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

Physical Considerations of Surgical Lasers

f

Terry A. Fuller

HISTORY
A laser, an acronym lor light amplification by stimulated emission of radiation, is a device for generating a high-intensity, ostensibly parallel beam of monochromatic (single wavelength) electromagnetic radiation. The possibility of stimulated emission was predicted by Einstein in I9I7; based on the work of Gordon in 1955 and Schawlow and Townes in 1958, Maiman created the first operational laser in 1960, a ruby laser emitting a brilliant red beam of light. This was followed within 3 years by the development of the argon, carbon dioxide ( C 0 ) , and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers, which remain the most widely used lasers in medicine. In 1963 the ruby laser was employed in the treatment of pigmented dermatologic lesions and for photocoagulation of the retina. Early applications of lasers in oral and maxillofacial surgery began to appear in the mid- to late 1970s. Potential advantages of surgical lasers were clear from the beginning, but the cost, unreliability, and operational complexity of the early machines greatly limited the actual use of lasers, except in the fields of ophthalmology and dermatology, until the past 15 to 18 years. In recent years improved understanding of light-tissue interactions and, of greatest importance to the surgeon, new technologies for delivering laser light to (he tissue, has transformed lasers into versatile and valuable surgical instruments. This chapter presents the fundamentals of laser physics and introduces the reader to the interactions between light and tissue. Full appreciation of the uses, limitations, benefits, and risks of surgical lasers requires a basic understanding of laser physics and the biologic action of light.
2

the radiation in the visible region of the spectrum (Fig. 1-1) defines the color of the light. Atoms (ions or molecules) at their lowest energy or ground state possess an intrinsic amount of energy. When excited through the process of absorption by the input of thermal, electromagnetic, or other forms of energy, they are raised to one of several distinct higher energy levels. 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, E = E ) . All particles making the transition between the same two energy levels will emit light of identical energy and wavelength (Fig. 1-2). Ordinary sunlight or lamplight consists of many wavelengths; even light, colored from passing through a filter, represents a broad spectrum of many wavelengths. Such light emanates in all directions from its source. The intensity diminishes as the inverse square of the distance from the source. As discussed below, a laser uses the principle of stimulated emission to produce light of a markedly different quality. The spontaneous emission of photons from an excited atom may occur at any time and in any direction. If, however, a photon of E strikes an atom already in an upper energy stale E , it stimulates the emission of a second photon of light. 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. If these two photons strike additional atoms in the excited state E-j, they will yield an amplifying cascade of photonslaser lightthat is monochromatic (a single wavelength), coherent (synchronous waves), and collimated (parallel rays).
2 a A 2

LIGHT THE LASER

Electromagnetic radiation is energy transmitted through space. It can be viewed either as propagated waves of characteristic energies, or as discrete (and the smallest) parcels of energy called photons. Electromagnetic radiation is quantified in terms of two reciprocal forms of measurement: frequency (v), expressed in Hertz (Hz) or cycles per second, and wavelength (\), expressed in metric units of length. Which units are employed in any particular application is largely a matter of convention. The wavelength of Lasers consist of a small number of basic components as shown in Figure 1-3. An active lasing medium, which can be a solid, liquid, or gas, is enclosed within a laser cavity bounded by two perfectly parallel reflectors (mirrors). High-energy radiation is pumped into the active medium by means of a pump source. The pump source is energy generally provided by an intense optical or electrical discharge. The energy from the pump source is absorbed by the active 1

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

Figure 1-1.

Electromagnetic spectrum.

Figure 1-2. medium until the majority of atoms, ions, or molecules are raised to their upper energy state. This is a condition known as a population inversion and is a necessary condition to generate laser light. 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. Thus, the light is repeatedly bounced between the reflectors. This will stimulate the emission of even more photons (amplification) in that axial direction. Light traveling in other directions escapes the cavity and is lost as heal. One of the mirrors is only partially reflective, enabling some of the light to escape the cavity as a beam of laser light. Different lasing media, because of their particular atomic, molecular, or ionic structure and energy levels, emit

Energy slate diagram. light of characteristic wavelengths. The properties of the most common surgical lasers are listed in Table 1-1.

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 gases are either sealed in a tube or are circulated from a tank. When excited by direct current (DC) or radio-frequency (RF) voltage, the carbon dioxide absorbs a portion of this energy and raises the CO> molecule to an upper energy state. The excited C 0 molecule spontaneously decays and emits mid-infrared photons at a wavelength of 10.6(H) nm
2

Physical Considerations of Surgical Lasers

Figure 1-3.

Basic laser components.

Table 1-1.

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. IO0W CW > 50W 25Wavg. 20W SSOmJ 250mJ

LASER TYPE C0 Holmium Nd:YAG Diode KTP/KDP Argon Excimer ArF -XcCI Erbium: YAG(Er: YAG)
2

WAVELENGTH 10.600 nm 2.100 nm 1,064 nm 800-890 nm 532 nm 488/514 nm. 190 nm 308 nm

Reproduced with permission of T.A.F.. modified from Fuller TA. Thermal Surgical Lasers. Philadelphia: Surgical Laser Technologies. Inc.. 1992.

(10.6 pm). Power (measured in units of watts, W) is the lime function of energy (measured in joules, J) and can be delivered either continuously (continuous wave, CW) or in a train of pulses. The carbon dioxide laser can be pulsed in a manner thai results in high energy, rapidly repeating pulses typically referred to as superpulses. In contrast to CW surgical lasers, which generate power up to 100 W, the superpulsed C 0 laser generates power up to 10,000 W in a repeating train of pulses. There are substantial differences in clinical effect between CW, conventional pulsing, and superpulsed modes of operation (see Chapter 3).
2

Infrared light is in a region of the electromagnetic spectrum that is not visible to the human eye. Therefore, 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 delivery system used to carry Ihe laser light to the lissue is of critical importance to the surgeon. The C 0 laser generally uses an articulated arm as its principal delivery system. An articulated arm is a series of hollow tubes connected together through a series of six to eight articulating mirrors. This is in contrast to very thin, continu2 2

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.

ously flexible, glass (fused silica) fiber optics generally used for near infrared and visible lasers. Glass is opaque to 10,600 nm light and thus is not suitable for C O laser transmission. The C O laser is primarily used for cutting and vaporizing tissue in open procedures or in procedures where rigid endoscopy is acceptable.
: :

Holmium:

YAG

Argon

and

Frequency-Doubled

Nd.YAG

Lasers

Argon and frequency-doubled Nd:YAG laser (also referred to as a KTP laser), although technologically very different from each other, are devices that generate laser energy in the green region of the electromagnetic spectrum. The argon laser employs an electrically excited ionized argon gas as a lasing medium. The high heat transfer requires a water-jacketed cooling system, which permits power outputs of up to 25 W. More portable, air-cooled units arc limited to power outputs of 5 to 10 W. This laser emits bluegreen light at 488 and 514 nm. The KTP laser uses a Nd:YAG laser in combination with a potassium titanyl sulfate (KTP) crystal. 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 result is a beam of green light at 530 nm. 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. Since the light is visible, no secondary aiming beam is required. Safety glasses are required to protect the patient and operating room personnel from the therapeutic beam of all surgical lasers. However, glasses used for the green lasers necessarily block green light and thus tend to obscure the overall visualization of the surgical field.

The holmium:YAG laser is technologically associated with the Nd:YAG laser. This solid-state laser uses holmium as its active medium doped into a matrix of yttrium, aluminum, and garnet. Due to its inherently inefficient operation and certain thermal design considerations, this laser is pulsed. It emits rapid pulses of energy at 2100 nm in the mid-infrared part of the spectrum. Like the NdiYAG laser, this laser requires an aiming beam. The holmium:YAG beam can be delivered through fiber optics. However, such fibers must be made of low OH (hydroxyl radical) glass due to the high absorption of this wavelength to water.

Diode

Laser

Nd.YAG

Laser

The neodymium.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. The active medium of this laser is the neodymium atoms doped into a matrix of yttrium, aluminum, and garnet. The neodymium atoms are optically excited by way of a bright arc lamp. This relatively efficient laser generates a wavelength of 1064 nm and is outside the visible region of the spectrum. Therefore, the Nd:YAG laser requires an aiming beam similar to that used by C 0 lasers. Safety glasses for this laser are transparent to visible light and do not obscure the surgeon's surgical view. The surgical Nd:YAG lasers commonly deliver continuous (CW) power up to KM) W and can be passed easily through inexpensive flexible fiber optics. In addition to the CW mode of operation, the Nd:YAG laser can be configured to operate in a special pulsed mode referred to as Q-switched. The Q-switched laser emits pulses of pico- to nanoseconds in duration. This mode is often
2

In contrast to the gas and solid-state lasers discussed thus far. diode lasers are in a category of devices that emit light from semiconductor materials. They are operated in a manner similar to a transistor in which an electric potential is applied to dissimilar semiconductor materials. In contrast to gas, solid state, and liquid lasers, semiconductor lasers require no high voltages or currents, no arc lamps or optical pump sources, and have no required moving parts. They are very efficient (typically >3035%), but arc capable of generating only relatively low power levels. Individual "highpower" laser diodes typically generate only 1 to 1^ W per diode. To gain useful power from the laser, multiple devices must be used in concert. Linear (one-dimensional) arrays or two-dimensional arrays are being developed to gain sufficient power for surgery. Additionally, ganging individual diodes in various optical configurations are being explored: each approach carries its own benefits and drawbacks. Both commercial and prototype surgical diode laser systems are able to deliver 20 to 50 W. There are currently severe fiber optic size and maximum power limitations as well as diode and system warranty and lifetime issues. Currently, the most popular diode lasers emit light in the 800to 890-nm range. Lasers in the shorter wavelength range provide biologic effects similar to those of the Nd:YAG lasers. Longer wavelengths have higher tissue absorption characteristics. The technological specifications of a given laser type and model indicate how much power (or in the case of a pulsed laser, energy) can be practically delivered to tissue and the means by which the power can be conveyed to tissue. When laser energy interacts with tissue its output power is distributed over the area of an illuminated spot. This distribution or power density or fluence (power/area. W/cnr) is intimately related to the tissue effect. The power density can be altered by changing either the power of the laser or spot size

Physical Considerations of Surgical Lasers of the laser beam. The effect that a particular laser emission has on tissue, and thus the surgeon's ability to effectively utilize that emission, depends upon power density and other specifications as well as the characteristics of tissue. 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.

THERMAL LASERTISSUE EFFECTS

The focus of this book is on the interactions of laser energy and tissue that result in an elevation of the tissue temperature. These so-called thermal lasers represent the majority of all applications of lasers in medicine. Thus, lasers that are Q-switched or lasers that operate at low powers for biostimulation or photodynamic therapy (PDT) interactions are excluded herein from discussion. This section presents an outline of the principal variables affecting the clinical end point. 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. The goal of laser surgery is thus to create a temperature gradient (Fig. 1-4) or profile in tissue that will result in coagulation or vaporization of tissue. Coagulation provides hemostasis and. if desired, necrosis of tissue. Vaporization (the conversion of solid and liquid phase tissue components

into gaseous phase components) provides the ability to cut, incise, excise, resect or ablate tissue. Coagulation and vaporization are two different effects created by the same process: heating of tissue. Coagulation generally occurs when the temperature is elevated from 60C to <100C. Obvious changes occur in the tissue at these temperatures resulting from the thermal denaturation of tissue protein, and include blanching and shrinkage as well as puckering due to dehydration. When the temperature is elevated near and above the boiling point of water (100C), vaporization of liquid and solid components occur. A frank defect is left that includes a zone of char (carbon, as a result of the combustion of tissue) surrounded by coagulated tissue. The extent of the area of vaporization, char, and coagulation (as well as a heat-affected zone surrounding the coagulation, which can cause edema) is defined by the temperature gradient. Thus, by altering the gradient, the surgical effect can be altered. There are several variables that determine the gradient. They include the laser parameters such as power density, duration of exposure, wavelength, and method of delivery of laser energy as well as tissue parameters. Light can be absorbed, transmitted, scattered, or reflected by tissue (Fig. 1-5). Only light that has been absorbed can yield a therapeutic result. Light that is transmitted through or reflected from tissue yields no effect until and unless it is absorbed. The measure of the degree to which tissue absorbs light is the absorption coefficient, a (measured in units of c m ) . It is a measure of the amount of energy ab- 1

Figure 1 -4. Temperature gradients in tissue.

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

OW?3SLT.INC./T.A.r

Figure 1-5.

Interactions of light and tissue. in the range of 50 to 120 mJ/pulse. 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. By way of contrast, Ihe Nd:YAG laser will penelrate deeply in tissue with a relatively low surface temperature and shallow temperature gradient. Scatter of light by tissue spreads the laser beam in a diffuse pattern defined by the tissue's scatter coefficient. B. Once the light is scattered, if it is absorbed, it will affect a volume of tissue larger than Ihe laser's optical spot size. In some instances scatter is an attribute desired by the surgeon. For example, when Nd:YAG laser energy is used to thermally destroy a tumor, the deep penetration of the laser beam coupled with the high scatter coefficient affects a deep and wide volume of tissue. In contrast, scatter can also be detrimental if one is attempting to localize the effect of the laser. The green light from the argon and KTP lasers is both scattered and absorbed by tissue. The degree of absorption is heavily dependent on the concentration of the chromophores hemoglobin and melanin. Thus, heavily pigmented skin or vascular areas such as a hemangioma will result in high absorption (low penetration). The scatter of the green lasers are greater than that of the C 0 laser. The method of delivering the laser light to the tissue also acts as a variable affecting the tissue response. In general terms this delivery of energy falls into two broad classes: free-beam lasers and lasers lor use in contact with tissue.
2

sorbed through a distance of the absorbing material. The penetration depth of the laser in a given tissue is proportional to the inverse of the absorption coefficient . The more highly absorbed the light (high a), the shallower the penetration. As can be seen in Figure I - 6 , this results in the light energy being converted to heat energy within a shallow layer of tissue, and therefore results in intense surface heat. A tissue with a high will create a steep temperature gradient. Figure 1-7 illustrates the absorption of light by tissue at different wavelengths. The y-axis indicates greater absorption (less penetration) and thus higher resulting temperatures. It can be readily seen that the C 0 and erbium (Er).YAG lasers would create high surface temperature and very steep temperature gradients in the tissue. Both the C 0 and EnYAG laser beams are preferentially absorbed by water, and because water is by far the largest component of most tissue, this results in the rapid transformation of light into heal within about 0.2 to 1.0 mm of the tissue surface. The intense thermal response quickly evaporates the water and vaporizes tissue. The temperature gradient is so steep that it has relatively poor coagulation properties. The duration of exposure is another key variable in determining the extent of a laser-induced lesion. Long exposure times result in conduction of heat into surrounding lissue and thus improve hemostasis and increase coagulation necrosis. In contrast, techniques exist to diminish coagulation necrosis. The superpulse C O laser is one such example. This laser uses rapidly repeating, high peak power pulses with pulse energy
2 2 :

Physical Considerations of Surgical Lasers

Figure 1-6.

Power/depth and temperature/deplh.

Figure 1-7.

Light absorption by composite tissue.

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, causing the final clinical result. The interactions between laser light and tissue described above are specific for free-beam lasers. They result from interactions between the native laser wavelength and tissue alone. Typical free-beam delivery systems include articulating arms, micromanipulators used in conjunction with surgical microscopes, and conventional fiber optics. Characteristic of these devices is that the effect on tissue is principally that of the laser emission alone. This is typically what occurs when there is no contact between the fiber optic end of the delivery device and the target tissue. Consider the laser beam exiting a laser delivery system used in a free-beam mode (Fig. 1-8, left). 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. Should the distance from the fiber to the tissue be altered, the power density at the tissue will change, changing the clinical effect. 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, but suffers from the loss of tactile feedback. The techniques for learning and using the freebeam laser are substantially different from those of conven-

tional instruments. Perhaps the most limiting feature of the free-beam laser is that different laser sources are required for different surgical maneuvers, e.g., Nd:YAG for coagulation and hembstasis and CO for incision and excision.
:

Modification of Free-Beam Laser Contact Laser Surgery

Surgery:

Despite the benefits of free-beam laser surgery, certain limitations and drawbacks exist. Perhaps the most significant is that to substantially change the tissue's temperature gradient (clinical effect), one must choose different laser sources, an expensive and intraoperatively difficult task. Contact Laser surgery has been developed to augment and overcome this and other fundamental deficiencies in free-beam surgery. Contact Laser surgery works by altering the tissue temperature gradient through changes in the laser delivery system, rather than by alteration in wavelength. 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. This is accomplished by use of interchangeable contact laser probes and scalpels (tips) made from synthetic sapphire or fused silica. The tips have several different sizes and shapes and can be easily affixed to the end of fiber optics. Several benefits result from the use of these tips (Fig. 1-8. right). In addition to providing the

Figure 1-8.

Noncontact vs. contact laser surgery.

Physical Considerations of Surgical Lasers

Figure 1-9.

Changes in temperature gradient and tissue effect by wavelength conversion effect surface treatments. sorbing material integrally between the contact tip and the tissue, a portion of the energy will be absorbed by that material. The energy absorbed will be converted to heat and will result in a very high temperature. Since the absorbing material is in contact with the probe and the tissue, it will elevate the temperature of the tissue by thermal combustion in addition to the radiation heating caused by the native wavelength. Thus, as can be seen in Figure 1-9, by use of this absorbing material the tissue temperature gradient induced by the laser emission has been altered. Depending upon the quantity and distribution of the absorbing material the contact tip can mimic the effect of other laser wavelengths. This event is referred to as the Wavelength Conversion Effect. The wavelength conversion effect does not result in changing the wavelength of the laser; rather, it changes the effect the wavelength has in the surgical situation. By adjusting the Wavelength Conversion Effect material on the probe tip, one can titrate the amount of laser light exiting the tip in comparison to the amount of heat generated by absorption at the tip. This means, in essence, that a single laser in combination with different interchangeable tips, can mimic the tissue temperature profile and effect of various lasers.

surgeon with tactile feedback, a sense lost in free-beam surgery, and controlling power density, the reflection of light from the tissue is significantly reduced. The improved efficiency in coupling of light into the tissue results in the requirement of less power, in most cases a reduction of 40 to 50% (Fig. 1-8, right). Altering the tip configuration of a probe and scalpel makes it possible to change not only the spot size (and thus power density), but the angle of divergence of the beam. A frustroconical tip, for example, concentrates the laser light on a small, precisely defined distal area from which light splays out at a wide angle, creating a region of high power density that drops rapidly with distance. Alterations in the tip's shape can result in a low divergence angle. In addition to placing tips onto the ends of fiber optics, the ends of fiber optics themselves can also be shaped, although they lack the mechanical strength and thermal resistance required for extended and precision use. The Contact Laser attributes thus far described, 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. It is a major attribute of Contact Laser surgery to have the temperature gradient altered by the Contact Laser tip. By placing a small amount of light ab-

Practical Laser Safety in Oral and Maxillofacial Surgery

Lawrence M. El son

A laser is a device thai produces an intense, highly parallel beam of coherent light. It is named after the composition of the excitable medium from which the laser beam emanates [e.g., carbon dioxide (CO,), argon (Ar), helium-neon (HeNe). etc.). Since the late 1970s, lasers have been studied in oral and maxillofacial surgery for the treatment of soft tissue lesions and occasionally for the cutting of bone. Light emitted by these surgical lasers is generally in the visible and infrared regions of the electromagnetic spectrum and is nonionizing. This radiation must be clearly differentiated from ionizing radiation exemplified by x-rays and gamma rays, which may produce deleterious effects on living tissue. Therefore, patients, medical personnel and particularly pregnant women working with or around lasers may do so without the risks- associated with x-rays. Each different type of laser produces a different wavelength (color) of light that is absorbed by specific target chromophores within tissues. The biologic effect of this light on tissue is dependent upon wavelength, energy level of the beam, and absorption characteristics of the tissue receiving this energy. For example, the carbon dioxide laser (10,600 nmmiddle infrared) light is absorbed heavily by water. Since human tissue is mostly water, it absorbs virtually all of the laser energy without significant reflection or backscatter from the surgical site. However, when this same light comes into contact with shiny surgical instruments, reflection will occur. In tissue, the depth of this laser's photovaporization or photocoagulation effect is directly dependent on the power density (watts/cm ), which is determined by the intensity of the focused beam, and the energy density (joules/cm ), which determines the rate at which energy is delivered to the tissue. The thermal damage produced adjacent to the surgical site by diffusion of heal can be reduced to a range of micrometers, depending on the energy density used. 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. Prior to patient use a "test spot" is made on a moistened wooden tongue blade to assess the coaxial HeNe aiming beam, spot size contour, power, and mode of operation [continuous wave (CW) or pulsed|. Hazards of the carbon dioxide laser in oral and maxillofacial surgery (OMFS) include corneal, scleral, and cutaneous injury ranging from transient pain to severe burns. Both the patient and the medical personnel are at risk for these injuries.
1 1 2 2

The argon laser emits a blue-green light of 488 and 514 nm, which is selectively absorbed by the red chromophore. oxyhemoglobin at 488 and 540/577 nm (double absorption peak). It is delivered to the target tissue by an optical fiber. This laser, depending on its spot size, power, time of application, and resulting energy density, can photovaporize or coagulate tissue with up to several millimeters of thermal damage adjacent to the zone of clinical laser treatment. The optical hazards of the argon laser include retinal and skin burns. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser emits an invisible 1060-nm (near-infrared) light that is heavily absorbed by pigmented tissue. It can photovaporize or photocoagulate almost all biologic tissue with which it comes in contact. 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. This powerful laser is delivered to the surgical site by an optical fiber or contact probe. Optical hazards of this laser are similar to that of the argon laser and include retinal and skin hazards (Fig. 2-1).

HAZARDS OF LASER SURGERY

Judgment Errors

As is the case with surgery, judgment error may be as harmful as the use of inappropriate surgical technique. Of the several types of judgment errors, the most severe is misdiagnosis or misinterpretion of the disease state being treated. After having appropriately decided to use a laser, it becomes necessary to match the wavelength, power, and energy densities to the target tissue absorptive characteristics to best eradicate the lesion. This mandates that the surgeon understand the applied laser physics and laser-tissue interactions at the selected wavelength. The technical skill to manipulate the laser delivery system safely to protect patient, surgeon, and operating room personnel must be acquired through instructional courses resulting in proper credentialing for each wavelength used. Ultimately, 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. In some cases, residency training may substitute for a laser 11

12

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

Figure 2 - 1 . Nd:YAG-induced relinal burns in a rabbit retina.

