a . and i n v a s i v e s q u a m o u s cell c a r c i n o m a . The laser was used to outline the carcinoma with a 2..D. Bastian. all in an outpatient setting.

9 . REFERENCES 1. focus of residual disease j u s t anterior to the process. c o n t a i n i n g a 4 0 0 . Bastian. Parameters A 0 . CASE PRESENTATIONS T h e following c a s e p r e s e n t a t i o n s h a v e been selected b e cause they represent lesions that a r e ideally suited for C 0 laser e x c i s i o n .p r o v e n s q u a m o u s cell c a r c i n o m a of the left true vocal fold i n v o l v i n g t h e m i d c o r d region (Fig. Parameters A 0 . T h e left vocal fold m o v e s freely and the anterior c o m m i s s u r e .y e a r .m m lens. T h e a r y t e n o i d and anterior c o m m i s s u r e r e g i o n s are free of d i s e a s e . M. .to 1.8 ) .5 ) . COMMENTS T h e lesion is carefully outlined (Fig. from L o y o l a University.6 ) .The Carbon Dioxide Laser in Laryngeal Surgery HEALING SEQUENCE T w o w e e k s p o s t o p e r a t i v e l y ( F i g .4 ) this mild true vocal fold e d e m a . A 4 0 0 . 9 . Bastian.23(l):49-66. and subglottic regions are free of d i s e a s e . . The carbon dioxide laser in laryngeal surgery.y e a r . C h i c a g o .o l d m a n with a significant history of s m o k i n g and ethanol use w h o presented with a 3-month history o f p r o g r e s s i v e h o a r s e n e s s and a n e p i s o d e o f h e m o p t y sis ( F i g s . 2.m m spot size. every 2 m o n t h s for t h e next year. EXAMINATION FINDINGS P a p i l l o m a s involving the true vocal folds bilaterally with involvement of t h e a n t e r i o r false vocal fold on the right (Fig.) EXAMINATION FINDINGS T h i s is a b i o p s y . vocal p r o c e s s . 2 . ACKNOWLEDGMENT T h e a u t h o r w o u l d like t o t h a n k R o b e r t W . M . Loyola University. Jakobowitz M.8 ) .D. 2 Laryngeal Papilloma HISTORY This 2 7 .W a v e r a g e p o w e r . 0.9 . and frozen section c o n f i r m a t i o n of free m a r g i n s is obtained ( F i g ..9 ) with the laser.5 t o 9 . 9 . Figure 9 . Bastian RW. C l o s e postoperative follow-up is i m p o r t a n t as the natural history of this d i s e a s e is o n e of m u l t i p l e recurrences. 125 patient h a s significantly N o t e small right vocal T. 2 5 .3 ) .o l d patient w i t h o u t a s m o k i n g history presented with 4 m o n t h s of p r o g r e s s i v e h o a r s e n e s s ( F i g s . for u s e of the c a s e illustrations. D . both subjectively and objectively. but t h e voice is i m p r o v e d .0-second pulse d u r a t i o n in a 1 0 % duty c y c l e ( s u perpulse m o d e ) . (Photo courtesy of Robert W. 9 . ventricle. HEALING SEQUENCE After resection of a midcord c a r c i n o m a a mucosalized scar band forms across the area of excision (Figs.5. 9 . Reynolds BN. Example of how the laser is utilized to outline a small glottic carcinoma prior to removal. Ear Nose Throat J 1988. 9 . 9 . TREATMENT Laser Type C a r b o n d i o x i d e laser with m i c r o m a n i p u l a t o r coupled to an o p e r a t i n g m i c r o s c o p e at 10X m a g n i f i c a t i o n .5second pulse duration in a 10% duty cycle (superpulse mode). Crockett DM. T h e c a s e s presented include laryngeal p a p i l loma and T | glottic c a r c i n o m a . Freche C. Laryngeal laser surgery. 0. Otolaryngol Clin North Am 1990. a small cuff of n o r m a l tissue is taken with t h e t u m o r . COMMENTS L a r y n g e a l p a p i l l o m a s g r o w superficially and s h o u l d b e ablated at the m u c o s a or s u b m u c o s a level without penetration into t h e vocal l i g a m e n t or vocalis m u s c l e .W average power. TREATMENT Laser Type C a r b o n d i o x i d e laser with m i c r o m a n i p u l a t o r c o u p l e d to an o p e r a t i n g m i c r o s c o p e at 10X magnification. Glottic Carcinoma HISTORY T h i s is a 5 7 . 2 5 .7 and 9 . Patients with glottic c a r c i n o m a should be seen o n c e a m o n t h for t h e first p o s t o p e r a t i v e year.3 and 9-4). 4 .m m spot size.m m lens on the m i c r o s c o p e p r o v i d e s e n o u g h w o r k ing d i s t a n c e for m i c r o l a r y n g e a l i n s t r u m e n t a t i o n . 9 . Chicago. and regularly thereafter for a total of 5 years so that recurrent d i s e a s e can be detected early and further t h e r a p y instituted p r o m p t l y .67:436-445.

and treatment o f small c a r i o u s c e r v i c a l lesions in teeth. Fried et al. 9 4 pm for c u t t i n g hard dental tissues. T h e y s h o w e d that this laser c o u l d effectively cut teeth to m a k e cavity p r e p a r a t i o n s for s i m p l e d e n tal restorations. They evaluated t h e p o s s i b l e u s e of t h e r u b y laser to fuse t h e caries susceptible o c c l u s a l pits on t h e c h e w i n g surface of teeth. T h e o p tically m a t c h e d solution g i v e s m o r e accurate values of the true optical p r o p e r t i e s of these tissues w h e n it is used. m a r k e t i n g efforts o u t s t r i p p e d research activity and the training m a n u a l s of s o m e of the n e o d y m i u m : y t t r i u m . T h e i r thermal studies s h o w e d little or no effect on teeth i n c l u d i n g dental p u l p w h e n this laser w a s used. a l l o w e d uniformity b e t w e e n the light and the s a m p l e . S o o n afterward Stern and S o g n n a e s ' 2 b e c a m e t h e f i r s t t o s t u d y potential dental hard tissue a p p l i c a t i o n s and reported their results in 1964. T h e s a m p l e w a s then s u b j e c t e d to s p e c t r o s c o p i c analysis. thereby r e d u c i n g the transmitted light d e t e c t e d i n t h e integrating s p h e r e . Unfortunately. r e m o v a l of s u b g i n g i v a l c a l c u l u s . i t w a s the d e v e l o p m e n t of the C 0 laser that s t i m u l a t e d an i n c r e a s e in activity investigating the tissue-altering effects of lasers on e n a m e l and dentin. Regrettably these r e c o m m e n d a t i o n s a r e largely unwarranted b e c a u s e thermal d a m a g e t o t h e treated tissues continues to be p r o b l e m a t i c . Clinical effects a r e p r e d o m i n a n t l y t h e result of the a b sorption of t h e laser light in t h e tissues being treated. which h a s t h e s a m e optical p r o p e r t i e s as t h e s a m p l e s . At these w a v e l e n g t h s their results s h o w e d that light in the visible ( 5 4 3 . e x a m i n e d t h e effects of the ruby laser on the dental p u l p and found that t h e r m a l d a m a g e w a s significant. 9 1 0 As with any light s o u r c e irrespective of w a v e l e n g t h the material that is b e i n g irradiated m a y either a b s o r b . p l a c e d t h e e n a m e l s a m p l e . 3 6 7 2 Recent y e a r s h a v e seen t h e d e v e l o p m e n t o f lasers w h o s e manufacturers h a v e s u g g e s t e d their u s e t o c u t hard d e n tal tissues. Integrating s p h e r e s a r e totally e n c l o s e d d e t e c t o r s that receive and c o n tain t h e light from t h e s a m p l e for e v a l u a t i o n . 8 LASER HARD DENTAL TISSUE ABLATION RESEARCH During t h e last few y e a r s research performed by Hibst and Keller has shed s o m e light o n t h e u s e o f a n e r b i u m ( E r ) : Y A G laser with a w a v e l e n g t h of 2 . U s i n g an integrating s p h e r e of a s p e c t r o p h o t o m e t e r the light from t h e s a m p l e w a s collected and a d e t e r m i n a t i o n w a s m a d e that quantified the a m o u n t of light a b s o r b e d by the s a m p l e .g a r n e t ( N d : Y A G ) laser manufacturers s u g g e s t e d u s e s i n c l u d i n g r e m o v a l o f s m a l l carious lesions of e n a m e l . a p i c o e c t o m y . T h e optically m a t c h e d solution. 1 2 W h e n d e n t i n s a m p l e s i n a n optically m a t c h e d solution 127 . T h e internal surface of t h e s p h e r e s are highly reflective.10 Uses of Lasers in Dentistry Harvey Wigdor T h e c o n c e p t of using lasers in dentistry is as old as t h e first laser d e v e l o p e d by M a i m a n in I 9 6 0 .a l u m i n u m . T h e s e coefficients a r e t h e quantifiable a m o u n t s of absorption and scatter in e n a m e l and d e n t i n . P r o g r e s s w a s slow in d e v e l o p i n g laser a p p l i c a t i o n s in cutting dental hard tissues b e c a u s e of the thermal d a m a g e caused by t h e laser w a v e l e n g t h s a v a i l a b l e at the t i m e . 6 3 2 and 1053 nm. as well as d e n t i n . After u n d e r s t a n d i n g t h e effects lasers m a y h a v e o n any material i n c l u d i n g dental hard tissues an u n d e r s t a n d i n g of the optical p r o p e r t i e s of dental hard tissues is in order. T h e p o w e r of t h e l a s e r used and t h e t i m e that t h e e n e r g y is in c o n t a c t with t h e tissue being treated a r e very important p a r a m e t e r s that d e t e r m i n e the o b s e r v e d clinical effect. a l l o w i n g the light to r e m a i n in the s p h e r e until hitting the detector. All of these p u b l i s h e d s u g g e s t e d a p p l i c a t i o n s were a d v o c a t e d p r i o r to t h e Food and D r u g A d m i n i s t r a tion's ( F D A ) c l e a r a n c e of hard tissue a p p l i c a t i o n s in d e n tistry. Fried e t a l . T h i s w o u l d c a u s e the s a m p l e t o reflect s o m e of t h e incident light. " ' d e t e r m i n e d t h e absorption and scattering coefficients. Visible light is scattered s o m e w h a t but the near infrared is strongly transmitted straight t h r o u g h t h e s e tissues and only w e a k l y scattered. 6 3 2 n m ) and the n e a r infrared ( 1 0 5 3 n m ) a r e only negligibly a b s o r b e d by e n a m e l and dentin. scatter. If it had not been used.s a m p l e interface that t h e light w o u l d p a s s through would act as t w o different optical materials. t h e a i r . H o w e v e r . or reflect the light e n e r g y . " A d r i a n et a l . T h e d e s i r e d clinical effects in s u r g e r y a r e mostly c o n t r o l l e d b y the absorption and s o m e w h a t by t h e scatter of t h e light in the tissue. Although investigational activity w a s s p a r s e t h e r e w e r e s o m e published research p a p e r s that e v a l u a t e d t h e effect of lasers on hard dental t i s s u e s . T h e y also investigated the u s e of t h e s e lasers to alter the smooth surfaces of teeth to r e d u c e their susceptibility to decay. S o m e of the u n a b s o r b e d light can also scatter c a u s i n g a m o r e diffuse effect in t h e tissue. T h e s u m m a t i o n of the light-tissue interaction will d e t e r m i n e the effect of the laser (see C h a p t e r 1). i n a n optically m a t c h e d solution. u s i n g w a v e l e n g t h s of 5 4 3 . transmit.

thereby r e d u c i n g both t h e depth of penetration ( a b l a t i o n ) and thermal injury. t h e high a m o u n t of e n e r g y n e c e s s a r y at these w a v e l e n g t h s to c a u s e clinical effects can also c a u s e very d a m a g i n g thermal side effects.5 W with an e n e r g y of 5 0 0 mJ per pulse at 3 Hz. T h e recent interest in the suitability of the E r : Y A G l a s e r ' s effects on hard dental tissues is based upon t h e characteristic of its 2 . H o w e v e r . T h i s requires c l o s e m a t c h i n g o f the w a v e length of t h e incident b e a m to the target c h r o m o p h o r e .m) c a u s e s significant h e a t i n g in hard tissue ( d e n t i n . N o t e the loose c o n n e c t i v e tissue in the pulp and the n o r m a l a p p e a r a n c e of the o d o n t o b l a s t s lining the dentin. T h e output p o w e r of the laser w a s 1. if l o w e r e n e r g y levels a r e used. W i g d o r et a l . T h e laser heats the w a t e r c a u s i n g it to b e c o m e s t e a m . After 4 d a y s the teeth w e r e extracted and decalcified. laser light from the n o n c o n t a c t N d : Y A G laser (1.06 u. It is very highly a b s o r b e d by w a t e r and m o d e r a t e l y well a b s o r b e d by h y d r o x y a p a t i t e . It w a s found that e v e n t h o u g h the a b s o r p t i o n coefficient w a s low. being a b s o r b e d as it passes into d e e p e r r e g i o n s of t h e d e n t i n . Sim u l t a n e o u s l y . Figure 1 0 . Clinically this is significant. F r o m Fried et a l . A m a l g a m restorations were then placed in the ablation h o l e s .1 . In addition the velocity of the ejection p l u m e for e n a m e l is less than that for dentin. B e c a u s e this is a very rapid action. the u n d e r l y i n g tissues b e n e a t h the area of treatment m a y be a d v e r s e l y affected by the laser.1 6 ) . U n f o r t u n a t e l y . This heating c a u s e s a c o n s i d e r a b l e e n e r g y loss. 1 4 evaluated the effect of the E r : Y A G laser on d o g teeth in v i v o a n d in vitro (extracted teeth). w h i c h requires a longer t i m e of e x p o s u r e on the tissue. T h e i r results substantiate the theory of the E r : Y A G laser m e c h a n i s m o b s e r v e d on dental hard tissues. T h e laser defect can be seen as a depression in the dentin. T h e inverse effect o c c u r s if the laser w a v e length is not well a b s o r b e d . T h i s l o n g e r e x p o s u r e w o u l d c a u s e a d e e p e r z o n e o f d a m a g e and m o r e thermal effect. ' s 1 1 ' 1 2 r e s e a r c h . O n e theory s u g gests that w h e n the laser interacts with t h e hard tissue it is a b s o r b e d by the water and h y d r o x y a p a t i t e . 1 0 . which prevents the e x p e c t e d linear increase in crater d e p t h with time of exp o s u r e . 9 4 . It s e e m s that al the present m o m e n t the optimal laser for oral hard tissue ablation is o n e that h a s high a b s o r p t i o n within t h e v o l u m e of tissue b e i n g treated. for if a laser w e r e used that h a s the potential for d e e p e r penetration. Recent studies included histologic and scanning electron m i c r o s c o p i c ( S E M ) evaluation of the effect of E n Y A G lasers on teeth. Note that the pulp- w e r e studied using t h e s a m e w a v e l e n g t h s as in the e n a m e l there w a s s o m e variability in t h e scattering coefficient based on tubule d e n s i t y and orientation.1 and in e n a m e l to be 1000 cm-1 . w h i l e t h e c o n t a c t N d : Y A G h a s less heat effect. T h e precise m e c h a n i s m o f the ablation o f hard tissues with t h e E r : Y A G laser r e m a i n s unclear. e n a m e l . . which h a s very little heat tolerance. if e n o u g h e n e r g y is d e p o s i t e d on the tissue o v e r the visible a n d n e a r infrared s p e c t r a it is a b s o r b e d by dentin. T h e effect of this laser is s o m e w h a t different in e n a m e l c o m p a r e d with dentin. Er:YAG laser holes on dog canine teeth. B e c a u s e of the high a b s o r p t i o n c h a r a c t e r i s t i c of ihis laser in both dentin and e n a m e l . thereby a v o i d i n g d a m a g e to t h e dental p u l p .1 28 Lasers in Maxillofacial Surgery and Dentistry sue. It must be the goal of any laser that is to be used in dentistry to p r o d u c e minimal heat as it cuts t h r o u g h the hard dental tissues. most of the light is transmitted a n d / o r scattered. Figure 1 0 . Further work by Hibst and K e l l e r " using ultrashort flash photography to e v a l u a t e the p l u m e arising from the ablation of denial hard i issues w a s p u b l i s h e d in 1993. it is e x p l o s i v e in n a t u r e . and b o n e ) .3 is a p h o t o m i c r o g r a p h of a tooth that had been irradiated by the E n Y A G laser. As t h e s t e a m e x p a n d s it also forces the cracked material a w a y from the ablation zone. After decalcification t h e teeth w e r e sectioned and stained with h e m a t o x a l i n and eosin. T h e y further suggest that the g l o w observed in front of the tissue surface is c a u s e d by the particles being heated after ejection from the tissue (see Fig. T h e y calculated the absorption of the Er: Y A G laser in dentin to be in the order of 2 0 0 0 c m . As d i s c u s s e d by Hibst and Keller 9 the E r : Y A G laser energy is a b s o r b e d about twice as intensely in dentin as in enamel.n m w a v e l e n g t h . Both of t h e s e characteristics are essential w h e n c o n s i d e r i n g that tissues b e i n g treated by d e n t i s t s are usually thin a n d very susceptible to thermal d a m a g e . T h i s e x p a n s i o n during t h e c h a n g e of state of w a t e r c a u s e s c r a c k i n g of the tis- Figure 1 0 . T h e y suggest that the relative ratio of water to hydroxyapatite is t h e r e a s o n for this difference.2 is a p h o t o m i c r o g r a p h of an untreated c o n t r o l tooth. E n Y A G h o l e s w e r e m a d e in the teeth. F i g u r e 10-1 is a p h o t o g r a p h of the holes created by the laser in the c a n i n e teeth. T h e differential ratio of the w a t e r and h y d r o x y a p a t i t e content in these t w o tissues a p p e a r s to be the reason for this difference. it can ablate these hard (issues efficiently with very little heat production. a major c o n s t i t u e n t of both d e n t i n and e n a m e l . the energy d e n s i t y must be a d e q u a t e to ind u c e t h e desired tissue effect d u r i n g an a p p l i c a t i o n t i m e short e n o u g h to p r e c l u d e lateral thermal c o n d u c t i o n (see C h a p t e r 3 ) . T h e m o s t efficient ablation with the lowest thermal effect o c c u r s w h e n the laser e n e r g y is highly a b s o r b e d in a small v o l u m e o f tissue. For hard tissue ablation a laser that is h i g h l y a b s o r b e d by one or m o r e of the c o m p o n e n t s in t h e hard tissue w o u l d be most a d v a n t a g e o u s .

N o t e that there a p p e a r s to be an i n c r e a s e in the d e n t i n adjacent to t h e defect. (X 100 H&E.) . A representative selection s h o w i n g a typical z o n e of E n Y A G irradiation can be seen in F i g u r e 1 0 . (X100 H&E Figure 1 0 . On a h i g h .8 .i n d u c e d defect.3 . T h e c a u s e o f this increased layer of dentin is not k n o w n . T h e s e inclusions can also be seen in the d e n t i n a l tubules j u s t a b o v e t h e predentin layer. T h e death o f o n e d o g from a n e s t h e t i c c o m p l i c a t i o n s j u s t after the teeth w e r e irradiated permitted the a s s e s s m e n t of the a c u t e effects of this laser on teeth. F i g u r e 1 0 . A n o t h e r tooth treated with the E r : Y A G laser s h o w e d a t h i c k e n i n g of t h e dentin b e n e a t h t h e laser defect. Higher power view of the predentin layer just beneath the laser hole. Note the increased dentin in the area beneath the laser hole. 1 0 .) Figure 10-5. H i g h e r magnification failed to d e m o n s t r a t e any harmful effects of the E r : Y A G laser on the pulpal tissue.7 i s a n S E M p h o t o m i c r o g r a p h o f the surface of d e n t i n that w a s cut with a high-speed dental h a n d p i e c e : n o t e t h e patent dentinal t u b u l e s .) Figure 10-2. (X100 H&E.p o w e r view ( F i g . It is e v i d e n t that the dentinal t u b u l e s h a v e retained their patency after t h e E n Y A G laser irradiation. F i g u r e 1 0 . T h e similarity o f t h e S E M ' s p h o t o m i c r o g r a p h s Figure 1 0 .4 s h o w s a p h o t o m i c r o g r a p h of the p u l p j u s t beneath t h e E r : Y A G l a s e r . F i g u r e 1 0 .6 is a view distant from the laser ablation in the s a m e tooth s h o w i n g n o r m a l predentin and dentin w h e r e n o i n c l u s i o n s are present. After j u s t 4 d a y s this c h a n g e w o u l d not b e e x p e c t e d . ( X 4 0 0 H&E. Note the dark inclusions in the predentin. Pulpal histology beneath an Er:YAG laser hole (right). T h e e x a c t c a u s e o f 129 these c h a n g e s is u n k n o w n but o n e consideration is that the p r e s s u r e from the E n Y A G ablation e x p l o s i o n m a y b e traveling d o w n the d e n t i n a l t u b u l e s c a u s i n g these c h a n g e s .) Normal pulpal and dentin histology. T h e lack of increased vascularity or of inflammatory cells and the a b s e n c e o f disruption o f t h e o d o n t o blastic layer s u g g e s t s no h a r m to t h e p u l p in this tooth.4 . Photomicrograph of the dentin just beneath the E r Y A G laser hole.Uses of Lasers in Dentistry al tissue a p p e a r s n o r m a l . T h e teeth w e r e rem o v e d just after t h e d o g died and decalcified a n d stained.5 ) t h e predentin layer j u s t beneath the laser defect s h o w s d a r k i n c l u s i o n s that are probably cellular c o m p o n e n t s o f o d o n t o b l a s t s . stain. Extracted h u m a n teeth s t o r e d i n 5 % s o d i u m h y p o c h l o r a t e solution w e r e also irradiated b y t h e E r Y A G laser using the s a m e p a r a m e t e r s a s a b o v e i n t h e d o g study and evaluated with S E M .

II) and the a u t h o r have repeated s o m e of the projects p e r f o r m e d by Hibst and Keller with w a t e r a d d e d as a coolant. T h e first series of studies w a s d e s i g n e d to e v a l u a t e t h e ablation efficiency o f t h e E n Y A G laser. A t l o w e r e n e r g y ( 1 8 7 m J / p u l s e ) 2 2 p m o f material w a s r e m o v e d .1 2 is an i m p r e s s i o n of the ablation holes and F i g u r e 1 0 .s with an 800-p. there w a s c o n c e r n a b o u t h o w t h e w a t e r might affect ablation efficiency. T h e e n e r g y p e r pulse w a s varied and a pulse width of 2 5 0 u. B e c a u s e w a t e r a b s o r b s the 2 9 4 0 .1 3 is t h e projected i m a g e of t h e impressions o f t h e s e holes.9 is a cross section o f dentin treated with the E n Y A G laser. SEM photomicrograph of dentin ablated with an EnYAG laser (X 1200 longitudinal section). w a t e r w a s used as a c o o l a n t . Extracted m o l a r teeth w e r e used and t h e buccal surfaces w e r e irradiated with the b e a m p e r p e n d i c u l a r to the surface. T h e next study e v a l u a t e d the ablation effic i e n c y and t e m p e r a t u r e c h a n g e s o f the E n Y A G laser o n d e n t a l h a r d tissues. of the dental h a n d p i e c e and laser-treated dentin m a y suggest that t h e laser affects dentin in a w a y similar to c o n v e n tional high-speed turbine tissue r e m o v a l . A p h o t o m i c r o g r a p h of the S E M (Fig. T o a c c o m p l i s h this holes w e r e c r e a t e d with t h e E n Y A G laser and then dental i m p r e s s i o n s w e r e taken o f these holes.1 1 ) of similar holes s h o w s well-defined holes in the e n a m e l . the patent d e n t i n a l t u b u l e s a r e o b v i o u s . 1 0 . A t h e r m o c o u p l e w a s placed on the side o p p o s i t e the .) Figure 10-9. Ashrafi. T o prevent this i n c r e a s e in t e m p e r a t u r e . F i g u r e 1 0 . T h e results s h o w e d that t h e a m o u n t o f material r e m o v a l is directly proportional to the e n e r g y deposited on the tooth. S e c t i o n s of extracted h u m a n teeth were c u t into k n o w n t h i c k n e s s e s and ablated with the E n Y A G laser.1 4 ) at high energy ( 6 2 6 m J / p u l s e ) 115 u.1 0 is a p h o t o g r a p h of t h e ablation holes created in t h e enamel of the buccal surface of an extracted m o l a r tooth.m spot size w a s used. SEM photomicrograph of dentin cut with a highspeed dental drill (X1000 longitudinal section).n m w a v e l e n g t h very efficiently. T h e silhouettes o f these i m p r e s s i o n s w e r e then projected on a grid for quantifi- c a t i o n . from N o r t h w e s t e r n University (Evanston. Higher power view of the predentin layer in an area not affected by the laser. Figure 10-7. As noted in t h e g r a p h (Fig. O u r studies s h o w e d that a t t h e p o w e r n e c e s s a r y for effective ablation of teeth and dental m a t e r i a l s ( 1 5 0 .6 5 0 m J / p u l s e ) s o m e heat i s p r o d u c e d b y the E n Y A G laser.) Figure 10-8.m of material w a s r e m o v e d per p u l s e . T h e lack of c h a r is evident.130 Lasers in Maxillofacial Surgery and Dentistry Figure 10-6. (X400 H&E. R e s e a r c h p e r f o r m e d by Visuri et al. Figure 1 0 . S. F i g u r e 1 0 . 1 0 . SEM photomicrograph of dentin ablated with an EnYAG laser (X500 cross section). A g a i n . (All SEM photographs are courtesy of Dr.

A stream of w a t e r w a s directed to t h e area of the laser b e a m and t h e How rate of w a t e r v o l u m e w a s controlled. Dental a m a l g a m is a mixture of a n u m b e r of m e t a l s . Table of ablation efficiency from the impression method in Figure 10-13. z i n c . Ablation holes from an extracted tooth. lack of char. In o u r s t u d i e s the effect of t h e E r : Y A G laser on dental a m a l g a m and c o m p o s i t e m a t e r i a l s w a s also studied. Note the Figure 10-13. . Figure 10-14. Figure 10-12. and tin. including silver. Dental impression from a tooth after Er:YAG ablation surface.1 7 is a p h o t o g r a p h of the holes that w e r e created by the laser in t h e c r o s s . D u r i n g the ablation process the t e m p e r a t u r e of the tooth w a s d e t e r m i n e d without w a t e r flow and then with w a t e r directed at the spot of the ablation.Uses of Lasers in Dentistry 131 Figure 10-10. ablation holes.1 1 . Figure 1 0 .s e c t i o n a l slice of d e n t i n . 10-12. SEM photomicrograph of Er:YAG laser holes in the buccal surface of an extracted tooth. c o p p e r .1 5 is a p h o t o g r a p h of the setup design of the e x p e r i m e n t . that a r e mixed with m e r c u r y to form a material that hardens a short t i m e after m i x i n g . Figure 1 0 . Projected image of the impression from Figure MEAN DEPTH PER PULSE pm/ pulse Figure 1 0 .1 6 is a p h o t o g r a p h of the ablation p l u m e during the ablation of dentin with t h e laser b e a m c o m i n g from t h e left and Figure 1 0 .

Ablation holes created in amalgam sections with the E n Y A G laser. Figure 1 0 . The .2 0 is a graph of the t e m p e r a t u r e c h a n g e s that o c c u r r e d as the ablation p r o g r e s s e d t h r o u g h the s a m p l e . T h e hole on the right was cut without water. For this study c o r e s of these m a t e r i a l s w e r e a b l a t e d by an E n Y A G laser. Studies a r e n o w u n d e r w a y t o a n a l y z e the p l u m e b y . Figure 10-16. It has a well-defined b o r d e r and no char is evident. Figure 1 0 . Therefore. and c o m p o s i t e ) w e r e very similar. laser. e n a m e l . T h e a m a l g a m ablation p l u m e w a s rather large and similar in size with and without water. As the ablation progressed the hole b e c a m e d e e p e r and closer to the thermoc o u p l e . T h e ablation efficiency o f the laser w a s d e termined with and without water. C o m p o s i t e s are tooth-colored dental materials that are used as restorative materials for dental restorations w h e n aesthetics are a c o n c e r n . T h e rate of this rise is a l m o s t the s a m e for the t w o e n e r g y levels. amalg a m . Laboratory setup for the study of dentin ablation. Figure 1 0 . T h e m e t h o d used w a s similar to that for the dentin ablation study s h o w n in Figure 1 0 .1 8 is a p h o t o g r a p h of the ablation holes created by the E n Y A G laser. the composite ablation results are presented here as a s u m m a r y of the laser effects on the materials tested. T h e y are a blend of acrylic and q u a r t z particles that are placed in cavity preparations in teeth to restore defects c a u s e d by dental d e c a y . It is a p p a r e n t that t h e w a t e r m a d e a d r a m a t i c difference w h e n it w a s used in the c o m p o s i t e ablation studies T h e results of the ablation efficiency and the thermal effects on t h e different materials tested (dentin. A n y laser that will be used to cut dental hard tissues must also r e m o v e the existing materials in teeth being p r e p a r e d for r e s t o r a t i o n s . Ablation holes created in dentin sections from extracted teeth with the E n Y A G laser.p r o d ucts and to e v a l u a t e their possible toxic effect to patient and treatment team m e m b e r s . T w o e n e r g y levels w e r e used with and without water.1 5 . Figure 1(1-17. T h e results s h o w that as the ablation hole deepens the t e m p e r a t u r e rises w h e n w a t e r is not used.1 9 is a p h o t o g r a p h of the ablation holes created in dental c o m p o s i t e restorative material with and without w a t e r c o o l a n t . N o t e the char that was caused by the laser.1 32 Lasers in Maxillofacial Surgery and Dentistry Figure 10-15. Of great interest for study a r e the p r o d u c t s c r e a t e d w h e n a m a l g a m is a b l a t e d . T h e three holes w e r e created at different p o w e r s and t h e effect w a s not influenced by the water coolant. T h e hole on the left w a s created with the laser using water as a c o o l a n t . Plume from dentin ablation with the E n Y A G Figure 10-18.

and 9 .p o w e r e d C 0 2 laser preferably tuned t o the highly a b s o r b e d 9 .to 1 0 . after r e a c h i n g a fluence of 60 J / c m 2 there is a c o n v e r g e n c e of the water How lines on the g r a p h and they a p p e a r to be s u p e r i m p o s e d o v e r each 1 9 T h e effects of the infrared laser (9. 6 . h a v e a m o d e r a t e to high a b s o r p tion in this area of the s p e c t r u m . W h e n w a t e r w a s used during ablation the t e m p e r a t u r e did not rise by m o r e that 3°C.p o w e r laser h a s an effect on the c a r b o n a t e ion in e n a m e l by dramatically r e d u c i n g its c o n t e n t in the h y d r o x y a p a t i t e crystal in e n a m e l .p m region. it s e e m s that this area of the s p e c t r u m m a y have a role to play in hard tissue ablation.Uses of Lasers in Dentistry 133 Figure 10-19. Figure 1 0 .0 to 11 p m ) on dental hard tissues and on denial c a r i e s susceptibility has been investigated. 3 .6(H) nm. T h e ultimate q u e s t i o n is w h e t h e r a laser can be d e v e l o p e d that can ablate at a s p e e d similar to the highs p e e d air t u r b i n e dental h a n d p i e c e (drill) that is used by d e n t i s t s t o d a y . C o m b i n e d with t h e high water a b sorption of h y d r o x y a p a t i l e in the 9 . which a r e close t o the main C O . T h e y s u g g e s t that the l o w . Ablution holes created in composite sections with the Er:YAG laser. a n d w h e t h e r a laser will be better tolerated by patients. As can be seen in the g r a p h . With water (L). 6 . it s e e m s that there is a potential for these laser w a v e l e n g t h s lo cut hard tissues efficiently.p m w a v e l e n g t h s o n extracted teeth leading to a reduction in the acid d e m o r a l i z a t i o n in s e c t i o n s of e n a m e l . Graph of the ablation rate as the fluence and water are varied. Graph of the temperature changes as the ablation progressed through the sample with and without water. other. w a t e r and h y d r o x y a p a t i t e . 2 0 . Figure 10-21 is a graph of the ablation rate as the e n e r g y (fluence) and w a t e r flow w e r e varied.2 3 T w o c o m p o n e n t s o f dental hard tissues. W o r k by Z a c h and C o h e n h a s s h o w n that if t h e t e m p e r a t u r e of the tooth rises more than 5°C the p u l p m a y b e h a r m e d .2 1 . m a x i m u m t e m p e r a t u r e of a b o u t I 7 ° C o c c u r r e d j u s t as the laser penetrates t h r o u g h the s a m p l e . DENTAL CARIES SUSCEPTIBILITY Figure 10-20. T h e a m o u n t of ablation w a s r e c o r d e d as the increase in depth of the hole per pulse. s u g g e s t i n g that water has very little effect at the h i g h e r fluences. F r o m a patient s u r v e y . 7 0 % would like a laser to be d e v e l o p e d that could replace the dental drill. B e c a u s e o n e of the major c o m p o n e n t s of dental hard tissues is h y d r o x y a p a t i t e . in this a u t h o r ' s practice. F e a t h e r s t o n e and N e l s o n 2 4 and othe r s u s e a l o w . e m i s s i o n of 10. 3 . without water (R). T h e graph s h o w s that at h i g h e r flow rates m o r e e n e r g y w a s n e c essary for equal a b l a t i o n . H o w e v e r . B e c a u s e of the moderate to high absorption in these s u b s t a n c e s infrared lasers h a v e been s h o w n to c a u s e less t h e r m a l d a m a g e to hard tissues. For h y d r o x y a p a t i t e there a r e strong spectral absorption p e a k s a t 9 3 0 0 and 9 6 0 0 n m . t h e r e b y m a k i n g this crystal less susceptible to d e m i n e r a l i z a - . w a t e r slightly r e d u c e s the c o m p o s i t e ablation efficiency at l o w e r fluences.

reported c o n s i d e r a b l e difference in the physical properties as the t i m e b e t w e e n c u r i n g and testing increased. T h i s characteristic may play a role in d i a g n o s i n g caries before the lesions are d e t e c t a b l e clinically. Impact of the laser on dental caries. Nature 1964:203:417. Laser beam effect on dental hard tissues. whereas in s o l d e r i n g i m p u r i t i e s (flux) and dissimilar metals are soldered. J Dent Rei 1968:47:311-317. d e v e l o p e d by N o b e l p h a r m a Industries. thereby a v o i d i n g the differential shrinkage that n o r m a l l y o c c u r s w h e n w e l d i n g is performed sequentially instead of s i m u l t a n e o u s l y . T h e F D A has cleared t h e use of the argon laser as a light source for the p h o t o p o l y m e r i z a t i o n of dental c o m p o s i t e materials. Lasers h a v e the potential for d e t e r m i n i n g the vitality of a tooth based on the c h a n g e s o b s e r v e d from laser irradiation on the buccal surface of a vital versus a nonvital tooth that can be detected by a laser. T h e y found that w h e n a laser is used to irradiate the e n a m e l of teeth c a r i o u s lesions will fluoresce. 3. As the metal c o o l s the t w o pieces of titanium j o i n together. B l a n k e n a u et a l . T h i s welding technique may be a p p l i e d even to a c o m p l e t e arch bridge. but the authors suggest it m a y be d u e lo the bacteria present in the lesion. Bhussry BR. In a n o t h e r related study on hard-tissue laser effects A l t s c h u l e r et a l . the welding must occur u n d e r an a t m o s p h e r e of argon gas. tion by bacterial acids. N e w t e c h n o l o g y h a s been d e v e l o p e d b y N o b e l p h a r m a Industries ( N o b e l p h a r m a A B . Preliminary investigational work s u g g e s t s exciting areas of investigation for lasers in dentistry. T h i s directed and possibly c o n c e n t r a t e d laser e n e r g y m a y c a u s e d a m a g e to the pulpal tissue instead of to the hard tissues at which the e n e r g y is being directed. Using the m e t h o d d e v e l o p e d by N o b e l p h a r m a . W i t h the lens system and m i r r o r focal point used in this proprietary s y s t e m a weld 6 0 0 to 8 0 0 pm d e e p is generated at t h e j o i n t . Stem RH. T h e e n e r g y p r o v i d e d from the laser melts each piece of titanium on either side of the j o i n t . Interaction of carbon dioxide laser radiation with enamel and denlin. the dentinal tubules may act as g u i d e s directing the laser e n e r g y to the p u l p of the tooth being treated. S w e d e n ) for the welding of dental implant supported bridges with a N d : Y A G laser. Laser effect on in vitro enamel permeabilily and solubility. investigated t h e physical properties of the c o m p o s i t e materials c u r e d with t h e a r g o n laser and found them to be e n h a n c e d o v e r c o n v e n t i o n a l m e t h o d s . 4. twin N d : Y A G laser b e a m s weld the c o m p o n e n t s on either side of the joint at the s a m e t i m e . 3 0 REFERENCES 1.78:838-843. 2 7 2 h LASER DENTAL MATERIALS PROCESSING A n o t h e r clinical application of lasers is in c u r i n g dental c o m p o s i t e restorative materials. s h o w e d that c o m p o s i t e materials e x p o s e d lo argon laser light ( 4 8 8 nm) required shorter c u r i n g t i m e s than for c o n ventional w h i t e light s o u r c e s . It is not u n d e r s t o o d w h y this o c c u r s . h o w e v e r . r e v i e w e d the optical p r o p e r t i e s of teeth. Hornby P. For instance. This method r e d u c e s distortion and therefore increases accuracy o f fit. Meyer R. investigated t h e use of lasers to d i a g n o s e e n a m e l d e c a y . T h e s i m u l t a n e o u s welding of t h e t i t a n i u m pieces e n h a n c e s the precise adaptation of these implant bridges to the underlying implants. T h i s a t m o s p h e r e assures that the weld joint is o x i d e free and of m a x i m u m strength. which is then w e l d e d by t h e laser. T h e laser-cured m a t e r i a l s also had a better bond strength to dentin at its interface with t h e c o m p o s i t e . N o n i o n i z i n g laser light has the potential for replacing the radiation n o w used to m a k e dental radiographs. J Dent Res I964. R e s e a r c h by Powell et al. Both of these t e c h n i q u e s can cause s h r i n k a g e of t h e metal and distortion of the bridge. Sognnaes RF. T h e y s u g g e s t e d that the a u t o p o l y m e r i z a t i o n of the c o m p o s i t e w a s a factor in t h e differences s e e n . T h e s e c h a n g e s are c a u s e d by a thermal effect. 2. Stern RH. 5):873 (abstract 307). Goldman L. the authors state that the actual m e c h a nism of action is still not clear. Goodman F. T h e i r m o d e l suggests thai the e n a m e l p r i s m s and d e n t i n a l tubules may affect laser light before the light is a b s o r b e d by t h e tissues. Certain bacteria contain p o r p h y r i n s in their cell walls that fluoresce w h e n certain w a v e l e n g t h s of light are used. is a flashlamp p u m p e d N d : Y A G laser in which t w o laser b e a m s are directed to t h e titanium bridge. Goldman B.43(suppl to no. Kelsey et al. T h e optical p r o p e r t i e s of teeth m a y c a u s e u n w a n t e d d a m a g e t o teeth and require m o r e study for a better u n d e r s t a n d i n g of their possible influence. W h e t h e r this s a m e effect will be seen in v i v o has yet to be d e t e r m i n e d . J Am Dent Assoc 1966. The potential for laser a p p l i c a t i o n s in dentistry portends an exciting future. T h i s method is different from the s o l d e r i n g m e t h o d s presently used bec a u s e with the laser similar metals are w e l d e d . Lasers also m a y be used as a light source in conjunction with a m i c r o s c o p e to e v a l u a t e the v a s c u l a t u r e of the ging i v a in v i v o to d i a g n o s e a c t i v e periodontal d i s e a s e . Lobene RR.134 Lasers in Maxillofacial Surgery and Dentistry b u r g . w h i c h can lead to a w e a k e r j o i n t . T h e m e t h o d thai is presently being used by dental laboratories for bridge assembly is eit h e r c a s t i n g of a bridge in total or soldering c o m p o n e n t s to fabricate the b r i d g e ." T h e laser s y s t e m . Fine S. LASER DENTAL DECAY DETECTION AND OPTICAL PROPERTIES OF TEETH Z a c h a r i a s e n et a l . Sognnaes RF. B e c a u s e of the t e n d e n c y for the titan i u m to d e v e l o p an o x i d e layer. T h e r e is s o m e c o n t r o v e r s y r e g a r d i n g w h e t h e r the laser provides a d e q u a t e benefit to c o m p e n s a t e for its m u c h h i g h e r cost. G o t h e n - . and K o n i g et a l . Lasers h a v e been used extensively in industry for cutting and w e l d i n g o f m e t a l s .

and m e r o c y a n i n e 5 4 0 as p h o t o s e n s i t i z e r s for the treatment of superficial m a l i g nancies. a ketone or 137 . E a c h of these potential applications will be r e v i e w e d . and m e m b r a n e d a m a g e (by oxidation of unsaturated fatty acids and c h o l e s t e r o l ) .1 2 3 . .. H a x t h a u s e n and H a u s m a n n ' " in 1908 w e r e the first to suggest that h e m a t o p o r p h y r i n w a s a p h o t o d y n a m i c photosensitizer. ' the recent clinical evaluation of h e m a t o p o r p h y r i n d e r i v a t i v e s .'' C r u s h e d leaves from plants related to parsley w e r e rubbed o v e r an area of d e p i g m e n t e d skin before e x p o s u r e to t h e s u n ' s r a y s lo p r o d u c e a severe form of sunburn only in the treated a r e a s . Both are used for eradication and i m a g i n g of c a n c e r s . w h o injected h i m s e l f intravenously with h e m a t o p o r p h y r i n and b e c a m e highly sensitive to light for 2 m o n t h s . T h e first medical use of c h e m i c a l l y e n h a n c e d p h o t o t h e r a p y (other than for restoration of pig12 m e n t a t i o n ) w a s reported by J e s i o n e k and T a p p e i n e r " in 1905. nucleic acid oxidation (primarily g u a n i n e ) . with a potentially high effective c u r e rate and l o w morbidity. HISTORY This first use of light-sensitive s u b s t a n c e s ( p s o r a l e n s ) in the treatment of d i s e a s e can be traced back o v e r 6 0 0 0 years to the ancient Egyptians. and t r y p t o p h a n ) . T h i s " s e n s i t i z e d " tissue is then e x p o s e d in the p r e s e n c e of o x y g e n to a light source of a specific w a v e length. " Mechanisms of Photooxyfienulion M a n y c h e m i c a l s . Reference to the use of a plant extract for the restoration of skin pigmentation w a s m a d e in 1400 B . H o w e v e r . 1 ls 1 6 PHOTODYNAMIC THERAPY Definitions P h o t o d y n a m i c t h e r a p y c o n s i s t s of the administration of a p h o t o s e n s i t i z i n g a g e n t . together with U V radiation. T h i s is particularly attractive because surgery a n d / o r radiation t h e r a p y m a y still be used if and w h e n recurrent d i s e a s e o c c u r s . ' " and p h o t o t o x i c effects of psoralens w e r e described in 1250 A . the field of p h o l o d y n a m i c therapy ( P D T ) has regained popularity. T h e s e pioneers in the study of p h o t o d y n a m i c therapy treated five basal cell c a r c i n o m a s by injecting eosin into the t u m o r and e x p o s i n g it to light. After resolution of the sunburn the skin would return to its natural color. to treat psoriasis. Laser p h o t o t h e r a p y can be further s u b d i v i d e d into t w o major areas: P D T and p h o t o d i a g n o s t i c i m a g i n g ( P D I ) . histidine. Filially. Castro. t h e current e x p e r i mental testing o f r h o d a m i n e . particularly m e t h i o n i n e . in 1925 G o e c k e r m a n successfully used t h e p h o t o t o x i c effects of coal tar. i. B e c a u s e lasers are n o n i o n i z i n g b e a m s . C .B e t z . w h i c h can be a d y e or p i g m e n t .e. Laser p h o t o t h e r a p y with d y e s (activated by specific w a v e l e n g t h s of light) m a y b e c o m e an attractive adjunctive modality for treatment of superficial m a l i g n a n c i e s w h e n fluorochromes with high t u m o r specificity and low s y s temic toxicity are d e v e l o p e d . each of these m o d a l i t i e s is either invasive or destructive with s o m e morbidity and restriction of further therapeutic options if and w h e n recurrent d i s e a s e occurs. Jacques Soudant For years s u r g e r y a n d / o r radiation therapy h a v e been the therapy of choice for the Successful treatment of superficial malignancies. c a l l e d " p h o t o d y n a m i c a c t i o n " requires o x y g e n and it d a m a g e s biologic target m o l e c u l e s by p h o t o o x i d a t i o n . T h i s t e c h n i q u e is simple and minimally invasive. Photosensitized oxidation is initiated by t h e absorption of light by a sensitizer. T h i s p r o c e s s . specifically since the introduction of lasers by M a i m a n . can a b s o r b light and by p h o t o c h e m i c a l reactions d a m a g e Ihe org a n i s m . w h i c h results in the destruction of this tissue.11 Phototherapy with Lasers and Dyes Dan }. proving that these c o m p o u n d s can induce systemic pholosensitization in m a n . M o s t of these t r e a t m e n t s can be performed as outpatient p r o c e d u r e s thereby r e d u c i n g the cost of hospitalization. ' superficial t u m o r s can be treated repeatedly by e n doscopically delivered laser fiberoptics. D . T h i s finding w a s c o n f i r m e d in 1913 by M e y e r . In the last t w o d e c a d e s . a c h e m i c a l at e x t r e m e l y low and n o n t o x i c c o n c e n t r a t i o n s that is a b s o r b e d selectively by living tissues. 2 U 7 s T h e p i o n e e r of m o d e r n p h o t o t h e r a p y in d e r m a t o l o g y w a s F i n s e n in 1 9 0 1 . three cures w e r e reported. B i o c h e m i c a l effects include e n z y m e d e a c t i vation ( t h r o u g h d e s t r u c t i o n of specific a m i n o a c i d s . including natural cell constituents. Saxton. Romaine E. w h o s e e x t e n s i v e e x p e r i m e n t s on the treatment of skin t u b e r c u l o s i s with natural and artificial ultraviolet ( U V ) radiation stimulated the current interest in cutan e o u s p h o t o b i o l o g y .

T h e most important point c o m m o n to both the d i a g n o s t i c and therapeutic photoradiation s y s t e m s e m p l o y e d with H P D is the requirement for sufficient a m o u n t s of light to reach t u m o r target sites. 2 0 i n 1979. all of w h i c h are in the visible s p e c t r u m of light. b y c a p t u r i n g a photon. p s o r a l e n s . recent s t u d i e s b y G o m e r and D o u g h e r t y 2 2 d e m o n s t r a t e d that k i d n e y . In 1 9 7 8 1 7 a n d 1979 18 this g r o u p reported clinical studies s h o w i n g that skin m e t a s t a s e s could be eradicated with the p r o p e r c o m b i n a t i o n Current Status of Laser Dyes A large n u m b e r of p h o t o s e n s i t i z e r s have been tested in labo r a t o r i e s a r o u n d the world with p r o m i s i n g results. " A l s o the l o w p o w e r (milliwatt r a n g e ) of the d y e lasers used for treatment h a v e limited effectiveness for t u m o r therapy because of limited d e p t h of tissue p e n e t r a n c e .1 38 Lasers in Maxillofacial Surgery and Dentistry of H P D and red light ( 6 3 0 n m ) . greater therapeutic effects w e r e o b t a i n e d w h e n the light e x p o s u r e w a s performed 96 to 168 h o u r s after H P D a d m i n i s t r a t i o n than after 24 to 72 h o u r s . rose bengal. T h i s w a s based on o b s e r v a t i o n s that d e m o n s t r a t e d that H P D w a s retained l o n g e r by m a l i g n a n t tissue than by m a n y s u r r o u n d i n g n o r m a l tissues and w a s d e tectable by t u m o r f l u o r e s c e n c e . rather than b e i n g attributable to the H P D c o m p o n e n t r e s p o n s i b l e for the in v i v o effects. 1 8 T h i s s u g g e s t e d that its activation w o u l d selectively d a m a g e only the a b n o r m a l tissue to which it had been b o u n d . T h e initial e n t h u s i a s m g e n e r a t e d by the early successful results o b s e r v e d in patients treated with H P D and laser light w a s d i m i n i s h e d substantially by its side effects and other treatment l i m i t a t i o n s . the result of studies by H e n d e r s o n et a l . F a c t o r s that govern the c o m p e t i t i o n include o x y g e n c o n c e n t r a t i o n . Hematoporphyrin Derivitives H e m a t o p o r p h y r i n derivatives ( H P D s ) w e r e recently tested as a photosensitizcr for specific laser treatment of superficial m a l i g n a n c i e s . T h e y h a v e not p r o v i d e d an a d v a n t a g e over the use of H P D . 2 4 b l a d d e r . In fact. nitro-red.2 c m ) as is necessary for this m e t h o d to be useful for c a n c e r therapy. T h e sensitizer ( S e n s ) . 5 0 7 . Lasers are o n e t y p e of light that can satisfy these conditions. H o w e v e r . these results m a y h a v e been c o m p r o m i s e d by the p r e s e n c e of H P D i m p u r i t i e s . High sensitizer reactivity. H o w e v e r . 2 1 indicate that the uptake kinetics of the active c o m p o n e n t of H P D ( D H E ) a r e quite different from t h e H P D m i x t u r e . C h a n g and D o u g h e r t y 2 0 e x a m i n e d t w o cell lines derived from n o r m a l tissue and t w o from malignant tissue u n d e r identical tissue culture c o n d i t i o n s and they found no differences in p o r p h y r i n affinity or p h o t o d y n a m i c killing for four cell lines of different o n c o g e n i c p o tential. that are a l w a y s in c o m p e t i t i o n . m e t h y l e n e blue. 1 7 . t y p e I and t y p e II. e v e n in the s a m e patient. T h e structure of the active e l e m e n t d i h e m a t o p o r p h y r i n e t h e r ( D H E ) w a s elucidated b y D o u g h e r t y e t a l . and t u m o r s of t h e head and neck (laryngeal b a s e of tongue. and floor of m o u t h t u m o r s ) .2 9 In a series of tum o r s treated with H P D and laser light. T h e c h e m i c a l c o m p o s i t i o n o f H P D h a s been s h o w n t o b e a mixture of several p o r p h y r i n s . a w a v e l e n g t h selected for optimal activation o f H P D . P D T has shown therapeutic effects. 2 3 . M c r o c y a n i n e . a t 4 0 2 . 3 0 Patients must be protected with adeq u a t e c l o t h i n g or s u n s c r e e n s against any sunlight and cannot even v e n t u r e o u t s i d e or sit near a w i n d o w d u r i n g this period. w h i l e the o p p o s i t e factors favor the t y p e II. 25 vagina and cervix. Thus the inconsistent r e s p o n s e implies that laser-tissue interactions and d o s i m e t r y r e m a i n as areas r e q u i r i n g further study. detection of t u m o r fluorescence is simplified when the e x c i t i n g light is both c o h e r e n t and of a different wavelength from the fluorescence e m i s s i o n of the tumor. 26 p r i m a r y and metastatic skin c a n c e r s . T h e absorption s p e c t r u m of H P D in h u m a n serum s h o w s five major absorption p e a k s . Pain is a n o t h e r c o m m o n side effect. C u r r e n t clinical applications of H P D for P D T have foc u s e d on a c c e s s i b l e superficial m a l i g n a n c i e s . w h i c h also allowed m a x i m u m penetration t h r o u g h tissue ( 1 . and s o d i u m fluorescein h a v e been investigated as potential p h o t o s e n s i t i z i n g agents with s o m e a d v a n t a g e s . particularly involving t h e c a l v a r i u m . H P D has been s h o w n to exhibit nonspecific uptake by inflammatory cells and t r a u m a t i z e d tissues. such a s acridine o r a n g e . and spleen of m i c e retain m o r e H P D than d o c s a transplanted m a m m a r y tumor. T h e depth of tissue d e g e n e r a t i o n d u e to this therapy was influenced by the e n e r g y d o s e delivered to the treated tumor.5 4 0 is currently used in p h a s e I clinical trials for purging t u m o r cells from a u t o l o g o u s b o n e m a r r o w grafts in . gastrointestinal tract. In addition. high substrate reactivity and c o n c e n t r a t i o n . 17 q u i n o n e . and singlet o x y g e n lifetime. and short singlet lifetimes favor the t y p e I m e c h a n i s m . the a c tive c o m p o n e n t r e s p o n s i b l e for its action w a s u n k n o w n . 2 2 . with patients frequently experiencing s e v e r e h e a d a c h e s after light a c t i v a t i o n . T h e least tissue penetration and the highest H P D absorption are at 4 0 2 n m : the greatest tissue penetration and least absorption are at 6 2 4 n m . 5 4 0 . is elevated to a h i g h e r e n e r g y state w h e r e it m a y n o w act as an oxidizer. palatal. T h e current interest in p h o t o d y n a m i c t h e r a p y s t e m s from studies begun in 1972 by D o u g h e r t y a n d c o l l e a g u e s at Roswell Park M e m o r i a l Institute in Buffalo. a n d 6 2 4 n m . liver. T h e s e side effects and limitations of H P D will p r o b a b l y remain significant limiting factors for its future clinical applications. substrate c o n c e n t r a t i o n . which decreases its potential as a " t u m o r specific fluorescent d y e . including canc e r o f t h e l u n g . T h e r e are t w o m e c h a n i s m s of p h o t o s e n s i t i z e d o x i d a t i o n . but until recently. the reactivities of the substrate and sensitizer excited state. l o w o x y g e n c o n c e n t r a t i o n . 5 7 3 . While n u m e r o u s early reports indicated that most n o r m a l (issues d o retain H P D . merc u r o c h r o m e . At the s a m e e n e r g y level. A variety of other p h o t o c h e m i c a l l y active d y e s . 1 9 Attempts to d e m o n s t r a t e c l e a r differences in affinity of porphyrins for n o r m a l or m a l i g n a n t cells in culture h a v e given a m b i g u o u s results. o r a n a r o m a t i c m o l e c u l e . 30 In addition. therapeutic effectiveness varies according to e a c h lesion.

38 14 x 700. w h i c h a r e w a t e r s o l u b l e c a t i o n i c c o m p o u n d s with various absorption m a x i m a b e t w e e n 7 5 0 and 8 7 5 nm. l e u k e m i a . In addition. K o d a k Q . with an absorption m a x i m u m at 7 0 0 nm in saline.0527 Wfl UisiMe MODE Scan Figure 1 1 . P h o t o c y t o t o x i c i t y of p h t h a l o c y a nines in m a m m a l i a n cells h a s been d e m o n s t r a t e d for vario u s cell lines.1 2 3 ) ( F i g s . Molecular structure of rhodamine dyes. adenocarcinoma. the c h a l c o g e n a p y r i l i u m d y e s . melanoma. the p u r p u r i n s h a v e major absorption p e a k s b e t w e e n 6 3 0 and 7 1 5 n m .1 2 3 a p p e a r s to h a v e p r o m i s i n g effects as a p h o tosensitizer for argon laser treatment of s q u a m o u s cell carcinoma (Fig. F r o m histologic studies in transplanted urothelial t u m o r s .S w i t c h II d y e (1051 n m ) h a s recently been e v a l u a t e d 3 6 in vitro in our laboratory as a nearinfrared laser d y e with p r o m i s i n g results. A l t h o u g h t h e s e l e c t i v e retention of p h t h a l o c y a n i n e in t u m o r m o d e l s a p p e a r s to be similar to that of h e m a t o p o r p h y r i n d e r i v a t i v e s . l y m p h o m a . T h e k r y p t o c y a n i n e d y e E D K C has been tested b y Ara and O h u o h a 3 5 and exhibits preferential u p t a k e b y c a n c e r cells of various o r i g i n s . Absorption spectrum of rhodamine dyes (Rh-123. h a s b e e n e x a m i n e d recently b y Segclman. Several oxazine d y e s 3 3 an d Nile b l u e A also h a v e been tested as fluorescent cationic d y e s . T h e c h a l c o g e n a p y r i l i u m d y e s represent a family of related c o m p o u n d s w h o s e properties as a c h r o m o p h o r c can be d e s i g n e d by proper choice of o r g a n i c structural substitutions. w h i c h permit control of their w a v e l e n g t h a b s o r p t i o n m a x i m a .Phototherapy with Lasers and Dyes patients with l e u k e m i a . is e x t r e m e l y efficient in leukemias. but most likely many d y e s will be suitable. and l y m p h o m a cell lines. on the o t h e r hand. recent preliminary s t u d i e s s h o w both relatively p o o r u p t a k e and significant toxicity of the c h a l c o g e n a p y r i l i u m s in cell cultures. l y m p h o m a s .1 2 3 ( R h . For e x a m p l e . it is clear that p u r p u r i n s and m e t a l l o p u r p u r i n s are capable of causing extensive tumor necrosis when combined with visible light.2 ) h a s recently been a p p r o v e d for p h a s e I clinical trials in patients with recurrent head and neck c a r c i n o m a s in o u r o w n studies at U C L A . they are h o m o g e n e o u s p u r e d y e s of k n o w n structure. a l o n g e r w a v e l e n g t h 8 139 ( 6 0 0 n m ) with g r e a t e r penetrating p o w e r in tissues than for h e m a t o p o r p h y r i n has been used. and n e u r o b l a s t o m a s . a chlorophyll derivative with a peak a b s o r p t i o n a t 6 7 0 n m . H o w e v e r . U n l i k e H P D . 11-3).9 ABS 0. . R h . o r metastatic n e u r o b l a s t o m a . T w o g r o u p s o f p h o t o s e n s i t i z e r s w e r e synthesized recently by M o r g a n et aL T h e s e p h o t o c h e m i c a l s include the p u r p u r i n s and their metallo derivatives. and hydrolytic stability. each with a specific affinity for a specific c a n c e r . p e r h a p s based on the cell line of origin. f l u o r e s c e n c e yields. Rh-6G. It is e v i d e n t that there is not o n e " m a g i c " antibiotic for all infectious p r o c e s s e s .o x y g e n induced cell killings h a s been reported. R h o d a m i n e . P h e o p h o r b i d e . D e t t y 3 3 at the E a s t m a n K o d a k Laboratories recently d e m o n s t r a t e d the potential usefulness of a n e w g r o u p of p h o t o s e n s i t i z e r s . 1 37 RHODAMINE 123 Figure 11-2. there m a y not be o n e " m a g i c " d y e for all m a l i g n a n c i e s ."' but h a s poor response in m e s o t h e l i o m a and s a r c o m a cell lines." M e r o c y a n i n e 5 4 0 . T h e s e d y e s should be c o m p a t i b l e with c o m m e r c i a l l y available g a l l i u m arsenide lasers. redox properties. which are w a v e l e n g t h s c a p a b l e of d e e p tissue penetration. but s h o w s p o o r uptake and effects in lung and ovarian c a r c i n o m a s .1 . By a n a l o g y . and e v i d e n c e for s i n g l e t . Recent w o r k d o n e b y R i e s / and K r i s h n a " d e m o n s t r a t e d the potential of sulfonated p h t h a l o c y a n i n e s as c a n d i d a t e s for p h o t o d y n a m i c therapy. Rh-3G). 11-1 and 1 1 . Future Directions: Photosensitizers and Light Sources T h e field of p h o t o d y n a m i c therapy with d y e s and lasers for t h e treatment of c a n c e r m a y b e c o m e clinically useful only after p e r f o r m i n g e x t e n s i v e drug s c r e e n i n g similar to antibiotic culture and sensitivity testing for infectious diseases.

T h i s m a y result in m o r e specific d y e u p t a k e by t u m o r s and longer retention in the target t u m o r . physicists.c o m p a t i b l e p r o b e s will allow t u m o r detection and real-time m o n i t o r i n g of interstitial laser phototherapy for treatment of l a r g e .140 Lasers in Maxillofacial Surgery and Dentistry A rapid technological a d v a n c e in the design of diode lasers c o u l d also open a p r o d u c t i v e new approach for investigation and clinical a p p l i c a t i o n s of P D T for several reas o n s . D2) while continued growth is noted for control tumors ( D l ) .v o l u m e t u m o r s using d y e s and lasers in a w i d e r a n g e of the e l e c t r o m a g n e t i c spectrum. and p h o t o c h e m i s t s . T h e field of p h o t o d i a g n o s t i c i m a g i n g with laser may be further subdivided into several potential applications inc l u d i n g laser s p e c t r o s c o p y . d i o d e lasers are the most efficient and stable lasers available. Pretreatment (A2). N e w fiberoptic d e v i c e s for efficient laser light dosimetry and delivery t o t u m o r during P D T a r e u n d e r d e v e l o p m e n t t o o p t i m i z e t h e effectiveness of this t e c h n i q u e . Argon laser phototherapy of experimental P. and 10 weeks (D2) post-laser therapy. I week (C2). N e w light delivery s y s t e m s for p h o t o d y n a m i c therapy are d e v e l o p i n g at a s t a g g e r i n g p a c e . Complete cure is noted in the experimental tumors (Rh-123 + laser. immediately post-laser therapy (B2). W i t h the collaboration of p h o t o c h e m i s t s . and m a g netic r e s o n a n c e . l o w e r s y s t e m i c toxicity. D y e s with synergistic a n d / o r a n t a g o n i s t i c effects on various n e o p l a s m s m a y be found. T h e s e d i o d e lasers will certainly revolutionize the field of laser t e c h n o l o g y . and d e e p e r tissue penetration. Photodiagnostic Imaging with Lasers T h e ability to localize and m a p t u m o r s has o b v i o u s o n c o logic applications for the clinician for potential identification of occult t u m o r s as well as m o r e precise t u m o r rem o v a l . redox p r o p e r t i e s . and c l i n i c i a n s . and then tested clinically. and d y e conjugated m o n o c l o n a l a n t i b o d y imaging. laser fiberoptics. because their absorption w a v e l e n g t h m a x i m a fluor e s c e n c e versus singlet yields. CONCLUSIONS Figure 11-3. short half-life. and lower s y s t e m i c toxicity can then be d e v e l o p e d . t u m o r c u l t u r e s m a y be initiated in the laboratory and then tested for sensitivity to m a n y photosens i t i z e s and laser w a v e l e n g t h s .m and s m a l l e r d i a m e t e r a r c currently available. with rapid m e t a b o lism. New tunable d y e lasers with e m i s s i o n s from the visible to the near-infrared s p e c t r u m are c o n t i n u o u s l y being developed. A n a l o g o u s to antibiotic t h e r a p y . and o p t i m a l l l u o r o c h r o m e s for p h o t o d y n a m i c therapy a n d / o r p h o t o d i a g n o s tic i m a g i n g with lasers can then be classified. A n e w and e x c i t i n g a p p r o a c h to c a n c e r d i a g n o s i s and therapy m a y be d e v e l o p e d using lasers and d y e s . A n e w era is d a w n i n g in the d i a g n o s t i c potential of laser W i t h the collaboration of c l i n i c i a n s . this t e c h n o l o g y is b e c o m i n g less e x p e n s i v e at the s a m e t i m e that the d i o d e lasers are being m i n i a t u r i z e d and increasing in p o w e r output. S o m e n e w d i o d e lasers h a v e a p o w e r output of nearly 25 W from a d e v i c e s m a l l e r than a Carousel slide tray. laser d y e fluorescence. p h o t o c h e m i c a l d y e s m a y b e " d e s i g n e d " in the laboratory. and a q u e o u s stability can be n o w modified by c h a n g i n g different c h a l c o g e n a t o m s and substitutions in the d y e c h r o m o p h o r e .s i z e p o r t a b l e lasers that might even be d i s p o s a b l e b e c a u s e of their l o w cost. and might e v e n result in the d e v e l o p m e n t of powerful p o c k e t . m a n y different photosensitizers and n e w laser w a v e l e n g t h s will be d e v e l o p e d . T h e optimal tumoricidal effects of laser-dye c o m b i n a t i o n s for a specific t u m o r may be defined and then a p p l i e d clinically. engineers. squamous carcinoma tumors in nu/nu mice after sensitization with Rh123. D y e s with h i g h e r affinity for specific n e o p l a s m s . T h e rapid technological revolution of m a g n e t i c r e s o n a n c e i m a g i n g . T h e c h a l c o g e n a p y r i l i u m d y e s are a good e x a m p l e of a " d y e d e s i g n " s y s t e m . . c h e m i s t s . First. biologists. T h i s c o u l d lead lo the identification of n e w d y e s with synergislic effects that e n h a n c e the tumoricidal effect of laser light. S e c o n d . Flexible fiberoptic cables of 2 0 0 u. t u m o r biologists.