Figure 2 - 1 . Nd:YAG-induced retinal burns in a rabbit retina. course, but the preceplorship credentialing program is still required. It is also very important to remember that improper use converts the laser into an expensive electro cautery unit. 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. This might well prove disastrous. Optical Hazards Since the clinical lasers utilized in oral, maxillofacial, and head and neck surgery photovaporize or photocoagulate tissue, they all have the potential to damage the eye. Depending on the laser's wavelength, different tissue effects will occur. Visible light laser radiation [argon, potassium titanyl phosphate (KTP). HeNe. gold vapor, pulsed dye, etc.], 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. 2-2) and partial loss of vision or even blindness. Laser light that is focused through the lens of the eye will increase its effective power up to l(K).(KM) times! The eye must always be protected to prevent visual field defects or blindness. 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, scleral epithelium, or eyelid and have the potential to burn or damage these areas. Therefore, it is imperative that all individuals in the operating room, i.e.. surgeons, nurses, technicians, and patients, wear adequate eye protection while the laser is being used. 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. All facilities using lasers must therefore have available appropriate wavelength-specific goggles (Fig. 2-3) or glasses with side shields to be worn by all personnel whenever the laser is
:

operating. 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. The material coating the lenses of these goggles or glasses absorbs and disperses the incident laser energy, preventing damage to the eye. For protecting the patient, in addition to wavelength-specific glasses or goggles, it is also acceptable to place wet gauze or eye pads across the closed eyelids and, depending upon the procedure (i.e., Nd:YAG laser procedures), an aluminum-metal type of eye shield should be placed over the gauze or pads. Skin Hazards

Even though, from a laser usage standpoint, skin hazards are regarded as a minor nuisance, they are painful and may be damaging. 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. 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. The resulting injury may potentially be substantial. It is therefore most important for the clinician to keep his foot off the foot pedal until ready to fire the laser. Simultaneously, the laser technician must be ready to change the laser to the "standby" mode whenever an interruption in laser use is encountered. The clinician should also inform the support staff of the danger of laser injuries to tissue, and must warn them to keep their hands away from the surgical site when the laser is in operation. Other important locations at risk of exposure in oral and maxillofacial surgery include the patient's facial skin, teeth, and soft tissues. Wet drapes or gauze sponges should also be placed over the patient's skin and teeth outside of the surgical site. A laser impact on a tooth has the potential to damage the enamel, penetrate into the pulp chamber, and

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. Absorption site of (A) visible and near-infrared radiation; ( B ) middle, far-infrared radiation and middle ultraviolet radiation; (C) and nearultraviolet radiation. (Reproduced from Laser Institute of America*s Laser Safety Guide.)

14

Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry shatter the tooth. A tooth damaged by the laser is caries resistant but unsightly. Fire Hazards

Figure 2-3. Goggles that are wavelength specific.

All lasers used in the operating suite have the potential to ignite materials on the surgical site and produce a fire hazard. Examples of these combustible materials include disposable drapes made from wood pulp, dry cotton swabs, gauze sponges, wooden tongue blades, and plastic instruments (Fig. 2-4). To reduce the potential for igniting the draping material by the laser, 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 greatest source of danger in surgery of the oral cavity is the endotracheal tube itself. 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. 2-5 and 2-6). New "laser safe" endotracheal devices are available for use during laser surgery. It is important to have an airtight endotracheal tube with a metal reflective exterior. The cuff at the distal end of the tube should be tilled with a saline and methylene blue dye. If the laser beam penetrates the cuff during surgery, the blue solution will spill, indicating to the surgeon and anes thesiologist that a laser-related puncture of the cuff has occurred. The stainless steel body of the armored endotracheal tubes will resist perforation by the laser. 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, causing ignition. Other safety-enhancing techniques to reduce tire risk include reducing the oxygen content of the anesthetic mixture

Figure 24. Laser burns in combustible materials present at surgery: gauze, wooden tongue blade, cotton, tipped applicators, and rubber glove.

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. Cuff of endotracheal tube penetrated by C O 2 laser beam. Methylene blue liquid lilling cuff escapes,

Figure 2-6. Ignition of oxygen-filled endotracheal tube results in ignition and creation of a blowtorch-like effect. Covered foot pedal.

to 30%, and insertion of wet cottonoids or gauze sponges as a hypopharyngeal throat pack. These serve as additional protection for the endotracheal tube by absorbing laser light and ensuring greater protection for the patient. However, it should also be remembered that the surgeon must remove these wet packs from the patient's throat upon completion of the procedure. As for all throat packs, the anesthesiologist should record the time of placement and removal of the pack. At the end of the case, he should ask the surgeon, "Is the pack removed?" The anesthesiologist must understand the surgical procedure being performed as if he himself were performing the operation. Simultaneously, the surgeon must know of any potential anesthetic problems so that both the surgeon and anesthesiologist may foresee and avoid mishaps. As always, communication between surgeon, anesthesiologist, laser technician, and nursing staff in a

safety-oriented environment is essential for successful and safe surgery. The surgeon, anesthesiologist, and operating room staff must always be prepared and have a written plan of action should an airway fire occur. In the event of this dramatic and frightening complication, rapid planned intervention may be lifesaving. The following protocol is recommended for an airway fire: simultaneously stop lasing. cease ventilation, turn off all anesthetic gases, including oxygen, extinguish flames using saline solution from a nearby basin, deflate the cuff, and remove the endotracheal tube. Make sure the entire tube is removed. Next, ventilate the patient's lungs with l(K)% oxygen by bag and mask, assess the airway for burns and foreign bodies (e.g.. tracheal tube and packing materials) by using a bronchoscope. If the damage is minimal, it may be possible to continue with the proce-

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. Jn 1993 these researchers reported the first transmission of laser plume-related disease in cows. Currently, additional research is being conducted nationally regarding this issue. As a result of the uncertainty surrounding the seeding ability of this plume material in humans, a proactive stance should be adopted. Use of a high-volume laser smoke evacuation apparatus that filters smoke particles to 0.1 u.m is recommended. Maintaining the suction wand within 4 cm of the surgical site to remove as much of the plume as possible is recommended. Disposable gloves and sterile technique should be used to change evacuation filters, which are treated as hazardous waste and disposed of in biohazard bags. 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. When working with infected patients or those at high risk for HIV/hepatitis, etc., 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. Lastly, all surgical instruments, e.g., microscopes, operating room tables, etc., should be wiped with a hospital-approved sterilizing solution after each laser procedure.
6 7

dure. However, extreme caution is advised in regard to proceeding even in the case of minimal observed damage. If the damage is extensive, it may be necessary to control airway ventilation by inserting an endotracheal tube or performing a tracheostomy, ventilation proceeds using humidified gases. Antibiotics and large dose steroids should also be given. Lastly, the laser safety officer and the surgeon must report the incident to the appropriate hospital quality improvement and risk management departments, as well as to the laser companies and fiber-optic manufacturers, and a report must be filed with the Food and Drug Administration.
4

Electrical

Hazards

Of all the laser surgical-related hazards, electrical hazards have the greatest potential to be lethal, with several fatalities having been reported since the initiation of the use of lasers in surgery. 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. Contact with the fully charged capacitor located inside the laser cabinet may result in electrical shock or even death by electrocution. It is mandatory that inspection, evaluation, and repair of electrical components in these specialized lasers be performed only by factory-trained technicians. Most surgical lasers use high voltage and high current electricity. 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, therefore, remain a reservoir of lethal electrical current. Consequently, if the electrical malfunction indicator light goes on during a procedure, the laser should be turned off and a service representative should be called in immediately to evaluate the extent of the problem. If a service representative is not available, the laser aspect of the procedure must be immediately terminated (unless a standby laser is available).

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. The LSO should attend a laser safety officer course to assist in the proper performance of his/her duties. The LSO evaluates all laser use policies and procedures, identifies potential laser-related hazards, and serves as the resource person for the education of hospital staff, medical staff, and nursing staff, and answers questions regarding laser capabilities. It is recommended that a laser safety policy and procedure be written in each institution using laser to treat patients. Once approved by the laser committee, this information should be disseminated to the employees of the operating room staff and to all laser surgeons, dentists, physicians, podiatrists, etc., and should be followed, as written. All lasers must have their keys removed when not in use and, if possible, they should be kept in a locked room to maintain equipment safety and security. Only LSOapproved personnel should have access to operate the laser equipment. Laser safety warning signs should be placed on the door of any operating room using lasers prior to usage. These signs should include the type and power of the laser being used. 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 plumea by-product of laser surgery. The laser plume is primarily composed of vaporized water (steam), carbon particles, and cellular products, which combine to produce a malodorous scent. This smoke has been found to be irritating to those operating room personnel who come in contact with it. It has also been reported that laser smoke contains many toxic substances, such as formaldehyde, hydrogen cyanide, hydrocarbons, and other airborne mutagens. The particles have an average size of slightly larger than 0.3 u.m.
4

Unfortunately, human papilloma virus DNA has been identified in the plume during the surgery for removal of papillomas. The initial observers of this phenomenon cau5

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

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

Specific Guide to the Use of Lasers in the course of the performance of useful work by most lasers. During healing the optical properties of the target tissue do change. For water, as the temperature increases the absorption coefficient decreases. This becomes more pronounced with repeated laser "hits" particularly at the base of the vaporization crater. Recent studies have shown that even a single pulse will change the absorption coefficient of water. Therefore, as the temperature increases during the pulse, so does the depth of absorption. For mid-IR lasers, which emit near the 1940-nm absorption peak for water, the absorption peak decreases, which results in a slightly greater depth of penetration than was predicted. The effect is more pronounced for the C 0 laser at 10,600 nm. At conditions of vaporization the absorption coefficient may change by a factor of 10\ Therefore, as the energy from repeated laser pulses accumulates, thermal damage extends progressively deeper into the tissue."' This effect is further exaggerated if the tissue has become charred, which radically alters its optical and absorptive properties. 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. This is the fraction of the incident light absorbed by (he tissue. 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), thus:
2

21

Figure 3-3. Zones of damage. H & F.. 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. Using a superpulsed laser of adequate fluence, coagulation necrosis is limited to a narrow, sharply defined zone at the crater margin, in which energy levels do not reach the vaporization threshold (Fig. 3-4). Under these circumstances, crater depth conforms closely to the true level of thermal destruction. With the superpulsed C 0 laser, basically, what you sec is what you get! This is its great difference compared with the Nd:YAG laser, in which, because of extensive scatter, the volume of tissue injury is approximately 40 to 50 times greater than that for C 0 . ' ' ' " ' ' In addition, with YAG there is no immediately visible change in the tissue surrounding the zone of vaporization, so it is very difficult to estimate the true extent of thermal necrosis. Studies of laser-target interactions for the C O , laser in water demonstrate an intense heating effect that is restricted to a small volume of water. The entire energy of the impact beam was absorbed in a depth of water of only 39 to 90 u.m. To minimize lateral heat conduction, the pulse width for CO, must be less than approximately 1 ms. For a free-beam Nd:YAG delivered by optical fiber in the same water model the absorption depth was 4 to 6 m m . " This great differential in the water absorption model predicts events occurring in soil (issue. The C O , beam is complc(ely absorbed, with an intense heating effect in a small volume of water, whereas Nd:YAG is absorbed in a much larger volume of water but with less vaporization. Using a contact tip converts Nd:YAG into a predominantly thermal instrument with reduced depth of absorption compared with free-beam Nd:YAG. Argon effects arc intermediate, with a depth of absorption of 0.5 to 2.0 m m . However, 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 /, = / ( 1 0 - ' ) o r / , = / / 1 0 .
0 0

The incident transmission /, now becomes reduced to 10% of its initial intensity. Therefore, the critical volume of tissue required to absorb 90% of the incident radiation is defined by the reciprocal of the absorption coefficient.''" 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. This extreme containment of the energy within a small volume of tissue results in instantaneous boiling of water within the tissue, which causes the formation of steam. This, in turn, results in explosive disruption of tissue at the impact site. The resultant crater consists of a vaporized area surrounded by a zone of carbonization (charring), which is in turn bordered by a zone of sublethal, and therefore potentially reversible, thermal injury "" (Fig. 3-3). 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. This is somewhat greater than the volume of absorption of water in laboratory studies.
12 13

22

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

Figure 3-4. Gaussian distribution curve. Tissue removed occurs within the area delined by the "vaporization threshold." (Courtesy T.A. Fuller. Ph. D.) if used inexpertly. Therefore, one must understand that the COi laser is an instrument that works by thermal destruction (Table 33) as do conventional instruments like the electrocautery or the Shaw scalpel. For conventional thermal instruments to work, they must maintain contact with the tissue during a lag phase until the target tissue is heated to the necessary temperature. During this time, lateral heat conduction results in absorption of heat in a progressively larger area of tissue. In short, the tissue is burned. Healing postoperatively will not occur until the damaged tissue is repaired, which is a slow process. On the other hand, the C 0 laser, as previously discussed, can be administered as a series of pulses that remove tissue through explosive vaporization by the direct thermal effects of the laser radiation, but not by lateral heat conduction from the laser crater. Therefore, heat-damage adjacent to the vaporization crater is generally restricted to a zone less than 100 to 200 u.m wide. The actual volume of heat necrosis is largely dependent on the application time of the laser. Consequently, healing begins quickly after laser surgery and reepithelialization occurs before excessive collagen (scar) is deposited. " '' There are also fewer myofibroblasts in the healing laser wound than in the conventional wound, which may also contribute to reduced wound contraction and scarring. ''"
2 17 1 1 1 21

Irradiance

(Power

Density)

Once again, to achieve the desired wound characteristics listed above, optimization of tissue effects must occur. This

is partly a function of the duty cycle in the pulsed mode of operation. A short pulse duration is chosen to permit photovaporization effects to predominate over photocoagulation thereby minimizing lateral heat transfer. This is accomplished by using high-power densities at pulse widths shorter than the thermal relaxation time of the target tissue. In addition, an interpulse interval at least twice as long as the pulse width permits significant, but not complete, tissue cooling between pulses. Unfortunately, rapid superpulse has one major disadvantage: the choice of a short duty cycle will reduce power output accordingly, which slows down the rate of tissue removal. Hence, in practice, rapid superpulse is generally reserved for situations in which small tissue volumes need to be treated with maximal precision. 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; see Chapter 4, Fig. 4-15), in which the laser tube is electrically pulsed to emit broader, flatter pulses with a shortened interval between pulses. Consider, for example, the electrical pulsing of a 120-W laser tube, governed such that the ratio of on/off time (duty cycle) will never exceed 5:1. When used at the highest duty cycle, maximal output would be 100 W (i.e.. 120 X 5/6). Conversely, selecting a 1:9 duty cycle would produce an output of only 12 W (i.e., 120 X 1/10). Because the peak power of each pulse is not amplified, an electronically pulsed laser tube does not have a refractory phase when used in the chopped mode. Hence, repetition rate can be increased to virtually any frequency. However, as pulse frequency approaches a duty cycle of

Specific Guide to the Use of Lasers 2:1, heat will accumulate at the impact site, and the clinical effects will resemble those of a continuous wave laser. Thus, the best compromise is a duty cycle of about 1:1 producing 60 W of power output, while preserving about half of the intcrpulse cooling. Physical cooling of the tissue with iced saline also helps reduce unwanted heat transfer during lasing. Fluence (Energy Density)

23

3. Irradiating a bleeding point at low PD, which heals the blood at the surface but does not coagulate the cut blood vessel. This causes cooking, not coagulation! Remember that soft tissues suffer coagulation necrosis at temperatures above 58C and bone is even more sensitive, succumbing at 47C.
22 23

Consequently, cooling the operative field with iced saline before lasing and prior to each raster is helpful in reducing unwanted heat damage. Power Density (PD) (W/cm )
2

In addition to power density, one must also consider the fluence (energy density), which is the rate at which energy is delivered. It must exceed the vaporization (ablation) threshold for mucosa (4 J/cm per pulse) or skin (5 J/cm per pulse). The fluence may be delivered in continuous or pulsed modes. The pulses themselves may be delivered in two different modes: superpulse, in which pulsing occurs within the laser tube (rapid superpulse, RSP) or "chopped" (gated) continuous wave, in which the beam is interrupted by a shutter. RSP lasers may produce peak pulse powers of individual pulses that exceed 500 W. A typical pulse duration is 150 to 300 u.s at approximately 50 to 150 mJ/pulse with an intcrpulse interval of several milliseconds. This provides excellent control of a cool beam, which will ablate small volumes of tissue very precisely. However, the very short duration of the pulse reduces power output compared with continuous wave function. The actual average power output for a pulsed laser corresponds with the duty cycle during which the pulse is actually occurring.
2 2

To calculate PD, a reasonable approximation is given by PD = - ^ 3 - ^ = 100 W/cm

2

where VV is power, in watts, of the exit beam, measured by the laser power meter, and d is the measured diameter in millimeters of the imprint left by a 10-W, 0.1-second pulse on a moistened wooden tongue depressor. Since the inverse square law of light applies here, changing the spot size will affect PD exponentially, whereas changing the inline laser power output will affect PD only linearly. Therefore, the greatest control by the operator on laser effects will be by altering power density through changes in focus and beam geometry, not by changing power output at the beam source (Table 3-1).
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. However, the effects on the target tissue as well as on the surrounding tissue differ greatly depending upon the rate of energy delivery. With a superpulsed laser of adequate fluence emitting pulses shorter than the thermal relaxation lime of the target tissue, thermal damage becomes a function of the optical properties of the incident energy. In contrast, when pulse duration exceeds thermal relaxation time, heat accumulates at the surface of the impact crater and lateral heat conduction begins. It is this technique error of prolonged time of application that causes thermal damage. This results in the loss of the major benefit of laser use: selective tissue removal. The following errors most commonly lead to unwanted heat damage: 1. Use of low irradiance by excessively defocusing the beam, resulting in PD <50O-60() W/cm for keratinized tissue. The same applies for nonkeratinized oral mucosa at PD < 350-400 W/cm . 2. Failure to remove carbonized debris from the wound before using the laser for its second application.
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. There is a wide distribution of power densities used for photovaporization. As experience was gained. PD clustered around several restricted ranges, as it became apparent that there was a specific relationship between PD and clinical effect. Consequently, one may now select the appropriate PD for
2

Table 3-1. POWER DENSITY < 100 W/cm > 100 W/cm
2 2

Power Density and Tissue Effects EFFECT 17 25

600-2500 W/cm

Desiccation, denaturation. warming Photovaporization, carbonization (carbon appears as target tissue temperature reaches approximately 150C) Photovaporization (ablation), minimal carbonization, superficial hemostasis; target tissue temperatures may reach 3(X)C Ultrarapid photovaporization, thermal incision Incision of tissue, approximately same rate of cutting as for a scalpel Plasma formation, acoustic shock waves: tissue destruction by mechanical disruption rather than thermal denaturation

> 10,000 W/cm >50,000 W/cm > 10* W/cm

2

24

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

Table 3-2.

Learner's curve.

ablative vaporization or incision and rapidly learn how quickly to move the beam across the target tissue to achieve the desired effect.

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. This is the working "spot size" of the beam. However, the peripheral 14% still heats the tissue, thereby contributing to thermal conduction, denaturation and subthreshold heating. Irradiance (PD) must be kept high enough to vaporize tissue quickly because low irradiance results in desiccation. Anhydrous conditions can cause excessive heating, carbonization, and even flaming. Consequently, temperatures at the impact crater may increase

Figure 3-5.

Beam profile: transverse and cross section. (Courtesy T. A. Fuller. Ph.D.)

Specific G u i d e to the Use of Lasers

25

the energy profile of the incident beam (Fig. 3-5). A highly focused beam, providing high PD that is suitable for incision, will produce a beam contour as seen in (Fig. 3-6). 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. One wishes to flatten the beam profile until the amplitude of the beam is about half that of the spot diameter (Fig. 3-7). The characteristics of the beam are also modified by the delivery system. Both systems destroy collimation, so that at the tissue the beam is slightly divergent. Both spot size and depth of field at any given wavelength will vary with the focal length of the objective lens. The operating microscope of long focal length objective (300-400 mm) produces a relatively large minimum spot size (approximately 0.6 mm) with excellent depth of field, while the handpiece objective (125 mm) produces a very small spot (0.3 mm) with a shallow depth of field. The maximum power density is higher, and the beam geometry is therefore sharper for the handpiece compared with the microscope at maximum power densities. This is the intrinsic difference that makes the handpiece the instrument of choice for rapid incision. However, 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); (2) enhanced visual resolution increases both beam control and monitoring of direct tissue effects.

Figure 3-6. Beam profile in bone: cross section of C 0 beam: RSP mode, in focus at high PD (left and center) and lower PD (right) (frozen ox femur). (Courtesy L. dayman, DMD, MD and Carlo Clauser, MD.)
2

THE PLANES OF TISSUE DESTRUCTION IN ABLATION

First Plane

Figure 3-7.

Amplitude beam 5 spot diameter.

from 100C to >600C. This increased heating causes a burn, which is similar to, or even worse than, that caused by electrocautery.' ' Recall that the exit beam, particularly after being modified by the lenses within a handpiece, or by the microscope's objective lenses, does not contain energy of uniform density. 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. Destruction of the first plane removes only the surface epithelium. Removal stops at about the level of the basement membrane. Therefore, the vaporization crater is placed deep in the parabasal layer of mucosa or skin. To achieve proper depth, the laser spot is manipulated to describe a series of parallel lines, overlapping by about one third. Each pass of the C 0 laser beam will cause a bubbling effect at the surface wherein the target tissue becomes opalescent, and actual bubbles occur on its surface (Fig. 3-8). This is accompanied by a crackling sound similar to that of pulmonary rales, or to the sound of Rice Krispies in milk. The presumed mechanism is that flash boiling of both intra- and extracellular water occurs, which ruptures the epithelium at the level of attachment of keratinocytes to the basement membrane. This first layer of removal is also referred to as the first raster. Either of these two distinctive signs (opalescence and bubbling) can be lost if deep penetration beyond
2

26

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

Figure 3-8. Surface bubbling and opalescence after treatment of buccal mucosa.

Figure 3-10. Visual end point: appearance of treatment area after second and linal raster has been applied perpendicular to the initial raster. higher PD may be used initially and the first raster will penetrate directly to plane II. After wiping away debris, the surgical site will show a roughened surface of yellow color. There is minimal heat damage to the deeper submucosa (or reticular dermis for skin). If thermal relaxation time is exceeded, then deeper transmission and wider scattering of the incident laser beam causes a larger, but predictable zone of coagulation necrosis. The extent of necrosis is directly proportional to the duration of irradiation, which elevates tissue temperature above 55C. The sublethal zone of thermal injury remains small. Healing is rapid but slightly delayed compared with plane I. and there will be no scar contracture. Third Plane

Figure 3-9. Magnified view (I6X) of collagen network deep to ablated epithelium after wiping away epithelial debris. the basement membrane occurs. Wiping away the altered tissue will expose the pink, shining, smooth intact surface of the basement membrane overlying the submucosa (Fig. 3-9). There will be no bleeding. Healing is complete by reepithelialization in less than 14 days for moderate-sized lesions and in approximately 3 weeks for large lesions. No scarring occurs. Second Plane

Thermal destruction to the second plane removes all of the epithelium and some of the upper submucosa, or for skin the papillary dermis. This is achieved by applying a second raster, at the same PD as the first but perpendicular in direction. This time there will be no opalescence, but some bubbling will still occur (Fig. 3-10). Alternatively, a slightly

Plane III is rarely used for mucosa since it will obliterate the entire submucosa. following which there will be delayed healing and some scar formation. In ablative oral and maxillofacial surgery, this will be limited in use to removal or recontouring of intraoral skin grafts, for removing cutaneous scars or keloids, or for debulking nonresectable cancers. Correct depth control is most likely obtained with use of the microscope, 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. 3-11). There will also be drops of blood from transected blood vessels in either the reticular dermis or the deep submucosa. Good surgical technique requires slower movement of the beam guided by visual recognition of a "fibrous grain" within the crater base. Therefore, this type of lesion extends deeply enough to create a burn. Regeneration of mucosa starts from the mucosal edge and from minor salivary gland epithelium. It is somewhat delayed because the heat-damaged tissue must be removed by phagocytosis before reepithelialization begins. This delay occurs consequent to thermal damage. Excess heat may cause

Specific G u i d e to the Use of Lasers

27

Figure 311.

Reticular dermis: collagen fibrils exposed, blood vessels visible. less well absorbed by intracellular water than is the C 0 beam. As a consequence, free-beam Nd:YAG energy causes more extensive scattering and transmission of the incident beam through the target tissue. Therefore, as expected, absorption length for water is 2 to 4 mm in a large volume of fluid' compared with <90 u-m for Co . More heating of tissue occurs at lower contact temperatures than for the C 0 laser, thereby producing a deep coagulation effect that increases with power and time of application. 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. 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. Precise control of tissue effects is therefore difficult. Consequently, the YAG laser is most useful for ablation of large volumes of tissue, particularly when strict hemostasis is required (e.g., hepatic resection). On the other hand, C 0 will be most useful for superficial ablation of surface disease or for incision where the need for hemostasis is moderate. As mentioned above, the Nd:YAG laser is useful in situations where coagulation is essential, particularly when the underlying tissue can tolerate thermal damage, as in larger, deeply sited vascular tumors. The YAG laser's ability to seal large blood vessels greatly enhances its utility for treatment of vascular lesions. The C 0 laser, 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), where it further delays healing and promotes fibrosis. This is the deepest plane from which optimal healing may
occur.

Postoperative

Care

For oral mucosa, care is very simple. The patient uses warm dilute saline rinses four to six times per day on the first day. After that, 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, or for postablation care of the vermilion border of the lips, an antibiotic cream or ointment is applied three times a day. Skin lesions are occluded for the first 24 to 48 hours.

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. This is a more highly energetic beam than that of the C 0 laser because of its shorter wavelength. (Energy is inversely proportional to wavelength.) Its target chromophores are pigmented molecules (melanin, hemoglobin, and other proteins) and it is
2

28

Lasers in M a x i l l o f a c i a l Surgery and Dentistry Table 3-3. Typical Laser Use CO, Laser (10,600nm) Handpiece: Spot: 0.3 mm at focal point A = 10.6 (j-m Output power: 5-80 watts Ablation: PD: 475-750 w/cm Incision: PD: 10,000 to >50,000 w/cm Pulsed average power: up to 25 W Duty cycle: up to 15% Fluence: 120-600 mJ/pulse Pulse width: 0.85-6.4 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, nor is scalpel excision, which may cause aesthetic and functional disabilities. 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. 3-12), which control and also limit thermal injury. This alters laser-tissue interactions without changing wavelength of the incident beam (see Chapter I). In considering treatment of cavernous hemangiomas and vascular malformations (AVMs) using the Nd:YAG laser, one must be cognizant of potential overtreatment, which may lead to rupture and hemorrhage of the lesions. 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 0.5 sec pulse width. The laser spots are placed 2 to 3 mm apart from one another to avoid overlapping of scattered laser energy. The resultant photocoagulation necrosis obliterates the pigmented or vascular lesion with preservation of normal tissue, leading to resolution of bleeding and swelling as well as improved function. One expects retreatment to be necessary to ablate residual tumor. Patients are usually reevaluated in 4 to 6 weeks for further treatment. Staged treatment helps to reduce overenthusiaslic single-stage therapy, which might result in tissue sloughing and compromised healing. The C 0 laser resembles the electrocautery unit, the electrodiathermy, and the cryosurgical probe, in that all are instruments of thermal destruction. With conventional devices, lateral heal propagation declines along a slow, linear gradient. 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. Moreover, collagen damaged by inept laser surgery can remain "mummified" in the dermis for many months, where it acts to delay healing and promote cicatrization. The noncontact C 0 laser consistently minimizes collateral heat damage when used properly. The Nd:YAG contact lasers act similarly and also provide tactile feedback through tissue contact.
2 27 2

Contact Nd-.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. ILP-fiber: 2-4 W CW mode. C 0 : Scanner Handpiece X = 10.6 urn Spot size: 26mm. Varied by handpiece P: < 20 W E: 200-500 mJ/pulse Fluence = 5 - > 15 J/cm" Cycle = approx. 0.2 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 3-12.

Nd:YAG contact laser probe tip.

Figure 3-13.

Argon laser: end point is "whitening" of lesion.

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). Its depth of penetration is 0.5 to 2.0 mm and the energy is absorbed mainly by hemoglobin. The depth of absorption is a function both of power density and heating effects. The effect on soft tissue is to create an initial pallor (Fig. 3-13) followed by blanching (whitening), liventually, the epithelial surface elevates, and a vesicle forms that then ruptures to reveal the effect of the laser on the subjacent deeper tissue. This vesicle itself may form from the vaporization of water into steam. This results in elevation of the epithelium away from the subepithelial plane due to dispersion and absorption of the beam within this deeper plane. For superficial coagulation a pulsed argon laser beam at 2-W output power with a 0.2-mm spot size and a 10-ms pulse width will be absorbed to a depth less than 1.0 mm. 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. For extensive telangiectasias, multiple sessions, averaging between four and five in number, are required. 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. However, at higher outputs some cutaneous absorption will occur and the probability of scarring increases. Therefore, for superficial cutaneous vascular lesions like port-wine stains or telangiectasias, other lasers like flashlamp-pumped dye lasers or copper vapor lasers emitting closer to the H b - 0 second absorption peak of 577 nm should be used. For intramucosal vascular malformations or for those thicker malformations involving critical anatomic regions like the vermilion border of the lip, 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.
26 2

29

Figurc 3-14.

Vascular malformation of labiobuccal vestibule.

Figure 3-15. Argon laser applied by liber to glass slide compressing the lesion. Laser beam may be used al its focal point or defocused.

TECHNIQUE To maximize the effectiveness of the argon laser for the treatment of thicker vascular lesions (Fig. 3-14) one may employ physical adjuncts to convert a thick lesion to a thin one with a reduced rate of blood How. 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. At this point the argon laser is applied to the surface of a glass slide placed over the lesion to compress it (diascopy). The spot size and power is adjusted and the application time in CW is prolonged until the test target tissue turns white. 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. 3-15 and 3-16). During the procedure, which takes about 1 minute, the glass slide is maintained in constant position under finger presFigure 3-16. Completion of treatment: entire lesion is white.

30

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

sure. At the conclusion of the initial treatment, the slide is removed and blood flow through the lesion is visually assessed. If the lesion is still quite red. ice is reapplied and the treatment is repeated. Antibiotic ointment is applied and the patient is given wound care instructions. Swelling and discoloration at the operative site are to be anticipated. The size of the acute lesion increases over 48 to 72 hours. Edema peaks at 72 hours and persists for several days. Wound healing, which is delayed initially, is apparent at the end of the first week. '' Analgesics, usually in the form of nonsteroidal anti-inflammatory agents, are prescribed. The patient is seen at 5 to 7 days to monitor wound healing followed by monthly reevaluations. The healed wound is generally 20 to 30% larger than is the vascular lesion. If resolution is incomplete, the lesion is retreated after 2 months. Two or three treatment sessions may be required until the lesion is eradicated (Fig. 3-17).
2

Figure 3-18. Diascopy: mucosa compressed. Lesion outlined with argon in C'W mode.

ALTERNATE TECHNIQUE: INTRALESIONAL PHOTOCOAGULATION For thicker vascular lesions, particularly for intraoral hemangiomata a more aggressive technique for photocoagulation is intralesional photocoagulation (ILP). For this technique to be effective one depends on both selective photoabsorption by the H b - 0 chromophore and a nonspecific heat effect. After anesthetizing the lesion with local anesthetic containing vasoconstrictor, ice is applied to help reduce blood How. thereby diminishing the capability of a well-vascularized lesion to function as a heat sink. The optical fiber is then activated usually starting at 3 W. Using diascopy technique the lesion is compressed and photocoagulated (Figs. 3-18 and 3-19). After the tip is heated it is brought into contact with the mucosal surface of the lesion (Fig. 3-20). Using only gentle pressure, the fiber is advanced into the substance of the vascular malformation. Care is taken to ensure that the tip does not enter the surrounding normal tissue.
2

Figure 3-19. Center of lesion "filled in'" with argon applied in decreasing concentric circles.

Figure 3-17. Similar case of vascular malformation of buccal mucosa eliminated. Mucosa stable at 18 months recall.

Figure 3-20. For intralesional photocoagulation the fiber tip is introduced into the lesion. First, the laser is activated and then using very gentle finger pressure so that the fiber is introduced "on its own weight.'" the lesion is entered. Note that entry is almost completely bloodless.

Specific G u i d e to the Use of Lasers

31

Figure 3-21. 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.

Figure 3-22. Thirty-four days after surgery healing has been complete. There is no vascular malformation present and the tongue has a full range of motion. is occurring. If a second ILP is required, the lesion should be iced for 3 to 5 minutes between ILPs. Postoperatively a nonsteroidal analgesic is given for pain, and the patient is instructed to rinse with dilute warm saline four to six times per day. Moderate edema is expected but the amount of postoperative pain is unpredictable. The patient is recalled in 5 to 7 days for interim reexamination and then at monthly intervals to assess regression. If regression is incomplete or progression occurs at the monthly recalls, then retreatment is suggested. If more than three treatments are required, then another treatment option should be chosen. Patient acceptance is generally quite high and significant improvement is usually seen within two treatment sessions (Fig. 3-22).

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. It is then redirected and the same action is repeated. It is the same technique used for fine needle aspiration technique to sample a mass for cytologic assessment (Fig. 3-21). Generally, four to six such passes are required. After the last pass the lesion should have become depressed and there should be little or no venous oozing from the lesion. If gentle pressure is not adequate to control bleeding, another series of ILP passes will be required. The power should be adjusted so that with each pass one hears a gentle crackling sound, indicating that absorption and some heating

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. In the following case of superficial vascular malformations of the lateral tongue border the argon laser was used at a power output of 2.5 W and a spot size of 2.0 mm in continuous wave function (Figs. 3-23 to 3-26).

Figure 3-25. tongue.

Six months postoperative. Full range of motion of

Figure 3-23. of tongue.

Superficial vascular malformation of free border

Figure 326.

No recurrence and no tear.

Figure 3-24.

Handpiece delivery system: dcfocused. CW: 2.5 W.

Specific G u i d e to the Use of Lasers

33

ARGON: COMPLICATIONS
COMPLICATION I: INADVERTENT SKIN PENETRATION

Figure 3-30. Skin damage. Fiber approached skin surface too closely during subcutaneous and submucosal photocoagulation.

Figure 3-27.

Vascular malformation of labiobuccal sulcus.

Figure 3-31. site in skin. Figure 3-28. Patient properly protected with goggles.

First postoperative day. Eschar forming at burn

Figure 3-29. coagulation.

Lesion photocoagulated using intralesional photo-

Figure 3-32. skin injury.

Thirteen months: depressed scar present at site of

34

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

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, 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. In this illustrative case facial telangiectasias (Fig. 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. 3-34). Argon at 2 W CW was used at the focal point of the laser fiber. Application of energy was continued until the lesion blanched (Fig. 3-35). One year later (Fig. 3-36) there was slight skin surface scarring, although the vascularity of the telangiectasia was significantly diminished.

Figure 3-35. Posttreatment: feeding vessels and. especially, central part of telangiectasia has been blanched.

Figure 3-33.

Facial telangiectasias.

Figure 3-36. One year later, vascularity of the telangiectasia has been greatly reduced but some skin scarring has occurred.

Figure 3-34. Lesion compressed (diascopy) and treated to end point of blanching.

Specific Guide to the Use of Lasers

H()I.MIUM:YTRIUM-ALUMINUM-GARNi: IT (HO: YAG) H o l m i u m : Y A G laser, by virtue of its ability to vaporize tissue within a Quid m e d i u m , 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 ) . 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. At higher p o w e r it is c a p a b l e of resecting fibrocartilage or bone. H o w e v e r , it is rare to require p o w e r greater than 10 W. In general, pulse repetition rates (PRR) of less than 10 W are sufficient. Useful characteristics of the Ho:YAG pulsed T M J laser a r e listed in T a b l e 3 - 1 .

35

Table 3-4. Tabic 3 - 4 . Suitable energy levels for the Ho: YAG pulsed TMJ unit

Average poweractual use in TMJ arthroscopic surgery: Aiming Beam0.6-1.0 J/pulse at 8-12 Hz: Avg P = 6-12 W. Peak Power|up to 5 J/pulse: Surgilase Ho:YAG]. ERBIUERBILM:YTRIUM-ALUMINUM-GARNETT (ER:YAG) The E r b i u m : Y A G laser e m i t s at 2 . 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 . or N d : Y A G lasers. Not only is it highly a b s o r b e d by water, 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 , 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, which is a major m a j o r constituent of b o n e , d e n t i n , a n d enamel. 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.
: 2

Er:YAG
X = 2.91nm 2.9lnm E= 125-625mJ/pulse PRR = Variable, usually < 2 0 H z P= P = <ISW <1SW chromophore: water, h y d r o x y a p a t i t e

REFERENCES
1. Filmar S. Jetha N. McComb P. Gomel V, et al. A comparative histologic study on the healing process after tissue transection. I. Carbon dioxide laser and clectromicrosurgery. clectromierosurgery. Am J Obstet Gynecol 1989:160(5. 1989;160(5, part 1): 1063-1067. 2. Sako K. Marchctta Marchetta FC. FC, Hayes RL. Cryotherapy of intraoral leukoplakia. Am J Surg 1972; 124:482-484. 3. Pospisil OA. MacDonald DG. The tumor potentiating effect of cryosurgery on carcinogen treated hamster cheek pouch. Br J Oral Surg 1981; 19:96-104. 4. Poswillo DE. Cryosurgery and electrosurgery compared in the treatment of experimentally induced oral carcinomas. Br Dent J 1971; 131 (8):347-352.

5. Guerry TL, Silverman S Jr. Dedo HH. Carbon dioxide laser resection of superficial carcinoma: indications, techniques and results. Ann Oiol Rhinol iMryngol 1986;95:547-555. 6. Catone G. leaser technology in oral and maxillofacial surgery. Part II: Applications. Selected Readings Oral Maxillofac Surg l994;3(5):l-35. 7. Thomson S. Medical Lasers: How they work and how they affect tissue. Cancer Bull I989;4I(4):203-211. 8. Hall RR. The healing of (issues incised by a carbon dioxide laser. Br J Surg 1971 ;58(3):222-225. 9. Jacques SL. Laser tissue interaction. Cancer Bull I989;41(4):211-218. 10. Jansen ED, van Lecuwen TO, Motamedi M. Borst C, Welch AJ. Temperature dependence of the absorption coefficient of water for incident infrared radiation. Lasers Surg Med 1994;14:258-268. 11. Polanyi TG. Laser physics: medical applications. Otolaryngol Clin North Am 1983; 16:753-774. 12. Anderson R, Parrish K. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiaiion. Science 1983;220:524-527. 13. l i c k in.in H, Barraco R, Sugar S, Gaynes E, Blau R. I-ascr irridectomies. Am J Ophthomal 1971 ;72(2):393-402. 14. Armon E, Laufcr G. The response of living tissue to pulse of a surgical C 0 laser: transections of the ASME. J Biomech F.ng 1985;107:286-290. 15. Reid R, Elfont GA, Zirkin RM, Fuller TA. Superficial laser vulvectomy II. The anatomic and biophysical principles permitting accurate control of (hernial destruction with carbon dioxide laser. Am J Ohstet Gynecol 1985;152:261-271. 16. Absten GT. Physics of light and lasers. Obstet Gynecol Clin North Am 199l;18(3):407-427. 17. Walsh JT. Flotte TJ. Anderson RR. Deutsch T. Pulsed C O , laser tissue ablation: effect of tissue type and pulse duration on thermal damage. Lasers Surg Med 1988;8:108-118. 18. Dobry MM, Padilla RS, Pennino RP. Hunt WC. Carbon dioxide laser vaporization: relationship of.scar formation to power density. J Invest Dermatol 1989;93( 1 ):75-77. 19. Mihashi S, Jako GJ, Ine/.e J, et al. Laser surgery in otolaryngology interactions of C0 laser and soft tissue. Ann NY Acad Sci 1976;267:263-294. 20. Gabbiani G, Ryan G B . Majno G. Presence of modified fibroblasts in granulation (issue and their possible role in wound contraction. Experientia l97l;27(5):549-550. 2 1 . Loumanen M. Lehto V-P, Mem man JH. Myofibroblasts in healing laser wounds of rat tongue mucosa. Arch Oral Biol 1988:33(1): 17-23. 22. Reid R. Dorsey JH. Physical and surgical principles of carbon dioxide laser surgery in the lower genital tract. In: Coppleson M, Monaghan JM, Morrow C P , Tattersall MHN, cds. Gynecologic Oncology. 2nd ed. London: Churchill-Livingstone; 1992:1087-1132! 23. Eriksson RA. Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: a vital microscopic study in the rabbit. J Prosthet Dent 1983;50:101-107. 24. Fuller TA. Laser tissue interaction: (he influence of power density. In Baggish M. cd. Basic and Advanced Ixiser Surgery and Gynecology: New York: Appleton-CemuryCrof(s;"l985. 25. Reid R. Physical and surgical principles governing expertise wild (he carbon dioxide laser. Obstet Gynecol Clin North Am 1987;14:513-535. 26. Gillis TM, Strong MS. Surgical lasers and soft tissue interactions. Otolaryngol Clin North Am 1983:16(4):775-784. 27. Kamat BR. Carney JM. Arndt KA. et al. Cutaneous (issue repair following C O , laser irradiation. J Invest Dermatol 1986:87:268-271.
2 2

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 carbon dioxide laser does not impart magical properties to the tissues, but it does provide a selective therapeutic advantage for the treatment of intramucosal preneoplasia by avoiding damage to subjacent tissue, thereby eliminating scar formation and the creation of oral deformities. Preneoplastic lesions of the oral mucosa include leukoplakia, erythroplakia, and oral submucous fibrosis, with 85% of the preneoplasias being accounted for by leukoplakia. The erosive variant of lichen planus has stimulated a great deal of debate in regard to its malignant potential; however, because this proclivity is still uncertain, erosive lichen planus will not be considered, particularly as C 0 laser treatment of lichen planus does not alter its natural history and is therefore ineffective. High risk of malignant transformation is associated with dysplasia, multicentricity, and anatomic site of the leukoplakias. " In regard to dysplasia the risk of malignant transformation is related to its presence but not necessarily its grade. The most recent World Health Organization (WHO) classification of leukoplakia will now include dysplasia as an indicator of risk of transformation." The areas at highest risk for transformation are the floor of the mouth, buccal mucosa, soft palate/anterior tonsillar pillar, tongue, and lip v e r m i l i o n . ' " Overall, the transformation rate ranges from 0.13 to 28% with cancer being detected on average 2.5 years after the diagnosis of the index leukoplakia. Leukoplakias are categorized as homogeneous (Fig. 4-1), nodular (Fig. 4-2), or speckled (Fig. 4-3). The latter occurs on the buccal mucosa adjacent to the oral commissure, which is a particularly notorious site for malignant transformation. Also worrisome are leukoplakias located on the anterior floor of the mouth covering the orifice of Wharton's duct. In this location both dysplasia and invasive carcinoma have the capability of invading directly into the lumen of the salivary ducts. Different varieties of leukoplakia may also occur simultaneously in the same patient (Fig. 4-4). The snuff dipper's lesion is usually homogeneous but may include areas of nodularity. Most commonly it is found on the area of mucosa with which the smokeless tobacco product is placed in contact. 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. 4-5). Erythroplakias are erythematous, are often severely dysplastic, 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. When the oral mucosal surface is dried with a gauze sponge, the alteration in the reflective surface of the oral mucosa becomes readily apparent (Fig. 4-6). The clinical diagnosis of the subset of lesions at high risk, the dysplastic leukoplakia, is facilitated by the application of a vital dye to the mucosal surface. 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), which is the gynecologic equivalent of leukoplakia with severe dysplasia or erythroplakia.