. Photodynamic therapy with hematoporphyrin derivative in cancer of the upper gastrointestinal tract. 3. Semin Surg Oncol 1985:1:1-11." Dorado. Jesionek A. Laryngoscope I987. Zur behandlung de hautcarcinome mil fluoresierenden Stolle. I lay .38:2628-2635. 15. Porphyrin Photosensitizaiion. 1. Kaufman JE.13:337-340. Die lichterkrankugen der haul. 9. 2. Exploration is j u s t b e g i n n i n g in a m o s t p r o m i s i n g n e w area that will require further c o l l a b o r a t i v e research b e t w e e n the clinician and basic scientist to d e t e r m i n e the usefulness of this exciting adjuctive m o d a l i t y for t h e treatment of c a n cer and other d i s e a s e s . vol 7.. Cortese DA. Castro DJ. Bellnier DA. J Surg Oncol 1980. Lawrence G. Castro DJ. Laryngoscope 1988:98(4):369-376. Mitt Fisen Instil 1900. N I H grant # U S H H S D C 0 0 3 1 .24:229-231. Fetterman HG. 1877. 31. Haxthauscn H. Dougherty TJ. Dougherty TJ. 25. May 5.. Fetterman HR.43:1562-1567.Phototherapy with Lasers and Dyes d y e fluorescence. Laryngoscope 19K7:97( 12): 1454-1459.Z E M . Saxton RE. R e s o n a n c e T e c h n o l o g y . eds. 14. 1983:129-138. Harvard Oriental Series. Photodynamic therapy in otolaryngology—head and neck surgery. Photoradiation therapy for the treatment of malignant tumors. Biostimulative effects of Nd:YAG Q-switch dye on normal fibroblast cultures: study of a new chemosensitizing agent for the Nd:YAG laser. . Gaffncy DK. eds. Laser Surg Med 1984. Cancer Res 1979:39:146-151. Arch Otolaryngol 1985:111:758-761. Cairo: Egyptian Government Press. I n . Translation by Barron P. Saxton RE. M o n o c l o n a l a n t i b o d i e s can n o w be produced with specific a n t i t u m o r b i n d i n g c a p a c i t y . and the A s s o c i a t i o n d c Recherche stir le C a n c e r ( A . Thermal considerations in murine tumor killing using hematoporphyrin derivative phototherapy. Castro DJ. Ward PH. 20. Huth GC. Hayata Y. Fetterman HR. T r i m e d y n e . Untcrsuchugen iiber die biologische (photodynamische). Forrest JB. Neue untcrsuchugen uber die einwirkung dess lichtcs auf die haut. Determination of | 3 H | and | I9C| hematoporphyrin derivative distribution in malignant and normal tissue. Castro DJ. Dougherty TJ. 6. Kinsey JH. (Translation and notes). Puerto Rico. In: Hayata Y. Saxton RE. Konaka C. t h e D u P o n t Merck. Stimulated optical radiation in ruby. Ward PH. 24. 5. Application of photodynamic therapy in plastic surgery. Case report: malignant melanoma arising during therapy for vitiligo. A c k n o w l e d g m e n t s T h i s study w a s s u p p o r t e d b y the Division of Head and Neck S u r g e r y . The effects Of argon lasers on human melanoma cells sensitized with Rhodamine-123 in-vitro. Atharva-veda Samhita. Dougherty TJ.. 19. Dougherty TJ.V i v o R e search Inc. Kinsey JH. Keller GS. be linked to photosensitizers. Radial Res 1978. Phthalocyanines und their sulfonated derivatives as photosensitizers in photodynamic therapy. O h m c d a . Finscn NR. Benson RC. Treatment of psoriasis. Phototherapy with the argon laser on human melanoma cells "sensitized" with Rhodamine-123: a new method for tumor growth inhibition. Saxton RE.6:62-66. Photochem Photoblol 1990. 18. R . Ward PH. Laser Surg Med 1986.. and laser-induced fluorescence s p e c troscopy is s h o w i n g p r o m i s i n g results for detection of o c cult c a r c i n o m a s . Dougherty TJ. 17.p o w e r illumination of dye-stained t u m o r n o d u l e s followed by treatment with h i g h . 4.p o w e r laser e m i s s i o n via interstitial fiberoptics. Meyer-Belz F. Doiron DR. 10. Tokyo. L a s e r s c o p e . Ward PH. Henderson BW. Ricsz P. Inc. Chest 1984:86:169-177. Fetterman HR.ia Y. CR Sac Biol (Paris) 1924:91:1423. S o o n it m a y be possible for the clinician to e x a m i n e and d i a g n o s e early r e c u r r e n c e s by l o w . Goldfarb A. a n d N I H grant # C A 6 5 0 5 3 . Goldman L. Forrest HJ. G E Medical S y s t e m s . 7. et al. 12. Kato H. REFERENCES 22. Binding of merocyanine 540 by cells labeled with anthroyloxy fatty acids. et al. Balchum OJ. C . Cancer. Presented at the Joint Meeting of the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons entitled.49 (suppl):315. 141 11. Photoradiation therapy with hematoporphyrin derivative in early and stage I lung cancer. Aspects of the cellular uptake and retention of hematoporphyrin derivative and their correlation with the biological response to PRT in vitro. Kaufman JH. J Urol 1983:130:1090-1094. Dougherty TJ. New York: Igaku-Shoin. Whitney WD.4:13-30. Castro DJ. Lasers and hematoporphyrin derivative in cancer. 28. 29. 1905. 26.98:109-116. New York: Plenum Press. Policard A.97(5):554-56I. Chang CT. In: Kessel D. Laryngoscope 1987. et al. Treatment of transitional cell carcinoma of the bladder with hematoporphyrin derivative phototherapy. 8.82:223-227. . 23.O l R . Muiman TH. 1985. BP 3-94801 Villejuif Cedex. 1929. Mofradai Al Adwiya. Sieber F. Biostimulalion of human carcinoma cells with the argon laser: a previously unreported potential iatrogenic effect of lasers.9( I): 18-29. 13. Castro DJ. Inc. 30. Kato H. Am J Otolaryngol 1988. Ward PH. and then be injected into p a t i e n t s with cancer. Dtsch Arch Klin Med 1913:112:476-503. Cancer Res 1983. Shumrick K. Waner M. U C L A School o f Medicine. 187:493-494. Canter Res 1978. Gregory RO. Gluckman JL. Cambridge: Harvard University Press. et al. 21. Photoradiation therapy: kinetics ol thermodynamics of porphyrin uptake and loss in normal and malignant cells in culture. Photodynamic therapy: a viable alternative to conventional therapy for early lesion of the upper aerodigestive tract. et al. 16. Ziring B. Hayata Y. Nature 1960. Photoradiation in the treatment of recurrent breast carcinoma. Etudes sur les aspects offerts pas des lumeur experimentales examinee a la lumiere de woods. Valley L a b . Dougherty TJ. Castro DJ. Fisher GU. Saxton RE. "Current Research and Clinical Concepts in Head and Neck Cancer. Cortese DA. the Elsa P a r d e e F o u n d a t i o n . Rhodamine-123 as a new photochemosensitizing agent with the argon laser: "Non-thermal'" and thermal effects on human squamous carcinoma cells in-vitro. J Nail Cancer Inst 1979:62:231-237. 27. 1:4. Hausmann W. France). 1:8. Castro DJ. Doiron DR. Photoradiation therapy of endobronchial lung cancers employing the photodynamic action of hematoporphyrin derivative. North West Med 1925.74:498-499. Fetterman HR. and the J o n s s o n C o m p r e hensive C a n c e r C e n t e r C I C R A w a r d . 1982:1-114. Dtsch Arch Klin Med 1905. Vienna: Urban and Schwur/enberg. Inc. Neel HB. E . Wirkung des Hamnloporphyrins und anderer derivate des blut-und gallenfarbstoffs. Gomer CJ. Tappeiner HV. Gocckerman WH. Okitsu H. Krishna M. Ibn El-Bitar.

d e v e l o p e d p r e l i m i n a r y optical d o s i m e t r y for interstitial p h o totherapy o f m a l i g n a n t t u m o r s . is rather i m p r e c i s e and treatment o u t c o m e s are u n p r e d i c t a b l e . it will b e c o m e clinically useful only w h e n noninv a s i v e d o s i m e t r y s y s t e m s deliver the e n e r g y in an accurate and r e p r o d u c i b l e w a y ( F i g . or laser e n e r g y . L a s e r t e c h n o l o g y h a s b e e n permissive in t h e d e v e l o p m e n t of less i n v a s i v e but h i g h l y effective surgical p r o c e d u r e s that r e d u c e both m o r b i d i t y and cost.g a r n e t ( N d : Y A G ) laser for h y p e r t h e r m i a . In addition. used a single N d : Y A G laser fiber at l o w p o w e r ( 1 . b u t t h e effect on survival w a s not clear. This method.a l u m i n u m . Breast t u m o r s w e r e treated using t h e g l o w i n g tip of a fire drill. 3 O t h e r m e t h o d s for i n d u c i n g localized tissue necrosis such as topical or interstitial c r y o t h e r a p y h a v e been tested by R a v i k u m a r et a l . w h i c h w a s associated with few complications and produced tumor necrosis. With the increasing cost of health c a r e d u r i n g t h e past 20 years. Castro. w h i c h a r e reliable but h a v e limited clinical a p p l i c a t i o n s . and l o w e r i n g of cost as a m b u l a t o r y s u r g e r y has b e c o m e a safe alternative to inpatient surgery. I m a g e g u i d e d m i n i m a l l y i n v a s i v e s u r g e r y is a n e w c o n c e p t that uses u l t r a s o u n d ( U T Z ) a n d / o r fast magnetic r e s o n a n c e i m a g i n g ( M R I ) t o g u i d e v a r i o u s e n e r g y sources such as lasers. H o w e v e r . m i c r o w a v e . B o w n investigated the interstitial u s e of the n e o d y m i u m : y t t r i u m . a p plied 5 to 15 W of N d : Y A G laser p o w e r with a modified 1 2 1 3 1 4 1 5 . 7 an d S h i n a e t a l . Saxton. 4 and Z h o u et a l . b e c a u s e its e n e r g y is rapidly a b s o r b e d in tissues. " I n 1985 S v a a s a n d e t a l . 2 Laser light h a s been used in a w i d e s p e c t r u m of a p p l i c a t i o n s both in m e d i c i n e and surgery since its introduction in t h e early 1960s. M a t t h e w s o n e t a l . Invasive m e t h o d s currently a v a i l a b l e u s e t h e r m a l p r o b e s . 1 Classical R o m a n and G r e e k p h y s i c i a n s also were a w a r e o f t h e h o m e o s t a t i c and d e s t r u c t i v e tissue c a p a bilities of heat and used it widely in m e d i c a l p r o c e d u r e s . radio frequency. 6 used interstitial implantation of radioactive s e e d s in t u m o r s to i n d u c e t u m o r necrosis. 4 . 5 BACKGROUND Localized h y p e r t h e r m i a m a y b e delivered externally a n d / o r interstitially using r a d i o frequency. and ultrasonic and c r y o t h e r a p y d e v i c e s for t h e r a p y o f d e e p t u m o r s w h i l e m o n i toring tissue c h a n g e s d u r i n g e n e r g y d e p o s i t i o n ( F i g .1 9 7 0 s . laser e n e r g y can be delivered to target sites e n doscopically a n d / o r interslitially using the p r i n c i p l e of minimally invasive s u r g e r y . T h e use of lasers as a s o u r c e of p h o t o t h e r m a l e n e r g y for treatment of c a n c e r and o t h e r d i s e a s e s .2 W ) .1 ) . Livraghi et a l . B e c a u s e m o s t w a v e l e n g t h s a r e e m i t t e d via fiber optics. and histologic a s s e s s m e n t . In several c a s e s both t u m o r eradication and survival t i m e s for o t h e r w i s e untreatable t u m o r s h a v e been i n c r e a s e d . and c o n t r o l l a b l e . to p r o d u c e areas of t h e r m a l necrosis in the normal rat liver ( b e l o w t h e surface). ultrasound. T h i s is exemplified by l a p a r o s c o p i c s u r g e r y . its effects are p r e d i c t a b l e . Its nonionizing characteristic simplifies safety r e q u i r e m e n t s . 8 injected 9 5 % alcohol into t h e c e n t e r o f t u m o r s using u l t r a s o u n d g u i d a n c e . for the treatment of liver t u m o r s . c r y o t h e r a p y r e q u i r e s a l a p a r o t o m y for its application. accelerated functional r e c o v e r y . and to e r a d i c a t e i n d u c e d rat colon tum o r s and i m p l a n t e d f i b r o s a r c o m a s . infrared t h e r m o g r a p h y . w h i c h r e d u c e s c o s t of t r e a t m e n t . its p h y s i o l o g i c effects. interstitial p l a c e m e n t of laser liberoptics h a s been a p p l i e d successfully in large s u b c u t a n e o u s m e t a s t a t i c t u m o r s . and a l c o h o l injection is subject to imprecision in a d m i n i s t r a t i o n a n d a requirement for repeat t r e a t m e n t s .1 7 1 8 143 . which is r e p l a c i n g " o p e n " l a p a r a t o m y . 1 2 . h o w e v e r . S i n c e t h e m i d . b e c a u s e t h e lowest t e m p e r a t u r e a c h i e v e d in a t u m o r m a s s is the key predictor of treatment r e s p o n s e . and b a c k g r o u n d a r e r e v i e w e d in this c h a p t e r . C l e a r l y t h e s e t e c h n i q u e s a r e not ideal. w h i l e u s i n g m i n i m a l l y i n v a s i v e surgical a c c e s s and improved "real" time monitoring systems. 5 D r i t c h i l o et a l .12 Laser Photothermal Therapy for Cancer Treatment Dan J. resulting in r e d u c e d morbidity. Jacques Soudant T h e therapeutic value of heat w a s first r e c o g n i z e d and reported in the t i m e of the ancient E g y p t i a n s m o r e than 2 0 0 0 years a g o . r e p r o d u c i b l e . a great public interest in t h e r e l a t i o n s h i p b e t w e e n cost and quality has d e v e l o p e d . 1 2 . a v a i l a b l e s e v e r e l y limits its utility. T h e u n e v e n heating a c h i e v e d by local h y p e r t h e r m i a t e c h n i q u e s presently Interstitial laser therapy of t u m o r s is a p r o m i s i n g n e w a p p r o a c h b e c a u s e it is m i n i m a l l y i n v a s i v e and allows precise and controlled delivery of p h o t o t h e r m a l e n e r g y into tissues. Romaine E. which limits r e p e a t e d treatment. W i t h all of these t e c h n i q u e s the major p r o b lem is to precisely focus t h e e n e r g y on the target tissue to predictably induce the required cell death. H a s h i m o t o e t a l .2 ) . T h e r e is an o b v i o u s need to d e v e l o p better techn i q u e s to i n d u c e t u m o r n e c r o s i s in a m o r e predictable w a y .

which a l l o w t h e insertion of multiple fibers. T2-weighted image of three in vivo laser lesions made at 2(X)() J in (he normal muscle of a rabbit. 2 2 Daiku/. T h i s c o n c e p t . has p r o v e d difficult to a c h i e v e in practice. Figure 1 2 . Mood. P h o t o c h e m i c a l effects depend on the a b s o r p t i o n of light to initiate c h e m i c a l reactions such as the . while attractive. the high power density at the distal end of the optical fiber resulted in frequent tip d a m a g e . nonuniform distribution of laser energy.ono and J o f f e 2 1 further developed a computer-controlled N d : Y A G system for intcrstital local h y p e r t h e r m i a To i n c r e a s e the area of n e c r o s i s that could be produced using a single laser as the e n e r g y s o u r c e . Lesions were produced using 5 W X 400 sec. and p h o t o t h e r m a l . 2 1 . and a uniform pattern of laser b e a m delivery from the probe have allowed testing of N d : Y A G l a s e r . 2 1 which h a v e high melting points (202O-2050°C).1 . demonstrating a transient hyperechoic signal during energy deposition. (B) The 10-MHz transducer is placed on the skin while the laser needle is introduced transcutaneously in the tumor and its position confirmed by ultrasonography. 1 9 . (C) The Nd:YAG laser is then turned on while the ultrasound monitors the tissue effects. (A) Interstitial Nd:YAG laser treatment of a recurrent midline neck squamous cell carcinoma guided by ultrasound. S t e g e r and B r o w n 2 2 e m p l o y e d f i b e r . 10 W X 200 sec. LASER TISSUE EFFECTS T h e p h o t o b i o l o g i c effects of laser light on tissue can be s e p arated into three c a t e g o r i e s : p h o t o c h e m i c a l . However. and 20 W X 400 sec.i n d u c e d hyperthermia in a d o g m o d e l . of 1-second duration to produce areas of vaporization and necrosis of 16 to 22 mm in the porcine liver. T h e recent introduction of synthetic sapphire p r o b e s .I 44 Lasers in Maxillofacial Surgery and Dentistry Figure 1 2 . 2 0 used high-powered N d : Y A G of up to 100 W. G o d l e w s k i et a l .o p t i c c o u p l i n g s y s t e m s . At the core of each lesion is the center filled with interstitial fluid. or air. greater tensile strength. difluser fiber tip to treat liver t u m o r s with evidence of reduction of t u m o r size.2 . Concentric layers of signal intensity change correspond to coagulated (dark) and interstitial edema (bright and diffused) zones. burning. and poorly reproducible tissue effects. p h o t o m e c h a n i cal.

it m a y reduce its c h e m o t h e r a p y a n d / o r ra- . Such effects occur. d e p e n d i n g on the type of tissue and e x p e r i m e n t a l or therapeutic c i r c u m stances. T u m o r cells are preferentially killed in the S-phase d u r i n g hyperthermia. 3 0 Moritz and Henriques studied the effects of t h e r m a l b u r n s induced in pig skin and h u m a n s after e x p o s u r e to t e m p e r a t u r e s above 4 4 ° C . h y p e r t h e r m i a inhibits D N A replication and D N A and protein synthesis. but do interact with a natural or e x o g e n o u s p h o t o s e n s i li/er to p r o d u c e the desired reaction. b e c a u s e the perfusion rate is r e d u c e d with increasing size of a t u m o r . and e n e r g y d e p r i v a t i o n . previously inaccessible to the o p tical p e n e t r a t i o n of the w a v e l e n g t h used. which radically c h a n g e s the optical characteristics of tissues and their absorption efficiency of infrared lasers. In addition. 28 Early o b s e r v a t i o n s of tissue h y p e r t h e r m i a w e r e m a d e in the late 1920s by W e s t e r m a r k 2 9 and P i n c u s a n d F i s c h e r . In h y p e r t h e r m i a cells that are heated to t e m p e r a t u r e s r a n g i n g from 4 0 ° to 4 5 ° C c a n sustain reversible injury that b e c o m e s irreversible ( d e a t h ) after e x p o sure from 25 m i n u t e s to several h o u r s . T h e s e p h o t o t h e r m a l effects can be further subdivided into three c a t e g o r i e s : (1) laser hyperthermia. and e n e r g y density can be controlled to shift the location of the m a x i m u m rise of tissue t e m p e r a t u r e at v a r i o u s d e p t h s . because the g l y c o l y t i c pathway remains a l m o s t unaffected for a p r o l o n g e d time. By this definition. although m e m b r a n e rupture m a y result from alterations in lipids. T h e r m a l c o a g u l a t i o n of tissues is d e fined as t h e r m a l l y i n d u c e d . m e m b r a n e s . In addition this t e c h n i q u e is slow.t e m p e r a t u r e . thermal tissue c o a g u l a t i o n differs from low t e m p e r a t u r e injury in that the a l w a y s lethal c o a g u lative lesions are m a r k e d by structural c h a n g e s seen i m m e diately after heating. blood perfusion rate.5°C b e c a u s e cells die after heating in a t i m e . specifically if their m i c r o e n v i r o n m e n t is characterized by h y p o x i a . and cis-platinum is enh a n c e d by heat treatment (T = 4 0 ° . 3 4 it results in d e c r e a s e d heat dissipation 31 3 BIOLOGIC EFFECTS OF HYPERTHERMIA A n u m b e r of biologic m e c h a n i s m s h a v e p r o v i d e d a rationale for c o n s i d e r i n g h y p e r t h e r m i a as an a n t i t u m o r agent. and leads to c h a n g e s in m e t a b o l i c p r o c e s s e s . P h o t o t h e r m a l effects result from the t r a n s f o r m a t i o n of absorbed light e n e r g y to heat. and difficult to a p p l y . w a t e r loss reduces the thermal conductivity and specific heat of tissues. and incident energy density. At and h i g h e r local t e m p e r a t u r e s for a given e n e r g y . c u m bersome.and cell c y c l e . H y p e r t h e r m i a acts as a c y t o t o x i c agent at t e m p e r a t u r e s higher than 42. and extracellular c o m p o n e n t s that are o b s e r v a b l e with the naked eye a n d / o r m i c r o s c o p e . for e x a m p l e . o r g a n e l l e s . A d r i a m y c i n . In most t u m o r s . Both s y s t e m i c a n d local h y p e r t h e r m i a h a v e been tested clinically with limited s u c c e s s . W h e n tissue t e m p e r a t u r e is raised a b o v e 100°C. despite the fact that blood flow inhibition m a y increase the cytocidal effects of h y p e r t h e r m i a . an elevated rate of m e t a b o lism is s e e n . tissue extinction coefficient. mainly b e c a u s e of the difficulties in delivering a uniform level of e n e r g y throughout the t u m o r m a s s . 2 3 Dethlefse n and Dewey. which p r o d u c e shock w a v e s and p l a s m a s . 5 ° C . a n d short laser pulses ( 1 0 -6 second or less). 145 a t e m p e r a t u r e r a n g e b e t w e e n 4 0 ° and 4 2 . H o w e v e r . 3 2 I n addition. In photoablation. heat can inc r e a s e cell killing in a synergistic w a y following e x p o s u r e of a t u m o r to ionizing radiation or to c h e m o t h e r a p e u t i c d r u g s . with heating t i m e s b e t w e e n 1 second and several h o u r s . T h e Iherm a l distribution in tissues. cells. P i n c u s and F i s c h e r " o b s e r v e d that a b o v e 4 4 ° C an inc r e a s e in t e m p e r a t u r e of 1°C w a s equivalent to increasing t h e t i m e of h e a t i n g by a factor of t w o and vice versa O n e of t h e m a i n s u b c e l l u l a r targets for h y p e r t h e r m i a is cell m e m b r a n e p r o t e i n . t h e rate of t e m p e r a t u r e rise. T h i s a d e n o s i n e triphosphate ( A T P ) depletion plays an uncertain role during heat-ind u c e d cell killing. irreversible alteration of proteins and other biologic m o l e c u l e s . 2 5 H o r n b a c k . w h e n a laser is o p e r a t e d in the Q . B i c h e r and B r u l e y . Black char.d e p e n d e n t m a n n e r ." W a t e r loss results in tissue desiccation.i n d u c e d radiosensitization is probably seco n d a r y to the inhibited repair of radiation induced D N A lesions. (2) p h o t o a b l a t i o n . 24 D i e t z e l . C o o l i n g at t h e surface. and the steady state t e m p e r a t u r e are d e t e r m i n e d by multiple par a m e t e r s including thermal c o n d u c t i v i t y . S u b surface heating g e n e r a t e s b u b b l e s that eventually e x p l o d e in a series of e v e n t s called the " p o p c o r n effect. will shift the location of the m a x i m u m t e m p e r a t u r e rise from the surface to a d e e p e r layer. indicating thermal c o a g u l a t i o n . t h e process of p h o t o c a r b o n i z a t i o n a n d / o r p h o t o e v a p o r a t i o n will occur with an e x p l o s i v e f r a g m e n t a t i o n of tissue loss. heating conditions at the surface. T h i s h e a t .s w i t c h e d m o d e .4 2 . T h e relationship b e t w e e n the t e m p e r a t u r e and t i m e for w h i c h it is a p p l i e d is not a simple linear product of these t w o variables. P h o t o m e c h a n i c a l responses o c c u r d u r i n g application of e x t r e m e l y high t l u e n c e rates (greater than 1 0 8 W / c m 2 ) . It is associated with low fluence rates that do not produce a significant t e m p e r a t u r e increase in the treated tissue. and gray s m o k e are the p r o m i n e n t p h e n o m ena characterizing the clinical u s e of the process of p h o t o carbonization.Laser Photothermal Therapy for Cancer Treatment production of reactive c h e m i c a l s p e c i e s in p h o t o d y n a m i c therapy. T h i s p r o c e s s is easier and faster to d e liver and control in tissues. which m a y be p o o r and sluggish in t u m o r s . yellow flames. F a c t o r s such as optical w a v e l e n g t h s . w h i c h is followed by an inhibition in energy production in m o s t c e l l s . 3 3 . h e a t losses at e x p o s e d surfaces. T h i s e n h a n c e d effect of heat on t u m o r cells m a y also be attributed to blood flow. Most of these alterations are due to thermal denaturation of structural p r o t e i n s . In addition. 5 ° C ) . t h e tissue is rapidly h e a t e d to a r a n g e of 60° to 100°C w h e r e visible w h i t e n i n g is seen. a significant reduction in blood flow will be o b s e r v e d if a p p r o p r i a t e tissue t e m p e r a t u r e levels and heat e x p o s u r e a r e c h o s e n . for e x a m p l e . and (3) p h o t o c a r b o n i z a t i o n or p h o t o e v a p o r a t i o n . D u r i n g m o d e r a t e inc r e a s e s in tissue t e m p e r a t u r e . specific heat s o u r c e . acidity. 2 6 an d S t o r m 2 7 d e m o n s t r a t e d that the action of b l e o m y c i n .

5 ) . T h e intercellular s p a c e b e c o m e s h y p o x i c .5 T S i g n a ( G E Medical S y s t e m s . introduction and position is made on the screen.1 9 9 4 ) a t t h e U C L A School o f M e d i c i n e . and g r o w t h rate. W i t h t h e c o l l a b o r a t i o n of a n u m b e r of different m a n u f a c t u r e r s a variety of n e w M R .3 ) .g r o w i n g . 4 2. w h i l e 1 7 % w e r e treated in an u p g r a d e d interventional M R I suite (Fig. In 9 0 % of the c a s e s the n e o d y m i u r m y l t r i u m . Most patients ( 8 3 % ) w e r e treated in the o p e r a t i n g r o o m using U T Z a s t h e g u i d i n g i m a g i n g m o d a l i t y ( F i g . 1 2 . local t u m o r " c o n t r o l " o r " c u r e " w a s o b s e r v e d (Fig. u s i n g the c o n c e p t of i m a g i n g . with 8 0 % s h o w i n g i m p r o v e m e n t a n d / o r resolution of s y m p t o m s after o n e to five sessions. the a b s e n c e of b e a m .c o m p a l i b l e d e v i c e s w e r e introduced in a standard sup e r c o n d u c t i n g 1. S m a l l e r . In 50 to 8 0 % o f the patients. H o w e v e r .h a r d e n i n g artifacts from b o n e .146 Lasers in Maxillofacial Surgery and Dentistry diosensitizing effects b e c a u s e heat d i m i n i s h e s t h e rate of d r u g delivery and m a k e s t h e t u m o r m o r e h y p o x i c . then s e r v e s a s a monitor for t u m o r destruction in real or " n e a r " real time. thereby inhibiting the repair of the thermal d a m a g e and the d e v e l o p m e n t of t h e r m o t o l e r a n c e . a lack of ionizing radiation. 1 2 . Most patients w e r e in the fifth and sixth d e c a d e of life and w e r e treated for palliation in an a t t e m p t to c o n t r o l s y m p t o m s such as pain. Ninety percent of the patients w e r e treated o n a n outpatient b a s i s . w h i l e the C 0 laser and ultrasonic energy w e r e used in the r e m a i n i n g c a s e s . histology. Based on laser dosimetry study presurgical planning of the needle. (B) Presurgical MR images of the same patient showing the needles in the tumor during energy deposition. d y s p n e a .5 2 T h e availability o f o b l i q u e and multiplanar i m a g ing capabilities.g a r n e t ( N d r Y A G ) laser w a s used either externally o r interstitially ( 6 0 0 p m b a r e fiber optic) t o p h o - Figurc 1 2 . several limitations of current MR s y s t e m s must be resolved for its effective and safe u s e for interventional p r o c e d u r e s . d y s p h a g i a . A series of 55 p a t i e n t s w e r e treated o v e r a 6 . T h i s r e s p o n s e w a s linearly related to t h e initial t u m o r v o l u m e . m o r e differentiated t u m o r s were 2 . high tissue contrast anil resolution.32-41 In recent years M R I h a s p r o v e n to be o n e of t h e most useful m o n i t o r i n g t e c h n i q u e s for interstitial t u m o r thera p y .3 . which further e n h a n c e s the c y l o c i d a l effects of hyperthermia. 1 2 . s l o w .c o n t r o l l e d interstitial t u m o r therapy ( I T T ) e m p l o y s M R I a n d / o r U T Z s y s t e m s t o safely g u i d e t r a n s c u t a n e o u s p l a c e m e n t of an e n e r g y s o u r c e in a t u m o r w h i l e a v o i d i n g s u r r o u n d i n g o b s t a c l e s . with a m e a n of t w o treatments.a l u m i n u m . T h e high m a g n e t i c f i e l d (1. M i l w a u kee) MRI suite p e r m i t t i n g the use of practical interventional p r o c e d u r e s in this r o o m (Fig.4 ) .y e a r period ( 1 9 8 8 .g u i d e d m i n i m a l l y i n v a s i v e therapy. 1 2 .1 ) . l o cated in different a n a t o m i c sites within t h e head and neck. and b l e e d i n g . (A) Presurgical 3D-MR1 of a patient with an unresectable recurrent submental carcinoma. T h e r e fore. T h e d e c r e a s e d blood flow to the t u m o r during h y p e r t h e m i a also g e n e r a t e s a cellular m i c r o e n v i r o n m e n t that can sensitize c a n c e r cells to heat. toablate the t u m o r s . a p p r o p r i a t e timing and s e q u e n c i n g is required w h e n using h y p e r t h e m i a in conjunction with c h e m o t h e r a p e u t i c d r u g s a n d / o r radiation therapy. 12^+). and the recent d e v e l o p m e n t of ultrafast MR pulse s e q u e n c e s m a k e M R I particularly useful d u r i n g minimally invasive s u r g e r y (Fig. IMAGING-GUIDED MINIMALLY INVASIVE THERAPY T h e c o n c e p t of i m a g i n g . Most treated t u m o r s ( 9 0 % ) w e r e s q u a m o u s cell c a r c i n o m a s . acidic and d e p r i v e d of nutrients.5 T ) o f the M R e n v i r o n m e n t and the closed cylindrical s h a p e of the m a g n e t s e v e r e l y restrict both physical access to the patient as well as a c c e s s to the m o n i toring and treatment d e v i c e s in u s e .