VITAL STAINING

14

Toluidine blue (TN), a metachromatic vital dye, selectively stains cytoplasmic sulfated mucopolysaccharides and nuclear DNA and RNA in rapidly dividing cells. Because it is the transformed (premalignant or malignant) epithelial cell that has escaped regulation by feedback inhibition of its replication, possibly by alteration of one or more tumor suppressor genes, this rapidly dividing cell, which accepts the stain, is an abnormal cell. The specificity of vital staining with 1% toluidine blue dye ranges from 87 to 100%, and the sensitivity ranges from 96 to 1 0 0 % . " False-positive rates are usually reported as being approximately 2.0% and false-negatives as 2.5%. 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. 4-7). The TN is applied with cotton-tipped applicators and is allowed to remain in situ for 60 seconds (Fig. 48). The area is now rinsed with acetic acid followed by a water rinse (Fig. 4-9). Any remaining blue stain is subjectively ranked as being mildly (Fig. 4-9), moderately (Fig. 4-10), or strongly (Fig. 4-11) positive. The examiner is now guided directly to the site of most heavy staining as being representative of the "worst" area of the lesion. In this way, a directed (by the stain) biopsy of the lesion is
1 5

37

38

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

Figure 4-1. Homogeneous leukoplakia of ihe ventral tongue and floor of mouth.

Figure 4-4. Multicentricity. Simultaneous occurrence of leukoplakia on the floor of mouth, ventral tongue and mandibular alveolar ridge. This patient also had leukoplakia of the hard and soft palate, maxillary alveolar ridge, and buccal mucosa.

Figure 4-2.

Nodular luekoplakia of Ihe buccal mucosa.

Figure 45. Typical snuff dippers leukoplakia at site of application of the tobacco product. Note staining of the teeth, which is also typical. In Scandinavia, these lesions rarely, if ever, progress to cancer, but in the United States, where snuff is formulated differently, they frequently do become malignant after a very long latency period.

Figure 4-3. Speckled leukoplakia occurring at its most common location, the oral commissure. This is frequently accompanied by Colonization with Candida albicans.

Figure 4-6. F.rythroplakia of the ventral tongue. The lesion is red, slightly raised and sharply demarcated from surrounding normal mucosa.

Preneoplasia of the O r a l Cavity

39

Figure 4-7. 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.

Figure 4-10. Moderately positive stain with toluidine blue: buccal mucosa, retromolar pad. and anterior tonsillar pillar.

Figure 411.

Strongly positive stain with toluidine blue.

Figure 4-8. Alter application of 1% toluidine blue, there is dense staining of the cancer as well as the peripheral tissue.

performed, subsequent to which a definitive treatment plan is formulated. Because oral precancer and cancer is frequently multicentric, it is wisest to stain in this way all of Ihe high-risk mucosa of the tongue, floor of mouth, soft palate-retromolar pad area, and the buccal mucosa. Staining of the more posterior area of the mouth may be carried out at the time of planned surgery of the index lesion, when the patient is sedated or anesthetized.

SURGICAL TREATMENT: C 0 LASER

2

Figure 4-9. After washing with saline. Ihe residual blue slain demarcates ihe area at the periphery of the lesion, which is most likely to contain areas of dysplasia. This is a mildly positive stain.

Conventional surgical treatment, which consists of excision with a scalpel, is successful and adequate for limited local disease. The literature reports control rates of around 90%. Failure becomes likely when this local treatment is applied to extensive disease. 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, a more global treatment concept than local excision is required. Failure rates
6 1 8 1 9

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 % . Muliicentricity demands excision of topographically large areas of mucosa. However, the denudation of large areas of oral mucosae results in scarring and wound contraction as well as postoperative pain, edema, and nutritional depletion. Despite the greatest care, the minimum thickness of tissue removed with a scalpel results in exposure and removal of the submucosa. Both scarring and incomplete epithelial regeneration OCCIir. The traditional solution to this problem is to replace the mucosa with a split-thickness skin graft. This, however, is an unsatisfactory solution because skin dews not function as well as mucosa. The graft ultimately contracts as time passes, and the grafted skin covers remaining elements of regenerated mucosa that may be unstable. Lastly, even for local treatment, site-specific consequences may dictate against locally invasive surgery that induces scarring. For example, removal of the thinnest layer of mucosa over the opening of Wharton's or Stensen's duct may cause scarring, glandular obstruction, and infection. Excision of large lesions at the oral commissure causes deformity of the oral stoma. 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 0.1 to 0.2 mm of reversible thermal injury to the submucosa. 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. 412 and 413). 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 . After healing, the mucosa al risk is still observable by direct visual inspection during recall examination. Of equal importance, there is little postoperative swelling and patients may take oral fluids immediately after surgery. These patients may be operated upon as outpatients, and there is usually no bleeding or swelling. Pain, which is highly variable, is easily managed with oral analgesics, rarely lasts more than a few days, and only occasionally shows a secondary in2 2

crease in intensity on days 3 to 5, which then abruptly terminates. " The CO, laser beam itself is delivered either by a handpiece (Chapter 3, Fig. 3-1) or a microscope (Chapter 3, Fig. 3-2) delivery system. 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. 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. 4-14). In this way. the spot size, power, and application time for each of the pulses to be used during surgery are "calibrated" on a wooden tongue blade. The power density is approximately equal to the exit power of the laser (generally 15 to 40 W), divided by the square of the spot size (in cm ). Using this rough approximation, one can achieve a power density of 500 to 1250 W/cm for ablation by evaporative vaporization (ablative vaporization). Modes of application include continuous wave (CW) or variations of a pulsed mode. These latter may be gated or "chopped" CW or, preferably, rapid superpulsed (RSP) (Fig. 4-15). For ablation, RSP is most desirable because the
19 21 2 2

Figure 4 - 1 3 . Vaporization of tissue over duct without damaging duct. No sclerosis or submandibular gland obstruction occurred postoperatively.

Figure 4 - 1 2 .

Lesion over duct.

Figure 4 - 1 4 .

Tongue blade: spot size.

Preneoplasia of the O r a l Cavity

41

Figure 417.

Fibrin coagulum day I.

TIME (msec)
Figure 4-15. CW (chopped or gated) and RSP profiles. (Courtesy of Lara d a y m a n . )

From the viewpoint of the microscopist, the laser wound (Fig. 4-16) has the following c h a r a c t e r i s t i c s . ' The superficial epithelium is homogeneously carbonized. Interspersed in the zone of thermal damage are "boiled away vesicles." The deeper layers of epithelial cells show intercellular voids as a sign of thermal damage. Denatured protein is found in the form of a coagulum near the wound surface. However, there is minimal damage to adjacent tissue across an area of potentially reversible thermal injury of 150 to 300 u-m. The amount of collagen found in the wound is diminished and epithelial regeneration is somewhat delayed and irregular. " However, during healing there is minimal inflammatory response, and compared with scalpel or cautery wounds, there are fewer myofibroblasts and very little wound contraction. - - In vivo, reepithelialization occurs within 4 to 6 weeks, but may be as brief as 2 weeks in cases having ablation of less than 2 c m of mucosa. During the entire healing process, tissues remain soft and pliable. Not only are small blood vessels and lymphatics sealed by the laser, but nerve endings are "rounded off." This latter may account for some of the diminution in postoperative pain anecdotally reported, but this is not uniformly consistent. A fibrin coagulum forms in the first 24 hours (Fig. 4-17), which is slowly replaced without the occurrence of significant wound contraction.
712 8,22 2 4 23 2 I8 24 25 2

Figure 4 - 1 6 .

Laser wound: soft tissue.

pulse width may be designed to be as brief as 250 to 950 u,s. which is shorter than the thermal relaxation time of oral soft tissues. At these power densities of 500 to 1250 W/cm , and using the pulsed mode at 50 to 250 pps, with a peak pulse power of 500 to 1000 W per pulse, 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.m. As the pulse width lengthens beyond I msec, thereby exceeding the thermal relaxation time of the target tissue, the region of lateral thermal damage exceeds 200 u-m.
2

SURGICAL TECHNIQUE
The oral mucosa is assessed and the requisite biopsies are obtained in the manner previously described. At the time of laser surgery, the vital staining is repeated. Local anesthesia is used unless the patient receives a general anesthetic. No pre- or perioperative antibiotics are given and no antiseptic preparation solution is used for the mouth. The face is protected with wet surgical drapes and the eyes are covered. If endotracheal intubation is utilized, the hypopharynx is packed with a wet gauze.

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, the laser is set at an average power of 20 to 30 W for pulsed modes, and 15 to 20 W for CW mode. The spot size will vary between 2 and 3 mm in diameter. 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." The lesion (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. 4-19). This is called rastering. After completion of this first layer of lasing, there should be almost no carbonization. If the wound appears blackened, 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. The more heat conducted, the greater the desiccation occurring at surgery. A moist gauze is now used to wipe away the treated area of mucosa. This allows one to assess the depth of penetration of the laser. A pale pink base that does not bleed indicates removal of the epithelium at the level of the basement membrane (Fig. 4-20). If there are scattered droplets of blood, then the superficial aspect of the submucosal plane has been breached. If the depth of penetration is too superficial, a second raster is applied to reach the required depth, which results in removal of the entire thickness of the epithelium (Figs. 4-21 and 4-22). In areas of thick hyperplasia as for nicotine stomatitis or fibroepithelial hyperplasia of the palate (see Chapter 6), several layers of rastering may be required. The submucosal layer is identified both by the appearance of blood vessels and by the appearance of tissue of granular appearance and yellow color. 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. as may be required in this case of papillary hyperplasia of the palate where four rasters are needed for complete tissue removal. The fibrin coagulum that formed within the first 24 hours is still present at one week (Fig. 4-23). Complete mucosal reepithelialization and healing has occurred within 5 weeks (Fig. 424).
21

Figure 4-19.

Outline of lesion with RSP. CO, laser.

Figure 4-20. First layer of treated tissue wiped away with a moistened gauze sponge (16X).

Figure 4-18.

Lesion: papillary hyperplasia of the palate (I0X).

Figure 4-21.

Second raster (16X).

Preneoplasia of the O r a l Cavity

43

HEALING
Epithelial resurfacing is rapid. A fibrinous coagulum tonus within the first 24 hours, which is progressively replaced by epithelium originating from the wound edge. Ablation of less than 2.0 c m of mucosa uniformly results in complete epithelial resurfacing in less than 3 weeks. Larger mucosal ablations (5.0 c m or more) require between 4 and 5 weeks. However, in one patient, even an extensive insult of more than 60 c m still required only 6 weeks for complete resurfacing. The major cause for delayed healing is from the creation of charring (carbonization) of the tissue. This occurs as a function of time of contact of the laser beam with the target tissue. Repeated application of the laser without removing the char from the previous exposure will dramatically increase heat transfer to the nontarget tissue. This will retard healing. Postoperative complications potentially include bleeding, infection and damage to teeth, lips. etc.. or ignition of the endotracheal tube by laser "mishaps." In the treatment of 148 leukoplakias by ablation technique in the series from Sinai Hospital of Detroit, there were three cases of inadvertent single pulse laser hits to teeth (1) and lip (2). There were no serious complications.
2 2 2

Figure 4-22. Residual lesion after wiping away tissue treated by second raster* I6X).

RESULTS
Reports from the literature on the subject of recurrence alter laser ablation of leukoplakia (dysplasia not specified), range from 4.5 to 22% at 3-year follow-up to 10 to 22% at 37- to 55-month f o l l o w - u p . Series with less than 2year follow-up may report spectacular results of lack of recurrence; however, this attenuates with time. Therefore, these patients require long-term surveillance, particularly if they continue to smoke and drink. There are no reports in the literature that laser treatment enhances malignant trans formation of oral preneoplasia. One report reported recurrence in five of seven cases of leukoplakia, a frequency that is not substantiated by reports of series with significant numbers o f c a s e s . "' '
2 5 1 5 1 8 2 6 26 27 2 1 4 1 8 1 2 6 2 7

Figure 4-23. Fibrin coagulum still present after one week. Reepithelialization commencing from wound periphery.

LEUKOPLAKIA
The most important subset of oral preneoplasia (precancer) is leukoplakia, a clinical term describing a white lesion of the oral cavity that cannot be removed by wiping the mucosa with a gauze sponge, and to which no other specific diagnostic category may be assigned. Histologically leukoplakias may range from simple hyperkeratosis to intramucosal dysplasia or neoplasia. The ideal treatment is by free-beam C 0 laser because ablation will completely remove the lesion. Furthermore, the mucosa will almost always reepithelialize in less than 4 to 6 weeks, with no scar2

Figure 4-24. Reepithelialization complete after 5 weeks. Condition remained stable for the next 28 months when the patient was lost to recall examination.

44

Lasers in M a x i l l o f a c i a l Surgery and Dentistry areas of previous dysplasias. From the point of view of the individual lesions rather than patients, the failure rate was only 9.6% (11/114) during the first 6 years of observation, which compares favorably with laser success rates of 10 to 22% reported in the literature after 37 to 55 months' surveillance.
5 ls

ring. There is no reduction of oral opening and the oral mucosa remains soft, moist, and pliable. This is particularly important because leukoplakia may affect many different locations within the oral cavity, may well recur, and may ultimately affect a large surface area of mucosa. Therefore, it is a great advantage to have the mucosa return to an undamaged state because retrcatment may be necessary. 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), clinical followup had been quite brief, at only 16 to 28 months. This suggests that there is certainly no enhancement of malignant transformation by laser treatment during the early postoperative observation period. However, one must be mindful of the fact that most of the recurrences, which also may include progression to carcinoma, won't appear for about 30 months after identification of the index leukoplakia." 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. Of the dysplasias, 68% were located in the most dangerous sites for malignant transformation: floor of mouth, tongue, soft palate, anterior tonsillar pillar, and retromolar pad. This series is very heavily skewed toward high-risk leukoplakias, with 64% of all the index leukoplakias being dysplastic. Seventeen lesions in 70 patients escaped control after laser treatment, with eight relapsing as leukoplakias and nine transforming into cancer. Therefore, the overall failure rate (relapse, progression, or development of new lesions) during the 8-year period was 24.2% of which 12.9% (9/70) developed cancer and 11.3% relapsed as leukoplakias. Of the cancer occurrences, eight of the nine (88.9%) arose from

Horch et al. had a 22 to 28% recurrence rate for lesions treated by ablation with a handpiece. Roodcnburg et al.'"' followed 70 patients with 103 leukoplakias. 33 of which were dysplastic and therefore probably at higher risk for recurrence or malignant transformation. Laser ablation was carried out using the microscopic technique al 10 to 15 W output (PD unspecified but probably approximately 375 w/cnr). A recurrence rate of only 10% in 103 leukoplakias observed from 7 to 55 months after ablation was reported. There was no degeneration of any case into cancer and recurrence could not be correlated with degree of dysplasia. Postoperatively, 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 was no scarring and no postoperative swelling, although soreness occasionally interfered with food intake. About one third of patients required analgesics for the first 24 hours after surgery, and only the rare patient required analgesics after day 5* However, there was an unpredictable subset of patients that required no analgesics immediately after surgery, but that later required two or three days' use of analgesics, generally between days 3 and 5. Narcotics are rarely required, with nonsteroidal analgesics being the drug of choice. All patients were treated as outpatients, using local or general anesthesia or intravenous sedation, as dictated by site and extent of lesions, by patient emotional needs, and by the need to use the microscope.
2

Five case reports demonstrate the technique.

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. 4-25). Vital staining with TN (Fig. 4-26) resulted in a mildly positive stain. The handpiece delivery system (Fig. 4-27) was chosen using a spot size of 2.5 mm (1.8-mm vaporization spot), 92 PPS superpulsed mode, PD = 617 W/cm , 216 mJ/pulse, P = 20 W, superpulsed by the 125-mm handpiece, T E M (transverse electromagnetic mode). Note the guide tip extension of the handpiece, which indicates that the laser is at its focal point at the tip of the handpiece. Moving the tip away from the target tissue results in reduction of the power density. The initial raster (Fig. 4-28) results in crackling and bubbling of the epithelium with slight brown discoloration of the treated mucosa. After wiping away the treated mucosa (Fig. 4-29) one may judge the thickness of tissue removal by observing the border of the untreated mucosa. The slightly yellow color of the base of the treated area indi2 0 0

cates that tissue removal has included the basement membrane. Any residual area requiring biopsy for assessment may be excised with the scalpel (Fig. 4-30) and bleeding from the base of the biopsy site may be controlled with the laser. A biopsy from an area of laser treatment at a magnification of I00X (Fig. 4-31) demonstrates that heat artifact is restricted to a thickness of approximately 0.21 mm. Note that the epithelium has been completely removed as was desired. At the conclusion of surgery, wiping away the treated mucosa (Fig. 4-32) demonstrates a clear demarcation between the normal epithelial border and the de-epithelialized treatment region. 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. At 13 days postoperative (Fig. 433) fibrin is present covering the wound surface and there are some signs of reepithelialization occurring. By 22 days (Fig. 4-34) healing is about 50% complete and by one month (Fig. 4-35) reepithelialization has been completed and maturation is occurring. At 5 months the lip looks normal (Fig. 4-36).

Figure 4-25.

Dysplastic leukoplakia of lower lip.

Figure 4-27.

Laser handpiece in position to start treatment.

Figure 4-26.

Vital staining with TN is mildly positive.

Figure 4-28. First raster at PD = 460 W/cm (2.5 mm HeNe guide spot, 1.8-mm vaporization spot, 92 PPS superpulsed. average power of 20W, 216 mJ/pulse l.l-ms pulse width with 125-mm handpiece).

46

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

Figure 4-29. Tissue treated by first raster removed by wiping with wet gauze. Note sharp border of untreated mucosa. Full thickness of mucosa has been removed.

Figure 4 - 3 2 . Completion of treatment. Dark color on right from coagulation of base of biopsy area with laser.

Figure 4-30. biopsy.

Selected, TN stained tissue sampled by excisional

Figure 4 - 3 3 .

Healing at 13 days. Fibrin still covers wound.

Figure 4 - 3 1 . Heat effect at base of treated area at edge of biopsy sample: depth of thermal damage is 0.21 mm.

Figure 4 - 3 4 . nent.

Healing ai 22 days. Reepitheliali/ation is promi-

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.

Figure 4-36. Five months. Maturation completed during second month. Mucosa has been stable for 12 months.

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. 4-39). Consequently uncomplicated complete epithelialization occurred within 30 days (Figs. 440 to 4-43). There was no transient obstruction of the submandibular salivary glands, no loss of attached gingiva, and no recurrence at 6 years' follow-up examination (Fig. 4-44). Six years after treatment, an erythroplakia reappeared that was restricted to the lingual frenulum and the same laser vaporization procedure was repeated to remove the second erythroleukoplakia. Again, healing was uncomplicated, with complete epithelial resurfacing having occurred in approximately 30 days. 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, i.e., there was no long-term damage to the native tissue from the first operation 6 years before.

CASE 2: LEUKOPLAKIA, 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. 437). Staining with TN was mildly positive. Treatment: The lesion was ablated with a C 0 laser using the handpiece (125 mm focal length), average output power 15 W. RSP at 104 PPS. and PD approximately 375 w/cnr. To ablate the lingual gingiva a front surface mirror was used to change the direction of the beam (Fig. 4-38). Spot size was between 2.5 and 3.0 mm. average output power 20 W at 58 PPS. The "slower" beam was used to permit easier coordination of energy delivery between the handpiece, mirror, and target tissue. Ablation of the mucosa included the region directly adjacent to the orifices of the submandibular ducts. Note the ab2

Figure 4-37. 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.

Figure 439. lated.

Lingual gingiva, sulcus, and area over ducts ab-

Figure 4-38. Use of front surface mirror to redirect the beam. Spot size is enlarged until PD is low enough not to damage the mirror.

Figure 4-40. Note sharp demarcation between normal epithelium and ablated area. Few areas of pinpoint bleeding indicate deeper penetration of beam. Note absolute absence of charring of base of ablation region.

Preneoplasia of the O r a l Cavity

49

Figure 441. 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

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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. 4-55). Three previous biopsies of the "worsf'-appearing areas of her dorsal tongue demonstrated hyperkeratosis with mild atypia. Incisional biopsy of the tongue cancer was inlerpretated as well-differentiated squamous cell carcinoma. Examination under anesthesia and vital staining also revealed a third white lesion of the left buccal mucosa. This stained only faintly with toluidine blue. No prophylactic antibiotics were administered. The dorsal tongue lesion was vaporized with a true rapid superpulsed C 0 laser and 46 PPS, average power of 20 W, spot size of 2.0 mm at a fluence of approximately 435 mJ/pulse width, a peak pulse power of 500 W, at a pulse width of approximately 4.2 ms, and an interpulse distance of 19 ms. Two rasters were applied with the target tissue being wiped free of debris between applications. There was
2

almost no char and no bleeding (Figs. 4 - 5 6 to 4-58). The cancer was then removed with the same laser at 30 W average power using the handpiece in focus at 0.3 mm spot size for incision and defocused to control bleeding. The partial glosscctomy wound was sutured closed. Estimated blood loss for the resection was 15 mL. Reepithelialization of the surface of the tongue was 100% complete at 27 days. Mild hyperkeratosis was present immediately after healing was completed.

Figure 4-57. Debris removed by wiping with gauze sponge. Note yellow color in central portion where vaporization was deeper especially in center area which had stained positively with TN.

Figure 4-55. Leukoplakia affecting majority of surface area of dorsal tongue.

Figure 4-56. First, horizontal, raster used to remove surface epithelium. Note HeNe aiming spot of approximately 2.0-mm diameter. Rastering half completed.

Figure 4-58. Surface reepitheliali/.ed at 3 weeks. Mature mucosa shown at 9 weeks.

Papillomas and Human Papillomavirus

Richard Reid, Myron Strasser

Although controversial, evidence from immunoperoxidase and DNA hybridization studies have implicated human papillomavirus (HPV) as the etiologic agent for many diseases within the oral cavity. 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. Well-established association of HPV with oral cavity disease includes condyloma acuminatum (HPV 45), 1,2 verruca vulgaris (HPV 6 and 1 6 ) , 2 - 4 squamous papilloma (HPV 6, I I ) , 2 5 focal epithelial hyperplasia (HPV 13 and 32) 1 , 2 ' 4 and squamous cell carcinoma (HPV 16 and 18) . 1 , 2 , 6-12 Human papilloma virus has also been detected in diseases that do not show obvious viral stigmata, such as ameloblastoma (HPV 16, 1 8 ) , 1 3 - 1 S leukoplakia (HPV 16)1,2.9.12,16 lichen planus ( HPV 16 )1.2.12 w h j t e s p o n g e nevus (HPV I 6 ) , 1 7 and odontogenic keratocyst (HPV 16) 18 In head and neck surgery as in other specialties, carbon dioxide ( C 0 ) laser surgery is gaining increasing acceptance in the treatment of such HPV-associated lesions as condyloma acuminatum, verruca vulgaris, squamous papilloma, and leukoplakia. 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 . 1 7 , 1 9 , 2 0
2 2

base pairs and a molecular weight of 5200 d. 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. When the nuclear proteins are stripped away, the viral DNA assumes a supercoiled shape (form I). Supercoiling is visible on electron microscopy and is also detectable by electrophoretic migration because of the relatively rapid mobility of these tight circular molecules. Cleavage of only one DNA strand by bacterial enzymes (restriction endonucleases) results in a relaxed circle, form 11 (Fig. 5-2), while cleavage of both strands at a single site produces a linear molecule form III, 20 which migrates more slowly in electrophoresis gels (Fig. 5-2C).

Viral

Genetic

Function

BASIC VIROLOGY
Taxonomy .

Papillomaviruses are small, double-stranded DNA viruses 12,21,22 that manifest qualitatively similar biologic characteristics. All papillomaviruses exhibit a similar pattern of genetic organization. DNA sequencing studies have shown that broadly equivalent areas of protein coding potential, known as open reading frames (ORFs), are preserved through the genome. 2 2 However, the actual nucleotide sequences within these ORFs are widely disparate; hence, individual papillomaviruses show enormous differences in species specificity, site predilection, and degree of oncogenicity. Human papillomaviruses compose the largest group, with more than 50 known t y p e s 3 , 6 , 2 3 (Fig. 5-1). DNA Organization

The papillomavirus genome is a closed, circular, doublestranded DNA molecule, with a molecular length of 7,900

As previously mentioned, alignment of sequenced papillomavirus DNAs revealed a highly conserved pattern of protein-coding potentialthe ORFs. In essence, each of these ORFs represents a viral gene. Virus-specified proteins apparently determine such characteristics as host range, tissue tropism, and the clinicopathologic consequences of infection. The papillomavirus genome can be subdivided into three functional portions. The "early" or " E " region is the longest segment, representing about 4 5 % of the viral genome. This region contains five ORFs that code for proteins; these either induce cell transformation or control viral DNA replication. The "late" or " L " region, which comprises about 4 0 % of the viral genome, contains two ORFs that are essential to vegetative viral replication. The third region of the genome is the upstream regulatory region (URR). This is a noncoding segment, representing about 15% of the viral genome. It contains the origin of DNA replication, several promoters (sequences needed to initiate viral RNA synthesis), and several enhancers (sequences that increase the rate of RNA transcription). The URR is located between the end of the LI ORF and the beginning of the E5 ORF. The URR is the genetic interval most likely to be divergent among viral types, and some of these differences have been correlated with changes in virulence and oncogenicity. 2 1 , 2 2 55

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

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

Papillomas a n d H u m a n Papillomavirus

57

Figure 5-2. (A) Structure, (B) genomic DNA, and (C) protein pattern of papillomavirus particles. Capsids were stained with phosphotungstic acid. DNA was extracted by phenol treatment. DNA of phage PM2 was included as a size standard (97 kd). The molecules appear as supertwisted covalently closed circles (CCC) or open circles (OC). Proteins were separated by polyacrylamide gel electrophoresis after disruption of viral particles by sodium dodecyl sulfate (SDS). VP1 and VP2@ represent structural proteins of the capsid shell. Histones H3, H2b, H2a, and H4 are associated with the viral DNA and appear in preparations of DNA-containing capsids. (From reference 35, with permission.)

PATHOPHYSIOLOGY OF INFECTION
Inoculation Inoculation occurs when material containing relatively large numbers of virus particles (e.g., exfoliated superficial cells or keratin fragments) lodge in sites of microtrauma within a susceptible epithelium. HPV virions penetrate to the basal layer of the damaged epidermis, where they then shed their outer protein capsid. The viral genome crosses the cell membrane and is then transported to the cell nucleus. There the infecting genome is translated and transcribed, thereby producing various virus-specific proteins. Transforming proteins induce conducive host cell functions, while regulatory proteins control viral gene expression.
22

may lead to active viral expression. Capture of the host cell results in pronounced alteration in cell growth in the basal layers, increased replication of the viral genome in the middle layers, and viral cytopathic effects in maturing cells. Such progression from episomal to productive viral replication depends upon the interplay of cell permissiveness, viral type, host susceptibility, and cofactor activity. Two basic types of cell-virus interaction are recognized: vegetative (productive) and transforming (nonproductive). Patients with high-grade dysplasia and those in whom oncogenic HPV subtypes are identified are at risk for higher recurrence rates after treatment.

Incubation

Phase

CLINICAL AND LABORATORY EVALUATION

Comprehensive history-taking can help in establishing the diagnosis of HPV-related oral lesions. Consider, for example, a patient presenting with multiple painless, sessile, soft whitish papules on the lower labial mucosa and lateral tongue border (Fig. 5-3). Knowledge that such a patient has an limit ancestry would raise a high degree of suspicion for focal epithelial hyperplasia. When a definitive diagnosis cannot be established by history and clinical examination, a specimen must be obtained for microscopic and/or other laboratory evaluation. The decision to perform incisional versus excisional biopsy depends on such considerations as lesion size, location, and possible diagnosis of cancer.

Initially the virus exists as a self-replicating extrachromosomal plasmid, termed an episome. Proteins specified by the early viral genes result in an initial burst of episomal replication, producing additional viral genomes that will gradually transfect neighboring cells. Because these episomal viral plasmids are programmed to replicate with each cell division, there is little dilution of viral copy numbers over the succeeding years.
22

Active

Expression

Phase

Many exposed individuals will remain in long-term latent infection; however, in susceptible hosts, viral colonization

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. The pathologist is able to examine the margins of the specimen because the laser destroys tissue in a precise manner, causing a central /one of tissue vaporization, and only 100 to 200 u.m of tissue necrosis adjacent to the points of impact." - In contrast, during vaporization strategic tissue biopsies need to be obtained prior to vaporization. Laser vaporization (ablation) or painting away of the oral lesions are performed in a layer by layer method (rastering). Carbonization produced by vaporization should be wiped away to improve visualization of the lased areas and to decrease crater temperature, thereby decreasing thermal conduction into the adjacent tissue. Tissue irradiance of this carbonized material raises the temperature from I00C (the boiling point of water) to more than 600C (the temperature of a red-hot coal). After the surgeon is confident that the lesion has been completelyremoved, 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. A fibrous coagulum replaces the carbonized layer after approximately 24 hours. Epithelialization of the laser wound occurs at approximately I week if its surface area is less than 1.0 c m . Larger wounds take 4 to 5 weeks to reepithelialize. Many authors have noted that laser wounds heal slower than scalpel wounds, being delayed from 2 to 4 days. There will be slight but pathologically unimportant shrinkage at the base of the specimen being removed for biopsy. Disadvantages of using the C 0 laser include higher cost for the equipment, limited availability, slower healing of the laser wound, and the possibility of the HPV DNA being liberated in the plume of laser vapors. It is mandatory to use a high-speed suction system to evacuate the vaporized material. The potential infectivity of virus panicles found in the effluent plume is under intense investigation at present. WARNING: If you smell the plume through the mask, there is a chance of inhaling particulate matter that may carry virus particles or whole virions. Although there is lack of consistent proof of the infectivity of these particles, prudence in regard to mask selection is strongly recommended.
8 29 30 7 31 2 2 19 32 2 33

Figure 5-3. Focal epithelial hyperplasia of lateral tongue. (Photo courtesy of Scott Boyd. D.D.S.. Ph. D.)

If the area under investigation is large or if one suspects malignancy, incisional biopsy is preferred. Conversely, small lesions that appear clinically benign may be excised. For both cases, tissue is sent to the pathology laboratory for routine processing. In the majority of cases, an oral pathologist will make a firm diagnosis with the light microscope, aided by clinical description and historical details. In difficult cases, if identification of the specific HPV is needed, ancillary testing is available. Viral analysis of formalin fixed tissue is done by either polymerase chain reaction or in situ DNA hybridization . 2,3,8,9,14 ' 24-27 Greater sensitivity can be achieved by filter hybridization of fresh tissue (e.g., a cellulose swab or a frozen biopsy sample). Virus testing is still expensive and is not available for routine use.

CARBON DIOXIDE LASER

Excision and vaporization are the two techniques employed in soft tissue surgery. Excision is the preferable mode for removal of oral lesions, because this method permits histologic confirmation of the diagnosis and establishment of

Papillomas a n d H u m a n Papillomavirus

59

CASE 1: PAPILLOMAS
(Courtesy Lewis dayman, D.M.D., M.D.) A 5-year-old African-American girl presents to her family doctor because of recurrent lip biting. Examination shows a 5-mm "wart" on the inner aspect of the mucosal surface of her left lower lip. With the lip in repose, this abuts a second similar lesion affecting the interproximal papilla between the left lateral incisor and canine teeth (Fig. 5-4). These are "kissing" lesions. A similar lesion is also noted adjacent to the upper right lateral incisor. A clinical diagnosis of oral papillomas is made. The parents are reported to be free of oral or genital papillomas by report from their family physician. The patient is brought to the operating theater for photoablation by vaporization with the C 0 laser. General anesthesia with oral endotracheal intubation was chosen because of the patient's age. 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 mm. The first raster removed the superficial mucosa. 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 0.3 mm. The remainder of the lesion was vaporized using two rasters to ablate just below the basement membrane. Figure 5-5 illustrates the depth achieved after wiping away the remainder of the treated mucosa. The lower incisor was protected with a metal matrix band (of the type used for placing interproximal amalgam restorations), and the interproximal gingiva was ablated at a power density of 500 W/cm (Fig. 5-6). An additional 1 x 3 mm lesion of the left buccal mucosa was similarly ablated. Estimated blood loss was nil. Histopathologic and viral studies demonstrated oral papillomas positive for HPV 6 and 11. At 3-month follow-up assessment, the "kissing" lesions of the left lower lip and gingiva had recurred. 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. These were retreated using the same laser parameters as before. At 14 days, the mucosa had completely resurfaced with normal epithelium. One year later, there was no recurrence (Fig. 5-7). However, 2 years later, there was reactivation or reinoculation of the left lower lip lesion. The gingival lesion had not recurred.
2

Figure 5 - 4 . 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.

Figure 5 - 6 .

Gingival site after wiping away treated tissue.

Figure 5-5.

Lip site after wiping away char.

Figure 5-7. Lip: no recurrence at one year. Gingival site: no recurrence at one year, even after trauma of eruption of the succedaneous tooth.

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, D.M.D., M.D.)

This 56-year-old African-American man presented with a chief complaint of inability to wear dentures because of "growths" in his mouth (Fig. 5-8). Twenty years earlier, maxillary split-thickness skin grafting and vestibuloplasty had been performed to aid in denture retention. Since then, progressive maxillary ridge resorption had resulted in the loss of all alveolar bone. The anterior nasal spine was now the most prominent feature of the residual ridge. Eighteen months before, his chronic renal failure had been successfully treated by a cadaver renal transplant. Following the institution of cyclosporine immunosuppression therapy, he developed extensive papillary hyperplasia of all of his oral mucosae, which precluded his ability to wear dentures. His list of illnesses active at the time of consultation included diabetes mellitus, hypertension, glaucoma, gout, and hypothyroidism. His transplanted kidney was functioning well. Current medications included: cyclosporine, prednisone, Imuran, lente insulin, Cardizem, Synthroid, Zantac, colchicine, potassium iodide, and ferrous sulfate. He was HIV negative. The histopathologic diagnosis of a representative biopsy of the papillomas of the maxillary alveolar ridge was verruciform hyperplasia. This sample was positive for HPV 6 and 11. The treatment recommendation for removal of the diseased oral mucosa by C 0 laser in several stages was explained to the patient, and he agreed to therapy. The first treatment was performed using general anesthesia and nasoendotracheal intubation. Aerodigestive endoscopy demonstrated mucosal changes extending into the pyriform recesses bilaterally, but not involving either the true or false vocal cords. Antibiotic prophylaxis with cephalothin was administered because of the renal transplant. No local anesthetics were used. 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 3.0-mm spot size at 90 W average output power at 60 pulses per second. The PD was approximately 1280 W/cm . The treatment field included the entire maxillary and mandibular ridge, labiobuccal sulci, and palate for a total treatment area of approximately 60 cm (Fig. 5-9). The entire dorsal tongue was similarly treated over an area of approximately 28 cm . The buccal mucosae, commissures, and upper and lower lips were treated at an average output power of 20 W superpulsed, using the handpiece delivery system with a spot size of approximately 1.6 mm at 120 pulses per second for an average power density of 780 W/cm . Estimated blood loss was 250 mL and operating time was 130 minutes. Postoperatively, the patient took only two analgesic pills during the first 8 days after treatment. On day 8 there was epithelial resurfacing of about 20 to 30% of the mucosa. The most uncomfortable area of his mouth was the palate. By day 19 there were signs of regrowth of hyperplastic tis2 2 2 2

Figure 5-9. 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 3.0 mm. the PD was 1280 W/cm . Estimated blood loss was 250 mL for treatment of more than 120 cm of oral mucosae.
2 2

Figure 5-8. Extensive papillomatosis and verrucous hyperplasia of maxilla, buccal mucosa, alveolar ridges, and tongue. Palate and commissures also affected.

Figure 5-10. ment.

Maxillary alveolus and palate 19 days after treat-

Papillomas and H u m a n Papillomavirus sue in the maxilla (Fig. 5-I0). The mandible had recpithelialized to about 60% of normal, and he was completely pain-free. By day 25 epithelialization was 80% complete. By day 40 resurfacing was more than 9 0 % complete, but there was approximately a 2 0 % recurrence level of mucosal hyperplasia. At this stage the patient developed an attack of Herpes zoster in a left thoracic dermatome. By day 70 there was approximately 50% recurrence in the maxilla and there were minor areas of recurrence in the retromolar pad bilaterally, the oral commissures, and the floor of the mouth (Fig. 5-11). The areas of recurrence were treated as before. The total surface area of the treatment field was 53 cm , which represented approximately half of the surface area of the initial treatment (Fig. 5-12). Examination and palpation under anesthesia did not demonstrate any scarring or loss of resiliency of the oral mucosa. Reepithelialization covered approximately 30% of the treatment area by day 14. The entire retreatment area was about 80% reepithelialized 31 days after treatment. There was slight scarring at the commissures but none intraorally. The patient remained disease free for 3 months, at which time minor recurrences were noted at the right mandibular alveolar ridge and left oral commissure. Using
2

61

Figure 5-13. One year after treatment and 5 months after maxillary ridge augmentation with corticocancellous block iliac crestal bone.

local anesthesia and intravenous sedation at a PD of 796 W/cm (parameters: HeNe guide spot size = 2.0 mm; average output power = 25 w, PRR = 156 PPS with defocused 125-mm handpiece), these two areas were retreated. After 2 months, small recurrences were observed at the left commissure ( 2 X 7 mm) and the midline of the hard palate (3 X 4 mm). These areas were completely reepithelialized in 24 days after a third retreatment cycle. 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. 5-13).
2

REFERENCES
1. Pogrel M, Yen C, Hansen L. A comparison of carbon dioxide laser, liquid nitrogren cryosurgery, and scalpel wound in
healing. Oral Surg Oral Med Oral Pathol 1990:69:269-273.

Figure 5-11.

Recurrent disease 70 days after initial treatment.

2. Shroycr K, Gree R. Detection of human papillomavirus DNA by in situ DNA hybridization and polymerase chain reaction in premalignant and malignant oral lesions. Oral Surg Oral
Med Oral Pathol 1991 ;71:708-713.

3. Pecaro B. Garehim W. The C 0 laser in oral and maxillofacial surgery../ Oral Maxillofac S'urg 1983;41:725-728. 4. Duncavage J. Ossoff R. Use of the C 0 laser for malignant disease of the oral cavity. Lasers Surg Med 1986:6:442-444. 5. Eversole L. Viral infections of the head and neck among
2 2

HIV-seropositive patients. Oral Surg Oral Med Oral Pathol

1992:73:155-163. 6. Greer R, Eversole L, Crosby L. Detection of human papillomavirus-genomic DNA in oral epithelial dysplasias, oral smokeless tobacco associated leukoplakias, and epithelial malignancies. J Oral Maxillofac Surg 1990:48:1201 -1205. 7. Reid R. Physical and surgical principles of laser surgery in
the lower genital tract. Obstet Gynecol Clin North Am

Figure 5-12. Retreatment again using the microscope delivery system, superpulsed at a PD of 780 W/cm .
2

1991;18:429-474. 8. Sachs S, Borden G. The utilization of the carbon dioxide laser in the treatment of recurrent papillomatosis: report of the case. J Oral Surg 1981 ;39:299-300. 9. Scully C, Cox M, Prime S, Maitland N. Papillomaviruses: the current status in relation to oral disease. Oral Surg Oral Med
Oral Pathol 1988;65:526-532.

Soft Tissue Excision Techniques

Lewis dayman, Paul C. Kuo

GENERAL PRINCIPLES OF CLINICAL LASER APPLICATION

Surgical lasers are instruments with their own specific indications for applications. Consideration must be given to ihe nature of the lesion to be treated, its anatomic location and functional implications after laser treatment, as well as the benefits, risks, and alternate modes of treatment available. Careful observation of the target tissue is well advised during laser application, particularly with the free-beam C 0 laser where there is no tactile feedback and the depth of penetration is shallow. The beam should be directed perpendicular to the target tissue unless dissection of tissue underlying the lesion is desired. When using the continuous or rapid pulse modes, the surgeon should work expeditiously and with even strokes. Both the power density and the fluence may change with small variations in operative technique and may affect clinical outcome in sensitive areas, such as facial skin. Be aware of tissue that is in the path of the laser beam beyond the target tissue. Protection of the underlying tissue should be provided in anticipation of any laser beam that may "escape" inadvertently after cutting through the target. Recall that the width of the laser cut corresponds to the beam diameter, the depth depends in part on the power set, and the degree of coagulation necrosis on the duration of laser exposure. 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, the heat produced sterilizes the surgical field. In addition, blood vessels and lymphatics adjacent to a target tumor are also sealed. 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. However, 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, nor was it found to promote metastases in a mouse adenocarcinoma model."
2 1 2 2 2 3,4 2 1

USE OF C 0 LASER IN INCISIONAL PROCEDURES

2

To use the C 0 laser as a precise cutting instrument, the spot size at its focal point should be small, approximately 0.2 to 0.3 mm. A focus guide probe, along with a coaxial helium-neon (HeNe) guide beam are helpful in acquiring evenness in the cut when a laser handpiece is used. 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, allows precise tissue ablation with minimal lateral thermal damage. This can best be achieved with a minimum energy of approximately 150 mJ/pulse. Where the target tissue can tolerate a wider zone of coagulation necrosis, such as incisions made in oral mucosa, a continuous wave (CW) laser may be used. At higher power densities the surgeon will have to work rapidly to minimize unwanted thermal damage. Charring will inevitably occur in inverse relationship to incisional speed. 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. This results in creation of a burn in the target tissue. Traction and countertraction of tissue with sponges, forceps, or sutures will facilitate precise surgery just as it does for conventional technique. The target tissue should be examined to see if the desired depth is reached. As with a scalpel, several passes may be necessary to achieve this. Although this is a "no-touch" technique, 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 2 2 6-7

Frenectomy

(Maxillary,

Mandibular,

Lingual)

Maxillary frenectomy can be accomplished using incision and/or ablation. Either CW mode at 3 to 5 W with a 0.2-mm spot size for incision or a pulsed mode at 20 W, 50 to 60 pps, and 2.0-mm spot for ablation size can be used. Topical anesthetic is usually adequate but infiltration technique may be preferred. With the upper lip everted and the frenum stretched taut (Fig. 6-1), a short (3-5 mm), vertical incision is made through the mucosa of the midportion of the frenum. Horizontal releasing incisions are then developed 63

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.

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 - 1 3 . 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. At approximately 7 weeks of age the patient was brought to the operating room where, using general anesthesia delivered by an oral endotracheal tube and without supplemental local anesthesia, the polyp was bloodlessly removed in one minute of operating time. Laser parameters were handheld C O rapid superpulsed laser at 50 pps. evaporative spot si/.e of 0.3 mm, average power output of 10 W [power density (PD) approximately 20,000 W/cm ].
: 2

Figure 6-12. Transection almost complete, cotton swab placed behind target area to prevent unwanted laser contact with adjacent tissue as transection is completed. No bleeding occurred during surgery.

Figure 6-10.

Fibrocpithelial polyp of dorsal midline of tongue.

Figure 6-11. Lesion placed under traction as incision commences across base of lesion. Note HeNe guiding beam in center of incision.

Figure 6-13. ture.

Primary closure of surgical site with resorbable su-

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. In this illustrative case a consultation was received from the newborn nursery to remove an ear tag. Otologic and auditory examinations were normal. The baby was brought to the laser lab where he was first fed. Then, after falling asleep the base of the lesion was inliltrated with 0.25 mL of 2% lidocaine. The lesion was then removed with the superpulsed CO, laser at 6 W average output power, 0.3-mm spot size using a handpiece at 118 pps. The operation required less than a minute and there was no blood loss (Figs. 6-14 to 6-15). Figure 6-14. Ear lag lifted away from underlying normal skin by a cotton tipped applicator, which also protected the underlying normal skin. A similar case in an adult man from India is illustrated in Figures 6-16 to 6-18.

Figure 6-15. Surgical site at conclusion of laser surgery. Area was resurfaced in approximately 10 days.

Figure 6-17. Base of treatment of area after excision of skin tag. Dissection performed after injection of local anesthetic at 6 W, 0.3-mm spot size, 118 pps in RSP mode. Note complete absence of char. Skin was completely healed by 17 days.

Figure 6-16.

Skin lag along periphery of ihe helix of the right car.

Figure 6-18.

Long-term appearance 4 years later.

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, there is less swelling, less postoperative pain, 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. 6-19 and 6-20). The C 0 laser may be used at PD of approximately 10,000 W/cm at 50 PPS, 10 W average output power and 0.3 mm spot size to incise around the impacted crown of the tooth. As dissection proceeds, the mucosal flap is elevated
2 2 2

with tissue forceps until the underlying crown is identified. Al this point, the handpiece is moved away from the tissue to diminish PD, thereby permitting dissection of the mucosa away from the crown without marring Ihe enamel surface from inadvertent laser strikes at high PD. Alternatively, as illustrated in Figures 6-19 and 6-20, the Nd.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. Rapid identification of the crown permits the operator to avoid inadvertently damaging it by excessive heating from the scalpel tip. There is no bleeding.