1 ) . a n d / o r i n d u c e p h o t o c o a g u l a t i o n necrosis and suction the d e b r i s . Inc. N d : Y A G laser e n e r g y ( 9 0 % o f c a s e s ) w a s a p plied interstially a n d / o r externally w h i l e using T2 fast spin echo (FSE) MRI or U T Z as a monitoring technique. a variable n u m b e r of 16-gauge M R I . In addition. T h e initial t u m o r v o l u m e as calculated by 3 D . T h i s patient did well afterward and died of acute m y o c a r d i a l infarction 4 years after her initial palliative treatment. palliated successfully and had a "better c h a n c e " for local cure than did rapidly d i v i d i n g m a l i g n a n c i e s . As tissue photoablation o c c u r r e d . The C 0 laser ( 7 % ) and ultrasonic ( 3 % ) e n e r g i e s w e r e used externally in the r e m a i n i n g c a s e s .000 e p i nephrine. 1 2 .M R I a n d / o r with U T Z d e t e r m i n e d the n u m b e r of treatm e n t sessions with larger t u m o r s r e q u i r i n g multiple treatm e n t s . the patients w e r e p l a c e d on continuous c a r d i a c and pulse o x i m e t r y m o n i t o r i n g and then heavily sedated or placed u n d e r general anesthesia by an ancsthesiologst. with special attention given to their p r o x i m i t y to t h e great vessels and to t u m o r neovascularity. kidney.Laser Photothermal Therapy for Cancer Treatment 147 Figure 12-4. the operator console (B). and prostate.E M .) w e r e then p a s s e d p c r c u t a n e o u s l y into the t u m o r m a s s .uxtron tluoroptic thermometer (£). 2 CONCLUSION T h e t e c h n i q u e o f interstitial t h e r a p y guided b y M R I a n d / o r U T Z is likely to b e c o m e a m i n i m a l l y invasive m e t h o d for initial treatment of b e n i g n t u m o r s of the head and neck. the t u m o r m a s s w a s frequently irrigated with normal saline and suctioned ( F i g . O v e r 8 0 % of the patients h a v e s h o w n significant functional a n d / o r c o s metic i m p r o v e m e n t and w e r e a b l e to r e s u m e daily activities for periods of up to 4 years posttreatment with a m e a n of 18 months (range: 3 m o n t h s to 5 y e a r s ) . P r o c e d u r e s w e r e carried out on inpatients using the operating r o o m and on outpatients using an M R I unit specially equipped with a v i d e o m o n i t o r i n g s y s t e m . which is kept outside the magnet (C). the Laserscope KTP:YAG laser. T h e m e a n survival for the study g r o u p w a s 18 m o n t h s . E n d o t r a c h e a l intubation w a s required to protect t h e a i r w a y . At the end of e a c h p r o c e d u r e a pressure d r e s s i n g w a s a p p l i e d and t h e patients w e r e a w a k e n e d from anesthesia. T h e surgical f i e l d w a s p r e p a r e d and d r a p e d in a sterile fashion. the Coherent power meter and detector head (I)). treatment m a y be r e p e a t e d m a n y t i m e s w i t h o u t the morbidity of surgery a n d / o r radiation therapy. B e c a u s e it is performed u n d e r local a n e s t h e s i a on an outpatient basis using a single needle stick. d e b u l k it. it will be m u c h less e x p e n s i v e than open p r o c e d u r e s . b e c a u s e laser light is n o n i o n i z i n g . After o b t a i n i n g appropriate informed c o n s e n t . T h e only p r e m a ture death o c c u r r e d in the first patient 3 m o n t h s p o s t o p e r a tively of unrelated c a r d i o p u l m o n a r y d i s e a s e . During the p r o c e d u r e att e m p t s w e r e m a d e t o either excise the t u m o r with m a r g i n s . Based upon the t u m o r v o l u m e to be treated. Setting of the MR suite showing the GE Signa MR magnet (A). O n l y o n e major c o m plication w a s o b s e r v e d in a c a s e early in this series. a n d t h e skin o v e r l y i n g t h e t u m o r m a s s was anesthetized with 1% l i d o c a i n e with 1:100. the l.c o m p a t i b l e needles (EZ . MRI (5 patients) or U T Z (25 patients) (Fig. 1 2 . A 6 0 0 p m f l e x i b l e N d : Y A G laser f i b e r o p t i c cable was then passed t h r o u g h the lumen of the needle and into the t u m o r m a s s . O v e r three million " o p e n " surgical p r o c e d u r e s per y e a r are p e r f o r m e d to r e m o v e tu- . A perioperative bleed o c c u r r e d during interstitial laser e n e r g y deposition that required e m b o l i z a t i o n .1 ) w a s used to c o n f i r m the position of the tip of the catheters within the t u m o r m a s s . breast.

76(4):378-381. this t e c h n i q u e m a y b e e x t e n d e d t o o t h e r d i s e a s e s such a s brain t u m o r s . Yu YQ. Inc. 10. 1907. Low power interstitial Nd-YAG laser photocoagulation in normal and neoplastic rat colon. Photoradiation in the treatment of recurrent breast carcinoma. Lawrence G. Br J Surg 1989. Inc. France). Small hepatocellular carcinoma: percutaneous alcohol injection results in 23 patients. Valley L a b . ethanol injection. Dougherty TJ. In t h e future. et al. Cady B. Milne JS. Am J Roentgenol 1987. 9. prostatic m a s s e s . O h m e d a . World J Surg 1983. Yasuda H. e m p l o y i n g lasers o f o t h e r w a v e l e n g t h s . Gutachten der Wiener Medizinischen Fakultaet. If only 1 0 % of these patients b e c o m e c a n d i d a t e s for this t e c h n i q u e of interstitial t h e r a p y g u i d e d by i m a g i n g t e c h n i q u e s . Hepatic cryosurgery with intraoperative ultrasound monitoring for metastatic colon carcinoma. DuPont M e r c k . Cummins L. Clinical evaluation of cryosurgery in the treatment of primary liver cancer (report of 60 cases). Breasted JH. et al. B P 3-94801 Villejuif Cedex. Tralau C. Dougherty TJ. a b d o m e n . Salmi A. Kane R. Ravikumar TS. Ma ZC. 1985.149:949-952. Acknowledgments T h i s study w a s s u p p o r t e d b y t h e Division of H e a d and N e c k S u r g e r y . Dritchilo AE. Am J Roentgenol 1986. Lasers Surg Med. it c o u l d lead to substantial s a v i n g s and benefit m i l l i o n s of patients. The thermal response of laser irradiated tissue.. vol 1. breast. 13.29:27-34. Nauenberg M. Barton T. et al. Livraghi T. or interstitial radioactive seed implantation.(A) and post.61:1889-1892. The patient's tumor regressed completely and remained free of local recurrence 2 years posttreatment m o r s of t h e head and neck.O l R . m i c r o w a v e s . R . L a s e r s c o p e .. Photoradiation therapy for the treatment of malignant tumors. Zhou XD. and single-level d i s k d i s e a s e s . . 11. and N I H grant # C A 6 5 0 5 3 . Inc. Figure 12-5. 7. Goldfarb A.42:99-102. Tang ZY. Thermal and optical properties of living tissue: application of laser-induced hyperthermia. T h e t e c h n i q u e s d e v e l o p e d for N d : Y A G I T T m a y b e a d a p t a b l e to o t h e r f o r m s of m i n i m a l l y i n v a s i v e interstitial t u m o r t h e r a p y . Gut 1988. t h e Elsa P a r d e e F o u n d a t i o n . 12. Jahrb Psychiat Neurol 19I7-18. Pre. all t u m o r m e t a s t a s e s . Bown SG. Cancer Res. Boerslid T. Phototherapy to tumors. . Matthevvson K.7:700-709. Kaufman JE. Shiina S. Radiology 1988. C .E M . o u t p a t i e n t basis. 16. Svassand LO. 122:403-409. a n d the Association d e R e c h e r c h e sur l e C a n c e r ( A . N I H grant # U S H H S D C 0 0 3 1 . U C L A School o f M e d i c i n e . Bown SG. et al. Low power interstitial Nd-YAG laser photocoagulation. T r i m e d y n e . Percutaneous ethanol injection in the treatment of liver neoplasms.(B) 3D-MR images on a patient with a large base of skull carcinoma that was treated using the concept of imaging-guided surgery. In-Vivo Research Inc.5:589-602. et al. 4. 6. S u c h treatm e n t s h a v e the potential to p r o v i d e meaningful palliation for patients with a d v a n c e d head and neck c a n c e r on a costefficient. Interstitial radiation therapy for hepatic metastases: sonographic guidance for applicator placement. c h e s t . et al. studies in a transplantable fibrosarcoma. Biophys J 1983. IEEE J Quant Electron 1984.Z .38:1^18. 8. Lewin MR.. 5. Harter KW. Oeveraasen M. 168:313-317. et al. 1985. REFERENCES 1. Arch Surg 1987. Oxford: Clarendon Press. Matthewson K. Cancer 1988. 3.20:1471-1484. Grant EG. Bolondi L. Welch AJ. 2. R e s o n a n c e T e c h n o l o g y . Wagner von Jauregg J.62:231-237. Surgical Instruments in Greek and Roman Times. Chicago: University of Chicago: 1930. Kaufman JH. Thermal effects of laser radiation in biological tissue. 14. liver.148 Lasers in Maxillofacial Surgery and Dentistry radio frequency. 15. Barr H. k i d n e y .. Muto H. E . The Edwin Smith Surgical Papyrus.38:2628-2635.164:275-278. c r y o t h e r a p y . J Natl Cancer Inst 1979. and the J o n s s o n C o m p r e h e n s i v e C a n c e r C e n t e r C I C R A w a r d . G E Medical S y s t e m s . and other p a t h o l o g i c c o n d i t i o n s .

A r t h r o s c o p y of the T M J h a s consequently progressed from an instrument of d i a g n o s i s to one of treatment. triangulalion. 1 2 3.3 m m .4 to 0. 5 THE Ho:YAG LASER T h e H o : Y A G laser is a solid-state laser e m i t t i n g at 2 1 9 2 n m . K o s l i n d e m o n s t r a t e d intraarticular t e m p e r a t u r e e l e v a t i o n s of an a v e r a g e of I 0 ° F (range = 1. a r e in u s e currently to r e m o v e d e g e n e r ated f i b r o c a r t i l a g e . w h i c h c l o s e l y c o r r e s p o n d s with a major spectral a b sorption p e a k for w a t e r in the infrared region of the electrom a g n e t i c s p e c t r u m . Lasers. excellent a c c e s s . ' T h e i r ability to b l o o d l e s s l y r e m o v e tissue in a p r e d i c t a b l e . particularly the h o l m i u m : y t t r i u m . Butler A d v a n c e s in arthroscopic i n s t r u m e n t a t i o n and t e c h n i q u e for small joint surgery h a v e recently found application in surgery for the t e m p o r o m a n d i b u l a r joint ( T M J ) . H o w e v e r . there is very little u n w a n t e d thermal d a m a g e lateral to the vaporization crater. T h e r e f o r e . o n e would not e x p e c t to e n c o u n t e r significant heat effects. and c o n t r o l l a b l e tissue r e m o v a l h a s m a d e this an exciting area for surgical development. the d e m a n d c r e ated by the refinement of surgical skills by the profession has resulted in the rapid r e s p o n s e by industry to p r o d u c e arthroscopes and high-resolution v i d e o s y s t e m s that a r e specifically d e s i g n e d for use in the T M J . particularly n o n r e d u c i n g d i s k displacement (closed lock). T h e objective of incising of a t t a c h m e n t s of the lateral pterygoid m u s c l e to the anterior b a n d or resecting the m e n i s c u s w o u l d be a c h i e v e d with e l e c t r o c a u t e r y but only at the e x p e n s e of e x c e s s i v e heat d a m a g e and carbonization ( c h a r r i n g ) of the target tissue and s y n o v i u m . C o u p l e d with the advent of high-resolution m a g n e t i c r e s o n a n c e imaging ( M R I ) the a c c u r a c y o f d i a g n o s i s o f T M J d i s o r d e r s has been greatly e n h a n c e d .2-22.13 Laser-Assisted Temporomandibular Joint Surgery Steven ]. r e p r o d u c i b l e w a y with m i n i m a l u n w a n t e d heat d a m a g e in a fluid m e d i u m c o m p a t i b l e with g o o d vision. arthroscopic surgery has b e c o m e an alternative to open arthrotomy for the treatment of internal joint d e r a n g e m e n t involving the m e n i s c u s (disk). C o n s e q u e n t l y . T h i s laser o p e r a t e s in a pulsed m o d e at a pulse width of 3 5 0 p s . o r b o n e . B e c a u s e the H o : Y A G e m i s s i o n is highly abs o r b e d by w a t e r with an a v e r a g e depth of absorption of 0.0 mm d e p e n d i n g on tissue t y p e and the e x p o s u r e p a r a m e t e r s of the individual laser. As a c o n s e q u e n c e of predictable successful o u t c o m e s with diminished m o r b i d i t y in surgery of the u p p e r T M J s p a c e . and the introduction of a r t h r o scopic hand i n s t r u m e n t s and m e c h a n i z e d s h a v e r s . T h e surgical alternative of using a mechanical s h a v e r w a s unsatisfactory because of its inefficiency and u n p r e d i c t a b l e results o c c u r r i n g as a c o n s e q u e n c e of limited access and maneuverability within the restricted confines of a small j o i n t space.6 m m . ' c o n t i n u e d technical d e v e l o p m e n t s resulted in the refinement of surgical t e c h n i q u e . it r e m o v e s tissue precisely. N e v e r t h e l e s s . T h e s e included predictable and r e p r o d u c i b l e joint entry a n d distension. As the safety and early s u c c e s s of a r t h r o s c o p y of the T M J b e c a m e e s t a b l i s h e d . In fact. s c u l p t i n g . which is well below the thermal relaxation time for m o s t tissues with high w a t e r content. they r e m a i n e d inefficient.a l u m i n u m . T a r r o " m e a s u r e d tissue necrosis with H o : Y A G and found it to be 0. As its usefulness for the treatment of internal d e r a n g e m e n t s . w h e r e a s e l e c t r o c a u t e r y p r o d u c e d necrosis of 151 .1 to 1. T h e y a l s o a r e c a p a ble of m a k i n g releasing incisions while cauterizing b l e e d i n g b l o o d v e s s e l s o r p h o t o a b l a t i n g the n e o v a s c u l a r ization of s y n o v i t i s . n e w i n s t r u m e n t s h a v e been d e v e l o p e d that permit j o i n t entry through c a n n u l a s less that 3 mm in d i a m e t e r . Fortunately. and c a u t e r i z a t i o n of j o i n t tissues h a v e been similarly refined. Instruments for incising. B e c a u s e the target tissue itself h a s a high w a t e r c o n t e n t and the laser o p e r a t e s within 7 T h e d e v e l o p m e n t of miniaturized laser delivery s y s t e m s using optical fibers and " u s e r friendly" control s y s t e m s for a fluid m e d i u m . s y n o v i u m . T h e H o : Y A G laser configured for arthroscopic surgery c o n s i s t s of a free-beam laser with a sterile fiber-optic delivery s y s t e m and the a p p r o p r i a t e l y a d a p t e d arthroscope and v i d e o s y s t e m . h a s b e c o m e generally a c c e p t e d .6°F) m e a s u r e d with an intraarticular t h e r m o c o u p l e d u r i n g H o : Y A G arthroscopic surgery. even with m i n i m a l u n w a n t e d heat effects the actual thermal inj u r y m a y vary from 0.4 small joint arthroscopic s y s t e m s in o r t h o p e d i c s resulted in their adaptation for use in t h e T M J . the search for i m p r o v e d i n s t r u m e n t a t i o n h a s resulted in t h e d e v e l o p m e n t of various laser s y s t e m s for T M J surgery.g a r n e t ( H o : Y A G ) laser emitting at 2 1 9 2 n m .

L o w e r settings are s u g g e s t e d for m a k i n g releasing incisions. In addition to the t h e r m a l effects the short pulse width of 3 5 0 ps associated with high fluence rates m a y also induce p h o t o m e c h a n i c a l and p h o t o a c o u s t i c effects that also c o n t r i b u t e to tissue ablation.8 m m . Several f i b e r delivery m e t h o d s are available. . C o m m e r c i a l l y available l o w output H o : Y A G lasers a r e quite a d a p t a b l e for T M J a r t h r o s c o p i c s u r g e r y .1 52 Lasers in Maxillofacial Surgery and Dentistry 0. T a b l e 13-1 s u m m a r i z e s suitable e n e r g y levels for different p r o c e d u r e s .7 to 1. S o m e s u r g e o n s prefer a side firing tip to a c c e s s t h e lateral a s p e c t s of t h e joint w h i l e o t h e r s prefer to bend the fiber slightly or use alternate port p l a c e m e n t s to reach this area. It is rare to require an output p o w e r in e x c e s s of 10 W or a post-repetition rate ( P R R ) e x c e e d i n g 10 Hz to resect fibrocartilage or rec o n t o u r b o n e . T h e specific styles and specifications vary a m o n g m a n u f a c t u r e r s .

a n d reduction with a blunt p r o b e prod u c e d a n a u d i b l e " s n a p .1 . S h e c o m p l a i n e d of severe pain in her right j o i n t w h e n a t t e m p t i n g to force her m o u t h o p e n and described a dull tight feeling in t h e joint "all the t i m e . S h e r e m a i n s pain free and functional since t h e n . " T h e patient d r e w a d i a g r a m that o u t lined her pain only in the p r e a u r i c u l a r area on t h e right side. T h e m e n i s c u s w a s found t o b e anteriorly and m e d i a l l y disloc a t e d ( F i g . T h e entire p r o c e d u r e lasted 32 m i n u t e s and t h e total laser u s a g e w a s less than 5 m i n u t e s .1 ) . T h e laser w a s d e f o c u s e d a t the s a m e settings and w a s u s e d to c a u t e r i z e and shrink t h e posterior tissues. There were no joint sounds or crepitus. T h e laser w a s set at 8 W o u t p u t p o w e r . recovery w a s uneventful and physical t h e r a p y w a s given in six sessions. A predicted right posterior o p e n bite w a s present after s u r g e r y and this o c c l u s a l c h a n g e w a s maintained during the p o s t o p e r a t i v e p h a s e u s i n g a prefabricated hard acrylic o c c l u s a l splint. w h i c h w e r e not p r o b l e m a t i c for her. 1 3 . T h r e e m o n t h s later she d e v e l o p e d limitation on o p e n i n g of 32 m m . Retrodiscal tissues are shown stretched over posterior portion of condylar head. Figure 13-2. A n arthroscopic release a n d r e p o s i t i o n i n g p r o c e d u r e w a s 2 153 carried out u n d e r a g e n e r a l a n e s t h e t i c using c o n v e n t i o n a l a r t h r o s c o p i c t e c h n i q u e s a s described b y M c C a i n .P D S E t h i c o n . A res o r b a b l e s u t u r e . Within 3 w e e k s of h e r surgery she had r e g a i n e d a m a x i m u m o p e n i n g o f 4 2 m m with n o detectable o p e n i n g click and 8 mm of lateral e x c u r s i v e m o v e m e n t s . pulsed m o d e at 5 Hz. T h e patient ultimately c h o s e c o m p r e h e n s i v e o r t h o d o n t i c treatment to correct h e r o c c l u s i o n . Bloodless releasing incision created through synovium and superior aspect of lateral pterygoid muscle using the Holmium:YAG laser. T h e masticatory m u s c l e s on the right w e r e slightly m o r e t e n d e r than t h o s e on the left but e s s e n tially all of her pain w a s focused in and a r o u n d t h e right T M J itself. T h i s resulted in a b l o o d l e s s releasing incision (Fig. She had an angle class I m o l a r o c c l u s i o n but t h e incisors w e r e retroclined and c r o w d e d . O . and a diagnosis of nonreducing T M J disk displacement (closed lock) w a s m a d e . " T h e H o : Y A G laser w a s used for a n t e r i o r release and p o s t e r i o r band cauterization. S h e reported little o r n o discomfort with mastication o r o p e n i n g but did notice o c c a s i o n a l a b n o r m a l noises in t h e joint. P o s t o p e r a t i v e l y . T h e r e w a s no pain on the left s i d e . Anterior and medial dislocation of TMJ mensicus. .2 ) . 1 3 . Joint i m a g i n g s h o w e d an a n t e r i o r dislocation of t h e right m e n i s c u s . Figure 1 3 . T h e left j o i n t w a s n o r m a l . H e r r e m o t e past history i n c l u d e d b r u x i s m and u s e of a soft interocclusal night g u a r d . H e r e x a m i n a t i o n s s h o w e d a m a x i m u m interincisal o p e n i n g o f 3 2 m m with significant deviation to the right w h e n her o p e n i n g r e a c h e d 28 mm.Laser-Assisted Temporomandibular Joint Surgery CASE 1 A 26-year-old w o m a n with a 5-year history of p o p p i n g in the right T M J d e v e l o p e d a s p o n t a n e o u s l y r e d u c i n g intermittent closed lock i m m e d i a t e l y after childbirth. w a s passed percutaneously t h r o u g h t h e posterior b a n d o f t h e disk. After d i s cussing nonsurgical and surgical t r e a t m e n t alternatives s h e c h o s e the surgical o p t i o n .

S h e had m a n d i b u l a r retrognathia with a d e e p bite. and the patient r e c o v ered uneventfully. removal of the m e n i s c u s with conventional shavers. T h e anterior recess c o n tained a d h e s i o n s and areas of e c c h y m o s i s and a p r o m i n e n t b o n y p r o t u b e r a n c e on the a n t e r o m e d i a l portion of the c o n d y l a r h e a d . T o m o g r a m s o f the t e m p o r o m a n d i b u l a r j o i n t s s h o w e d a small flattened m a n d i b u l a r c o n d y l e on the right. S h e had c o m p l a i n e d of noise in the joint and intermittent e p i s o d e s of locking that had been treated o v e r several years with v a r i o u s t y p e s of splints with s o m e i m p r o v e m e n t i n her s y m p t o m s . CONCLUSION A r t h r o s c o p i c s u r g e r y of t h e t e m p o r o m a n d i b u l a r joint has b e c o m e a valuable treatment modality that is rapidly replacing open joint p r o c e d u r e s for internal d e r a n g e m e n t . 2 4 Figure 1 3 . C o n s e q u e n t l y . a n d a m o n o p o l a r coagulation p r o b e w a s used to isolate several large pieces of disk. and rotary i n s t r u m e n t s is tedious and inaccurate. S o m e difficulty w a s e n c o u n t e r e d in a c c e s s i n g the most lateral aspect of the anterior joint s p a c e . Figure 13-5. Arthroscopic surgery w a s c h o s e n as the t r e a t m e n t of choice with a d i a g n o s t i c suspicion of a perforated m e n i s c u s . " A large disruption in the m e n i s c u s w a s seen ( F i g . B l e e d i n g w a s m i n i m a l . T h e right T M J w a s e n t e r e d without difficulty using standard triangulation t e c h n i q u e s . T h e laser fiber w a s placed in the anterior portal and serial sections of m e n i s c u s w e r e r e m o v e d and t h e joint m e c h a n i c s e v a l u a t e d (Fig. Her occlusion d e m o n s t r a t e d p r e m a t u r i t i e s on t h e right side and o r t h o d o n t i c follow-up w a s r e c o m m e n d e d . 1 3 . t h e d e c i s i o n w a s m a d e t o rem o v e t h e m e n i s c u s using the H o : Y A G laser. T h e left s i d e w a s n o r mal. the joint w a s inj e c t e d with a 0 .1 54 Lasers in Maxillofacial Surgery and Dentistry CASE 2 A 46-year-old w o m a n presented with pain in and a r o u n d her right t e m p o r o m a n d i b u l a r j o i n t . Physical e x a m i n a t i o n s h o w e d a m a x i m a l interincisal o p e n i n g of 18 mm with e s sentially no translation to the left. e v e n with resection of the a n t e r o m e d i a l portion of t h e m e n i s c u s . Palpation of t h e right p r e a u r i c u lar area d e m o n s t r a t e d c r e p i t u s and t e n d e r n e s s w h i l e the left side w a s n o r m a l . Figure 13-4.3 . Varied e n e r g y levels and pulse settings w e r e used r a n g i n g from 5 to 8 p u l s e s per s e c o n d at an a v e r a g e p o w e r of 8 to 10 W.3 ) . A g g r e s s i v e physical therapy w a s initiated on the s e c o n d postoperative day and no p o s t o p e r a tive c o m p l i c a t i o n s w e r e o b s e r v e d . M R I c o n f i r m e d a g r a d e IV d i s l o c a t i o n of t h e right m e n i s c u s with p o s s i b l e f r a g m e n t a t i o n . S h e d e nied a history of recent t r a u m a but noticed increasing c r e p i tus and pain o v e r the past 6 m o n t h s . H e r p o s t o p e r a t i v e interincisal o p e n i n g w a s 28 mm after 5 d a y s and 34 mm after 7 w e e k s . 1 3 . While anterior releasing incision and posterior scarification can easily be a c c o m p l i s h e d by t h e trained arthroscopist using e l e c t r o c a u t e r y . S h e c o n t i n u e d lo h a v e a mildly d e c r e a s e d left lateral e x c u r s i v e m o v e m e n t of the m a n d i b l e but related that although she still had s o m e mild discomfort in the j o i n t her pain was 9 0 % i m p r o v e d and she had no restrictions in her diet. 5 % b u p i v a c a i n e with dilute e p i n e p h r i n e s o lution after removal of the c a n n u l a s . Large perforation of meniscus with visible deformed condylar head. T h e r e w e r e no areas of defined m u s c l e tenderness. Resection of residual perforated meniscus using the Holmium:YAG laser. Completed laser-assisted menisectomy: View of intact cartilidge over deformed condylar head. S h e d e s c r i b e d h e r current pain as a periodic "jolt" in her right e a r and t e m p l e area that would be followed by a h e a d a c h e and l i g h t n e s s in her j a w . In .4 ) . After c o m p l e t i n g the m e n i s e c t o m y (Fig. T w o w e e k s prior t o her presentation she noted t h e onset of inability to open her m o u t h fully and slated that her level of pain had greally increased.5 ) . 1 3 .

St. TMJ Internal Derangement and Arthrosis: Surgical Atlas. In addition. Lasers are safe and effective w h e n standard p r e c a u t i o n s are taken. Arthroscopy: A Diagnostic and Surgical Atlas. 2. p e r m i t t i n g the perform a n c e of a w i d e r a n g e of p r o c e d u r e s on v a r i o u s tissue types. b e c a u s e the fiber is smaller and m o r e m a n e u v e r a b l e than c o n v e n t i o n a l rotary instruments.B. Louis: Mosby. 1992. 1987. Mooar P. 1985. M D : Dyonics. And o v e r . .Sanders B. Palo A l t o C A : Coherent.6 m m . use of the laser for arthroscopic s u r g e r y permits precise intraarticular tissue removal with excellent h e m o s t a s i s without the resultant heat d a m a g e to tissue that electrocautery p r o d u c e s . Philadelphia: J. De la Rua H. ablation is readily confined to the a b n o r m a l menisc u s .4 to 0. . Lippincott: 1993. 6. Oral Maxillofac Surg Clin North Am 1989:1:135-151. 7. Martin JC. C o n s e q u e n t to its excellent h e m o s t a t i c properties. T h e H o : Y A G laser is a m a z i n g l y versatile. J Oral Maxillofac Surg 1993:51:122-123. 8. Puncture technique and portals of entry for diagnostic and operative arthroscopy of the temporomandibular joint. McCain JP. McCain JP.Laser-Assisted Temporomandibular Joint Surgery contradistinction. B e c a u s e t h e depth of tissue penetration is usually only 0. 155 REFERENCES 1. Holmiuin:YAG laser arthroscopy of the temporomandibular joint. Tarro AW. An Illustrated Guide to TMJ Arthroscopy. Ciatcno J. postoperative h e m a r t h r o s e s h a v e been e l i m i n a t e d as a complication of intraarticular surgery. C o n t i n u e d study of the intraarticular a p p l i c a t i o n s of lasers will result in the d e v e l o p m e n t of m o r e s o p h i s t i c a t e d laser s y s t e m s p e r m i t t i n g the arthroscopist of the future even more c h o i c e s w h e n treating the d i s e a s e d t e m p o r o m a n d i b u lar joint. thereby m a x i m a l l y p r e s e r v i n g the n o r m a l areas of m e n i s c u s . 4. 3. Arthroscopy 1991:2:221-232. 5. The use of the holmium laser for temporomandibular joint arthroscopic surgery. McCain JP. Principles: practices of operative arthroscopy of the human temporomandibular joint. it m i n i m i z e s scuffing of c o n d y l a r surfaces. Hendler BH. Koslin MG. J Oral Maxillofac Surg 1992:50:931-934. et al. Arthroscopic Laser Debridement of Perforated Articular Disc Using the Versa Pulse Surgical Laser. Koslin MG.

T h o s e with p r e e x i s t i n g sinus disease also m a y be c o n s i d e r e d for t r e a t m e n t p r i o r to o r t h o g n a t h i c surgery. allogeneic. Most i m p o r t a n t l y . Claus R. If s y m p t o m s arise. Moses. which laterali/. O c c a s i o n a l c a s e s w e r e noted with direct interruption of infundibular patency attributable t o inadvertent m u c o u s m e m b r a n e synechial w e b and wall formation.I ) . If contact occurs bet w e e n m u c o s a l surfaces. Messerklinger (A. the application of e n d o s c o p i c e v a l u a tion of the m i d d l e m e a t u s h a s given O M S a n e w diagnosticaid to predict patients at risk for the p o s t o p e r a t i v e d e v e l o p ment of sinusitis.es the uncinate process and hiatus semilunaris of the infundibular outflow pathway. T h e s e anatomic alterations predispose to the development of postoperative sinusitis. and frontal s i n u s e s . 1 4 . n o r m a l ciliary beats of I0 to 15 strikes p e r m i n u t e c e a s e altogether. High-level septal deviations could lead to distortion of the middle turbinate on the convex side of the septum. W i e g a n d ( C ) d e v e l o p e d his p a n s i n u s e v a l u a tion and treatment from p o s t e r i o r to anterior s t r u c t u r e s a s sociated with m o r e a g g r e s s i v e eradication o f t h e s a m e sin u s e s . W i t h increasing familiarity and s o p h i s t i c a t i o n . B e l o w I 8 ° C and 50% h u m i d i t y . o r the c r e ation of n a r r o w e d or b l o c k e d ostia in conjunction with altered a i r w a y flow patterns o c c u r r i n g after high-level Le Fort I o s t e o t o m y . T h e e s s e n c e of e n d o s c o p i c s u r g e r y is to restore aeration and mucociliary flow patterns (Fig. as can h a p p e n w h e n the infundibular m u c o s a s w e l l s . For t h e Figure 1 4 . e s p e cially as it relates to its p e r m i s s i v e role in sinus a e r a t i o n . i n c l u d i n g e x t e n s i o n t o the s p h e n o i d s i n u s . direct d i a g n o s t i c a s s e s s ment of the maxillary sinus and e n d o n a s a l structures is n o w possible with e n d o s c o p i c t e c h n i q u e s . T h i s p e r m i t s a s s e s s ment of the mucosal and b o n y r e s p o n s e to a u t o g e n o u s . and alloplastic materials placed adjacent to the sinus during surgery. Coronal view of paranasal sinuses. these t e c h n i q u e s also permit c o m p l e t e evaluation of the e n d o n a s a l a n a t o m y . Lange With the use of Le Fort osteotomies for the correction of skeletofacial deformities there has developed within the discipline of oral and maxillofacial surgery ( O M S ) a renewed interest in the management of sinonasal pathology. T w o o f these in c o m m o n u s e are the M e s s e r k l i n g e r and W i c g a n d techniques. it has b e c o m e evident that some cases of postoperative sinusitis occurred consequent to midfacial orthognathic surgery. Ciliary function is both t e m p e r a t u r e and h u m i d i t y sensitive.14 Endoscopic Sinus Surgery: A Significant Adjunct to Maxillofacial Surgery Jeffrey J. As enhanced awareness of the importance of the patency of the osteomeatal unit ( O M U ) grew. B) technique evaluates and alters structure from an a n t e r i o r to p o s t e r i o r a p p r o a c h . which subsequently also b e c o m e s tortuous. majority o f o r t h o g n a t h i c s u r g e r y patients w h o have d e v e l o p e d sinusitis p o s t o p e r a t i v e l y . In contrast. Arrows indicate direction of normal ciliary directed mucous flow toward natural ostea. i m p a i r m e n t o c c u r s . c o n centrating on the m a x i l l a r y . S i n c e these beats are required to m o v e the thicker m u c i n o u s blanket along the less viscous RATIONALE FOR ENDOSCOPIC SINONASAL SURGERY T h e c o n c e p t o f reversibility o f sinus d i s e a s e b a s e d upon the restoration of n o r m a l d r a i n a g e p a t t e r n s and aeration led t o the d e v e l o p m e n t o f several surgical t e c h n i q u e s .1 . 157 . e t h m o i d a l . t h e M e s s e r k l i n g e r a p p r o a c h p r o v i d e s a d e q u a t e t r e a t m e n t .

frontal. 1. swollen or paradoxical turbinate positioning and a n a t o m i c variations of the uncinate p r o c e s s all can lead to obstruction of the O M U .. (B) Diagram of cross section of ostca lumen with less than 2. A n y d e v i a t i o n s of t h e s e p t u m . A d d i t i o n a l l y . 8.158 Lasers in Maxillofacial Surgery and Dentistry B Figure 14 -2. d e v i a t i o n s of the superior and m i d d l e a s p e c t s of the s e p t u m . T h e convex side of the s p u r or deviation can c a u s e a paradoxical form of the mid- Figure 14-3. 6. leading to m u c o s a l s e c o n d a r y bacterial infection within 24 to 48 hours. . Inc. 4.2 A ..s h a p e d fashion. Structurally. resulting in c h r o n i c sinus disease. Lamina p a p y r a c e a Anterior e t h m o i d Infundibulum Uncinate process 5. T h e focus of e n d o s c o p i c sinonasal s u r g e r y is on the mucociliary and l o w e r c o n c h a s y s t e m . similarly impairs mucociliary function. along with the middle turbinate. t h e c o m m o n rhinitis o c c u r r i n g after a viral u p p e r respiratory tract infection i n d u c e s m u c o s a l e d e m a and ciliary paralysis. Cross-sectional coronal diagram of normal structure in the nose and osteo-meatal complex.5 mm diameter indicating paralysis of ciliary motion and inadequate aeration potential due to mucous stagnation. 3. and location and patency of the ostia and O M U (Fig. O s t i a d i a m e t e r s less than 2. occupies the m i d d l e m e a t u s . p r o viding a culture m e d i u m for bacterial infections. the infundibulum r e c e i v e s d r a i n a g e from the e t h m o i d a l . Infundibular m u c o s a l s w e l l i n g induced by alterations in airflow patterns. 2. 7. B ) . stasis o c c u r s . T N 3 8 7 7 6 U S A ) to a s s e s s the nasal valve. layer i m m e d i a t e l y adjacent lo the cilia. I 4 . Of particular i m p o r t a n c e is a visual c h e c k of the middle m e a t u s for the p r e s e n c e of high septal d e v i a t i o n s or spurs and contralateral c o m p e n s a t o r y turbinate hyperplasia. laterally or in a vertical to inferior S . 1 4 . as m a y o c c a s i o n a l l y o c c u r after Le Fort o s t e o t o m i e s in the lateral nasal wall.5 mm diameter indicating healthy cilia and aeration. should be noted.3 ) . and maxillary sinuses within the hiatus s e m i l u n a r i s which. and lateral wall airw a y resistance should also be d o n e before and after the dec o n g e s t a n t treatment. T h u s . Maxillary o s t e u m Middle m e a t u s Middle t u r b i n a t e Inferior t u r b i n a t e PREOPERATIVE EXAMINATION Preoperative e x a m i n a t i o n should include s p e c u l u m and headlight-assisted inspection of t h e nasal cavity both before and after the application of the d e c o n g e s t a n t spray.5 mm a r e p r e d i s p o s e d to infections primarily b e c a u s e of the phen o m e n o n of cilia i m p a i r m e n t s e c o n d a r y to m u c o s a l approximation (Fig. (A) Diagram of stylistic oslca lumen of greater than 2. 7 4 5 0 B r o o k s Rd. M e m p h i s . Additional tests such as those of M u e l l e r and Cottle (Smith and N e p h e w Richard.

Endoscopic Sinus Surgery d i e turbinate. It is therefore helpful to h a v e laserassisted carbon d i o x i d e ( C 0 ) o r H o I m i u m : y t t r i u m . Settings of 10 W of p o w e r and h i g h . After its identification. a l o n g with a s h a r p C o t t l e e l e v a t o r . then CT s c a n n i n g b e c o m e s n e c e s s a r y as a first d i a g n o s t i c step in establishing a d i a g n o s i s and treatment plan. and nasal drip p a d s a r e applied to p r e v e n t t h e f o r m a t i o n of lateral s y n e c h i a e and to aid m u cosal w o u n d healing. 159 can be utilized for e n d o n a s a l soft tissue ablation. On selected c a s e s . O t h e r w i s e . T h i s m a y lead to a d e l i c a t e b a l a n c e b e t w e e n O M U p a t e n c y and o b s t r u c t i o n . which is then attached to a S l r y k e r solid-state v i d e o opticale n h a n c e m e n t and m o n i t o r i n g c a m e r a s y s t e m . inhibiting access to the hiatus s e m i l u n a r i s . First. t h e septoplasty is p e r f o r m e d following the functional e n d o s c o p i c s i n u s s u r g e r y in o r d e r to reduce the incid e n c e o f h e m o r r h a g e . the u n c i n a t e process is identified and a vertical incision m a d e with t h e s h a r p e d g e of t h e C o t tle e l e v a t o r .B l a k e s l e y forceps and p u l l e d inferiorly to t h e level of the m i d d l e turbinate. A d d i t i o n a l i n s t r u m e n t a t i o n for e n d o a n t r a l t r i a n g u l a tion p r o c e d u r e s o c c a s i o n a l l y r e q u i r e s u s e o f t h e S t o r z c a n nula trocar s y s t e m . bacit r a c i n .c o a t e d Telfa strip. A c u r v e d o s t i u r n . septal d e v i a t i o n s can lead to lateralization and toruosity of the i n f u n d i b u l u m . insulated e l e c t r o c a u t e r y should be accessible. p h o t o c o a g u l a t i o n . Should these s y m p t o m s first a p p e a r p o s t o p e r a t i v e l y . B o t h e l l . # 1 0 F r e n c h c a t h e t e r t u b i n g . T h i s condition p r e v e n t s a c c e s s t o t h e m i d d l e m e a t u s o r p u s h e s the m i d d l e turbinate against the lateral nasal w a l l . turbinate hypertrop h y .a l u m i n u m . 2 INSTRUMENTATION T h e s e p r o c e d u r e s a r e usually a c c o m p l i s h e d u n d e r g e n e r a l anesthesia with oral e n d o t r a c h e a l intubation. " Occasionally. F o r patients with midfacial skeletal a s y m m e t r i e s or preexisting obstructive nasal respiration ( O N R ) as e x e m p l i f i e d by those patients with a p e r t o g n a t h i a or " l o n g face s y n d r o m e " w h o are m o u t h b r e a t h e r s . which leads to a cessation of ciliary m o tion that blocks O M U function. 0 . We h a v e found that a c u r v e d laser-delivering p r o b e o r a b e a m . 2 TECHNIQUE OF FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) I n t r o d u c i n g t h e e n d o s c o p e along the nasal f l o o r j u s t b e y o n d t h e sill p e r m i t s better a c c e s s and control for instrumentation and a i d s in visibility. thereby n a r r o w i n g its lumen to less than 2. o r e v e n n o r m a l turbinates that h a v e been p u s h e d into o b s t r u c t i v e positioning within t h e O M U by posterior septal d e v i a t i o n s . can readily b e r e m o v e d w i t h the S t r y k e r " H u m m e r .c u t t e r " a n d m e d i u m r e verse biting instruments. with s u b s e q u e n t risk of mucosal a p p r o x i m a t i o n and n a r r o w i n g of t h e m a x i l l a r y ostia. Le Fort I o s t e o t o m y m a y alter airflow patterns. In these c a s e s . If s e p t o p l a s t y w a s p e r f o r m e d . 5 % b u p i v a c a i n e with e p i nephrine 1:1(X). T h e C 0 laser ( L u x a r C o r p o r a t i o n .s e e k i n g p r o b e and suction-assisted s o u n d a r e used to p a l p a t e t h e m a x i l l a r y ostium. M o s t of the s u r g e r y can be p e r f o r m e d with straight and 4 5 ° a n g l e d W e i l .o r 4 . S u r g i c a l m a n a g e m e n t o f s i n o n a s a l d i s e a s e is tailored to e l i m i n a t e a b n o r m a l i t i e s s u c h as p o l y p s .B D 120-090 B e a m Deflector Sheath for L X 2 2 0 L a s e r S y s t e m ) can also be used for these p r o c e d u r e s . the o s t i u m is e n l a r g e d with the r e v e r s e biting forceps working anteriorly until sufficient d i a m e t e r (3.c u t " R i c h a r d s forceps and the laserassisted e n d o s c o p i c nasal t u r b i n o p l a s t y a r e indicated. septoplasty is p e r f o r m e d first if there is d e v i a t i o n or high posterior septal s p u r s .g a r n e t ( H o : Y A G ) p h o t o c o a g u l a t i o n available. M i n o r alterations in airflow c a u s e a p p r o x i m a t i o n of the m u c o s a lining t h e ostia. C A 9 5 6 0 3 U S A ) with a q u a r t z f i b e r h a n d p i e c e 2 T h e indications for the j u d i c i o u s removal of portions of t h e m i d d l e turbinate a r e c o n c h a b u l l o s a . and c o n v e n i e n t tips are availa b l e for directed b e a m localization. u n c i n a t e process.s p e e d p l u m e e v a c u a t i o n a r e utilized. a n d t u r b i n o p l a s t y w h e n indicated.m m d i a m e t e r i s u s e d . If not available. both the " t h r u . and s y m p t o m a t i c O M U b l o c k a g e . T h e u n c i n a t e p r o c e s s is g r a s p e d at t h e superior m a r g i n of this incision with t h e W e i l . soft tissue r e s e c t i o n s a r e performed with a m e d i u m " t h r u . L a r g e r m u c i n o u s s t r u c t u r e s . A u b u r n . If required. 5 . D e c o m p r e s s i o n of t h e i n f u n d i b u l u m by this m a n e u v e r frequently r e q u i r e s e n l a r g e m e n t of the maxillary o s t i u m .d e f l e c t i n g p r o b e ( C 0 L u x a r o r modified H o : Y A G C o h e r e n t ) is useful in reestablishing a d e q u a t e patency o f this o s t i u m . A R i c h a r d ' s 3 0 ° angled e n d o s c o p e o f 3 . e s pecially in patients w h o h a v e had high-level Le Fort o s t e o t o m i e s with resultant a b n o r m a l b o n y architecture o r s y n e c h i a ! w e b b i n g .0 mm plus) is a c h i e v e d . A s i m p l e setup of instrumentation is preferred by t h e author. with care b e i n g taken to orient the b e a k s of the forceps vertically to p r e v e n t inadvertent e x t e n s i o n laterally through the l a m i n a p a p y r a c e a and t h e r e b y e n t e r i n g t h e orbit. h y p e r t r o p h i c t u r b i n a t e s . such a s e n g o r g e d turbinates o r intranasal p o l y p s .. 7 9 2 0 6 North C e n t e r P a r k w a y . mucosal h e m o r r h a g e is e n c o u n t e r e d despite the injection of local anesthetic.B l a k e s l e y forceps.8 2 0 5 . In addition. 7 7 8 0 2 K e m p e r Rd.000. L X S . w h i c h induce c o m p e n s a t o r y m u c o s a l r e s p o n s e s that block O M U p a t e n c y . p r e o p e r a t i v e c o m p u t e d t o m o g r a p h y ( C T ) o f t h e s i n u s e s d o c u m e n t s d i s e a s e o r predisposition for p o s t o r t h o g n a t h i c s u r g e r y d e v e l o p m e n t of O M U dysfunction. its m u - . T h e H o : Y A G laser ( N e w S t a r L a s e r s . this s i m plifies m a i n t e n a n c e o f e q u i p m e n t a n d m i n i m i z e s t h e need for assistance. W A 9 0 8 7 7 . o r p a r a d o x i c a l turbinate m o r p h o l o g y . T h e s e s a m e forceps a r e then u s e d to o p e n the bulla e t h m o i d a l i s . U s e of a c u r v e d p r o b e is essential to identify the m a x i l l a r y o s t i u m . 0 .5 m m . and irrigation. and infundibulum. a F E S S silicone stent. w h i c h o b s t r u c t s vision. and timed nasal cottonoid p a c k i n g soaked with 4% c o c a i n e . F o l l o w i n g these p r o c e d u r e s .

c u t t i n g b o n e r o n g e u r .0 c h r o m i c m a t t r e s s s u t u r e s to prevent septal h e m a t o m a . fixation h a r d w a r e . Pathology reports w e r e consistent with cholesterol g r a n u l o m a initially read from tissue p a t h o l o g y s p e c i m e n s .s e g m e n t a l Le Fort 1 o s t e o t o m y c o m b i n e d with m a n d i b u l a r o s t e o t o m y . c o s a is r e a p p r o x i m a t c d with 4 . Figure 14-4. tooth or foreign b o d y r e m o v a l s . vertical m a x i l l a r y hyperplasia and retrognathism.6 ) . COMPLICATIONS AND POSTOPERATIVE CONSIDERATIONS O c c a s i o n a l l y . and partial t u r b i n e c t o m i e s . the a u t h o r utilizes this w i n d o w to place a small e n d o s c o p e postoperatively t h r o u g h a S t o r z c a n n u l a placed transnasally to view t h e sinus m u c o s a (Fig. and severe septal spurs and d e v i a t i o n s . Significant findings at the time of t h e Le Fort I r e v e a l e d a cyst of the left maxillary antrum. Figure 14-5. T h e s e are placed at the junction of the anterior m a x i l l a r y walls and the lateral nasal walls at the anterior aspect of the maxillary a n t r u m . Diagram of a down fractured maxilla at the Lc Fort 1 level indicating view of notches (Hosaka Window) placed in the lateral nasal wall. Placement of endoantral cannula and endoscope through a "Hosaka Window" approach.o l d m a n status p o s t . Intranasal e x a m i n a t i o n r e v e a l e d a p o l y p o i d m a s s present and nasal topical s t e r o i d s w e r e e m p l o y e d to assist m a n a g e m e n t . T h e s e w e r e unsuccessful in reducing the size of the tissue and a CT scan w a s ordered. and there h a v e been no r e c u r r e n c e s in the past 16 m o n t h s . M o r e m a t u r e a d h e s i o n s m a y require surgical or laser-assisted lysis. followed by H o : Y A G laser ablation of soft tissue tags r e m a i n i n g . as well as o b s t r u c t i v e nasal respirations d u e to septal deviation and h y p e r t r o p h i c turbinates. t h e r e b y allowing the drainage of the maxillary a n t r u m d u r i n g healing. Additionally. T h e s e p r o c e d u r e s were a c c o m p l i s h e d for treatment of facial skeletal asymmetry.1 60 Lasers in Maxillofacial Surgery and Dentistry In certain c a s e s mucosal w e b s a n d / o r shelf-life plicae. patients with c h r o n i c sinusitis and obstructive nasal respiration u n d e r g o i n g rigid fixation receive nasoantral n o t c h i n g procedures of t h e lateral nasal walls. and b o n e grafts can also be e v a l u a t e d with this a c c e s s . T h e status of b o n e healing. m a y also be present and r e q u i r e lysis. 1 4 . 14—4).a n t r a l t r o c h a r . such as t h e H o s a k a w i n d o w (Fig. h y d r o x y a p atite. During t h e c o u r s e of down-fracturing of the m a x i l l a in the Le Fort I operation. the patient reported a large tissue obstruction of the right nasal p a s s a g e w a y . nasal irrigation and even steroid nasal sprays a r e required in the postoperative period following pack and stent r e m o v a l . septoplasty. 1 4 . and end o s c o p i c a l l y assisted laser d e b r i d e m e n t of reactive m u c o s a .c a n n u l a puncture can b e utilized at the area of the c a n i n e fossa for surgical access. transantral p o l y p . T h e m a x i l l a r y .r e t e n t i o n cyst p h e n o m e n o n with m u c o u s gland hyperplasia w e r e o b t a i n e d . F o l l o w .y e a r . P u n c t u r e s a r e usually left open to heal by s e c o n d a r y intention o n c e t h e i n s t r u m e n t a t i o n is r e m o v e d . P o s t o p e r a t i v e intranasal steroids w e r e applied. A large ( 2 . Pathologic confirmation of p o l y p s and the m u c o u s . E n d o n a s a l e x a m i n a t i o n s are d o n e with a headlight and s p e c u l u m to detect early synechial formation since these can frequently be interrupted with antibioticc o a t e d c o t t o n applicators or with m i n i m a l l y invasive man i p u l a t i o n s . which m a y inhibit p h y s i o l o g i c m u c o u s flow. . CASE ILLUSTRATIONS Case 1 T h i s is a 4 2 . Functional e n d o s c o p i c a l l y assisted nasal s u r g e r y w a s p e r f o r m e d with surgical r e m o v a l of the p o l y p o s i s .3 c m ) oblong soft tissue m a s s w a s d i s c o v e r e d in the right lateral aspect of the nasal c a v i t y (Fig.5 ) . T h i s is a c c o m p l i s h e d using an e n d . O t h e r areas of antral a c c e s s a r e s o m e t i m e s utilized.u p antibiotics are given routinely with all patients. W i t h i n 2 to 3 w e e k s after surgery.

and evagination of inferior turbinates into the maxillary antrum. S e v e r a l years later. H o : Y A G laser-assisted m i d d l e t u r b i n o p l a s t y . Coronal CT scan of patient (Case 3) with OMU blockage and synechial web obstruction of the maxillary oslea.m u l t i p l e facial o s t e o t o m i e s for correction of posterior vertical maxillary hyperplasia with a p e r t o g n a t h i s m and retr o g n a l h i s m . and e n l a r g e m e n t of t h e m a x illary o s t i u m on the left side. Figure 14-7. S e g m e n t a l Le Fort I o s t e o t o m i e s . Figure 14-8. the patient had nocturnal s n o r i n g and clinical e v i d e n c e of h y p e r t r o p h y of the uvula and r e d u n d a n c y of the soft palate. m a n d i b u l a r a s y m m e t r i c p r o g n a t h i s m and concurrent h y p e r t r o p h i c t u r b i n a t e s . 2 Case 3 T h i s is a 3 5 . . which was accomplished. sagittal split r a m u s o s t e o t o m y . s y n e c h i a l lysis. CT scan r e v e a l e d that the left maxillary sinus had e x t e n s i v e inflammatory c h a n g e s that e x t e n d e d throughout the e t h m o i d a l air cells.o l d w h i t e w o m a n w h o w a s treated in 1987 with t e m p o r o m a n d i b u l a r joint ( T M J ) arthroscopic surgery for t e m p o r o m a n d i b u l a r dysfunction ( T M D ) with internal joint d e r a n g e m e n t ( I J D ) . along with m a n d i b u l a r o s t e o t o m i e s . w e r e a c c o m p l i s h e d without septoplasty or t u r b i n e c t o m i e s .o l d w h i t e w o m a n w h o presented status p o s t . w h i c h w e r e sent for p a t h o l o g i c confirmation of i n f l a m m a t o r y p o l y p s with increased n u m b e r of e o s i n o p h i l s of the nasal m u c o s a .y e a r . obstructed OMU. F E S S treatment c o n s i s t e d of partial laser-assisted t u r b i n o p l a s t y . T h e patient returned in 1995 with a c o m p l a i n t of sinusitis and c h r o n i c nasal r h i n o r r h e a . and C 0 laser-assisted uvulopalatoplasty. 14-7). the patient returned with a c o m p l a i n t of h e a d a c h e s and c h r o n i c sinusitis resistant to medical mana g e m e n t . Coronal CT scan of patient (Case 1) having a large Concha Bullosa and nasal polyp in right nasal parragenay. and o b s t r u c t i v e nasal r e s p i r a t i o n s . B l o c k a g e of the O M U w a s noted on the left side (Fig. T h i s w a s present despite the patency of a large nasal antral w i n d o w placed at the t i m e of the original Le Fort I o s t e o t o m y ( H o s a k a w i n d o w ) . A surgical plan for treatment i n v o l v e d F E S S with o p e n i n g of the maxillary o s t i u m and O M U with anterior e t h m o i d e c t o m y . Her treatment w a s related to m a n a g e m e n t of her posterior vertical maxillary h y p e r p l a s i a with resultant a p e r t o g n a t h i a . A c o m b i n a t i o n of e n d o s c o p i cally assisted e n d o n a s a l e x a m i n a t i o n s and C T scan analysis r e v e a l e d s y n e c h i a l w e b b l o c k a g e o f the maxillary o s t i u m . t u r b i n e c t o m i e s . T h i s is a 5 4 . DISCUSSION E x a m i n a t i o n of the maxillary antral walls through the H o s a k a w i n d o w placed at t h e t i m e of the Le Fort o s t e o t o m y in most c a s e s revealed a b s e n c e of d i s e a s e d m u c o s a next to the rigid fixation h a r d w a r e protruding into the sinus. A d d i t i o n a l l y . and septoplasty. T h e maxillary nasal sinuses had p o l y p s p r e s e n t .8 ) .Endoscopic Sinus Surgery Case 2 161 Figure 14-6. Coronal CT scan of patient (Case 2) showing Concha Bullosa. resulting in p h y s i o l o g i c flow restriction of maxillary sinus m u c o u s (Fig.y e a r . and in 1989 with Le Fort I o s t e o t o m y with s u p e r i o r r e p o s i t i o n i n g . 1 4 .

E v a l u a t i o n of patients by both e n d o s c o p i c a l l y assisted intranasal e x a m i n a t i o n and axial and c o r o n a l C T scan a n a l y s i s i s r e c o m m e n d e d .f r a c t u r e (Hosaka w i n d o w ) d o e s not a p p e a r to e n h a n c e d r a i n a g e of the maxillary a n t r u m b e c a u s e the p h y s i o l o g i c flow pattern of the muc o u s b y p a s s e s this region. Avoiding complications of endoscopic sinus surgery: analysis of coronal. 174:231.1 0 ) .9 ) . and skeletal g r o w t h disturbances such as long face s y n d r o m e or a p e r t o g n a t h i a m a y be predisp o s e d to the d e v e l o p m e n t of clinically significant sinonasal d i s e a s e p o s t o p e r a t i v e l y . 1995. Other etiologic factors to c o n s i d e r include p r e d i s p o s i n g anatomic variants. has been successful in the m a n a g e m e n t of the majority of these c a s e s . Hilding AC. as well as to view the h e a l i n g of t h e lateral nasal wall within the m a x i l l a r y sinus. and sagittal computed tomographic images. Endoscopic view of maxillary antral wall showing step and hardware entrance into the maxillary sinus. R e g i o n s e x p o s e d to sinus lift implants and interpositional h y d r o x y a p a t i t e or b o n e grafts can be visualized and e v a l u a t e d . Holliday RA. 2. 1967. the i m p a i r e d m u c o s a and a i r w a y patencies of patients with obstructive nasal respiration. p o l y p s . F E S S with the m i n i m a l l y invasive M e s s e r k l i n g e r a p p r o a c h . T h e use of nasoantral w i n d o w s placed in the anterolateral nasal wall at the t i m e of Le Fort I d o w n . Observations on the reactions of normal nasal mucous membrane. 1927. Shiptner BA. W h e r e a s n o r m a l airway anato m y and m u c o s a l health m i g h t h a v e been able to tolerate these c h a n g e s . 1 4 . m a y not be able to a d a p t r a p i d l y e n o u g h after Le Fort o s t e o t o m y to avoid these airway problems. Man Med. T h i s p r o b a b l y led to a "fall b a c k " inhibition of n o r m a l p h y s i o l o g i c m u c o u s f l o w t o w a r d t h e natural o s t i u m (Fig. Operative Tech Otolaryngol Head Neck Surg. such a s c o n c h a b u l l o s a and e n l a r g e m e n t s of the m i d d l e turbinate. The role of respiratory mucosa in health and disease. Am J Med Sci. T h i s w a s i n d e p e n d e n t of the type of metal used for the hardw a r e (Fig. T h e p r e s e n c e o f high septal spurs and a s y m metric d e v i a t i o n s lead to a p r e d i s p o s i t i o n of t h e narrowed airway p a s s a g e s and d r a i n a g e spaces to b e c o m e obstructed after o r t h o g n a t h i c surgery. 1 4 .162 Lasers in Maxillofacial Surgery and Dentistry i n f u n d i b u l u m . Figure 14-9. In o u r e x p e r i e n c e . such as those with t h e classic a p e r t o g n a t h i a — l o n g face s y n d r o m e — w i t h c o n c u r r e n t m o u t h b r e a t h i n g patterns. several patients h a v e required lysis of s y n c c h i a l w e b s at the level of the m a x i l l a r y ostium in o r d e r to restore aeration of the m a x i l l a r y s i n u s . combined with intranasal u s e of laser-assisted turbinoplasty and soft tissue lysis. and O M U blockage. Figure 14-1(1. With the a d v e n t of office-based e n d o s c o p i c instrumentation. (3):149-157. REFERENCES 1. 50:915-919. c r e a t i n g the contact p h e n o m e n o n that inhibits ciliary m o v e m e n t at t h e hiatus s e m i l u n a r i s and SUMMARY C e r t a i n patterns of facial skeletal a s y m m e t r i e s with highlevel septal d e v i a t i o n s and o t h e r s with obstructive nasal resp i r a t i o n / m o u t h b r e a t h i n g . Heetderks DL. T h e s e m a y in part be d u e to the O M U b l o c k a g e o r with s y n c c h i a l shelves and w e b s blocking n o r m a l m a x i l l a r y antral mucosal flow. the oral and maxillofacial s u r g e o n is better e q u i p p e d to i m m e d i a t e l y e v a l u a t e and treat p o s t o p e r a t i v e untoward seq u e l a e such a s s y n e c h i a ] w e b s . Cross-sectional coronal view diagram of steps formed within the maxillary antrum and resultant potential for redirected/inhibited ciliary mucous flow following Le Fort I osteotomy. Utilization of the 7 0 ° e n d o s c o p e and careful rotation for better visualization r e v e a l e d s y n c c h i a l w e b s and s h e l v e s in s o m e patients at the Le Fort I o s t e o t o m y site in t h e m a x i l lary a n t r u m . 3. axial. .

By t h e 1930s. and g a s lasers h a v e multiplied. rickets. and herpes zoster. E x p o s u r e to sunlight w a s considered to be p r e v e n t i v e m e d i c i n e and its effects on bone growth w e r e recognized by the 6th c e n t u r y B . o p h t h a l m o l o g i s t s b e c a m e the first users of medical lasers by a p p l y i n g the ruby laser to p h o t o c o a g u l a t i o n of the retina to weld d e t a c h e d retinas back into place. r h e u m a t i c arthritis. oral and maxillofacial s u r g e r y . at that t i m e . d e r m a t o l o g y . A Modulation of Biologic Processes by Low-Intensity Laser Radiation Joseph S. arthritis. although not universally a c c e p t e d . 1. T h e w o r s h i p of the sun w a s practiced throughout the R o m a n E m p i r e until it w a s s u p p r e s s e d by early Christianity. d y e . and c a r b u n c l e s . Shortly after the introduction of this new source of light. T h e c o n d i t i o n s for which UV t h e r a p y w a s . It is used in o p h t h a l m o l o g y to r e m o v e o p a c i t i e s that s o m e t i m e s d e v e l o p in the posterior c a p s u l e after removal of a cataract and insertion of an intraocular lens and for transclcral destruction of p o r t i o n s of the ciliary b o d y in intractable cases of g l a u c o m a . Greek and R o m a n p h y s i c i a n s . boils. T h e foll o w i n g a r e s o m e e x a m p l e s o f medical laser applications: T h e C 0 laser. plastic s u r g e r y . Solid-state lasers p r o d u c e w a v e l e n g t h s in the visible and infrared r e g i o n s of the spectrum. UV light t h e r a p y w a s c l a i m e d to be successful in treating h u n d r e d s of c o n d i t i o n s including nephritis. c o h e r e n t . dietary s u p p l e m e n t s . and few opportunities for a d e q u a t e e x p o s u r e to sunlight. r e c o m m e n d e d sunbathing as therapy for a variety of c o n d i t i o n s i n c l u d i n g e p i l e p s y . Despite the current c o n c e r n s r e g a r d i n g the p o o r findings from c o n t r o l l e d The neodymium:ytlrium-aluminum-garnet (Nd:YAG) laser p r o d u c e s IR radiation at a 1060-nm wavelength. the only effective treatment are t o d a y s u c c e s s fully treated by m e d i c a t i o n s . is used in both CW and pulsed m o d e s as a surgical laser b e c a u s e of its excellent hemostasis and s h a l l o w penetration depth in neurosurgery. g y n e c o l o g y . a n infrared ( I R ) emitter a t 10. oncology. sun. ULTRAVIOLET (UV) THERAPY clinical research and the potential for harmful effects from UV e x p o s u r e . for stimulation of w o u n d healing in ulcers. and d e p r e s s i o n . C e l s u s and G a l e n for e x a m p l e . o p h t h a l m o l o g y . long h o u r s in dark w o r k p l a c e s . T h e use of UV therapy h a s u n d e r g o n e alternating p e r i o d s of e n thusiastic e n d o r s e m e n t and d e n o u n c e m e n t . and general s u r g e r y . medical a p plications of the intense. r h e u m a t o i d arthritis. o t o l a r y n g o l o g y .N M E D I C I N E T h e d e v e l o p m e n t of light s o u r c e s for medical p u r p o s e s took a giant leap forward with the b u i l d i n g of the first laser by T h e o d o r e M a i m a n in I960. A r r a y s of these lasers c a n p r o d u c e p u l s e s with peak p o w e r s of 100 W or CW radiation with an a v e r a g e p o w e r of tens of watts. and healing. M a n y of the most c o m m o n of these solid-state near-IR lasers 165 . e d e m a . poor diets. there w a s a large transfer of rural p o p u l a t i o n s to cities with p o o r l y illuminated housing. and a s t h m a . 2 Al the turn of the 2()th c e n t u r y . etc. S i n c e that time. As a c o n s e q u e n c e of the Industrial R e v o l u t i o n . h e m o p h i l i a . A n u m b e r of s c i e n tific investigations into the biologic effects of sunlight eventually resulted in t h e d i s c o v e r y of its bactericidal effects and its role both in the prevention and treatment of rickets by the end of the 19th century.600-nm w a v e l e n g t h . T h e s e c o n d i t i o n s resulted in o u t b r e a k s of s c u r v y . applications of the intense electromagneticradiation at different w a v e l e n g t h s b e c a m e possible. With the availability of o t h e r lasers. Rosenshein BACKGROUND Therapeutic Use of Light in Medicine HELIOTHERAPY Light therapy can be traced back to healing p r a c t i c e s of the ancient E g y p t i a n s and G r e e k s w h o p r a i s e d R a o r Helios as the god of light. m o n o c h r o m a t i c radiation available from a variety of pulsed and c o n t i n u o u s w a v e ( C W ) solid-state. a c t i n o t h e r a p y is still r e c o m m e n d e d . and for treatment of acne vulgaris and neonatal j a u n d i c e w h e n used cautiously and prudently.C.2 L A S E R S I. for which s u n bathing w a s often prescribed as a c u r e . a t t e m p t s to artificially d u plicate the s u n ' s radiation using artilicial light resulted in the d e v e l o p m e n t of c o n v e n i e n t s o u r c e s of UV radiation that were effective in treating the o p e n w o u n d s found in tuberculosis and rickets.15 Laser Biostimulation: Photobioactivation.