Figure 6-19. of bleeding.

Crown of impacted tooth exposed. Note absence

Figure 6-20. Mucosa well healed at 3 weeks. Bonded bracket ready to be used to start tooth movement.

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, pulsed mode. 50 pps. 0.2-mm spot size. A completely bloodless and char-free base was obtained (Fig. 6-21). A free palatal graft was obtained with scalpel dissection and thinned with scissors to the correct thickness. This was secured to the recipient site with sutures (Fig. 6-22). The donor site was "sealed" to stop bleeding with one raster in the defocused mode. The graft was readily accepted and the mature graft is demonstrated at 6 weeks recall examination (Fig. 6-23).
2

Figure 6-22.

Free palatal graft secured in position.

Figure 6-21. Recipient site prepared with RSP CO> laser with P SW, PRR = 50 Hz. spot size = 0.2 nun.

Figure 6-23.

Mature graft. Complete "take" at 6 weeks.

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. Large, higher-flow lesions are occasionally treated with the Nd:YAG laser. However, small, localized, low-flow lesions may be excised with the C 0 laser. In the illustrated case (Figs. 6-24 to 6-27) a small vascular malformation of the labial sulcus was excised with the C 0 laser.
2 2

figure 6-24.

Small vascular malformation of labial sulcus.

Figure 6-26.

Dissection of the lesion itself.

Figure 6-25. Dissection of the inferior mucosal flap. An absolutely dry field was achieved with RSP C 0 laser, handheld at IIS pps. 150 mJ/pulse. at 10 W average output power. 0.3-mm spot size which was defocused when necessary to control small bleeding points.
2

Figure 6-27. Two weeks postoperative, the wound was nearly healed with some contraction of the surgical site, which had been left open to heal by secondary intention. The surgical site was completely healed in an additional 2 weeks. Ten years later there was no recurrence.

72

Lasers in Maxillofacial Surgery and Dentistry

USE OF THE CO, LASER AS A VAPORIZATION INSTRUMENT

Vaporization with the C O , laser is used when ablation of localized, superficial strips of tissue is desired. It works in a similar manner to incisional and excisional techniques except that a larger beam size is preferred. The PD used, which is best adjusted by varying the distance of the incident beam to target tissue, depends on the preference and experience of the surgeon. Slow vaporization with lower PD causes greater coagulation necrosis, increases pain and delays healing. On the other hand, 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. In general, the power can be set from 15 to 30 W average power at 50 to 150 pps at 50 to 650 mJ/pulse. Usually approximately 100 to 150 mJ/pulse is used. A defocused spot size of 1 to 5 mm at the target is

used. The target tissue is vaporized with a defocused beam in a "painting" (rastering) fashion. With deeper lesions it is better to ablate the entire surface of the lesion to the same shallow depth in layers, repeating the process until the desired depth is reached. Each treated layer is wiped away with a gauze sponge before applying the next raster. This prevents excessive overlapping of laser crater margins, which results in increased thermal damage, as can be the case when narrower areas are first vaporized to the desired depth. 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, especially when multiple passes are performed. 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. However, careful use of the handpiece will usually produce satisfactory results. (For detailed examples of clinical use, see Chapter 4.)

Soft Tissue Excision Techniques

73

GINGIVAL HYPERTROPHY
A 34-year-old African-American male recipient of a cadaver renal transplant receiving azathioprine. prednisone, diltiazem. doxazosin, captopril, clonidine, and cyclosporine was treated for hypertrophic gingivae. 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 2.0 and 2.5 mm at 58 pps 600 mJ/pulse at an average power output of 25 W. 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. Gingiva removed by each raster is wiped away to remove the carbonization prior to applying additional rasters with the laser (Figs. 6-28 to 6-32).
: 2

Figure 6-30. Series of test spots hi assess for suitable I'D to produce opalescent bubbling of lirst layer of tissue to be removed. Note red HeNe aiming beam adjusted to approximately 2.0-mm spot size.

Figure 6-28. Gingival hypertrophy. Loss of normal interproximal gingival contour. Bulbous papillae and hypertrophy of marginal and attached gingiva.

Figure 6-31. Gingiveclomy complete: charred area consequent to defocused beam application to control bleeding.

Figure 6-29. Toftlemire-type metal matrix band applied snugly around tooth at or below cervicoenamel junction.

Figure 6-32. Six months follow-up. Patient has not received recommended dental prophylaxis every 3 months. Still on cyclosporine. Some recurrent hyperplasia present between the lower central incisors.

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. Gingival hypertrophy was extensive and was much more fibrotic than was the hypertrophy

induced by cyclosporine illustrated in the previous case. A superpulsed C 0 laser at 30 W average output power, with a 2- to 3-mm spot size was used. Blood loss was less than 5 mL and four quadrant gingivectomy, without the use of local anesthetic, required 60 minutes under general anesthesia (Figs. 6-33 to 6-36).
2

Figure 6-33. Severe gingival hypertrophy induced by phenytoin (diphenyl hydantoin).

Figure 6-35. Healing gingivae at 1 week. At 2 weeks the wound was 50% epithelialized.

Figure 5-34. Removal of excess gingivae. Bone exposure was studiously avoided. Note placement of self-retained matrix bands.

Figure 6-36.

Two years postoperative.

Soft Tissue Excision Techniques

75

FIBROEPITHELIAL HYPERPLASIA OF PALATE

A 65-year-old while woman with a history of rheumatoid arthritis, emphysema, and colon resection for adenocarcinoma presented with a complaint of a sore mouth under her upper denture. She smoked two packs of cigarettes per day, and took 2.5 g of aspirin per day, having completed a full course of gold therapy for her rheumatoid arthritis 8 months ago. She had a family history of an undefined "bleeding disease." Her coagulation profile was normal. She has a 1.5-cm raised, reddish, irregular midline palatal lesion that, when biopsied, is reported to be representative of fibroepithelial hyperplasia of the palate. Ablation by vaporization with the C 0 laser is chosen as the treatment of choice. Consequent to her medical history, this patient is admitted to the hospital on the morning of surgery and discharged the following day. She is treated under general anesthesia with nasoendotrachcal intubation, no prophylactic antibiotics are used, and the surgical site is not prepared with antiseptic solutions. Local anesthetic with vasoconstrictor is administered for postoperative pain relief. At surgery, 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. The parameters for the laser treatment are spot size 2.0 mm, power output 20 and 30 W, CW function, at average PDs, respectively, of 500 W/cm and 750 W/cm . 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. Observation for 10 minutes by the clock at the conclusion of surgery shows no bleeding. Total surgical time including the period of observation is 27 minutes, and the estimated blood loss, measured prospectively, was 18 mL. The area ablated measured just over 15 cm". Postoperatively, a single diflunisal tablet was taken for pain control on the evening of surgery. However, on days I. 2. and 3 the patient required four analgesics (Synalgos) per day and a single dose of acetaminophen (500 mg), with 300 mg of codeine on the evening of day 3. She required similar analgesics for the next 4 days, and none thereafter. By day 21, 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. Epithelialization was complete on day 26. There was no recurrence when she was discharged from follow-up observation 28 months after surgery (Figs. 6-37 to 6-46).
2 2 2 2

Figure 6-37.

Fibroepithelial hyperplasia of palate.

Figure 6-39.

First raster after wiping away the char.

Figure 6-38. Completion of tirst raster. CO\ laser in CW mode at 20 to 30 W.

Figure 6-40.

Last raster (third application of laser).

76

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

Figure 6-41. Last raster after wiping away the char. Note general yellow color as submucosa deep to minor salivary glands has been excised.

Figure 6 - 4 3 .

Day 6.

Figure 6 - 4 2 . First postoperative day. Characteristic appearance of fibrin covering the wound.

Figure 6-44.

Day 19.

Soft Tissue Excision Techniques

77

Figure 6-45. Day 26. Treatment area has become completely reepithelialized.

Figure 6-46. Long-term results; 15 months postoperatively mucosa has been stable.

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. Vaporization technique with rapid superpulsed (RSP) C 0 laser was chosen to reduce scarring. Laser parameters: RSP C 0 laser (110 mJ/pulse) at 108 pps using the microscopic and microslad system. The laser spot size was 2.0 mm at an output power of 15 W and a PD of approximately 450 W/cm . The target site was anesthetized by infiltration of 1% lidocaine local anesthetic. No skin preparation was performed (Fig. 6-47). 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. 6-48). One year later there was only a faint depression at the treatment site and there was no change in skin color (Fig. 649).
2 2 2

Figure 6-48. Treatment of nevus. After two rasters at PD = 450 W/cm , RSP CO, with microscope at I OX magnification.
2

Figure 6-47.

Facial nevus.

Figure 6-49. Result at one year. Very minor depression. Perfect skin color at treatment site.

79

SKIN RESURFACING IN AESTHETIC SURGERY

,Skin wrinkles, or rhylidcs from excessive sun exposure, 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). This microprocessor controlled device creates char-free ablation by moving a high-irradiance beam at a rapid rate, thereby preventing the dwelling time at any one point scanned to be greater than the thermal relaxation time of the skin. The scanner can be attached to any C 0 laser that provides a CW, collimated beam, and is capable of removing very shallow skin craters whose penetration level is restricted to the epidermis and upper dermis. The subjacent papillary and reticular dermis receives no
3

thermal damage. 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 0.2-s cycles. This permits assessment of the laser effect after completion of a single cycle (one complete revolution of the flash scanner within its target circle). As always, the target tissue is removed with a saline moistened gauze sponge (Figs. 6-50 to 6-57). Pending the area to be treated, a second and third pass may be necessary to penetrate into or through the papillary dermis. Alternatively, 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. Benign cutaneous growths and atrophic scars and pits can be treated similarly (see chapter 4, White Lesions of the Lip.) Postoperative results are consistently good.
2

Figure 6-50. 62-year-old female with line wrinkles in lower lid. lateral and infraorbital areas.

figure 6-51. C02 lasers resurfacing with Coherent Ultrapulse 5000C CPG scanner at 225 ml, 60W. with one pass at moderate density over lower lid and 2-3 passes over lateral and infraorbital/malar areas.

Figure 6-52. 3 weeks post surgery Note resolving edema and erythema.

Figure 6-53. 6 months post surgery.

Figure 6-54. 18-yearold male with small area of burn scar, mildly raised, sustained 2 years prior, over right temporal area.

Figure 6-55. CO. laser resurfacing with the Coherent Ultrapulse 5000C CPG scanner at 300 ml, I (WW with 2 passes at moderate density.

Figure 6-56. post surgery.

I week

Figure 6-57. 2 months post surgery. Note smoothened area with the slight hypo-pigmentation, which is expected to improve in time.

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. In fact, the versatility of the C 0 laser in its ability to incise, coagulate, and ablate by simply moving the laser handpiece into and out of focus is a major advantage of the instrument in its medical applications. As long as laser-tissue interaction principles are understood and adhered to, the desired tissue effect can be obtained.
2

Rhinophyma Treatment of rhinophyma is an example. (Fig. 6-58) Previous treatment methods with dermabrasion was often incom-

plete, whereas electrocautery would leave significant scars. Recontouring with a scalpel is complicated and also difficult because of excessive hemorrhage. The CO, laser allows good precision and a dry field for easier sculpting. 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. The presence of intact sebaceous glands should be noted on the deep margin to minimize scarring. Reepithelialization takes place in 3 to 5 weeks (Fig. 6-59).

Figure 6-58. Rhinophyma. (Courtesy of Dr. Andrew Van Hassel.)

Figure 6-59. Postoperative result at 5 weeks.

Soft Tissue Excision Techniques

81

EPULIS FISSURATUM
Epulis fissuratum, which consists of hyperplastic mucogingival folds from fibroepithelial proliferation secondary to ill-fitting dentures, prevents proper denture seating on a stable base. It responds well to laser excision with minimal postoperative discomfort and swelling. In this case, a defo-

cused beam at 5 to 10 W CW is used to aid hemostasis and promote a dry field. Alternatively, a pulsed waveform at 20 W, PRR = 50-200 pps at 2.0 to 3.0-mm spot size may be used. The existing denture is relined with soft denture liner. The wound re-epithelializes in about 3 weeks with little loss or no loss of sulcus depth (Figs. 6-60 to 6-63).

Figure 6-60.

Fpulis

fissuratum

secondary to a poorly fitting

Figure 6-62.

After treatment and wiping away treated area.

maxillary denture.

Figure 6-61. CO, handpiece. Focus mode used to excise much of the redundant tissue.

Figure 6-63. Three weeks. Sulcus deepened approximately 5 mm after frenectomy. Stability was maintained at a 6 month recall visit.

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. At 6 to 8 W CW, the lesion is first unroofed. The gland is then propped up and excised in toto to prevent recurrence. Large ranulae are marsupialized by having the " r o o f excised. The wound margin is then sealed with a defocused beam. Reepithelialization is complete in 2 or 3 weeks depending on the size of the wounds (Figs. 6-64 to 6-67).

or rim of the wound is then recontoured with the larger spot size and adequate energy/pulse to level raised areas. If residual pigment is present in the deep dermis, it can be left alone until such pigment rises to the surface of the dermis during healing. The area can then be resurfaced again.

Aphthous

Stomatitis
2

Benign
2

Pigmented

Lesions

The C 0 laser used in combination with scalpel surgery facilitates wound management and healing. Skin moles can be excised sharply with a scalpel flush to the skin. A pulsed laser at 3 W of power output with 200 mJ/pulse of energy using a 1- to 2.5-mm spot size can then be used to "paint" over the surgical wound to a slightly grayish color. The center of the wound may become slightly concave due to contraction of collagen fibers. The periphery

A similar technique with the C 0 laser can be used to primarily desensitize oral wounds. Mucosal donor sites in the palate can be glazed over to provide a thin layer of fibrinous coagulation. CW and defocused mode using a char and wipe technique is adequate here, as occasional minimal scarring can be well tolerated. Similarly, painful, ulcerative lesions can be removed and treated palliatively. Aphthous and traumatic ulcers are first painted over with topical anesthetic. A lower power, defocused C 0 beam is then passed over the entire lesion including the red halo rim. The lesion heals in 2 to 3 weeks without pain. Likewise, 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.

Recurrent mucocele of floor of mouth.

F'igure 6-66.

Part of sublingual gland ablated.

Figure 6-65. Hene guide beam beyond periphery of "roof" of mucocele, the central portion of the lesion is lifted with a forceps.

F'igure 6-67. Three months. Slight scar at surgical site. No submandibular gland obstruction.

Soft Tissue Excision Techniques the defocused mode until the mucosal tissue begins to blister and turn white. This tissue can be peeled away with a hemostat and the underlying tissue assessed. Any remaining disease can be treated with a second pass. Improvement of symptoms varies from patient to patient. In general, some improvements can be expected with smaller lesions. The ultimate late of the lesion, however, will be determined by the natural history of lichen planus.

83

WOUND CARE
The objective of postoperative wound care is to protect the wound, provide patient comfort, and promote healing. Wound care ideally should be simple such that the patient can perform the tasks at home. Smaller oral and pharyngeal wounds are left open, covered only with coagulum, which is the intermediate zone of coagulation necrosis. Carbonized eschar (char) should be wiped and removed. The coagulation necrosis widens in the first few postoperative days and sloughs, accounting for the delay in initial wound healing and possibly some increase in patient discomfort at thai time. Larger oral wounds may be covered initially with gauze packing impregnated with a topical agent like Balsam of Peru, Whitehead's varnish, Bips paste, or an antibiotic ointment. Warm saline rinses four to six times daily and general oral hygiene care should be instituted. Skin wounds should be cleansed gently twice daily with a mild soap solution and topical antibiotic ointment applied. Extra protection with a dressing such as Duoderm is advisable until new epithelium is formed in 4 to 6 weeks. Sun exposure should be avoided for 6 to 12 months.

Charring is expected with laser burn. Charring promotes hemostasis but also can act as a heat sink and mask the depth of laser effect on tissues. The degree of thermal damage tolerance of the target tissue should be understood. Long-term complications are related to regeneration of wound tissue. This includes granulation tissue, hypertrophic scar, wound contracture, and hypo- and hyperpigmentation. Management of these complications is similar to those resulting from scalpel or electrocautery surgery. Prevention of their formation by choosing the proper wavelength and parameters is paramount. Postoperative edema is usually minimal. However, both edema and pain will increase if poor technique results in excessive heating of the tissues during surgery. The advantage of C O laser usage is evident, particularly in treatment of widespread, superficial diseases, bloody procedures, and vascular tissues. It is useful as a surgical instrument in patients with bleeding disorders, patients who arc on anticoagulants, patients in whom the use of epinephrine vasoconstriction is contraindicated, and in those patients who are on monitoring or pacemaker devices. It can also be helpful in infected surgical sites as it theoretically sterilizes during application.
;

REFERENCES
1. Oosterhuis JW. Tumor Surgery with the CO, Laser. Studies with the Cloudman S9I Mouse Melanoma. Groningen. Nether-

lands: Rijksuniversiteit; 1977:1 II. 2. Braun RE. Leibow C. Clinical evaluation of tumor promotion
by C 0 laser. In: SPIE vol 1424: Lasers in Orthopedic. Dental, and Veterinary Medicine. 1991:138-144.
2

3. Roodenburg JL. Panders AK. Vermey A. Carbon dioxide laser

COMPLICATIONS
Laser-related complications in the orofacial area are minimal if proper precautions are taken. Many of the laser procedures are minor and can be performed under local or topical anesthesia. With the latter, care should be taken to monitor the pain tolerance of the patient and prevent patient movement. Supplemental 0 should be avoided unless delivered through an endotracheal tube. Unintentional burns should be diligently avoided.
2

surgery of oral leukoplakia. Oral Surg Oral Med Oral Pathol

1991:71:670-674. 4. dayman L. Management of mucosal premalignant lesions.

Oral Maxillofac Clin North Am I994;6(3):431^143.

5. Ammirati M, Rao LN, Morthy Ms, Buchmann T. Goldschmidt RA. Scanlon BF. Partial nephrectomy in mice with milliwatt carbon dioxide laser and its influence on experimental metastasis. J Surg Oncol 1989;41:153-159.

6. Absten GT. Physics of light and lasers. Obstet Gynecol Clin North Am l99I;18(3):407-427. 7. Rox Anderson R, Parrish JA. Selective photolhermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-527.

Transoral Resection of Oral Cancer

Lewis dayman

The most s e r i o u s , 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 . Despite the p o tential for early detection, 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 ) . 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 . 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 , 0 0 0 per year. 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. 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, G A ) e s timates that in 1993 less than 1 4 . 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 . 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 . 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."
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 . 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. 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. 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 , c r y o s u r g e r y , 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 . 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 , 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 , less p o s t o p e r a t i v e e d e m a , shorter hospital stay, d i m i n i s h e d infection rates, a n d elimination of the need for s p l i t - t h i c k n e s s skin grafting. In addition, in t h e o r y , 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 , 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 , 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.

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 . ' 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 - 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 . 3 % . A s e x p e c t e d , 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 % a n d it is better for local d i s e a s e (tumor, node, metastasis tumor stagingstage I: T 1 N 0 M 0 , s t a g e II: T 2 N 0 M 0 ) a t 7 8 . 9 % . T h e r e f o r e , 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 , 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 . 9 % . R e p o r t s in t h e literature- 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 . C o l l e c t i v e l y , 178 patients w e r e studied, 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 . As reported later in this c h a p ter, in my o w n e x p e r i e n c e at Sinai Hospital of Detroit, 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. O f this g r o u p , 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 . T h e d e t e r m i n a t e 5 - y e a r survival rate is 9 2 . 3 % . S e r e n d i p i t o u s l y , it is noted that for T glottic c a n cer, a n o n o r a l head and neck site, 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 - 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. 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 . 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. 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. 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, 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 . 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

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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 . 1 ' 5 , 1 0 - 1 2 A t 5 y e a r s , t h e s u r v i v a l rate for T , 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 , r e s p e c t i v e l y . 1 1 - 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 % , respectively, 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. transoral resection with elective neck dissect i o n . 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. 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 , 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.3,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 - 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 - r e g i o n a l o r distant s i t e s . 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, 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 . T h i s b e i n g t h e c a s e , 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 , in fact, 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 . 3 , 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 , 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 < . 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 , b i o s t a t i s t i c i a n , Sinai H o s p i t a l , D e t r o i t ) . S u c h a study h a s n e v e r b e e n d o n e . 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 3.0 t o 4 . 0 m J / c m a n d inhibitory effects a b o v e 4 . 0 m J / c m 2 (see C h a p t e r 15). 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. 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 . 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 - a l u m i n u m - 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. 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 10.6-u.m laser light ( C 0 ) .
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 . 2 4 ' 2 5 in 1979. 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 - 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 . T h i s c o n c e p t received further support by t h e early 1980s, particularly from Panjer et a l . and C a r r u t h . 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 - 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 . 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 5,000 to 10,000 W / c m . 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 . 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 ) . 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 . 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 0.5 to 1.0 mm. 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,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 . In v i v o , 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. 7 - 8 ) . 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 . In addition, 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 . 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; h o w e v e r , 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 .
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. 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. S i m i l a r l y , 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 - 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. 7 - 4 4 ) . 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 , 0 0 0 ) e p i n e p h rine or Pitressin ( 1 . 0 u n i t s / m L ) . 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

Transoral Resection of Oral Cancer

to Operating. 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. 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. 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, particularly m u s c l e , 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 . T h i s is most a p p a r e n t during surgery on the t o n g u e . T h e result is that the target tissue lies passively during e n e r g y application, which e n h a n c e s t h e precision of resection.

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 . 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 . 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 . 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.

AVOIDING GENERAL ANESTHESIA Surgical CO, AND CONTACT Nd:YAG

For transoral c a n c e r resection, the t w o lasers of greatest value are the free-beam C O , and the v a r i o u s c o n t a c t N d : Y A G lasers. 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 . Most of these patients h a v e significant intercurrent d i s e a s e s , particularly c a r d i o v a s c u l a r , pulmonary, and c e r e b r o v a s c u l a r , 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 . 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, 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 . 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. 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 - 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. W h e n used for the resection of a d v a n c e d - 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 , fistula formation, and distant flap complications.
: 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 1:200,000. For floor of mouth c a s e s . Pitressin (1.0 unitvmL) w a s also added to the local a n e s t h e t i c . 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. 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. 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 , 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. 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 . 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 . 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 . ( S e e c a s e reports for details.) S i n c e 1988, there h a v e been 13 patients with T, or T mal c a r c i n o m a s , 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. 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. 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. 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.