In v i v o s t u d i e s — H o w do the cellular studies c o m p a r e to a p p l i c a t i o n s in a n i m a l s or h u m a n s ? L a s e r light s o u r c e s — W h a t a r e the characteristics of the light s o u r c e . d. E v e n w h e n translated. Pain relief d. T h e s e lasers emit light primarily at 6 3 2 . T h e early reports of L I L R . a n d v a p o r i z a t i o n with the increased t e m p e r a t u r e s a s s o c i a t e d with e n e r g y a b s o r p tion. c. Dentistry R e d u c t i o n of e d e m a and h y p e r e m i a Wound healing Pain relief T r e a t m e n t of herpes labialis and herpetic gingivostomatitis e. Similarly. c o a g u l a t i o n . what w e r e the pulse c h a r a c t e r i s t i c s ? . b.i n d u c e d p h o t o b i o s l i m u l a t i o n w e r e published in Russian and E a s t e r n E u r o p e a n j o u r n a l s ihat were inacc e s s i b l e to most r e s e a r c h e r s in A m e r i c a . Activation of bone growth 3. T h e use of low-intensity laser light for therapy is dislinct from the use of lasers in s u r g e r y in that t h e therapeutic effects apparently arise either directly or indirectly from the e l e c t r o m a g n e t i c interaction of the light with tissue and not from thermal effects. Laser acupuncture a. T r e a t m e n t of respiratory tract infections d. 4 5 6 A l t h o u g h laser therapy or laser b i o s t i m u l a t i o n is freq u e n t l y used in E u r o p e and Asia as a therapy for a variety of d i s e a s e s . Early r e s e a r c h e r s used very low p o w e r lasers of less than I milliwatt ( m W ) but present research is b e i n g c o n d u c t e d at p o w e r s b e t w e e n 1 and 75 m W . w h i c h p r o d u c e s radiation of 8 2 0 . T h e s e lasers p r o m i s e to deliver even greater p o w e r d e n s i t i e s with greater reliability and lower cost as they c o m e into c o m m o n u s e in t h e near future.w i n e stains. Until such e v i d e n c e is p r e s e n t e d . Soft tissue injuries C. it s e e m s unlikely that the F D A will grant a p p r o v a l for use of this therapy in the United States. P h y s i o t h e r a p y a.i n t e n s i t y laser biostimulation has been applied to some of the f o l l o w i n g a r e a s : 1. As t h e field h a s m a t u r e d .to 9 0 4 . including intensity. A n o t h e r recent application of argon lasers is in p h o t o d y n a m i c therapy ( P D T ) of c a n c e r . V e t e r i n a r y practice a. it has not been generally a c c e p t e d in t h e United Slates d u e to the difficulty in g a i n i n g Food and D r u g A d - In vitro v s .n m w a v e l e n g t h s . I m p r o v e m e n t of foot g r o w t h in horses 4. leading to m o r e credible and reliable results. T r e a t m e n t t i m e s a r e typically short ( ^ 3 0 s e c ) . CONTROVERSY S i n c e M e s t e r s initial work. resulting in delivery of e n e r g i e s of only a few j o u l e s per square c e n t i m e t e r to the treated s i t e . resulting in ablation relatively free of t h e r m a l effects. W o u n d h e a l i n g b.e n e r g y p h o t o n s from t h e e x c i m e r laser disrupt m o l e c u l a r and a t o m i c b o n d s . T h e typical low-intensity l a s e r currently used in biostimulation research or in a clinical setting has a p o w e r of at least 15 mW and may be as high as several h u n d r e d milliwatts. there has been c o n s i d e r a b l e c o n t r o v e r s y r e g a r d i n g t h e effectiveness and even the exist e n c e of low-intensity laser b i o s t i m u l a t i o n . T h e s e lasers are e m p l o y e d in o p h t h a l m o l o g y to treat proliferative retinopathy and glauc o m a b e c a u s e their light is highly a b s o r b e d by v a s c u l a r ized tissue. A l m o s t all the lasers used in surgical a p p l i c a t i o n s e m p l o y the p h o t o t h e r m a l effects of light a b s o r p t i o n . and Hawed m e t h o d o l o g i e s . T u n a b l e d y e lasers and m o r e recently t u n a b l e T k s a p p h i r e lasers provide a w i d e r a n g e of visible and IR w a v e lengths for use in o p h t h a l m o l o g y and d e r m a t o l o g y . W o u n d healing c. LOW-INTENSITY LASER THERAPY Clinical Areas of Application L o w .n m w a v e l e n g t h and c o m m o n l y are used as a i m i n g b e a m s for IR lasers. R e v e r s a l of n e u r o p r a x i a e. the rigor of reporting has i m p r o v e d . Most recently argon fluoride e x c i m e r lasers p r o d u c i n g e x t r e m e UV radiation of 193 nm h a v e been d e v e l o p e d for use in p h o t o a b l a t i v e refractive k e r a t e c t o m y for correction of m y o p i a and a s t i g m a t i s m . 8 . which involve protein d e n a t u r a t i o n . Arthritis 2. (he initial w o r k suffered from i n c o m p l e t e description of e x p e r i m e n t a l p a r a m e t e r s . A r g o n ion gas lasers p r o d u c e visible light w a v e l e n g t h s of blue and blue-grecn. T h e e x t r e m e ultraviolet radiation of h i g h . Pain relief b . M o d e r n r e s e a r c h in this field should specifically report: 78 T h e use of low-intensity laser radiation ( L I L R ) for therapy w a s p i o n e e r e d by E n d r e M e s l e r in B u d a p e s t in the late 1960s. m a k i n g c o m p a r i s o n s and replication of results difficult if not i m p o s s i b l e . T h e r e is no c l e a r e v i d e n c e that laser b i o s t i m u l a t i o n is superior to e x i s t i n g therapy options. protocols that w e r e not blinded or c o n t r o l l e d . the specifications of L I L R research w e r e inconsistently presented. b e a m profiles.n e o n ( H e N e ) g a s lasers are p e r h a p s the most c o m m o n l y k n o w n visible light p r o d u c i n g lasers b e c a u s e of their relatively l o w cost and availability. and stability? W a s t h e light pulsed or c o n t i n u o u s ? If p u l s e d . polarization. they a r e useful for the treatment of vascular m a l f o r m a t i o n s and p o r t . H e l i u m . In particular. and i n d e p e n d e n t l y by Dr. Friedrich P l o g in C a n a d a .166 Lasers in Maxillofacial Surgery and Dentistry ministration ( F D A ) approval for n e w medical d e v i c e s a s safe and effective. arc constructed from g a l l i u m a r s e n i d e ( G a A s ) or g a l l i u m a l u m i n u m a r s e n i d e ( G a A l A s ) .

. After treating 1120 ulcers and o t h e r n o n h e a l i n g w o u n d s with 4 J / c m of H e N e laser light and later with an argon laser t w i c e p e r w e e k o n t h e entire w o u n d surface. The average healing time was 12 to 16 w e e k s . and benefit. T h i s lack o f c o m p l e t e d e s c r i p t i o n o f t h e L I L R p a r a m e t e r s used in research m a y a c c o u n t for the c o n fusion and c o n t r a d i c t i o n p r e s e n t in this field. H o w e v e r . B e a m m o d e and profile a. 12 14 1 5 A. Multimode c.d e s i g n e d and controlled studies find pain lessened. T h e s e effects m a y d e p e n d o n the species o f animal used.y e a r p e riod. 5. Photoactivation a p p a r e n t l y o c c u r s at t w o levels in b i o l o g i c s y s t e m s : t h e cellular level. possibly d u e to e n h a n c e d c o l l a g e n a c c u m u l a t i o n in the w o u n d e d a r e a . A multicenter. w h i l e only 8% remained unhealed. 6.0 167 LASER PARAMETERS T h e specific characteristics o f L I L R r e s e a r c h need t o b e considered w h e n e v a l u a t i n g the effects p r o d u c e d .8 2. A l t e r a t i o n s o f s e d i m e n t a t i o n rates. a r e frequently reported but o c c u r s p o r a d i c a l l y . T h e r e a r e . CURRENT RESEARCH Cellular Effects 8 Parameters Used in Studies WOUND HEALING T h e early w o r k o f M e s t e r o n w o u n d h e a l i n g o f c h r o n i c ulcers i n v o l v e d the effect of L I L R p h o t o b i o s t i m u l a t i o n on ulcers that had been u n r e s p o n s i v e to o t h e r t r e a t m e n t m o d a l ities. W a v e l e n g t h Inherent Laser Parameters EXAMPLES OF LASER-MEDIATED ANALGESIA Examples of laser-mediated analgesia shown in Table 1 5 ..1 . 3. h o w e v e r . b e c a u s e o f the diversity o f e x p e r i m e n t a l protoc o l s a n d the n o n s t a n d a r d m e t h o d s of r e p o r t i n g the c o n d i t i o n s of e x p o s u r e a n d results. C W b . c a u s e s " s h o w e d significant beneficial results.s k i n n e d a n i m a l s such a s rabbits. R h e u m a t o i d arthritis ( R A ) is t h e subject of c o n s i d e r a b l e r e s e a r c h interest b e c a u s e of its p r e v a l e n c e in the general p o p u l a t i o n . By radioactive labeling of cellular c o m p o n e n t s .c o n t r o l l e d m u l t i c e n t e r s t u d y in 1990 and 1991 evaluated the effect of L I L R therapy on RA of the h a n d s with c o n t r o l p a t i e n t s treated c o n v e n t i o n a l l y . An overview of t h e s e r e s u l t s indicates that L I L R m a y d e m o n s t r a t e effects of p h o t o b i o s t i m u l a t i o n on w o u n d healing. o v e r a 2 0 . Homogeneous 4 . w h i c h m a y be associated with L I L R effects on t h e i m m u n e s y s t e m . 1. O t h e r u n c o n t r o l l e d trials of the effect of L I L R on healing of d e c u b i t u s u l c e r s ' " and of leg ulcers from various 2 R e s e a r c h on t h e effects of L I L R has been most e x t e n s i v e a n d s y s t e m a t i c a l l y carried out in the area of cell p r o c e s s e s . h a v e e x a m i n e d the influence of L I L R on the following: 1 2 16 . O t h e r i n v e s t i g a t o r s h a v e found n o benefit o f L I L R o n v e n o u s leg ulc e r s . B e a m temporal t y p e a. if a n y . 6. L o o s e . T h e study w a s s t o p p e d before c o m p l e t i o n d u e t o c o n c e r n s that i m p r o v e m e n t s .Laser Biostimulation W a v e l e n g t h s — W h a t a r e t h e w a v e l e n g t h s and b a n d w i d t h s of the light used in t h e r e s e a r c h ? D o s i m e t r y — H o w w a s t h e e n e r g y d e l i v e r e d ? O v e r what a r e a ? W h a t w e r e t h e peak and a v e r a g e p o w e r s per unit a r e a ? H o w long w a s the e x p o s u r e ? T e c h n i q u e s — W h a t w e r e t h e treatment s c h e d u l e s ? D e scribe t h e c o n t r o l s and limited b l i n d i n g b y r e s e a r c h e r s . w e r e t o o limited to justify c o n t i n u a t i o n . multiyear study involving HeNe LILR photobiostimulation of hands with R A w a s presented t o a n F D A advisory c o m m i t t e e i n 1988. w h i c h is t h e localized p r i m a r y response. patient selection. s w e l l i n g d i m i n i s h e d .2 a r e not e x h a u s t i v e but indicative of s c o p e of work d o n e in this a r e a of clinical pain m a n a g e m e n t and therapy. b e n e f i t s m a y b e limited. T h e r e l a t i o n s h i p of these factors to clinical effectiveness is still unclear. M e s t e r and his s o n s . rats. T h e s t u d y w a s not a p p r o v e d d u e t o c o n c e r n s about d e s i g n limitations. 8. 4. A n o t h e r w e l l . Polarization 3 . a n d m i c e s e e m to s h o w a p r o m i n e n t r e s p o n s e to L I L R . 1.. l e u k o c y t e c o u n t s . 7 8 % healed and a n o t h e r 1 4 % w e r e i m p r o v e d . platelet a g g r e g a t i o n . H o w e v e r . Adjustable Parameters P o w e r density E n e r g y density Pulse width Pulse repetition rate Duration of e x p o s u r e Exposure schedule T h e s e p a r a m e t e r s a r e essential t o u n d e r s t a n d i n g the m e c h a nism u n d e r l y i n g t h e effects of p h o t o b i o s t i m u l a t i o n b e c a u s e too l o w an e x p o s u r e will h a v e no effect and t o o high an e x posure can p r o d u c e d e t e r i o r a t i o n o r e v e n d e s t r u c t i o n o f t h e cells and tissues. A n u m b e r of w e l l . TEM. 2. medication u s e r e d u c e d a n d m o r n i n g stiffness i m p r o v e d following multiw e e k c o u r s e s o f both visible a n d I R L I L R . and C reactive protein c o n c e n t r a t i o n s .—gaussian b. and then o v e r a larger c o n t i g u o u s area. which is m o r e of a syst e m i c s e c o n d a r y r e s p o n s e . T h e e x t e n t of the i n v e s t i g a t i o n of t h e effect of L I L R on wound healing is shown in Table 1 5 . n e g a t i v e results rep o r t e d for p i g s that are m o r e similar to h u m a n s . t h e interpretation of the p u b lished information p r e s e n t s difficulties. Pulsed B. particularly in its e a r l y p h a s e s .

neuron degeneration HeNe 633 nm Abergel (1987)* Abergel (1987)*' Lyons (1987) 47 Mice Open skin 4.5.3 days 2 x weekly None None Increased rale of closure Increased collagen and tensile slrenglh Increased levels Increased collagen and tensile strength Increased rale of healing.05 0. 1. 20 Once daily Kuna (1981)"' Rat Open skin HeNe 633 nm 45 Once daily Surinchak (1983)" ' • I I " '-I'. 4.6 1.65 HeNe 8.5. no other difference. except increased tensile strength Size decreased.5 Argon 488 and 514 nm 830 nm HeNe 633 nm Argon 488 and 514 nm 50 200 17 64 20 N/A 1 4 2 0. 10 1 4 6 EFFECT 1 J/cnr increased healing 4 J/cm increased healing and collagen synthesis Immediate: increased regeneration but adverse with repealed treatment Increase up to 4 J/cnr.168 Lasers in Maxillofacial Surgery and Dentistry I able 15-1.05 1. 1. but fibroblasts and collagen aligned Increased rate of healing. 10.km Open skin (1983) 41 Mashiko (1983) 42 After 4 days None then 2 x weekly Increased rate Every 2 days of healing N/A Every 2 . decrease in LDLs Increased SOD Hunter (1984)'" McCaughan (1985)* Mesicr (1985) 45 Wound area.3.4. effect of eschar removal.25 IR N/A Enwemeka (1990)'° Rabbits Tendons HeNe 633 nm N/A 1. 5mJ/cm Daily 2 /arkovic (1991)" Mice Open skin Wound area. strain HeNe 633 nm and infrared N/A 1. action potential increased and degeneralion reduced None. collagen content Wound area.4. peripheral andCNS HeNe 633 nm N/A 7. collagen content. energy absorption. then decrease None but 4 J/cm increased 3-12 days 2 2 Mester (1973) Rat 3 6 Open skin Complete wound and collagen synthesis N/A Day 5 Postop Postop Mester (1975)" Rat Muscle injury Regeneration of muscle Ruby 694 nm N/A 1 Every 3rd day X 4 Haina (1981) Rat w Open skin Granulation tissue formation Rate of wound closure and collagen synthesis Wound area. tensile strength Procollagen levels Wound area. Ruby 694 nm cellular content of granulation tissue Wound area.I Every 3rd day 2X daily 2X daily None Rats Guinea pig Pig Guinea pig Mice Open skin Open skin Open skin Open '. tensile strength. tensile strength Wound area Wound area Wound area Wound area HeNe 633 nm 50 0. 2 0 4 .96 2 I. 7 days Rossetti (I99I)' Rat 2 Brain Superoxide dismulase HeNe 633 nm 5 1.5. tensile Strength.1 22 4. In v i v o animal e x p e r i m e n t s POWER DENSITY ImW/cnr) N/A ENI-RCi DENSITY (J/cm ) 2 MITHOR Mester (1971) 35 ANIMAL Mouse WOUND Burn EVALUATED Diameter LASER WAVELENGTH Ruby 694 nm Ruby 694 nm 1 XI'OSURISCHEDULE 2 X weekly 0. burns.56 4.08 N/A .2.22 Rochkind (I989) * 4 Rats Open skin.1 Rabbits Open skin HeNe 633 nm Variable 1. 5. collagen area Size.6 10 10 Braverman (1989)* Rabbils Open skin Wound area.. tensile strength. serum lipoprotein content GaAs 830 nm 50-W pulses N/A 210 seconds daily. epidermal thickness.22 Every other day 3X weekly Every other day Daily for 20-21days Pig Mice Open skin Open skin HeNe 633 nm HeNe 633 nm 1. 1 0 . action potential.

T 5 mW. scan. (1987)*' Burgudjieva et al. CW X 3 pw. 904 Various pain Tcndinopalhies 160 0 64 N Y N Y 85% ns Report Numeric* Sicberl ct al. *62% acute effect. X5pw. X 5 pw. 5 min. (1987) 54 Bicglio el al. (1987)" H. X5pw. T X URx. 250 Hz.3 mW. T P + Acu < 3 0 m W . (1986)" Jensen et al.00l. K i l l KI.T 0. 15/365. x5pw. 1 Rx. LBP. 7 200 N N ? [Ab]. X 5 pw.001. X 2 pw. T 5 . **+goniomelry 633 IR < 6 0 s . Acu 7 RA pain Postop pain (gynecologic) Painful elbow Tri neuralgia Sports injuries 17 179 1 106 62 Y Y ns +ve 67* +ve 90%* VAS* Report Report* Report Scotl/VAS** N N [FLA] *+glucocorticoid excretion [F1.90s. <20min. CW?. <7. max post 1 h. X5pw.lt80% +ve >70%* * + thermography |Ah| Clust CO. scan. X 3 pw. ** +thermography Duhenko ct al. etc. (I987) * 7 Simunovic(l987)"" 633 TernovoylP^)" 1 Oral pain Locomotor pain 7 - 633 T + TP 400 - +ve +ve Report Report* [FLA] . 10/365.4/52. (1985) 77 co 2 < 2 5 W . 3/52. effects cxlend>l h [Ab] |Ab| *+thermography [Ab] * +thermography.iid et ul. etc. (I986) ' 7 830 633. 1200 Hz. Acu 10 min. placebo. X2 pday 15 m W . (1985)"" 633 Krcc/i and Klinger (1986)"" 633 633/IR* 1 N N 7 [FLA]. (1989)"' Galpcrti cl al (1987)"' Gartner cl al. X 3 pw Wound pain OA pain 82 7 7 N 7 . 1DIAGNOSIS RA pain OA thumb pain \1. (1987) ** Kamikawa and Kyoto (1985) 67 904/633 904 IR PA shoulder PA knee Various Oral pain* Radicular pain OA pain hand 30 29 60 88 21 40 Y Y Y SO' 'i nil 79%* +ve -l-ve* +ve** Report* Report* Numeric Report Adapt V A S 7 Kalsclal.1 0 min. (1986)" Mester and Mesicr (1987)" Morselli el al. X2 pday 50 mW < 2 5 W scan.'analysis *+X-ray invest crossover study: *+drug intake *46% "effective / 34% fair - 10-20 min. T N + IR 169 Examples of laser-mediated analgesia N 163 81 D Y Y P Y Y LIT 82%* ns MEASURE Report Numeric* COMMENTS • 4 0 % placebo *+ROM.T 7 Glykofridis 633. T. 5 .onaiiiT (I986) " Lukashcvich (1985)" Martinof^S?) 72 7 633 CO. Sports injuries 10-15 min. (I986) * 5 633 Radicular pain 7 7 ? + ve* Report •inflamm phase: ?ncural/vasc mechanisms • + EMG etc.950 (I987) M N N* +ve Gussetti el al. (1985a) 75 co 2 < 2 5 W. 'sialadenitis */><. T < 3 0 s/pt. 3/52. and Diamantopoulos 660. 9 0 s. CW?. ** + grip strength. (1985)" Choi cl al.NCI LASER 830 633 TREATMENT 60 mW CW and pulsed 0. PA.60s. 3 0 s. T 7 >I0 0 31 N Y +ve +ve Report VAS* 820 Snorts injuries Shiroto ct al.2 0 min. 1 1 1 1 1 1 ct Jl. 30 min. T Y Y 1 . |FLA| 'versus alternatives [Ab] 2 mW. 100 Hz. (19856)'* Roumeliotis et al. vartime.AI Cumulative effect *25%.1 0 min. CW. < 2 5 min. ?systemic effect* 633 633 904 10 mW. < 7 min. 3/52. (1987)" Bliddal el ill.i. .T < 2 5 mW.etc. CW.2J/cm 2 PA pain AS. Locomotor pain 5 . T T <1 mW. Locomotor pain 60 546 200 - - +ve 87% Quest Report* Numeric * +functional.9 mW.'placebo: 10-citi distance [Ab] Morselli et al. x3pw. effects • 9.6 ii •combination preferable. (1976)" ? Y Y Emmanouilidis 820 and Diamantopoulos (1986) 60 l5mW. C W . 2/52.2/52 England ct al.l. 15 min.Laser Biostimulation T a b l e 15—2. strength. CW. N + T PHN Mastalgia 150 50 +ve* 32% Report Keele/Lasa/ Map Numeric* Mayordomo cl al. (1987)" 904 Tendinitis 30 Y Y +ve* VAS** *p< . 5 min. cumulative effect •Comparative sludy: . 4000 Hz. T 3 mW. x 5 p w . 2/52. CW.

< 3 0 s .8 17 8 19 2 02 1 2 2 . visual analogue scale. A l t h o u g h t h e effects o f L I L R on cell function h a v e been repeatedly d e m o n s t r a t e d .170 Lasers in Maxillofacial Surgery and Dentistry T a b l e 15 -2. RA. p h a g o c y t o s i s . applied to nerves/nerve r<x>ts. C o l l a g e n s y n t h e s i s — A series o f e x p e r i m e n t s i n v o l v i n g ulcers and n o n h e a l i n g w o u n d s . ROM. b l a s t . low back pain. a n d 8 2 0 n m . w h i c h increased with s u b s e q u e n t e x p o s u r e s to L I L R . 20 Hz. but not to p r o l i f e r a t i o n . o x y h e m o g l o b i n d i s s o c i a t i o n . u s i n g L I L R from H e N e and argon ion lasers of a b o u t 4 J / c m . D N A s y n t h e s i s — H u m a n l y m p h o c y t e c u l t u r e s stimulated with p h y t o h e m a g g l u t i n i n ( P H A ) and treated with 1 J / c m of L I L R had a 2 0 % i n c r e a s e in t r a n s f o r m a t i o n of l y m p h o c y t e s t o large-size. Scan laser used in conjunction with scanning 1. * + 5 IIIAA */><. T h e s e effects generally a r e significant and a r e t o o wides p r e a d t o b e e a s i l y d i s m i s s e d . foreign language abstract. It w a s t h o u g h t that t h e rates of incorporation of g l y c i n e and proline indicated that the p r i m a r y effect of L I L R w a s in t h e s y n t h e s i s of collagen d u r i n g t h e c o l l a g e n o u s p h a s e o f w o u n d healing. T h e effect of L I L R on c o l l a g e n and protein s y n t h e s i s and cell proliferation h a s b e e n found by s o m e r e s e a r c h e r s to p r o d u c e both inc r e a s e s and d e c r e a s e s in those p r o c e s s e s . to this d a t e t h e r e has been n o elaboration o f t h e p r e c i s e m e c h a n i s m s by w h i c h these effects are p r o d u c e d . alter cellular s i g n a l i n g . X 3 pw. Measure. e.d e n s e nuclei in both i n t r a c y t o p l a s m i c and intercellular material. etc. Acu. abstract. PHN. EMG. *+drug intake co M 2 Y Y VAS* VAS* Walker (1983) 633 1 mW. Examples of laser-mediated analgesia (continued) •<. (1985)" Zhou Yo Cheng (1987) 633 904 C0 64 67 40 S Y Y +ve* 62% 95% VAS** MPQ* Report* ? 2 D. In t h e treated w o u n d s . cell motility. efficacy. trigeminal. range of movement. nonsignificant findings. 1000 Hz. T h e action s p e c t r a reveal m a x i m a in the s y n t h e s i s of D N A and R N A a t 4 0 0 . per week. AS. 3/52 = 3 weeks. |Ab|. l. 6 3 0 .s t a g e is the stage of D N A synthesis p r i o r t o cell d i v i s i o n . n e u r o t r a n s m i t t e r release. and respiration. R e c e n t l y . m e m b r a n e potential. Cell replication and p r o l i f e r a t i o n — H e a l i n g o f artificially c r e a t e d skin defects in w h i t e m i c e w a s significantly accelerated w h e n treated by ruby l a s e r L I L R . pw. cell g r a n u l e r e l e a s e . Rx. T h e r e w a s a significant i n c o r p o r a tion of t h y m i d i n e related to t h e n u m b e r of fibroblasts in t h e S-stage of t h e cell c y c l e . T h e S . |FLA|. T h e i n c o r p o r a t i o n of uridine and valine w a s only increased by a s m a l l a m o u n t . motility. 10/52 6 0 s . postherpetic neuralgia. L I L R of 1 J / c m from a H e N e laser p r o d u c e d a significant a c c u m u lation of t h e E and F types of p r o s t a g l a n d i n in the first 4 d a y s after w o u n d i n g . 6. N + T 1 mW. 3 . there w a s a h i g h e r n u m b e r of dividing cells and the w o u n d s c l o s e d m o r e q u i c k l y . 6 8 0 . T. **+drug intake | A b ] . P. T h i s implies an increase in t h e n u m b e r of cells in t h e process of r e p r o d u c t i o n . ns. treatment. Chronic effect. T h e action s p e c t r u m of L I L R for w a v e l e n g t h s from 3 0 0 to 9 0 0 nm m e a s u r e d by t h e synthesis rate of nucleic acids in H e L a cell c u l t u r e s h a s been d e t e r m i n e d . ankylosing spondylitis. 2 2 2 M a n y o t h e r r e s e a r c h e r s e x a m i n i n g t h e effects of L I L R on cell function h a v e reported c h a n g e s in cell proliferation. 11 K : \ i i Vidovich el al. H o w e v e r . 2 . osteoarthritis. or increase production of A T P .0()l. i m m u n e r e s p o n s e . applied to acupuncture points. topically applied to lesion. placebo-controlled. 4 . p h a g o c y t o s i s . T h i s w a s associated with an increase in t h e rate of s y n t h e s i s of D N A of t h e l y m p h o cytes. BIT. pain measurement method used.BP. Tri. OA. (1987) B LASER TREATMENT 1 mW DIAGNOSIS RA pain N 272 36 D P El'T 75% 73% Ml A M Kl COMMENTS |Ab] * + drug intake.t y p e c e l l s c o m p a r e d with cultures that w e r e only s t i m u l a t e d with P H A but not treated with L I L R . T h e r e h a s been s p e c u l a t i o n that t h e respiratory chain c o m p o n e n t s of the mit o c h o n d r i a — t h e c y t o c h r o m e s and the p r o p h y r i n s — m i g h t be t h e p r i m a r y p h o t o a b s o r b e r s in t h e visible and near-IR wavelengths. a d e n o s i n e triphosphate ( A T P ) s y n t h e s i s . T h e r e w a s n o effect o f L I L R o n l y m p h o c y t e s that had not been stimulated with P H A . T h e r e w a s also a n a p p e a r a n c e o f vesicles h a v i n g e l e c t r o n .. *+drug intake [Abl. Irradiation of n o r m a l h u m a n m u c o s a l fibroblasts with infrared d i o d e lasers has been s h o w n to h a v e a biostimulative effect on D N A s y n t h e s i s ' similar to that o b s e r v e d in H e L a cells. rheumatoid arthritis. cell b i n d i n g affinities. 7 6 0 . s h o w e d a significant increase in c o l l a g e n fibers. investigators h a v e s h o w n that a n e n h a n c e m e n t o f cultured h u m a n k e r a t i n o c y t e m i g r a t i o n s u b s e q u e n t t o L I L R e x p o s u r e c o u l d be attributed to an increase in kera t i n o c y t e motility. and p r o s t a g l a n d i n synthesis. I t h a s b e e n s u g g e s t e d that L I L R may activate t h e e n z y m e s in the electron-transport chain directly.g. periarthrilic pain. Chronic pains X 3 p w . Basford h a s o b s e r v e d increases i n R N A s y n t h e s i s . the direct activation of e n z y m e s as t h e basis for increased D N A s y n t h e s i s a n d c o n s e q u e n t therapeutic effects h a s not yet been verified. T h e s e vesicles w e r e t h o u g h t t o r e l e a s e bioactivc s u b s t a n c e s that p r o m o t e d h e a l i n g in nonirradiated areas of the w o u n d . Acu RA pain OA pain hands Minor surgery Walker el al. electromyography. double-blind. PA. intercellular m a t r i x . 10/52. (1986)" Willner e! al. N. Protein s y n t h e s i s — T h e effect of r u b y laser L I L R on R N A and D N A protein s y n t h e s i s i n h u m a n f i b r o b l a s t c u l t u r e s w a s studied. VAS. foll o w e d b y the a u g m e n t a t i o n o f D N A s y n t h e s i s and cell proliferation. 30 mW.