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 - 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. 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. 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 ) . 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 . 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 . 5 % and e p i n e p h r i n e 1:200,000. 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 , and their a v e r a g e b l o o d loss w a s 190 m L . 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 . O b j e c t i v e l y , 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 , particularly with electrocautery. During f o l l o w - 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 . As noted in the literature" " and
1,1

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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 . 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 ) . 2 9 S t r o n g et a l . ' 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.
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, the d e g r e e of pain to be anticipated is unpredictable. F u r t h e r m o r e , 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 . A m o n g those with less pain, a s u b g r o u p will e x p e r i e n c e a 2- 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 . 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 . 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 . After day 5, 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 .
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 . 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 , 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 . 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 . T h e s e treatment areas in h u m a n s , as in d o g s , 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 , 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 . In addition, the healed oral m u c o s a p r e s e r v e s its elastic properties. 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 . 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 , 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 . 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 s t a y e d an a v e r a g e of 2 d a y s . H o w e v e r , 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 , 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 .
2

A l t h o u g h Panje et a l . 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, w e did not specifically m o n i t o r s w a l l o w i n g difficulties. 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 . 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.
2

TIME AT OPERATION COMPLICATIONS

N o s p l i t - 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 . 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 , 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 . 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 , floor of the m o u t h , 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, 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 . 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, w h o " o o z e d " for 2 to 3 d a y s after s u r g e r y . 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 , 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 , 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, 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 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. 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 , laser c a s e s go quite quickly. In fact, 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, 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 , vital s t a i n i n g with toluidine b l u e , and a m a n d a t o r y 5 - 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.
2

THE SUBMANDIBULAR DUCT

F o r anterior floor of m o u t h resection, no special care is taken in regard to W h a r t o n ' s duct. In fact, they are c o m pletely i g n o r e d . 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. 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 , 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. 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. 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 .

Transoral Resection of Oral Cancer SURGICAL CASES General Comments: Free-Beam C0 Contact Nd: YAG
2

89

vs.

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 . 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 , 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 ; a dry o p e r a t i v e f i e l d ; and a b s e n c e o f m u s c u l a r fasciculations, particularly of the t o n g u e , 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. 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. Surgery itself g o e s q u i c k l y , usually lasting less than I hour, 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 . B l o o d loss is m i n imized. H o w e v e r , 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 . 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 % . Reconstruction after floor of m o u t h resection is particu-

larly simplified by the lack of need for split-thickness skin grafts. 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 , retromolar pad, or anter i o r tonsillar pillar is u n c o m m o n . 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 . 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 . 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 . O n t h e o t h e r hand, 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. 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, 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 . 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. 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 , but heat d a m a g e m a y e x c e e d 3.6 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 0.3 m m . F r e e - b e a m C 0 w o u n d s heal slightly faster but this is not clinically significant.
2 2

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Lasers in Maxillofacial Surgery a n d Dentistry

TRANSORAL CASE 1: FLOOR OF MOUTH

A 5 4 - y c a r - o l d A f r i c a n - A m e r i c a n w o m a n , with a 2 5 - 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 , presents with a 2 - m o n t h history of an "irritation u n d e r m y t o n g u e . " E x a m i n a t i o n , incisional b i o p s y , 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 . 7 - 1 a n d 7 - 2 ) . 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, c h r o n i c obstructive lung d i s e a s e , stable c o r o n a r y artery d i s e a s e , and insulin-controlled d i a b e t e s mellitus. T h e free-beam CC2 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.
TECHNIQUE

Figure 7 - 2 .

During operation, tongue properly retracted.

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 , 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 . 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 , and the h y p o p h a r y n x is packed with a wet throat pack. Local a n e s t h e t i c solution c o n t a i n i n g 1:200,000 e p i n e p h r i n e and Pitressin 1.0 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 . W h i l e a w a i t i n g m a x i m u m vasoconstrictor effect, the oral m u c o s a is stained with toluidine blue. ( S e e C h a p t e r 4.) 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 . After w a s h i n g the field with saline, the areas retaining the stain a r e noted (Fig. 7 - 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 . 7 - 4 ) . 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 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.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 . 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 . 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 - n e o n ( H e N e ) g u i d e b e a m spot size is varied from 0 . 3 to 3.0 m m . T h e true

Figure 7 - 3 . Lesion retains toluidine blue vital slain after aectk acid rinse. HeNe guide beam placed into contact with tissue ai focal point of probe demonstrating 0.3-mm guide spot size foi incision.

Figure 7 - 1 .

T | N()M() SCC of anterior floor of mouth.

Figure 7-4. Defocused spots to mark resection margin. Handpiece is moved away from focal point until 2- to 3-mm spot size is obtained. Bloodless markings are made with single pulses (PD <500 W / c m ) .
2

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 r e f o r e , the p o w e r d e n s i t y ( P D ) will range from 3 5 , 0 0 0 W / c m 2 t o 3 5 0 W / c m 2 a t 2 0 - W o u t p u t and from 5 2 , 0 0 0 W / c m 2 t o 5 2 5 W / c m 2 a t 3 0 - W output. The former values a r e used for e x c i s i o n and t h e latter for coagulation. Surgical principles of traction-countertraction a r e used to facilitate dissection (Fig. 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 . T h e s u b mandibular ducts are transected at will at high PD in the pulsed m o d e , 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 . After d e t e r m i n i n g the d e p t h of resection anteriorly, 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. 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 . 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. 7 - 6 ) . 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. 7 - 7 ) . 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 0.16 m m (Fig. 7 - 8 ) . E s t i m a t e d b l o o d loss w a s 5.0 m L and operating t i m e w a s 4 0 m i n u t e s . 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. (If used, 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 , or in t h e office on the f o l l o w i n g day.) T h e day after s u r g e r y , 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. 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 . 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 . 7 - 9 t o 7 - 1 4 ) until reepithelialization w a s c o m p l e t e , 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. At 1-year recall ( F i g s . 7 - 1 5 to 7 - 1 7 ) speech, s w a l l o w i n g , 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 . 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.

91

Figure 7 - 6 . Base coagulated in CW mode al 30 to 40 W, defocused for maximum hemostasis. Note that both resection and coagulation violate the submandibular ducts.

Figure 7 - 7 . pathologist.

Specimen oriented and pinned for transfer to the

Figure 7 - 5 . Specimen mobilized. Dissection made to base of deep resection margin. Note instruments retracting both tongue and specimen to provide traction-countertraction for good surgical exposure.

F'igure 7 - 8 . Histology: Note zone of thermal necrosis on base of specimen is only 0.16 mm (100X).

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Lasers in Maxillofacial Surgery and Dentistry

Figure 7-9. Fibrinous coagulum appears within the first 24 hours. still present at 1 week.

Figure 7-12 twenty-two days. mirror demonestrate area of exposed bone. one will expect squestrum, but not progressive osteomyelitis to develop. The patient has received no antibiotics.

Figure 7-10. Two weeks. Note that reepithelialization occurs from the periphery. Note the exposed area of lingual plate of mandible on the patient's left side.

Figure 7-13. Thirty-two days. Most of the surgical site has reepithelialized.

Figure 7-11. Twenty-two days. Note that most of oral floor is covered by new epithelium. Bone is still exposed.

Figure 7-14.

Forty-six days. Completely healed.

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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. 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 . If hemostasis is satisfactory after 5 to 10 m i n u t e s of observation, t h e patient is b r o u g h t to t h e recovery r o o m . On (he o t h e r hand, if h e m o s t a s i s is imperfect, 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. 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 . 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 , 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 . T h i s m a y be d o n e in several w a y s . E i t h e r t h e scalpel is used to incise to b o n e , 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 , 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 . 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 . 7 - 1 9 ) to redirect the b e a m . A l t e r n a t i v e l y , 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 . Or, if using t h e laser, a c o n t r a - 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. 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 . H o w e v e r , s h o u l d t h e latter o c c u r to a mild d e g r e e , 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 . It is not, h o w e v e r , u n c o m m o n for a s m a l l , 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. After r e m o v i n g t h e s p e c i m e n (Fig. 7 - 2 0 ) , m a r g i n s w e r e harvested from the patient for frozen section. 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. 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.

A 5 6 - y e a r - o l d w h i t e m a n with a 2 5 - 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 - m o n t h history o f a n "irritation u n d e r m y t o n g u e . " E x a m i nation, incisional biopsy, 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 . 7 - 1 8 ) . 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. 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 .
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 , 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 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 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 , 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. Local a n e s t h e t i c solution of 0 . 5 % b u p i v a c a i n e c o n t a i n i n g 1:200,000 e p i n e p h r i n e and Pitressin 1.0 U / m L ( 1 . 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. 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 . 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, 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 . 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 , and no s i a l o d o c h o p l a s t i e s a r e performed. 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 , 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. 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 . 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 - 1 8 . Microinvasive T|N M squamous cell carcinoma of anterior oral floor arising in proximity to Wharton's duct.
0

Figure 7 - 1 9 . (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.

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. 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 . 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 . At this t i m e , (he base of the w o u n d is fibrin c o v e r e d ( F i g . 7 - 2 1 ) . 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. 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 . 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 - 2 2 and 7 - 2 3 ) , 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. For a n terior floor of m o u t h r e s e c t i o n s , there is no interference with n o r m a l s w a l l o w i n g . 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 . 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.

Figure 7-20. The specimen is pinned onto a wooden tongue blade, marked for orientation and demonstrated to the pathologist in the operating room. Frozen sections are obtained from the palient as required.

Figure 7 - 2 2 . Oral floor well healed. Wound was reepithelialized in 25 days. Mature, pliable mucosa present (10 weeks).

Figure 7 - 2 1 . Fibrin coagulum still present at floor of resection, postoperative day 10.

Figure 7 - 2 3 . Lingual gingiva stripped at surgery has recovered completely (10 weeks). Recover)' of tongue range of motion was complete.

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 - B E A M C 0

of the e p i n e p h r i n e . Essentially, 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. 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 . 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 , 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 , 0 0 0 W / c m 2 ( A v g . P = 3 0 W , p p s = 1 1 8 , H e N e spot = 0.3 m m . pulse w i d t h = 2 . 4 m s , intcrpulsc d i s t a n c e = 9.9 m s , 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, 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. 7 - 2 5 ) . 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.
2

T h i s 8 2 - y e a r - 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 - 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. 7 - 2 4 ) . 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 , 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 . 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 . At s u r g e r y , after p r o v i d i n g s e d a t i o n , the t o n g u e w a s anesthetized by lingual, 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 . 5 % b u p i v a c a i n e with 1:200,000 e p i n e p h r i n e . T h i s w a s given slowly o v e r a

Figure 7-24. T NM ,i moderately well-differentialed squamous cell carcinoma of mobile tongue.

;

Figure 7-26. 4.3 X 1.5 cm.

Oral side of specimen. Specimen measured 4.7 X

Figure 7 - 2 5 . Margins marked. Superpulsed mode, defocused handpiece. PD = 450 W / e n r .

Figure 7 - 2 7 . Deep resection margin of specimen. Note relative lack of charring. Approximately 5 mm of additional "marginal" tissue was vaporized at the depth of resection. (PD approximately 52.000 W/cm for resection.)
2

Transoral Resection of Oral Cancer

At the p o s t e r i o r limit of t h e resection, the incision w a s e x tended laterally to j o i n t h e line of resection at the oral floor. 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. 7 - 2 6 and 7 - 2 7 ) . 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 - m m spot s i z e , d e f o c u s e d to provide a PD = 4 2 5 W / c m . 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. 7 - 2 8 ) . N o t e the contrast to F i g u r e 7 - 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. 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. Estimated blood loss w a s less than 50 m L , 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. P o s t o p e r a t i v e l y , narcotic a n a l g e s i c s w e r e required for 4 d a y s . 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 . 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 , 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. 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 - 2 9 t o 7 - 3 3 . F u n c t i o n a l l y , 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 . 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 , 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.

Figure 7-28. Base of resection. CW effect causing char left in situ to inhibit bleeding.

Figure 7 - 3 0 . Day 10. Most of fibrin has been replaced by immature epithelium.

Figure 7 - 2 9 . Day 4. Fibrin covering of laser wound left to heal by second intention. This forms during the first 24 to 48 hours after wounding and is gradually replaced by epithelial tissue.

F'igure 7 - 3 1 . Day 18. Some wound contraction has occurred and most of wound is covered by new epithelium.

98

Lasers in Maxillofacial Surgery and Dentistry

Figure 7 - 3 2 . Day 25. 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 - 3 3 . Eight weeks. Complete epithelialization occurred by day 3 1 ; 24 days later the surface is unchanged and the range of motion of the tongue is very good but slightly restricted.

Transoral Resection of Oral Cancer CASE 4: T O N G U E CANCERPRIMARY 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 . 7 - 3 4 to 7 - 3 7 ) .

99

Figure 7 - 3 6 .

Primary closure of wound.

Figure 7-34. tongue.

T,N M
n

squamous cell carcinoma of mobile

Figure 7-37. Normal tongue protrusion at 33 months. Patient had no evidence of disease at 8 years.

Figure 7-35. Starting the incision with the laser handpiece tip adjacent the tissue at the focal point. PD approximately 30,(X)0 W, superpulsed mode. Note HeNe aiming beam just below tip within incision. Field is dry.

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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 - y e a r - 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. 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 . 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 , 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 . 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 . 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 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 . 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 . In addition, 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 . T h e silica c o n t a c t scalpel p r o b e s (Fig. 7 - 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.
2 2

F'igure 7 - 3 9 . Laser is activated prior to touching probe against tissue. When probe tip reaches operating temperature, it is gently stroked along the path of incision. Tactile sense regulates rate and depth of incision. Dissection proceeding into depth of tongue. Note absence of bleeding.

At operation, 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 . B u p i v a c a i n e 0 . 5 % with e p i n e p h r i n e 1:200.000 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 . 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 ) . 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. 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. 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 - 4 0 . Posterolateral aspect of tongue adjacent to tongue base retracted laterally to demonstrate extent of posterior element of the excision. Note proximity of high-speed laser suction to laser probe tip.

Figure 7 - 3 8 . Silica scalpel tips for the contact Nd:YAG laser. (Scalpel tip number 6 used for incision at 15 W.)

Figure 7 - 4 1 .

Depth of resection in residual mobile tongue.

Transoral Resection of Oral Cancer

101

Figure 7 - 4 2 .

Specimen.

Figure 7 - 4 3 . Bovine collagen dressing sutured in place lo facilitate hemostasis (from a similar case).

o u t p u t p o w e r of 15 W, and using the n u m b e r 6 scalpel tip probe, 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 . N o w , 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, t h e laser t u r n e d o n , 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, 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 . 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 , 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 . In this w a y , the dissection w a s c o m p l e t e d ( F i g s . 7 - 3 9 t o 7 - 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 . 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 . 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, 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 . 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 , 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 . T h e s p e c i m e n (Fig. 7 - 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 . 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, 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 , which w a s sutured a l o n g its p e r i p h e r y (Fig. 7 - 4 3 ) . T h e histologic s p e c i m e n (Fig. 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 . 3 to 0.7 m m . After s u r g e r y , 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 . He r e s u m e d oral intake the next m o r n i n g , and h e w a s d i s c h a r g e d t h e following d a y . H i s s p e e c h w a s intelligible on t h e d a y after surgery, 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. 1-AA). 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 . H o w e v e r , 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. S w a l l o w ing w a s n o r m a l by w e e k 8. 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 , as w a s s w a l l o w i n g (Fig. 745). 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 .

Figure 7-44. Histology of resection margin. Note that depth of coagulation necrosis from the contact YAG tip is only 0.22 mm. (Depending upon area examined it ranged from 0.22 mm to 0.67 mm.)(H&E200X.)

Figure 7 - 4 5 . At 18 weeks. Range of motion of tongue good. Mild speech impediment. Normal swallowing.

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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. 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. 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 - A m e r i c a n w o m a n with a I - 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 . 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 . 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 . 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. On oral e x a m i n a t i o n , a globular e x o p h y t i c m a s s m e a s u r ing 3.2 cm at its widest d i m e n s i o n w a s p r e s e n t (Fig. 7-46). 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 . On b i m a n u a l palpation, it was estimated to be 1.5 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 . T h e r e w a s no l y m p h a d e n o p a t h y . 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. The c h e e k w a s infiltrated with 8 mL of 0 . 5 % b u p i v a c a i n e containing 1:200.000 e p i n e p h r i n e . 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. 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 . R e s e c t i o n i n c l u d e d a 1.0-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 . 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.

T N M well-differentiated squamous cell cancer.

; (( a

Figure 7-48. Buccal fat pad graft is partially epithelialized (6 days). By 16 days it was approximately 50% reepithelialized.

Figure 7-47. Development of buccal fat pad for partial coverage of surgical defect.

Figure 7 - 4 9 . Thirty-six days. Completely reepithelialized. By 15 weeks the wound was mature and maximum oral opening was 50 mm.

Transoral Resection of Oral Cancer

range from 0 . 3 2 t o 0.34 m m i n t h i c k n e s 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 . 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 . 7 - 4 7 ) . 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 . 7 - 4 8 ) . At

103

1 5 d a y s , 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 . A t 3 6 d a y s , 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 . 7 - 4 9 ) . 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 . A t 1 5 w e e k s t h e patient o p e n e d 5 0 m m . S h e had res u m e d her n o r m a l d i e t , w a s m a i n t a i n i n g her w e i g h t , and had n o p a i n .

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Lasers in Maxillofacial Surgery and Dentistry COMPLICATIONS

T h e r e w e r e no unexpected extensions of the palatal cancer. 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. Output p o w e r w a s 12 to 20 W. 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. N o w using the number 8 scalpel tip at 15 W, the tip w a s angled to maintain proper position in t h e depth of the resection. 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 . Histopathologic assessment of the specimen confirmed adequacy of resection. 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 1.6 mm of thermal necrosis. H o w e v e r , 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. 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.

Case

7: PalatePostoperative Tonsillar Hypertrophy

T h i s 4 9 - y e a r - 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 . 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 . 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 , and to drink t w o or three beers per d a y . A s e c o n d p r i m a r y t u m o r , a T1N0M0 well-differentiated s q u a m o u s cell c a r c i n o m a , 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 . 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 .

Figure 7 - 5 0 . Outlining the mass: SLT contact YAG: number 6 scalpel tip at 15 W.

Figure 7 - 5 2 .

Specimen.

Figure 7 - 5 1 . Traction as dissection reaches depth of tonsillar crypt. No bleeding. Note smoke generation. The high-speed laser smoke evacuation system still must be used, just as it is for the free-beam C 0 laser.
2

Figure 7 - 5 3 . weeks.

Complete reepithelialization and healing at 3

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 - 5 0 ) . 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. 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. T h e lesion w a s easily delivered from a bloodless field ( F i g s . 7 - 5 1 and 7 - 5 2 ) . 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. 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. 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. 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 . 7 - 5 3 ) . Postoperatively, 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 .

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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 . A n t e r i o r floor of mouth. 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. 7 - 5 4 and 7 - 5 5 ) .
0 0

Figure 7 - 5 5 . Restricting scar band: Pseudoankyloglossia at 19 months. Release of wide and thick scar band causing pseudoankyloglossia. RSP, 118 pps. PD approximately 500 to 6(H) W/cm .
1

Figure 7-54. of mouth.

T1N0M0 squamous cell carcinoma of anterior floor

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, T 2 N 0 M 0 of the right buccal m u c o s a , 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, 0 . 3 - m m spot size for incision, d e f o cused spot size of 2 . 0 to 2.5 mm for coagulation at 86 pps, 2 9 0 mJ/pulse ( F i g s . 7 - 5 6 t o 7 - 5 9 ) . A l t h o u g h , m o s t of the treated area reepithelialized normally, a 1.5-cm-diameter mass of granulation tissue persisted at the proxi2

107

mal e d g e of the resection margin. Trauma from her m o lars o c c l u d i n g into the proliferative scar prevented its resolution. After an additional 2 months of maturation the l e s i o n persisted. It w a s , therefore, e x c i s e d using the same parameters described a b o v e . 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. Within 1 month of e x c i s i o n , 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. S h e has been cancer free and the proliferative lesion has not returned.

Figure 7-56. cosa.

T2N0M0 verrucous carcinoma of righl buccal mu-

Figure 7-58.

Maxillary prosthesis to protect cheek.

Figure 7-57. Proliferative granulation tissue arose, at proximal edge of resection margin. Matured lesion now appeared as a large pedunculated polyp. Excised with the RSP C 0 laser.
2

Figure 7-59. Buccal mucosa, 9 months after excision of polyp. Three years later there is still no recurrence of the polyp or the cancer; mouth opening and buccal mucosa are both normal.

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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 LASERTUMOR DEBULKING

When treating patients with head and neck cancer w h o have failed definitive therapy, 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, create a wound that is easy to clean, and reduce the smell of necrotic tissue, and the palliative procedure should be brief. The high-powered free-beam C 0 laser serves this purpose well. A 68-year-old man developed recurrent squamous cell carcinoma under his pectoralis major myocutaneous flap that extended into the submental triangle (Figs. 7 - 6 0 to
2

7 - 6 3 ) . The original tumor was a stage IV, 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, radiotherapy, and surgical resection with immediate soft tissue reconstruction. 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 . 0 to 3.0 mm giving an average PD of 3 5 0 0 W / c m to 1560 W / c m . This provided adequate hemostasis while permitting debulking of the tumor. General anesthesia was used and the operation required less than 30 minutes. A collagen hemostatic dressing w a s applied to the depth of the wound to aid in hemostasis. The wound remained clean and without an offensive odor until the patient's death 3 months later.
2 2 2

Figure 7-60. 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.
l

Figure 7 - 6 2 .

Tumor bed is clean 3 weeks after treatment.

Figure 7 - 6 1 . Ablation of recurrent tumor. Free-beam C 0 , 90 W, 2- to 3-mm spot size. Note HeNe aiming beam in upper left comer of wound. Significant plume production occurred at this power density.
2

Figure 7 - 6 3 . Three months after treatment just before death. The treated area remains quite clean.