O n l y careful research in the future c a n e l u c i d a t e t h e m e c h a n i s m s r e s p o n s i b l e for t h e effects of L I L R on biologic m a t e r i a l s . o n e h y p o t h e s i s p r o p o s e d for the basis of the p h o t o bioslimulative effects of L I L R h a s been the direct stimulation o f A T P p r o d u c t i o n . T h e formation o f A T P following e x p o s u r e t o H e N e L I L R a t a n e n e r g y d e n sity of 5 J / c m points to t h e o x i d a t i v e p h o s p h o r y l a t i o n s y s tem in the inner m i t o c h o n d r i a l m e m b r a n e s . T h u s . ' T h e c o m b i n e d effects o f multiple w a v e l e n g t h L I L R ( M W L 1 L R ) m a y result in e n h a n c e d p h o t o b i o s t i m u l a t i o n b e c a u s e of s y n ergistic a c t i o n . C y t o c h r o m e o x i d a s e h a s a n absorption peak a t 8 3 0 n m and also a t 6 0 5 n m . relatively high p o w e r m a y be required to initiate p h o t o n 23 2 2 4 25 2 6 171 sure. M W L I L R e x p o s e s b i o l o g i c m a t e r i a l s t o m u c h h i g h e r p h o t o n d e n s i t i e s a t specific w a v e lengths than w o u l d be e n c o u n t e r e d in light from o r d i n a r y . or a n a e r o b i o s i s . C y t o c h r o m e s A . C y t o c h r o m e s o f the mitochondrial o x i d a t i v e p h o s p h o r y l a t i o n s y s t e m might prod u c e a series of c h r o m o p h o r e s that a b s o r b light o v e r t h e w i d e r a n g e of w a v e l e n g t h s in w h i c h L I L R p h o t o b i o s t i m u l a tion is o b s e r v e d to occur. maintaining a s y n c h r o n i z e d cell culture m a y e n h a n c e the effects o b s e r v e d in L I L R p h o t o b i o s l i m u l a t i o n . such information w o u l d e n a b l e t h e m e c h a n i s m s of p h o t o b i o s t i m u l a t i o n t o b e m o r e precisely elucidated and p e r h a p s b e used m o r e effectively. B e c a u s e ascorbic acid c r o s s e s the cell m e m b r a n e against a c o n c e n tration gradient t h r o u g h a p r o c e s s that can be b l o c k e d by u n c o u p l i n g o x i d a t i v e p h o s p h o r y l a t i o n . p r o d u c i n g a c h a n g e in the m o l e c u l a r absorption spectra.2 T h e r e h a v e been s u g g e s t i o n s that the effects of L I L R may be d u e to the absorption of light in c h r o m o p h o r e s producing photophysical vibrational a n d local thermal eff e c t s . It has been s h o w n that free radicals are present after e x 18 Effects of Exposure to Simultaneous Multiple Wavelengths O n l y a f e w reports of m u l t i p l e w a v e l e n g t h e x p o s u r e to L I L R b i o s t i m u l a t i o n can be found in the l i t e r a t u r e . 3 1 28. this h y p o t h e s i s s e e m s t o be ruled out by the c o n t r a d i c t i n g o b s e r v a t i o n that b i o s t i m u lation by H e N e laser radiation of H e L a cells i n c r e a s e s t h e stress from trypsinization and plating 5 m i n u t e s after e x p o sure. H o w e v e r . incoherent s o u r c e s . T h e c o m b i n e d a b s o r p t i o n o f t w o sequential p h o t o n s c a n result in g r e a t e r e n e r g y transfer to the cell c o n t a i n ing t h e b i o m o l e c u l e than w o u l d be e x p e c t e d from the absorptivity of e a c h p h o t o n individually. there m a y be a relaxation lime for the bioc h e m i c a l p r o c e s s e s resulting from photon a b s o r p t i o n . the n u m b e r of irradiated cells increased within the first w e e k and later d e c r e a s e d to b e l o w t h e level of t h e control cells. d u r i n g D N A s y n t h e s i s the b o n d s o f the D N A m o l e c u l e are altered.e n e r g y p h o s p h a t e ( A T P ) . T h i s c h a n g e in a b s o r p t i o n s p e c t r a w o u l d d e p e n d on the stage of replication in the cellular c y c l e . T h e variability of the effects of L I L R in s o m e of t h e s t u d i e s cited m a y be explained by this sensitivity to t i m i n g of e x p o 32 length by a c h r o m o p h o r e can e x c i t e that m o l e c u l e into a long-lived state. T h e c h a n g e s in the stereotaxic c o n f i g u r a t i o n of biologic m o l e c u l e s p r o d u c e d by excitation of vibrational slates by the L I L R as well as by localized h e a t i n g c o u l d alter t h e kinetics of b i o c h e m i c a l r e a c t i o n s at specific sites d u r i n g those p h a s e s of cellular p r o c e s s e s that a r e particularly v u l nerable to alteration.Laser Biostimulation O n e of the most o b v i o u s c a n d i d a t e s for absorption of the longer w a v e l e n g t h s is a h e m o p r o t e i n . t h e c h a n g e in intracellular a s c o r bate c o n c e n t r a t i o n can selectively alter c o l l a g e n s y n t h e 27 Timing of Exposure to Cellular Processes As m e n t i o n e d in the p r e v i o u s section. p r o b a b l y o n e or m o r e c o m p o n e n t s o f the mitochondrial o x i d a t i v e p h o s p h o r y l a t i o n system and its constituent c y t o c h r o m e s .A 3 and c o p p e r c o m p l e x . For e x a m p l e . T h u s . ' ' T h e p h o t o c h e m i cal or p h o t o d y n a m i c p r o d u c t i o n of free r a d i c a l s and o x i dants has been p r o p o s e d as t h e c a u s e of t h e effects on cellular function p r o d u c e d by L I L R . the initial and short-term effect of LILR cannot be a result of direct stimulation of t h e A T P production. T h e lifetime o f s o m e e x c i t e d m o l e c u l a r states m a y b e l o n g e r than the p e riod of t h e p u l s e . a l l o w i n g for less efficient absorption of e n e r g y . B e c a u s e laser light i s highly m o n o c h r o m a t i c . H o w e v e r . T i m i n g of e x p o s u r e to t h e c e l l u l a r p h a s e s w o u l d be critical a n d difficult to c o n t r o l unless c a r e ful s y n c h r o n i z a t i o n of the c u l t u r e s w e r e m a i n t a i n e d . If t h e trypsinization w a s d e l a y e d until 3 0 t o 2 4 0 m i n u t e s after e x posure to L I L R . 3 0 . which m a y be longer than t h e pulse period that would reduce the efficiency of e n e r g y transport into the cellular process. FURTHER RESEARCH Effects of Repetition Rates In pulsed laser a p p l i c a t i o n . t h e pulse rate m a y be an important e x p e r i m e n t a l p a r a m e t e r t o e x a m i n e . A l s o . inhibiting electron transport. a significant d e g r a d a t i o n o c c u r r e d in the e x p o s e d cells c o m p a r e d with the n o n i r r a d i a l e d c o n t r o l c e l l s . T h u s . T h e p r o b l e m i s q u i t e c o m p l e x b e c a u s e t h e action s p e c t r a of m u l t i p l e w a v e l e n g t h s in cellular p r o c e s s e s a r e not easily m e a s u r e d . T h e s e factors only serve to further o b s c u r e an already confused area of research. B e c a u s e of the low a b s o r p l i v i t i e s . T h e a b s o r p t i o n of a p h o t o n of o n e w a v e 33 34 posure o f biologic m a t e r i a l s t o L I L R . the t i m i n g of e x p o sure to L I L R m a y be critical in d e t e r m i n i n g the effectiven e s s o f the e x p o s u r e t o alter cellular p r o c e s s e s . or c y t o c h r o m e o x i d a s e . . T h e m o l e c u l e in t h e excited state m a y h a v e e n h a n c e d a b s o r p t i o n of a p h o t o n with a w a v e l e n g t h that w o u l d not be a b s o r b e d by the m o l e c u l e w e r e it in its unexcited s t a t e . form a functional c o m p o n e n t of the t e r m i n a l electron transport s y s t e m that a b s o r b s light e n e r g y in t h e r e d u c e d but not in t h e oxidized s t a t e . sis c o n v e r s i o n into h i g h .

along with the e m e r g e n c e of n e w . e x p o s u r e d u r a t i o n .16 Paul Kuo Tissue Fusion Laser t e c h n o l o g y h a s b l o s s o m e d in recent y e a r s . and its s u c c e s s and reliability a r e d e p e n d e n t on o p erator skill and j u d g m e n t . and easy t o use. a l t h o u g h it d o e s not entirely obviate operator j u d g m e n t in the final o u t c o m e . Clinical u s e of lasers in s u r g e r y and dentistry has not yet been universally a c c e p t e d for a n u m b e r of r e a s o n s . portable. as c o m p a r e d with c o n v e n t i o n a l sutures that inhibit g r o w t h . F u r t h e r m o r e . circumferential seal of the w o u n d for a watertight c l o s u r e and d e c r e a s e s l e a k a g e . laser tissue fusion requires training. D e w and c o w o r k e r s ' used c o m puter-controlled N d : Y A G laser w e l d i n g in 169 laser skin c l o s u r e s in pigs. potential h a s increased for further clinical application of lasers in surgery and m e d i c i n e . duty cycle) tends to provide a more uniform result. each with its o w n specific properties and h e n c e clinical a p p l i c a t i o n .e n h a n c e d p h o toablation and p h o t o a c t i v a t i o n will facilitate the use of these l o w e r .a l u m i n u m .n m diode laser. using indocya nine green d y e . In addition to forming stronger b o n d s . E x p e r i m e n t s c o m p a r i n g bursting p r e s s u r e s of sutured versus laserg l u e . T w o such areas are laser tissue fusion and p h o t o a c t i v a t i o n . t h u s s p a r i n g the u n d e r l y i n g host or native tissue from collateral thermal d a m a g e r e g a r d l e s s of w a t e r content or p i g m e n t a t i o n . T h e N d : Y A G provided similar penetration depth regardless of tissue w e t n e s s or p i g m e n t a t i o n . For w i d e s p r e a d laser use in surgery and m e d i c i n e . T h e y reported g o o d healing without dehisc e n c e with good c o s m e t i c results. which facilitates laser t i s s u e . T h i s allows efficient target-specific d e l i v e r y of laser e n e r g y and e n h a n c e m e n t of laser tissue fusion. reliable. At t h e s a m e t i m e . the laser/dye pairs a r e c h o s e n so that their w a v e l e n g t h s / a b s o r p t i o n peaks are closely m a i n t a i n e d . research is being c o n d u c t e d to increase the p o w e r output of d i o d e lasers with the e x p e c t a t i o n that they m a y b e c o m e the d o m i nant laser s y s t e m in surgery. Laser tissue fusion is being investigated as an alternative to surgical closure with s u t u r e s . It also a l l o w s w e l d e d tissue the ability to g r o w . miniaturized m o d e l s of C O s laser with flexible w a v e g u i d e delivery s y s t e m s and n e o d y m i u m : y t t r i u m . active media and w a v e l e n g t h s . In addition. A l t h o u g h sutures a n d staple h a v e w o r k e d well in g e n e r a l . lack of portability.n m w a v e l e n g t h c o r r e s p o n d s to an o p tical window * for vascular and o t h e r tissues. Photoaclivation refers to the use of laser w a v e l e n g t h s to initiate solidification of protein tissue a d h e s i v e s and tissue substrates. T h e 8 0 8 . D y e . g r e a t e r speed. especially for a e r o s p a c e and military applications (see C h a p t e r 17).* DEVELOPING FRONTS As with laser p h o t o a b l a t i o n . Laser tissue fusion h a s the a d v a n t a g e of s m a l l e r instrumentation. M o r e o v e r . and d e c r e a s e d inflammatory r e s p o n s e with little or no foreign b o d y r e a c tion. i n e x p e n s i v e .p o w e r lasers. the margin for error is greater as unsuccessful or imperfect " w e l d s " m a y be adjusted by s e c o n d a r y t r e a t m e n t s without ill effects to t h e host tissue. In addition. T h e s e are d e s k t o p and h a n d h e l d units that are s m a l l . T h e s e included the large size and cost of e q u i p m e n t . the a u t o m a t e d welding with c o m p u t e r controlled laser d o s i m e t r y ( p o w e r density. But the system that h a s the best p r o s p e c t for w i d e a c c e p t a n c e in s u r g e r y and dentistry is that of t h e d i o d e lasers. laser tissue fusion t e c h n o l o g y is particularly suited to e n d o s c o p i c and l a p a r o s c o p i c surgery. a d d s to the confusion in this field. T h e myriad w a v e l e n g t h s and s y s t e m s a v a i l a b l e .r e in forced a n a s t o m o s e s in a rabbit a o r t o t o m y model s h o w e d greater early strength in t h e latter. T i s s u e g l u e o r " s o l d e r " refers t o fibrinogen o r o t h e r protein c o m p o u n d s that a r e used to a b s o r b laser energy during w e l d i n g . e a s e of u s e . t h e s y s t e m s h o u l d be c o m p a c t . W i t h these i m p r e s s i v e a d v a n c e s . T h i s further p r o v i d e s selective localization of the laser e n e r g y .e n h a n c e d p h o t o a c t i v a t i o n . laser delivery s y s t e m s are being miniaturized and h a v e b e c o m e m o r e flexible and c o n v e n i e n t t o use. adding i n d o c y a n i n e green d y e permits selective tissue effects at the a r e a of d y e application w h i l e sparing adjacent native tissue.g a r n e t ( N d : Y A G ) lasers w i t h o u t need for w a t e r c o o l i n g h a v e been d e v e l o p e d . M o r e importantly.w e l d i n g . the p r e s e n c e of tissue g l u e requires less e n e r g y for welding and allows t h e use of s i m p l e r laser s y s t e m s . T o a c h i e v e d y e . and relatively i n e x p e n s i v e . it offers a c o m p l e t e . and the unfamiliarity of a n e w e r s y s t e m that requires training and practice as c o m p a r e d with c o n v e n t i o n a l s u r g i cal instruments such as scalpel or e l e c t r o c a u t e r y . b e c a u s e the latter d o e s not a b s o r b within the 7 1 175 .n m solid-state d i o d e l a s e r . T o a c h i e v e these ideals.t i b r i n o g e n g l u e e x p o s e d to 8 0 8 . 2 1 especially w h e n g l u e reinforcement is a d d e d . O n e such laser/dye c o m b i n a t i o n u s e s fibrinogen e x tracts with i n d o c y a n i n e green and an 8 0 8 .

T h e o r e t i c a l l y . 16-1 to 1 6 . Increased c o l l a g e n formation w a s found. Other workers h a v e noted w e a k e r tensile strength at coaptation sites in n e r v e treated with laser tissue f u s i o n . Bailes and c o w o r k e r s " studied laser-assisted anastom o s e s in p r i m a t e peroneal nerves using a u t o g e n o u s sural interpositional fascicular grafts. by m a n i p u l a t i n g the p r o p o r t i o n s of these s u b s t a n c e s . with greater strength of . In g e n e r a l . and w e l d e d vessel tissue has been o b s e r v e d to g r o w freely as c o m p a r e d with restricted g r o w t h of suture-repaired t i s s u e . 9 S i m i l a r o b s e r v a t i o n s of d e c r e a s e d foreign b o d y reaction and e a s e of operation w a s noted for skin c l o s u r e . t h u s a l l o w i n g for a m o r e c o m p l e t e epineurial seal than w a s possible by suture repair. forming a n e u r o m a with i n c o m p l e t e reinnervation. parallel a l i g n m e n t of n e r v e libers at the laser n e u r o r r h a p h y site w i t h o u t inflammatory reaction or carb o n a c e o u s d e b r i s .t e r m w o u n d c o m p r o m i s e i n strength o r c o s m e s i s . C h a n g e s in c o l l a g e n substructure were a l s o e v i d e n t . Notably. axon fiber density. 9 IN VIVO STUDIES In v i v o studies performed on blood vessels h a v e p r o v i d e d s o m e insight into the process of laser a n n e a l i n g or c o a p t a tion. to aid in the repair and found no difference b e t w e e n the laser e x p e r i m e n t a l g r o u p as c o m p a r e d with the s u t u r e control g r o u p with respect to c o n t i n u i t y of n e r v e . Further work in this a r e a is clearly n e e d e d . M o r e o v e r . c o n d u c t i o n velocity. T h e r e is also speculation as to w h e t h e r p h o t o c h e m i c a l b o n d s are formed or c h a n g e d d u r i n g the fusion p r o c e s s . M o r e o v e r . b e c a u s e t h e full potential for physically c o a p t i n g s e v e r e d n e r v e e n d s with s u t u r e s h a s seemingly been r e a c h e d ( F i g s . S t u d i e s of stressstrain analyses reveal similar strength in laser-repaired v e s s e l s . in c o n t r a d i s tinction to the c a s e w h e n sutures are used. Laser tissue fusion p r o v i d e s a circumferential seal with less constriction at the repair site b e c a u s e of t h e lack of foreign b o d y r e a c t i o n . these a d a p t a t i o n s w o u l d c o m p r o m i s e n e r v e regeneration. o b t a i n i n g fibrinogen for clinical u s e is p r o b l e m atic. this m i n i m i z e s d a m a g e t o t h e native host tissue. " ' T h e first successful n e r v e regeneration of transected rat sciatic n e r v e after epineurial repair using C O . C a m p i o n and c o w o r k e r s ' used a n argon laser to repair transected p e r o n e a l n e r v e of rabbits ( p o w e r density 100 W/cm*. and d i s t a l / p r o x i m a l m y e l i n a t e d liber d e n s i t y . T h e y noted e n h a n c e d . A g a i n . A x o n s sprout o u t s i d e the fascicular and epineurial c o n f i n e s . Studies of the effect of laser w e l d i n g on structural protein ( c o l l a g e n ) a r e not c o n c l u s i v e . p r o p e r t i e s of the tissue g l u e can be altered to suit specific u s e s and r e q u i r e m e n t s .b o n d e d vessels a r e found to be s m o o t h e r and less rigid than sutured controls. a wider a n g e of w a v e l e n g t h s and e n e r g y w e r e used in these studies on peripheral n e r v e or interpositional grafts to decrease ten sion at coaptation sites and support the laser fusion. particularly w h e n the use of tissue glue o b v i a t e s t h e need for precise tissue e d g e a p p r o x i mation w h i l e also p r e v e n t i n g e x c e s s i v e h e a t i n g of host tissues.5 m m via m i c r o s c o p e with m i c r o m a n i p u l a t o r ) . with actual interdigilation of the layered fibrils o c c u r r i n g . therew a s less a x o n a l e s c a p e into extrafascicular s p a c e in the laser-assisted g r o u p . l a s e r . T h i s is in part d u e to t h e u s e of different w a v e l e n g t h s and w e l d i n g p a r a m e t e r s . and fibrin g l u e . w h o s e sites of repair w e r e not disc e r n i b l e g r o s s l y or m i c r o s c o p i c a l l y at harvest. A t t e m p t s t o c i r c u m v e n t p r o b l e m s with sutures and additional a n a s t o m o s i s sites from interpositional grafts by using o t h e r m e t h o d s such a s s u b c u t a n e o u s ( S Q ) w e l d i n g with a SQ tissue s l e e v e " to boost strength of the anastom o s e s h a v e o n l y had limited success. It is g e n erally a c c e p t e d that fusion is a result of p h o t o t h e r m a l a c tion. " in 1982. 2 1 8 0 8 . and light electron m i c r o s c o p i c studies of t h e laser-repaired nerves d e m o n s t r a t e d c o m p a r a b i l i t y to c o n v e n t i o n a l suture repairs. a high e n o u g h e n e r g y or t e m perature is n e e d e d to c a u s e protein d e n a t u r a t i o n in target tissues so that an a m o r p h o u s c o a g u l u m is formed that infiltrates the native tissue. A s s e s s m e n t of these studies has been m a d e difficult by the use of different laser w a v e l e n g t h s and p a r a m e t e r s in different studies.4 ) . laser-assisted n e r v e c o a p t a t i o n c o u l d be p e r f o r m e d in difficult to reach p l a c e s and c o u l d b e d o n e m o r e rapidly.n m w i n d o w . In this s e n s e . I n v e s t i g a t o r s h a v e a t t e m p t e d to block such aberrant a x o n a l g r o w t h by using different materials such as c o l l a g e n sleeves. vein. R e g e n e r a t i o n of transected nerves is predicated upon successful a x o n a l g r o w t h into e n d o n e u r i a l tubes left patent by wallerian d e g e n e r a t i o n of distal s e g m e n t s . there a r e s o m e s u g g e s t i o n s of formation or d e g r a d a t i o n of covalent b o n d s . N e v e r t h e less. a x o p l a s m i c transport. because h o m o l o g o u s s o u r c e s present a risk of a c q u i r e d infection. O v e r a l l . H o w e v e r . T h e o r e t i cally this results in less turbulent (low d o w n s t r e a m and h e n c e less t r a u m a to the intima. pulse d u r a t i o n 2 0 0 m s . t h e fibrin g l u e or s o l der constitutes a b i o d e g r a d a b l e scaffold on w h i c h tissue edges heal. T h e physical a n d optical p r o p e r t i e s of tissue g l u e are d e t e r m i n e d by the protein and carrier g r o u n d s u b stance as well as by the d y e . fibrinogen g l u e is reabsorbed w i t h o u t a foreign b o d y reaction. spot size 0. Reapplication and retrial of fusion can also be carried out w i t h o u t d a m a g e to native tissue. Potentially. laser was reported by D e w et a l . T h e y are s i m p l e r to weld. MECHANISM T h e exact m e c h a n i s m of tissue fusion is not clear. g l a s s .176 Lasers in Maxillofacial Surgery and Dentistry laser-fusion skin repair without any l o n g . C o a p t a t i o n of transected n e r v e with s u t u r e s inherently d o e s not provide a watertight seal. C l e a r l y . w h i c h w a s later r e m o v e d . ' The a d v a n t a g e of laser w e l d i n g is especially e v i d e n t in small vessels a n a s t o m o s e s w h e r e s u t u r i n g is difficult. silicon. T h e y used a single slay suture. T h e e l e c t r o p h y s i o l o g y .

) Figure 1 6 .) Partial neuroma at site of stay suture. Proc SPIE 1991.M. Proc SPIE 1991.1 . Rat sciatic nerve. M. Morris JR.) .) Figure 1 16-2. 6. Schlossburg SM. Dew DK. Tissue soldering using indocyanine green dye enhanced fibrinogen with the near infrared diode laser. J Surg Res 1988. 660-u.D. Oz MC.2 sec. Hsu LS.) (Courtesy of Lewis dayman..) Figure 1 6 . Ozc MC..D. et al. Wang S. Parangi S. M. 6 .D.) (Courtesy of Lewis dayman. Laparoscopic applications of laser-activated tissue glues. D. D. Frazier OH. et al.) (Courtesy of Lewis dayman. Johnson JP. Dense Dense staining staining vertical vertical band indicates persistent scar. (S100 stain. 1421: 164-168. Sciatic Sciatic nerve nerve at at 6 6 weeks. Hsu TM. Richmond IL. 11:718-725.3 .. 5. Laser assisted skin closure at 1.Tissue Fusion 177 Figure 1 6 .D. D. Nerve transected and then fused with KIO-nm dye laser. M. Auteri JS. CW COo laser. Grubbs PE.M.m spot size.D.4 .M.D.D. M. et al. CW at 680 mW for 20 seconds.. Minor disturbance of axonal architecture. 4. Painvin GA.45:112-119.M. (I0X. Six weeks: nerve continuous.) (Courtesy of Lewis dayman.m spot size. J Urol 1988:139:415-417. Enhancement of C 0 laser microvascular anastomoses by fibrin glues.D. (250X.D. 2 Figure 1 6 .2 . Healing complete. Laser-assisted microvascular anastomoses: angiographic and anatomopathologic studies on growing microvascular anastomoses: preliminary report. Rat sciatic nerve. J Vase Surg 1980.D. et al.) M.M. ct al. Surgery 1985.. D. 600-p.D. Marini C. Poppas DP. 2.) (25X.) REFERENCES 1. (25X. 3. (50X.4 W. M. weeks. Laser welding in urethral surgery: improved results with a protein solder.97:585-590. 1422:111 -115. Bass LS.) (Courtesy of Lewis dayman.32 microns: The use of a software driven medical laser system. et al. PW = 0. Residual histologic signs of thermal damage and incomplete nerve healing still present. (S100 stain. D.5 . P = 0. Same rat. Six weeks.

c o n t r o l l e d p a r a m e t e r s for predictable w o u n d tissue r e s p o n s e . Colvard MC. Kuo PC. An expandable surgical chamber for use in conditions of weightlessness. Field Medical Laser System (FMLS) for the Special Operations Command. and collect fluids.u s a b l e lasers for e x p e d i e n t stabilization of w o u n d s in aviation and possibly in the z e r o gravity. R e c e n t l y . but it is difficult to c o n t r o l . New Mexico. vibration. Avial Space Environ Med 1990:61:170. d u e to m i c r o g r a v ity.2 T h e first use of a C O . Nelson BD. reliable. Furthermore. NASA 1990.C a d battery p o w e r e d d i o d e laser that e m i t s 7 W of energy al 81(1-900 nm c a p a b l e of c u t t i n g . Aerospace. Phillips Laboratory Laser and Imaging Directorate. C u r r e n t l y . REFERENCES 1. Nelson BD. C o n v e n t i o n a l Surgical t e c h n i q u e s arc possible in m i c r o g r a v i t y . 1994. Markham SM. 3. et al. A p p r o p r i a t e clinical features a r e being d e v e l o p e d as m e n t i o n e d a b o v e . Rock JA. The role of smart medical systems in the space station. Ostler DV. T h e need for surgical repair is clear. 8 Keipert AG. c o n t a i n . As previously discussed. and there is a tendency for arterial blood to scatter. Yaroshcnko. Michael D. 7. laser to perform facial and a b d o m i nal surgery on rats while a b o a r d an aircraft during high-altitude pressurized flight w a s r e c o r d e d in 1992. and rugged to withstand 8 179 . Int J Monit Comp 1989:6:91. Garber DD. Early h e m o s t a s i s and w o u n d sealing r e d u c e s bacterial e x p o sure as well as b l o o d and fluid loss and i m p r o v e s w o u n d healing. 6. 7 w e a t h e r e x t r e m e s . et al. Mokov MD. Colvard MD. To be effective. Laser surgery procedures in the operational KC-135 aviation environment. the r e d u c e d flotsam and the reusable nature of the portable laser a l l o w e d for a reduction in the quantity of surgical materials required without c o m p r o m i s i n g p r o p e r surgical and w o u n d care in e x p e r i m e n t a l rats. N : . they must be extremely lightweight. Biological d r e s s i n g and d y e . a small. totally r e c h a r g e a b l e . In addition. Medical impact analysis for the space station. Caleel R. et al. Kuo. T h e investigators o b s e r v e d that surgical precision c o u l d be e n h a n c e d by the use of a c o n t a c t laser to c o u n t e r to s o m e extent the unpredictable nature of air t u r b u l e n c e . Airforce Material Command. Avial Space Environ Med 1989:60:76. these miniaturized units s h o u l d be configured with pre-set. 5. Avial Space Environ Med I992. Gardener RM.Feb:5. Characteristics of surgical intervention under conditions of weightlessness. Ostler V. r e p r o d u c i b l e results.17 Laser Application in Microgravity. r e . T h e e x p e r i ment d e m o n s t r a t e d that aircraft safely and o p e r a t i o n s are not c o m p r o m i s e d by the u s e of a medical laser in flight. small. and Military Operations Paul C. Kirkland AFB. 2. R(xk JA. will further e n h a n c e the potential for rapid w o u n d closure using these laser s y s t e m s . 1. particularly in unskilled h a n d s with less surgical e x p e r t i s e .63:619. GL. Deploying and testing an expandablesurgical chamber in microgravity. w h e n d e v e l o p e d .e n h a n c e d s u p c r s t r c n g t h tissue g l u e or s o l d e r c a p a b l e of photoactivation. but not e l i m i n a t e d . In this light. 4. the miniaturization of laser t e c h n o l o g y with s m a l l e r d i o d e lasers of various w a v e l e n g t h s will p r o v i d e t h e flight surgeon with p o r t a b l e . Offices of Space Science and Applications. and the introduction of d i o d e laser s y s t e m s with further i m p r o v e d features and delivery p a r a m e t e r s s h o u l d be f o r t h c o m i n g . Space Life Sciences: A status report. and shock. Voen-MedZH 1967:10:69. Environmental c o n t a m i n a t i o n by tissues and fluids w a s minimal with the use of laser p h o t o a b l a t i o n and p h o t o c o a g ulation for control and stabilization of b l e e d i n g w o u n d s . Avial Space Environ Med 1984:55:403. Gardener RM. c o a g u l a t i n g and c l o s i n g wounds in the search and rescue e n v i r o m e n t h a s been d e veloped. T h e y must have self-contained p o w e r s o u r c e s and be c o m p a t i b l e with an external p o w e r supply. d i o d e lasers a r e the most p r o m i s i n g in t e r m s of size and cost. Similar miniaturized and c o m p a c t laser units c a n be used in trauma care and in field military o p e r a t i o n s by ( c o m b a t ) medics for w o u n d stabilization and e m e r g e n c y p r o c e d u r e s . Colvard Research in s p a c e m e d i c i n e s u g g e s t s thai t r a u m a t i c injuries in space are reduced. t h e u s e of tissue solder allows for a greater margin of safety to native tissues as well as m o r e uniform. weightless s p a c e e n v i r o n m e n t s . Terentyn VG.

S p e e c h and s w a l l o w i n g were normal. One year. Figure 7-16. Patient has been in regular c a n c e r surveillance protocol s i n c e month 3. . Note norma! range o f motion o n tongue Figure 7-17. Hull range of motion of tongue. Patient had DO e v i d e n c e of disease at 3 years.Transoral Resection of Oral Cancer Figure 7-15. S p e e c h is normal as it has been since the s e c o n d postoperative month.

Appendix

C 0 X = 10.6 p m / 1 0 , 6 0 0 n m P o w e r : C W — u p t o 100 W . RSP—up to 25W Pulse width 3 5 0 - 1 2 0 0 p s Peak p o w e r 500-12(K) W / p u l s e Pulsed: 1 0 - 6 0 0 m J / p u l s e ( u p t o 4 0 0 m J with S u r g i l a s e 150; 2 0 0 m J / p u l s e with Ultrapulse s y s t e m ) M i n i m u m spot size: 0 . 1 5 - 0 . 3 0 m m (0.3 m m with 125 mm focal length h a n d p i e c e ) 0 . 6 - 0 . 8 m m for m i c r o s c o p e units with m i c r o s l a d attachment Delivery s y s t e m s Waveguide Articulated a r m (with coaxial H e N e a i m i n g b e a m ) Incision: spot size 0.3 m m : P D » 1 0 W / c m ( 1 0 , 0 0 0 to >50,000 W / c m )
2 4 2 2

Contact N d : Y A G Silica tips: varied Typical power Up to 10 W to mark periphery of t u m o r To incise: 5 - 2 5 W d e p e n d i n g on tissue N d : Y A G : free b e a m : X = 1064 nm Aiming beam: HeNe: 5 mW Power: l O O m W t o 100W Pulse c a p a b i l i t y : 0.1 to 1.0 s e c and CW fiber delivery system S L T Contact N d : Y A G X = 1064 n m Absorption characteristics ABSORPTION COEFFICIENT water (cm-') blond (cm-') PENETRATION IN MEDIUM water blood (cm' )
1

A b l a t i o n : spot size 2 . 0 - 2 . 5 m m P D
2 2

= 400-750

W/cm Estimation of PD = 100 W / d (d = d i a m e t e r of spot in mm) Representative Articulated A r m S y s t e m ( S h a r p l a n ) CW:0.I-I00W RSP 0.5-2.0 W Peak P = 4 3 0 W @ 4 5 0 m J / p u l s e E n e r g y / p u l s e = 150 m J / 2 0 0 mJ Pulse width = 7 7 0 ps Aiming beam: 5 mW HeNe Duty c y c l e : u p t o 1 5 % C(>2 S c a n n i n g Lasers A u t o m a t e d scanner: 1 7 5 - 3 0 0 mJ/pulse Preset output for wrinkle r e m o v a l T h e majority of the c a s e s presented in C h a p t e r s 4 and 7 w e r e performed with an R S P C O 2 laser with the following characteristics:

co

2

Nd:YAG Argon

778 0.40
0.0001

800 4 330

0.001 2.5 10.000

0.001 0.25
0.003

From Fuller TA. Chapter 1: Fundamentals of Laser Surgery (pp. I -17). In: Surgical lasers: A Clinical Guide. New York. NY: Macmillan. 1987.

ErbiurmYAG X = 2.94 nm A r g o n / a r g o n :dye X = 488, 514,585 U p to 5.0 W Spot size: 5 0 p m t o 6 m m

CO2 Sharplan Laser Pulse Characteristics* Actual (pulses per second Avg. power (watts) Pulse width (millisec) Pulse period (millisec) Duty cycle (%) Avg. pulse power (watts) Pulse energy (millijoules) 46 20 4.24 21.74 19.50 102.60 435 42 25 6.40 23.90 93.50 93.50 597 92 20 1.62 10.82 133.60 133.60 216 86 25 2.40 11.60 120.90 120.90 290 165 20 0.85 6.05 142.30 142.30 121 157 25 1.15 6.35 138.10 138.10 159

•Note: Pulse characteristics measured from pulse generating circuitry. not from actual output. Data courtesy J. Rosenshein. Ph.D.

181

182

Lasers in Oral and Maxillofacial Surgery
4 J/cnr, 8 J/cm 3 - m m . 5 - m m spot size G o l d v a p o r laser 2.0 W X = 6 2 7 . 8 nm For P D T Copper vapor
3

P = up to 5.0 W Dye lasers C a n d e l a S P T L vascular lesions laser Pulsed d y e laser. I l a s h l a m p e x c i t e d 10J/cm 2 - m m spot size AlexandriaPulsed d y e / a l e x a n d r i t e
:

Matching Laser to Chromophere LASER NAME ArF XeCI Ar KTP (Nd:YAG freq. doubling) Cu vapor
\\ A M . i I:NC,TII(S) NAMH

CHROMOPHORK PEAK ABSORPTION 220 nm -310nm 400 - 500 nm 550-600 nm 550-600 nm. •=600 nm 510-532 nm 350-630 nm 400-700 nm 550-600 nm 350-630 nm 694, 755. 1064 nm 600 nm 694. 755. 1064 nm 694, 755. 1064 nm 694, 755. 1064 nm — > 1,400 nm > 1.400 n m Maximum at 2.940 nm > 1.400 nm

193 nm 308 nm 488 and 514 nm 532 nm 511 & 5 7 8 nm

Peptide bonds Bilirubin. Beta-carotene Hemoglobin. Melanin. Bilirubin, Beta-carotene Hemoglobin. Melanin Hemoglobin. Cytochrome a-a3. Red & orange tattoos HpD Melanin Hemoglobin. Tattoos. Melanin. Cytochrome PDT Green/Blue/Black Tattoo ink Cytochrome aa3 Green/Blue/Black Tait(x> ink Green/Bluc/Black Tattoo ink Green/Blue/Black Tattoo ink Non-specific Water Water Water Water

Au vapor Kr Dye

627.3 nm 647 nm 500-800 nm

Ruby TLSapphire Diode Alexandrite Nd:YAG Th:YAG Ho: YAG ErYAG CO,

694.3 nm 600-1,100 nm 670-1,550 nm 720-800 nm 1.064 nm 2.010 nm 2.140 nm 2.940 nm 10,600 nm

Prmii: Roscnshoin J S . Ph.D. Physics oj''Surgical Lasers Oral and Maxillofacial Clinics of North America. I W 6 .

Glossary

Laser light o c c u p i e s several different positions within the electromagnetic s p e c t r u m . T h e infrared e m i t t e r s a r e arranged in the near infrared ( I R ) [ n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( N d : Y A G ) 1064 n m . H O : Y S G G / 2 0 8 0 n m , holmium (Ho):YAG/2100, erbium (Er):YAG/292() n m ] , mid I R ( C 0 : 10,600 n m ) ; the visible light g r o u p e n c o m passes all c o l o r s ( K T P / y e l l o w , a r g o n / g r e e n , h e l i u m neon/red, t u n a b l e flash p u m p - d y e / m a n y c o l o r s , and t h e ultraviolet g r o u p m a i n l y to 193 n m ) . All f o r m s of laser light are properly c h a r a c t e r i z e d by the t e r m s listed b e l o w . A b s o r p t i o n l e n g t h ( E x t i n c t i o n coefficient) A b s o r p t i o n of the first 6 3 % of the delivered e n e r g y (rather than 9 0 % as for extinction coefficient). T h i s 6 3 % absorption is m e a s u r e d from the histologic s p e c i m e n c o r r e l a t i n g with the v a p o r i z e d region of the target s p e c i m e n . T h e r e a r e a p p r o x i m a t e l y 2.3 absorption lengths in e a c h extinction length. D u t y cycle D u t y cycle refers to the p e r c e n t a g e of t i m e the laser is on per second w h e n used in a repeat-pulse m o d e . It is the p r o d u c t of pulse width and repetition rate multiplied by 100. E n e r g y Energy is the c a p a c i t y to do w o r k or. in laser terms, to v a p o r i z e tissue. It is m e a s u r e d in j o u l e s (J) and can be looked upon as a m e a s u r e m e n t of d o s e . An important concept to r e m e m b e r is that a finite a m o u n t of e n e r g y will vaporize a finite v o l u m e of tissue. Studies h a v e s h o w n that it takes 2.4 J of e n e r g y to vaporize 1 m m ' of soft tissue at a fluence of a p p r o x i m a t e l y 4 J / c n r . Laser e n e r g y is a product of power (watt) and t i m e of a p p l i c a t i o n (sec):
2

of e n e r g y delivery p e r unit area of target tissue. Practically s p e a k i n g , it is a m e a s u r e of h o w intensely the b e a m is c o n c e n t r a t e d o v e r a g i v e n s u r f a c e area ( W / c m ) . T h e h i g h e r t h e i r r a d i a n c e . t h e faster a g i v e n v o l u m e of t i s s u e is vaporized. L a s e r p u l s e a n d p u l s e w i d t h ( P W ) D e p e n d i n g o n the l a s e r m e d i u m , the laser light e m i t t e d m a y be c o n t i n u o u s or pulsed. A c o n t i n u o u s w a v e laser b e a m (e.g., C 0 ) e m i t s a n u n i n t e r r u p t e d b e a m at t h e output p o w e r set for as long as the switch is turned on. It can also be c h o p p e d or gated to form a train of p u l s e s . If t h e on-off duty cycle is controlled by r e p e a t e d direct current c y c l i n g or by radio-frequency c o n t r o l , rapid s u p e r p u l s e d output pulses of brief d u r a t i o n occur. T h e s u p e r p u l s e b e a m h a s a p e a k p o w e r that far exc e e d s that set on the c o n s o l e p o w e r . U s u a l e n e r g y is 50 to 2 0 0 m J / p u l s e at p e a k p o w e r s up to 1200 W p e r p u l s e . Ultrap u l s e d lasers m a i n t a i n h i g h e r e n e r g y / p u l s e and produce p u l s e s of 2 0 0 m J / p u l s e . T h e laser e x p o s u r e t i m e , called p u l s e width or pulse d u r a t i o n , refers to t h e duration of an individual pulse d u r i n g which e n e r g y is delivered. It has been e s t i m a t e d that a pulse width as long as 6 5 0 ps is short e n o u g h to p r e v e n t significant heat diffusion from the target tissue to adjacent tissue, thereby p r e v e n t i n g significant unw a n t e d thermal d a m a g e .
2 2

P o w e r P o w e r is the rate of e n e r g y delivery, or h o w fast e n e r g y flows. It can be t h o u g h t of as an instant m e a s u r e of e n e r g y output. T h e unit of m e a s u r e m e n t is the watt ( W ) . which is defined as o n e j o u l e per second. T h e line p o w e r o u t p u t of a laser is the p o w e r of the laser b e a m at its exit point from the laser. P u l s e r e p e t i t i o n r a t e ( P R R ) Repetition rate i s the numb e r of laser p u l s e s p e r s e c o n d , m e a s u r e d in H e r t z ( H z ) . S p o t size Spot size refers to the d i a m e t e r of the laser b e a m as m e a s u r e d by c r e a t i n g a laser impact of 0.1 sec at 10 W on a m o i s t e n e d w o o d e n t o n g u e blade. It varies with the d i s t a n c e of the incident b e a m from the laser h a n d p i e c e to the target tissue (see Fig. 3 - 7 ) . T h e e n e r g y distribution within the b e a m s p o t is not uniform. R a t h e r , it follows a G a u s s i a n c u r v e , b e i n g highest in t h e c e n t e r and t a p e r i n g off t o w a r d the p e r i p h e r y , c r e a t i n g a laser crater as the b e a m hits t h e target tissue (see Fig. 3 - 4 ) . A p p r o x i m a t e l y 8 6 % of this b e a m is a v a i l a b l e to c r e a t e t h e v a p o r i z a t i o n crater. W h e n the b e a m is in focus, the p o w e r d e n s i t y is at its h i g h e s t for any given output p o w e r . B e c a u s e the a r e a of a circular spot

Energy (J) = Power (W) X Time 10 J = 1 W X 10 sec 10 J = I 0 W X sec ( T h e s a m e a m o u n t o f tissue i s r e m o v e d ) E x t i n c t i o n l e n g t h Distance from the tissue surface at which the incident b e a m has been r e d u c e d to 1 0 % of its initial intensity. F l u e n c e ( E D ) F l u e n c e , or e n e r g y d e n s i t y , is the total a m o u n t of e n e r g y delivered per unit area of the a p p l i e d laser b e a m . It is the p r o d u c t of irradiance ( W / c m ) a n d t i m e of laser application, e x p r e s s e d in J / c m . T h i s t i m e of laser e x p o s u r e also d e t e r m i n e s t h e a m o u n t of heat c o n d u c t i o n to cells i m m e d i a t e l y adjacent to the target tissue, referred to as lateral thermal heat transfer. I r r a d i a n c e ( P D ) Irradiance. or p o w e r density, is the rate
2 2

183

T h e r m a l relaxation is the t i m e required for tissue to dissipate 5 0 % of t h e heat a b s o r b e d from the laser pulse by diffusion. T h e r e f o r e . c h a n g e s with the square of its radius. w h e n the laser is used in the d e f o c u s e d m o d e . Z o n e o f v a p o r i z a t i o n V o l u m e o c c u p i e d b y the vaporization crater. / o n e o f s u b l e t h a l i n j u r y Peripheral area injured b y lateral heat c o n d u c t i o n that has the capacity to recover. w h e n the b e a m is d e f o c u s e d . a d o u b l i n g of the spot size. . will result in a fourfold d e c r e a s e in p o w e r density. T h i s is the tissue actually r e m o v e d by the explosive vaporization of t h e laser pulse. which permits controlled ablation of tissue to occur. t h e b e a m g e o m e t r y is flattened out. T h e r m a l r e l a x a t i o n t i m e T h e p r o c e s s b y which heat diffuses through tissue by c o n d u c t i o n is referred to as thermal relaxation. M a y also be a carbonized region.1 84 Lasers in Maxillofacial Surgery and Dentistry Z o n e o f c o a g u l a t i o n n e c r o s i s Lethally d a m a g e d tissue s e c o n d a r y to lateral thermal d a m a g e (heat c o n d u c t i o n ) adjacent to t h e v a p o r i z a t i o n crater.

palate. oral cancer. 20-22. 67 Fibroma. coronal view of. cross section. 23 cxcisional procedures. 19-20 articulated arm. plume from. 19-25 advantages of. defined. 23t tissue effects and. 137 light sources. 78 Facial telangiectasias. mucosa compressed. 183 Facial nevi. 72 W/cm2. 38 prencoplasia. defined. 23t preneoplasia. 134 dental caries. 8 modification. 127-133 decay detection. 159-160 Energy defined. susceptibility. 132 histology. 12. 137-142. phototherapy with. 24-25 handpiece. oral cavity. 134 Dental caries. laser-mediated. 66 Fire hazards. See Fluence Energy state. overview. 87 tumor debulking. 29-30 diascopy. 65 Ouence. 26-27 Absorption. 28 postoperative care. prencoplasia. 57 Duty cycle. 128 dentin ablation. laser. 132 laboratory setup. oral cavity. 87 Gingiva grafting. 51 first raster. 183 length. 87 power density. I OK tissue destruction. 34 Fibrin coagulum. 139-140 overview. 30 Diode laser. 159 overview. 20 Hazards. 179 Aesthetic surgery. 20 incisional procedures. 157 postoperative considerations. 127-133 of recurrent tumor. dental. of lasers. zone of. 27-28 contact laser probe tip. scarring after treatment. CO. 160 preoperative examination. 129 Dentistry. lasers and. defined. 63-65 frenectomy. excision. 29-31 technique. 4-5 DNA organization. 73 severe. mechanisms of. laser surgery. 183 Absorption spectrum. 20 basis for use of. 108 uvulopalatoplasty. 2-4. 13-14 185 . lasers and. susceptibility. 39-41 outline of lesion with. 81 Erbium. matched. 111-120 as vaporization instrument. 25-31 argon laser. transoral resection. 29 Nd:YAG. 70 hypertrophy. 102-103 Carbon dioxide laser. 160 instrumentation. 183 density. 48-49 Goggles patient protection with. scarring after. 24 Buccal mucosa nodular leukoplakia. laser. inadvertent. 87 Argon laser. 8-9 transoral resection. papillomas. excision. defined. 131 hard dental tissue ablation. leukoplakia. 129 ErYAG. 14-16 judgment errors. nonconlact. 23-24 microslad. 139 definitions. laser. laser. 29-30 telangiectasias. 127-135 ablation. laser. 8-9 contact laser surgery. cross section. 41. 20 energy. 139 Ear tag. 20 Nd:YAG. 23 2 Gaussian distribution. 34 Bean profile. oral cancer. 38 Er:YAG laser. 139 molecular structure. 138 history. 139-140 rhodamine dyes absorption spectrum. laser application in. 129 Deoxyribonucleic acid. laboratory setup. 11-16 electrical hazards. defined. prencoplasia. CO. 2 Endoscopic sinus surgery. of light. excision. 24-25 profile. 183 Free-beam lasers. 183 Dyes. yttrium-aluminum-garnetl. 74 lingual. 32 skin penetration. laser Caries. 22-23 laryngeal surgery. 3 Contact laser surgery. 50-51 cpithclialization. 33-35 telangiectasias. Coagulation necrosis. composite tissue. transverse. 16 Electromagnetic spectrum. 68 ED. ventral tongue. 14-16 Fluence.43 Fibrocpithelial hyperplasia. oral cancer. 30 first plane. 132 Extinction coefficient. 28t beam geometry. 127-133 materials processing. 134 pulpal histology. 86 Frenectomy. transoral resection. 29-31 complications. laser surgery. 26 third plane. ablation holes. 7 Absorption length. See Er:YAG laser Jt Erthroplakia. with CO. 51 mucosa. laser surgery. 133-134 Dentin ablation. 14 Handpiece. vascular malformation. 182 C 0 laser. oral cancer. 140-141 photodiagnostic imaging. 133-134 dentin ablation Er:YAG laser. 2 Epulis fissuratum. 107 transoral resection. 30-31 labiobuccal vestibule. Set Fluence Electrical hazards. 137 hematoporphyrin derivatives. 137-140 photooxygenation. 35 " canine teeth. 158-159 rationale. 8-9 Decay detection. 137-138 photosensitizes. 4 nonconlact. 133-134 Characteristics. healing. 157-163 case study. avoiding. transoral resection. 121-126 Learner's curve. transverse. oral cancer. of lasers. 51 second raster. canine teeth. susceptibility. 25-26 intralesional photocoagulation. 63-64 General anesthesia. hole. 51 proliferative granulation tissue. See CO. 64-65 irradiance. 16 fire hazards. 11-12 optical hazards. 24 disadvantages of. 161-162 paranasal sinuses. 3t Chromophorc. 79 Analgesia. oral cancer. 34 frequency-doubled Nd:YAG laser. vs. 50 postoperative. 132 histology. 139 Aerospace. general.Index Ablation of dentin. 182 Components. skin resurfacing in. lasers in. transoral resection. 33 wavelength specific. 33 technique. 27 second plane. rluxlamine dyes. 160-161 complications. 28. 28t. defined. oral cancer. 75-77 Fihroepithelial polyp. diagram. 42 transoral resection. 23. avoiding. dental. 50. See DNA Diascopy. lasers and. planes. 157-158 technique. 128 extracted t<x>th. I69t-170t Anesthesia. 63-64 vestibuloplasly. 160 "Hosaka window" approach. energy. 55. mucosa compressed. 167. 140 photodynamic therapy. 23.

125 parameters. laser surgery (Continued) plume hazards. endoscopic sinus surgery. CO. 33 luibiobuccal vestibule. effects of. prencoplasia. 95. 166 overview. papillomas. laser. 11-12 KTP laser. positioning. 48-49 lip dysplastic leukoplakia. 125 healing sequence. 12-14 Heliotherapy. CO. laser. glottic carcinoma. 146-148 Impacted teeth. frequency-doubled. 57 Inoculation. 55. 57 inoculation. oral cavity. 168t wavelengths. 43 laser handpiece.57 taxonomy. 29 Laryngeal hemangiomas. 125 cysts. 121-122. effects of exposure to. 2 in medicine. I68t Laser handpiece. timing. energy levels for. 94-95 technique 90-93. 4 Laser biostimulation. 123 granuloma. leukoplakia. phototherapy and. 4. I Holmium. 38 fibrin coagulum. to redirect beam. 180 CO.186 Index Laser. 12 Necrosis. temporomandibular joint surgery. 28 retinal burns. 56 viral genetic function. laser. laser application. 57 laryngeal. spot size. 6 Lingual gingiva. 48-49 ablation. 55 Hyperthermia. 37-53 buccal mucosa. 43-44 Light absorption. therapeutic use of. prencoplasia. 40 vaporization. 59 site. ablation. 122. See Argon. 38 nodular leukoplakia. CO. clinical. 145-146 Imaging-guidcd minimally invasive therapy. 55-56 DNA organization. zone of. 125 examination findings. biologic effects. 125 Up no recurrence. 57-58 epithelial hyperplasia. (. CO. 122-126 laryngeal surgery. buccal mucosa. 166-167 current research. 41 leukoplakia. 61 Paranasal sinuses. 60 recurrent disease. 55-62 carbon dioxide laser. 43 healing. 45 laser wound. simultaneous. 42 duct. 179 Mouth. of lasers. transoral resection. 35t Human papillomavirus. 167. 165-172 analgesia. 183 Judgment errors. I69t-I70t background. interactions. 57 active expression phase. 57 incubation phase. 125 history. 125 examination findings. human papillomavirus. laboratory. 49 sulcus. coagulation. exposure to. 50. 48 postoperative.43 tongue. laryngeal. 87 contact laser probe tip. 55. 58 gingival site. 48 Lip. 40 erthroplakia. 56 viral genetic function. 125 laser type. 3t chromophorc. 48 lingual gingiva. 7 lasers and. 57 active expression phase. to redirect beam. 37-39 Palate papillary hyperplasia of. 122-126 Hematoporphyrin derivatives. CO. pulpal. 39-41 outline of lesion with. 43 surgical technique. 40 vital staining. 4 Nd:YAG laser. 16 skin hazards.l> 61 Hazards. lateral tongue. lingual anterior mandibular gingiva. human papillomavirus. composite tissue. preneoplasia. overview. 139-140 tissue. 114-115 Obstructive sleep apnea syndrome. 30-31 Irradiance CO. 51 CO. laser. 167-171 controversy. pathophysiology of. 123 T. malignant. 57-58 infection. 122. 82 Nd:YAG laser. laser. tissue over duct. 45-47 Meniscus. 58 clinical. laser. 104-105 Papilloma. 167 repetition rates. laser-mediated. 4-5 Ho:YAG laser. 23-24 Leukoplakia. 165-166 cellular effects. 125 treatment. 122-126 malformation. yltrium-aluminum-garnctt. photolhermal therapy. ablation. 59 virology. See also Sleep apnea syndrome Optical hazards. 2-4 components. 167-171 . 12. 13-14 Oral cavity. 4. 122-123. in laser surgery. 122-126 laryngeal hemangiomas. 123 maxillary alveolus. 43-44. 125 vocal Ibid polyps. 50-51 epithelialization. papillary hyperplasia of. 144-145 Learner's curve. 115. 125 Reinke's edema. 138 Histology. 166-167 current research. 125 healing sequence. 184 Nonapneic snorers. medial dislocation of. 51 first raster. multiple. lesion over. palate. 165 in vivo animal experiments. 27-28 argon. 167. 125 parameters. 122-123. 45 leukoplakia. CO. 59 infection. 48 multicentricity. healing. 165 laser parameters. 55 Papillomatosis. 52 debris removed. laser. 57 Intralesional photocoagulation. 125 laser type. 124. 165-166 parameters. 52 tongue blade. 123. 169-1701 background. laser application. 57 inoculation. 82-83 benign pigmented lesions. 124. subglottic. 167-171 cellular processes. 157 Photobioactivation. 171 ultraviolet therapy. coronal view of. vascular malformation. 42 postoperative tonsillar hypertrophy. See also Photobioactivation overview. 125 healing sequence. 51 second raster. oral cancer. after treatment. matched. pathophysiology of. 82-83 aphthous stomatitis. 48 postoperative. 122-126 neoplasms. 45 Laser pulse. 57 taxonomy. 41-42. timing. 48 front surface mirror. transoral resection. 48^*9 lingual gingiva. 129 History. leukoplakia. exposure of. vascular malformation of. 43 results. ventral tongue. 165-166 sources of. 55-62 carbon dioxide laser. 4 characteristics. 41. 1. 38 palate. 179 Military operations. 121-126 case presentations. lateral tongue. defined. 167-171 exposure to cellular processes. 165-172 analgesia. 22-23 defined. papillomas. 123. 50 postoperative. 42 reepithelialization complete. 125 parameters. dysplastic leukoplakia. 125 laser type. 171 heliotherapy. 90-93. with dysplasia. floor of. 123-125 papilloma. 48-49 front surface mirror. 57 virology. 160 Ho:YAG laser. 55-56 DNA organization. See Ho: YAG laser "Hosaka window" approach. 71 subglottic. 125 treatment. 55. photolhermal therapy. 171 controversy. 123 hemangiomas. 125 history. oral cavity. in laser surgery. 125 examination findings. 183 Laser tissue effects. 104. oral cancer. 52 surface reepithelialized. frequencv-doublcd Nd:YAG laser I^ibiobuccal sulcus. 171 wound healing. frequency-doubled Nd:YAG laser. soft tissue. laser. renal transplant recipient.94-95 aftercare. 35 temporomandibular joint surgery'. 153 Microgravity. overview. 1-5 argon. 167 low-intensity laser therapy. ablation. 55. 171 research. 3 diode laser. 45-47 mouth. positioning. laser-mediated. 124. laryngeal. 94 Mucocele. 125 history. 165-166 cellular effects. 4 CO. 167. 51 mucosa. anterior. 165 Hemangioma laryngeal. laboratory evaluation. 58 evaluation. 125 treatment. 49 sulcus. laser. 69 Incubation phase. 58 epithelial hyperplasia. defined.

140 pholodynamic therapy. 51 second raster. laser excisional procedures. 67 fibroma. 154 Ho:YAG laser. overview. 151-155 case study. oral cancer. C 0 laser. 112-113 one stage. 14-16 judgment errors. benign.Index exposure to cellular processes. 139 Safety. 137-138 Photosensitizers. wavelength specific. laser. 16 fire hazards. laser surgery. 51 first raster. effects of exposure to. description. 52 debris removed. 52 tongue blade. 82-83 Subglottic hemangioma. 174 sciatic nerve. biologic effects. papillomatosis. 167 low-intensity laser therapy. description. 74 hemangiomas malformation. 4-5 Ho: YAG laser. in tissue. 114-115 operative outcome. liming. 69 2 . 113-114 uvula. 138 history. 147-148 Pigmented lesions. 50. 183 Prencoplasia. spot size. oral cancer. 113 "multiple-stage" technique. 42 rccpitheliali/ation complete. 63-65 frenectomy. 7 temperature/depth. exposure of. 4 power/depth. laser-assisted uvulopalaloplasty. 111 multiple sessions. healing. 43 results. 88 Surgical lasers. 1-5 argon. with laser. 5-7 Thermal relaxation time. 78 fibrocpilhelial hyperplasia. 48 lingual gingiva.43 tongue. 144-145 overview. 184 Submandibular duct. 3t CO. mechanisms of.2 absorption. 6 overview. 171 ultraviolet therapy. 137 dyes. in laser surgery. 171 wound healing. 37-39 PRR. 154-155 Thermal laser-tissue effects. 167 repetition rates. 114 "multiple-stage" technique. 165 wavelengths. defined. 125 treatment. 1 -9 contact laser surgery. 116 procedure. zone of. compared. 111 Snoring. 45-47 mouth. 143-144 hyperthermia. 124. 171 heliotherapy. 11-12 optical hazards. 4 characteristics. 139-140 rhodamine dyes absorption spectrum. 8 modification. 83 ear tag. ablation. transoral resection. 38 nodular leukoplakia. 111 laser-assisted UPPP. 177 Skin hazards. 112 LAUP multiple sessions. 81 facial nevi. 5 thermal laser-tissue effects. 11-17 goggles. 52 Tongue blade. 43-44. mechanisms of. 40 vital staining. 5 Temporomandibular joint surgery. medial dislocation of. CO. vs. 16 Power. 52 surface reepithelialized. palate. laser. 52 surface reepithelialized. 40 erthroplakia. 70 hypertrophy. lesion over. 71 impacted teelh. 82-83 aphthous Momaritis. 137-140 Photooxygenation. laser. 139-140 Phototherapy with dyes. 66 187 gingiva grafting. 4 Nd:YAG laser. 83 Spot size. 8-9 electromagnetic spectrum. in aesthetic surgery. laser. 111-120 contact Nd:YAG. 112-113 nonapneic snorer. 12-14 retinal burns. 140-141 photodiagnostic imaging. 48-49 lingual gingiva. 63 CO. 104-105 Tooth.51 mucosa. 183-184 Stomatitis. 139 molecular structure. 112-114 "single-stage" technique. 50-51 epithelialization. 12. 114 overview. 43 laser handpiece. glottic carcinoma. buccal mucosa. 41-42. 7 interactions. 13-14 plume hazards. palate. defined. CO. anterior. 114 operative outcome. simultaneous multiple. 41 leukoplakia. 8-9 history. 139 molecular structure. after treatment. 140 Pholodynamic therapy. soft tissue. 123 Renal transplant recipient. 165 laser parameters. 2 free-beam lasers. 125 examination findings. tissue fusion. 48 laser tissue effects. 80 complications. in aesthetic surgery. 137-138 photosensitizers. 72 combination uses. 145-146 imaging-guided minimally invasive therapy. 119 incisions. 79 Sleep apnea syndrome. ventral tongue. leukoplakia. 80 rhinophyma. defined. 125 history. 8-9 contact laser surgery. 143-149 background. 7 temperature gradients. 138-139 hematoporphyrin derivatives. 75-77 fibroepithelial polyp. 151-152 meniscus. defined. 11-16 electrical hazards. 7 tissue. defined. Nd:YAG-induced. cancer. noncontact. 69 mucocele. 3 diode laser. 122-126 Sublethal unjury. 111-120 contact Nd:YAG. See Pulse repetition rale Pulse repetition rate. 114 overview. 82 Plume hazards. 113-114 uvulopalatopharyngoplasty. laser. 43 healing. 52 debris removed. 117 Soft tissue excision. 137-142 definilions. 5 Tongue. papillary hyperplasia of. 166 parameters. 51 CO. 153 overview. 48 multicentricity. 82 skin resurfacing. 176-177 light absorption. 183 Reinke's edema. 12 Rhinophyma. 50 postoperative. postoperative. exposure of. 125 healing sequence 124. 79 vascular malformation. 14 hazards. 137-140 photooxygenation. uvulopalatoplasly. 139 Photothernial therapy. diagram. See also Dentistry impacted. 73 severe. 167. 153. 63-83 clinical laser application. 1. to redirect beam. 61 Retinal burns. 71 wound care. effects of. 139-140 overview. 48-49 lip leukoplakia. oral cavity. in tissue. leukoplakia. 43 surgical technique. 117 indications. composite tissue. tissue over duct. spot size. 12-14 resurfacing. 42 duel. 37-53 buccal mucosa. 39-41 outline of lesion with. 5-7 T. 65 incisional procedures. 34 Temperature gradients. 80 Rhodamine dyes absorption spectrum. 184 Tissue fusion. 125 Telangiectasias. 48 postoperative. 183 width. 116 procedure. with dysplasia. in laser surgery. 124. 45 laser wound. 119 indications. 60-61 maxillary alveolus. 82-83 benign pigmented lesions. 68 epulis lissuratum. 38 fibrin coagulum. vertical incisions. 60 recurrent disease. 41. 63-64 vcslibuloplasty. 137 light sources. 16 skin hazards. Nd:YAG-induced. 146-147. aphthous. transoral resection. ablation. 112-114 "single-stage" technique. I light. 40 vaporization. 38 palate. defined. 64-65 as vaporization instrument. 175 in vivo studies. interactions. 173-176 mechanism. 40 Tonsillar hypertrophy. 6 temperature gradients in. I68t Photodiagnostic imaging. 48-49 front surface mirror. 113 one stage. positioning. physical considerations. 2 energy state. 49 sulcus. 171 research. 125 laser type. 2-4 components. 125 parameters. 12 Sciatic nerve.

116 personal series. 88 surgical cases. 117 indications. 87 surgical protocol. 86. laser. postoperative tonsillar hypertrophy. defined. 64-65 Viral genetic function. 111-120 case study. 55-56 papillomas. 87 vs. 114 overview. 184 . 114 OSAS patients. 86-87.94 palate. 167. laser. 112-113 nonapneic snorers. 100-101 free beam CO 96-98 motion. 116 contact Nd:YAG. 33 Vcstibuloplasty. CO. defined. 85-109 buccal mucosa. compared. 111 Vaporization.YAG. results of. 85-86 operative outcome. avoiding. zone of. 96-98 tumor debulking. floor of. 87-88 contact Nd. 114 "multiple-stage" technique. defined. 94-95 technique 90-93. 104-105 proliferative granulation tissue buccal mucosa. 107 submandibular duct. 113 one stage. 55 Virology human papillomavirus.188 Index time at operation. 88 tongue cancer. 114-115 obstructive sleep apnea syndrome. 123 2 Ultraviolet therapy. 88 consequences. 107 CO. 95 lingual anterior mandibular gingiva. oral cancer. 184 of sublethal unjury. 102-103 with proliferative granulation tissue. 112-114 "single-stage" technique. 71 labiobuccal sulcus. primary closure. 55-56 Vocal fold polyps. papillomas. 90-93. 184 Vascular malformation. 114-115 procedure description. 106 tonsillar hypertrophy. 104-105 tumor debulking. defined. 108 Tumor debulking. transoral resection.AUP multiple sessions. postoperative. restricted. I IS Wound healing. 108 complications. 87. 108 : Transoral rcsoclion. 184 of vaporization. oral cancer. CO. 101 general anesthesia. 87 mouth. 89 survival. 89 free beam. photobioactivation and. 165 UV. See Ultraviolet therapy Uvulopalatoplasty. 111 I.94-95 aftercare. C 0 laser. laser. with CO. laser. 119 incisions. 87 dry field. 113-114 uvulopalatopharyngoplasty. I68t Zones of coagulation necrosis. contact Nd:YAG. 99 contact Nd:YAG laser scalpel.