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 ) . 1 , 2 T h i s is a short operation, performed in the office using local anesthesia a n d a surgical laser. 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, the v e l u m , and the superior part of the posterior p h a r y n g e a l pillars.

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 . F o r t h o s e w i t h severe O S A S ( R D I > 7 5 ) , 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 , o t h e r t r e a t m e n t m e t h ods, 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 , a r e required. H o w e v e r , 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 , 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 .
1

of u n c o n t r o l l e d scar f o r m a t i o n . 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, 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 . U n l i k e U P P P , 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 . 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. 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 , less tissue l o s s , and better overall c o n t r o l of s u r g e r y . 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 w e l l i n g , 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). 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. 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 - r e l a t e d risks. In all c a s e s , t h e h e a l i n g of t h e l a s e r - i n d u c e d w o u n d s is faster than after standard U P P P , 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. In these c a s e s , 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 . A s i s t h e c a s e for U P P P , 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 . 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 , o b e s i t y , t o b a c c o and a l c o h o l use, 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 - h y p n o t i c d r u g s o r tranquilize r s , or untreated h y p o t h y r o i d i s m . If s y m p t o m s of snoring or O S A S recur, 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 . 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 - a l u m i n u m - 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 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. 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 , 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. 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 - t o u c h " t e c h n i q u e , 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 . 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 , 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.
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, L A U P is also not of benefit.

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 . T h e accessibility of t h e velum, uvula, 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 . After t r e a t m e n t , 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, p r e d i c t a b l e , a n d free
2

111

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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 . 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. Standard C O laser safety p r e c a u t i o n s h a v e to be followed. 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 , d e p e n d i n g on the thickness of tissue that is to be incised. A specific s n o r i n g h a n d piece is used with a variable spot size of 0.6 to 3.51 mm at a focal length of 3 0 0 m m . T h i s h a n d p i e c e h a s a focus-defocus ring: focus to cut. and defocus to c o a g u l a t e . 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. Blood pressure is m o n i t o r e d d u r i n g the operation. At the time of the session, the patient is placed in a scaled position with the m o u t h o p e n . 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 . T h e patient then is given breathing instructions: to take a d e e p breath and very slowly let it out. 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 (1.25 mg in 2 . 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.
:

Kinure 8 - 1 . Laser-assisted UPPP (LAUP) in four to five sessions. Illustration demonstrates the vertical and horizontal incision cutting of the soft palate, laterally to the root of the uvula, at the left, then at the right side of the uvula.

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. Usually the surgery is repeated a s e c o n d or a third t i m e . 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 . Bilateral vertical incisions a r c m a d e lateral to the u v u l a , s p a r i n g the uvula itself. T h e s e are full-thickness " t r e n c h e s " on either side of the uvula (Fig. 8 - 1 ) . 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 . " A " n e o - u v u l a " is created, with further d e b u l k i n g of the inferior and lateral sides of t h e uvula. Its anterior and p o s t e r i o r sides must be preserved, leaving the m u c o s a intact to prevent g r a n u l o m a formation and facilitate reepithclialization. T h i s is d o n e by vaporization al the point of focus (0.6 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, 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. 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. No s u t u r e s are r e q u i r e d . At e a c h of the p l a n n e d s e s s i o n s , about 5 to 8 mm of the v e l u m is r e m o v e d . 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 this w a y the n e o - 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. 8 - 2 and 8 - 3 ) . 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 . 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.

Figure 8 - 2 . of uvula.

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 . 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. In patients with a narrow n a s o p h a r y n g e a l orifice, a horizontal section is performed on t h e u p p e r part of the posterior tonsillar pillars, to e n l a r g e the aperture. T h i s r e m o v a l of the upper part of the

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 , 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 , generally s p a c e d at monthly intervals. 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. T h e a v e r a g e n u m b e r o f sess i o n s is 3.77 in n o n a p n e i c snorers and 4 . 3 in O S A S patients.

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 , 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 . 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 . 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 . 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." 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. 8 - 4 ) . 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, resulting in a s m a l l " n e o - u v u l a . " T h i s n e o - u v u l a h a n g s from t h e r e a r of the hard palate, p r e v e n t i n g centripetal s c a r fibrosis, 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 - s n o r e r s ) (Fig. 8 - 5 ) . In a d d i t i o n , 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 - 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. 8 - 5 ) . 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 , like a m a i n m a s t s u p p o r t i n g the palatine arch, a

Kigure 8 - 3 . LAUP: multiple sessions. Creation of a "neouvula," by debulking of the inferior and the lateral sides of the uvula. Repeat sessions will gradually result in the "nco-uvula" assuming a more superior and dorsal position, closer to Passavant's ridge.

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 - u v u l a , as retraction occurs. In the O S A S p a t i e n t s , 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 . 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. If there is h y p e r t r o p h y of t h e lingual tonsils, 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 , 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 . 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. 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. W h e n there is b l e e d i n g , it is controlled with the defocused b e a m , w h i c h c o a g u l a t e s vessels less than 0.5 mm in d i a m e t e r . If b l e e d i n g c o n t i n u e s , it is c o n t r o l l e d with bipolar electrocautery. S m o k e is e v a c u a t e d by a h i g h - s p e e d dedicated laser e v a c u a t i o n s y s t e m , 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 . 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. 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, a C 0 laserassisted partial inferior turbinectomy ( L A P T ) or a septoplasty may have to be performed. Actually, 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.
2

Figure 8-4. neo-uvula.

LAUP: one-stage vertical incisions and creation of

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u n n e c e s s a r y . 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. 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 . Nasal regurgitation h a s not been reported after t h e laser surgery. 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 .

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, 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 - 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 . 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 , p o l y s o m n o g r a p h y i s rep e a t e d . 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.

RESULTS OF A PERSONAL SERIES

Figure 8 - 5 . LAUP: one stage. Debulking the superior part of the posterior pillars to create a U shape.

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 , flanked by t h e t w o lateral p o s t e r i o r pillars. 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 . T h i s s m a l l , s p i n d l e - s h a p e d , 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 ; its m a i n action is to raise t h e uvula, 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 . 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 . 3

OPERATIVE OUTCOME
After the p r o c e d u r e , 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 , p e r o x i d e and w a t e r g a r g l e s , topical a n e s t h e t i c throat l o z e n g e s , a n e s t h e t i c m o u t h s p r a y s , a n d viscous l i d o c a i n e to relieve throat p a i n . 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 , e a t i n g food with vinegar, l e m o n , 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 . 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 . 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 , but d o e s n ' t inhibit e a t i n g food or d r i n k i n g , s p e a k i n g , or w o r k i n g i m m e d i a t e l y afterward. R a r e l y , 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 , 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 . U s u a l l y , 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 . 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, 8 5 6 patients were treated with L A U P b y t h e author. T h e r e w e r e 7 1 5 m e n and 141 w o m e n , with a m e a n a g e of 4 9 . 2 years ( r a n g e : 25 to 8 0 ) . T h e m e a n b o d y m a s s index ( B M I ) w a s 2 5 . 9 (range: 17.1 to 4 5 ) . 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, 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 . After t r e a t m e n t , 7 0 . 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 , with no long-term r e c u r r e n c e ; 2 4 . 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 , 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 , and 5.1 % ( 4 4 patients) s h o w e d no r e s p o n s e after L A U P . 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. 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 , 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 . 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, and t h e mean s e s s i o n n u m b e r w a s 3.77. A m o n g t h e 2 1 2 patients cured with t h e o n e - s t a g e t e c h n i q u e , 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 , 1 m o n t h later. 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 11.2 d a y s . 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 , but longer follow-up s h o w e d reduced success. After several m o n t h s , s n o r i n g had reappeared in a few c a s e s , but with m u c h less d i s t u r b a n c e than before. A further study of l o n g - 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 . 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 ; 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 ) . U s u a l l y , after L A U P , 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

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currence h a v e been cured of their d i s c o m f o r t . 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 . 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 . there were 14 c o m p l e t e c u r e s , 10 w e r e i m p r o v e d , and I failed. In the majority of the patients, 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 , sleep a w a k e n i n g s , m o r n i n g tiredness, m o r n i n g h e a d a c h e s , and sexual p r o b l e m s (erectile dysfunction). 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- and p o s t o p e r a t i v e nocturnal E E G studies. 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 63%> of p a t i e n t s confirmed by nocturnal E E G s t u d i e s . F u r t h e r m o r e . 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 . 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 . 4 % ) , 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 . 1 % ) , 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 . Eight patients ( 1 1 . 4 % ) w e r e u n i m p r o v e d . H o w e v e r , 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. As for U P P P , 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 . 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 . 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 % . 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 % . 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 37.6 t o 15.9, a n d t h e m e a n a p n e a index from 2 3 . 3 to 6.2, 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 . 8 t o 17.5. 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 . For all 70 p a t i e n t s , 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. 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 . 3 t o 7.7. 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 . 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 . 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 . 1 % p r e o p e r a t i v e l y t o 9 3 . 9 % p o s t o p e r a t i v e l y . 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 . 3 % t o 8 0 . 5 % p o s t o p eratively. F o u r patients w e r e surgical U P P P failures corrected by L A U P . After L A U P , 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. 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 . It is essential to c o n v i n c e our treated patients to maintain l o n g - 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 .
; :

Obstructive Sleep Apnea Syndrome

F r o m D e c e m b e r 1988 t o M a y 1994, 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 , " 64 m e n and 6 w o m e n , with a m e a n age of 5 3 . 9 ( r a n g e : 2 3 - 7 2 ) . T h e m e a n BMI w a s 29.2 ( r a n g e : 2 2 . 3 - 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 . All had pre- 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 . For severe O S A S , C P A P w a s initiated before L A U P . 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 . After L A U P , 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 , 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. In 56 patients ( 8 0 % ) . there w a s c o m p l e t e or n e a r - c o m p l e t e elimination of snoring, with no recurrence. In 11 patients ( 1 5 . 7 % ) , there w a s i m p r o v e m e n t of snoring, but still a small a m o u n t of occasional noise persisted. In three patients ( 4 . 3 % ) there was a d e c r e a s e in snoring, but the noise w a s still disturbing to the s p o u s e . D a y t i m e s l e e p i n e s s disappeared in 8 2 % of cases, decreased in 1 5 % of cases, and w a s u n c h a n g e d in 3% of cases. M o r n i n g tiredness disappeared in 9 4 % of cases and decreased in 6% of c a s e s . 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 , this s y m p t o m d i s a p p e a r e d in 25 cases, and r e m a i n e d u n c h a n g e d in o n e case. A m o n g the 56 patients with frequent sleep a w a k e n i n g s , this s y m p t o m disappeared in 30 c a s e s , d e c r e a s e d in 18 c a s e s , and r e m a i n e d as before L A U P in eight cases. A m o n g the 27 patients w h o suffered sexual p r o b l e m s (erectile dysfunction, loss of libido), 23 said that their sex life w a s i m p r o v e d after L A U P .

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Lasers in Maxillofacial Surgery and Dentistry CASE 1 CASE 2

A 5 0 - y c a r - o l d medical d o c t o r presented with a 1-year history of snoring, m o r n i n g tiredness, sexual p r o b l e m s , no d a y t i m e s o m n o l e n c e , and a BMI of 24.6. He underwent a o n e - 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, although he c o m p l a i n e d of c h r o n i c nasal obstruction. 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. Laser-assisted turbinectomy of the left inferior and m i d d l e turbinates, w a s carried out in two s e s s i o n s . W h e n reevaluated 4 m o n t h s later, 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 . T h e r e w a s n o m o r e snoring.

A 55-year-old o b e s e ( 1 0 2 k g . or 2 2 5 lbs) m a n , 1.73 m (5 feet. 8 inches) tall, presented with a 3 0 - y e a r history of snoring and m o d e r a t e sleep a p n e a . 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 , 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. N o maxillofacial a b n o r m a l i t y w a s found. 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 , with a n R D I o f 6 2 . 8 / h o u r and a sleep a p n e a index of 4 6 . 6 / h o u r , 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 ; 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 % . 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 , resulting i n R E M positive sleep. A strict weight reduction diet w a s started. 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 - 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 . 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 . 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, which found significant i m p r o v e m e n t of the O S A S , with an RDI of 2 2 . 6 and an a p n e a index of 12.5, a m e a n S a 0 of 9 3 . 9 . and a lowest S a 0 of 6 1 . 6 % . 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 . 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 , 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 ) . Four m o n t h s after the initial L A U P , a third o p e r a t i o n w a s performed. 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. and an a p n e a index of 7.3/hour. T h e m e a n S a 0 w a s 9 2 . 9 % and the lowest S a 0 was 7 2 . 5 % . The N - C P A P was decreased to 7 cm H 0 . A fourth and fifth session w a s d o n e , r e s p e c t i v e l y . 7 and 8 m o n t h s after initial treatment. 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. T h e patient later com plained of nasal o b s t r u c t i o n , 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 right turbinates w e r e treated by L A P T 3 w e e k s later. 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 , 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, and o n l y o c c a sional soft s n o r i n g , still a bit d i s t u r b i n g to h i s wife.
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, similar to the w a y a theater curtain rises. After 5 years of e x p e r i e n c e with L A U P , 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. It would b e c o m e a valuable alternative technique to conventional U P P P , with its great potential to r e d u c e morbidity and cost to patients. 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 - t e r m a s s e s s m e n t , especially in surgery for O S A S , 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. In these patients, 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.

REFERENCES
1. Kamami YV. Laser C 0 for snoring, preliminary results. Ada Otorhtnolaryngol Belg 1990;44:451-456. 2. Kamami YV. Outpatient treatment of sleep apnea syndrome with C 0 laser, LAUP: laser-assisted UPPP results on 46 patients. J Clin User Med Surg 1994;12:215-219.
2 2

Section 2: Further Comments on the Laser-Assisted Uvulopalatoplasty

lames W. 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 , 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 ) . 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. R e covery is relatively uneventful. L o n g - 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 . 4 % of c a s e s , satisfactory in 2 4 . 4 % , and u n i m p r o v e d in 5.2%. 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. If s n o r i n g persists or if the patient can still snort, then the p r o c e d u r e can be repeated. 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 . If l o w palatal w e b b i n g persists, 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, an additional vertical release of 3 to 5 mm is placed laterally to t h e original vertical incisions. 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. 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.

Procedure1,2,5-7 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 . 8 - 6 a ) . 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 . 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. 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 , anterior and s u p e r i o r to the b a s e of the u v u l a . It is r e c o g nized by h a v i n g the patient forcefully s a y . " H a ! , 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. 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 , ) 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 . 8 - 6 b ) . 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 ) , r e s u l t i n g in nasal reflux of fluids and hypernasal s p e e c h . T h i s must b e a v o i d e d . 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 , 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 . 8 - 6 c ) . 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 . 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. 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. 8 - 6 d ) . T h e s e a r e generally less than 3 cm in length. A 3 9 - y e a r - 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 . He is 6 feet tall.

Figure 8-6. (A) Vertical incisions are made on each side of the uvula. (B) Superior extension of incision is detemiined by the position of attachment of the levator palati. (C) The uvula is generally reduced the same length as the vertical incisions. (D) lateral trenches are created on the anterior surface of the posterior pharyngeal pillars.

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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 . 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. W i t h the s a m e h a n d p i e c e , a 4 mm w i d e , 2 mm d e e p , 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. 8 - 8 ) . 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. Postoperative medications were ketorolac Irimethamine ( T o r a d o l ) 6 0 m g i.m. 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 . 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 , 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 , 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.r.n. w a s g i v e n . A nystatin s u s p e n s i o n was prescribed with 1 mL to be gargled and expectorated q.i.d. 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 . 8 - 9 ) . 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 . 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, alt h o u g h it still persisted. U p o n retesling, 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 . S e v e n w e e k s after t h e initial s u r g e r y , 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. U s i n g the s a m e i.v. 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 , 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 . 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. ( 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. 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 . D u r i n g 1 8 % o f his sleep time, o x y g e n saturation w a s less than 8 0 % . 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. 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 . 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. T h e lateral p h a r y n g e a l walls w e r e thickened (Fig. 8 - 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 , but t h e p a tient w a s u n w i l l i n g t o d o either. T h e r e f o r e , 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 . 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 , the p a tient agreed to h a v e t h e o p e r a t i o n s . 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 - 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 . 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 , 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 . Local a n e s t h e s i a w a s o b tained with 0 . 5 % b u p i v a c a i n e using 0.2 to 0.3 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 , 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. 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 . 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 , 13-mm t h r o u g h - a n d - 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. T h e inferior a s p e c t o f
8 2

Figure 8-7. Prcoperatively the patient has a long uvula and a low webbed soft palate.

Figure 88. Vertical incisions of 13 mm length were placed on each side of the uvula. The uvula was shortened the same distance. Lateral trenches 4 mm wide, 2 mm deep, and 15 mm long were created on the anterior surface of the posterior pharyngeal pillar.

Further Comments on the Laser-Assisted Uvulopalatoplasty

using 15 W output power. Additional vertical incisions of 4 to 5 mm in length were placed 3 to 4 mm lateral to the original cuts. The uvula was then shortened 4 mm and lateral trenches 1 cm long, 4 mm wide, and 2 mm deep were created on the anterior surface of the posterior pharyngeal arch (Fig. 8 - 1 0 ) . The postoperative regime was the same as for the first procedure and the recovery was uncomplicated. Three months after the original surgery, a repeat sleep study demonstrated an apnea index of 1 and an o x y g e n desaturation index of 2 3 . Most impressively, the patient's lowest o x y g e n saturation was 7 2 % and only 1.7% of his sleep time was associated with an o x y g e n saturation of less than 80%. His dormitory mates reported c o m p l e t e cessation of snoring. Four months after the initial surgery, the palate has g o o d form with a less constrictive velopharyngeal ring and a shorter uvula (Fig. 8 - 1 1 ) . The patient is very satisfied. Instructions to lose 15 to 2 0 % body weight were o n c e again given to the patient.

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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 . A scalpel-type probe tip (see Fig. 7 - 3 8 ) is chosen for the incisions that are made as recommended by Kamami earlier in this chapter. After creating the general U-shaped form for the neo-uvula as illustrated by Kamami and W o o t e n in Figs. 8 - 4 , 8 - 6 and 8 - 1 0 ) , 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 . Preoperative assessment and the technique for adequately anesthetizing the operative site remain the same. With the patient seated and the mouth open, 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. The long contra-angle handpiece is used to provide a
z

Figure 8 -10. The secondary procedure was less extensive when performed at 7 weeks after initial surgery.

Figure 8-9. At 3 weeks the mucosa was healed but, some snoring persisted.

Figure 8 -11. Four months after original surgery, the patient has a well-contoured soft palate and is sleeping without snoring.

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with C 0 laser. LAUP: laser-assisted UPPP results on 46 patients. J Clin Laser Med Surg 1994; 12:215-219. Couly G. Analomie Maxillo-faciale 25 questions pour la preparation des examens et concours. Paris: Pr6lat J; 1974. Levin BC, Becker GD. Uvulopalalopharyngoplasty for snoring: long term results. Laryngoscope 1994; 104(9): 1150-1152. Krespi Y, el al. The efficacy of laser assisted uvulopalatoplasty in the management of obstructive sleep apnea and upper airway resistance syndrome. Operative Tech Otolayrngol Head Neck Surg l994;5(4):235-243. Cornay WJ III. Personal communication. Krespi YP, Keidar A. Laser-assisted uvulopalatoplasty for the treatment of snoring. Operative Tech Otolaryngol Head Neck Surg l994;5(4):228-234. Sher AE, Thorpy MJ, Sphrintzen RJ, Spielman AJ. et al. Predictive value of Muller's maneuver in selection of patient for uvulopalatopharyngoplasty. Laryngoscope 1985;95( 12): 1483-1487.
2

tips that, by d e l i v e r i n g a flatter b e a m profile, 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 . 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. 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, excellent hemostasis, and predictable results. 6. 7. 5. 3. 4.

REFERENCES
1. Kamami YV. Laser C 0 for snoring, preliminary results. Acta Otorhinolaiyngol Belg f99<);44:451-456. 2. Kamami YV. Outpatient treatment of sleep apnea syndrome
2

8.

The Carbon Dioxide Laser in Laryngeal Surgery

Robert). 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 . 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 0.25 mm at a 4 0 0 - m m w o r k i n g distance, 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 . 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 , especially in R e i n k e ' s s p a c 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. 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 , m i n i m a l s c a r r i n g , and rapid w o u n d h e a l i n g . It is ideally suited for r e m o v a l of recurrent laryngeal papillomas, 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 , laryngeal c y s t s , g r a n u l o m a s , a n d early glottic c a r c i n o m a s . 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.
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 , 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 . T h e s e m a y include cuff rupture, e n d o t r a c h e a l tube ignition, ignition of pledgets or d r a p e s , 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 , corneal injury, p n e u mothorax, s u b c u t a n e o u s e m p h y s e m a , and h e m o r r h a g e (see Chapter 2 for m o r e details). 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. H o w e v e r , 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, r e d u c e d b e a m spot size, 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 , or i m p r o v e d , vocal fold mucosal healing a n d voice q u a l i t y . 5
2 1

in a 1 0 % duty c y c l e ) ; (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, 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; (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, t h u s p r e v e n t i n g h e a t - i n d u c e d soft tissue damage.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, indications for their r e m o v a l , and C O 2 laser t e c h n i q u e s . G e n e r a l l y , 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 . 0 to 6.5 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 ) . 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." 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 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 - b o r e l a r y n g o s c o p e with 10X to 2 5 X magnification, 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, 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 , respectively (Figs. 9 - 1 a n d 9 - 2 ) .

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. 9 - 3 and 9 - 4 ) . T h i s lesion is t h e most c o m m o n benign neoplasm of the larynx. During infancy or adulthood its presenting s y m p t o m s are hoarseness o r airway obstruction. T h e natural history of this disease is o n e of multiple recurrences, especially with the j u v e n i l e onset type; therefore, C O 2 laser vaporization of these lesions, although the accepted procedure of choice today, is thought to be only palliative in most cases. 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. 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 0.25 mm with a 4 0 0 mm focal length lens; (2) utilizing l o w power settings (0.5 to 6 W ) ; (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 (0.1 to 1.0 s e c o n d s

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Lasers in Maxillofacial Surgery and Dentistry

Figure 9 - 1 . Intraoperative view demonstrating the equipment used for a patient undergoing suspension microlaryngoscopy and C O , laser excision of subglottic granulation tissue. The microscope is coupled to a C 0 laser micromanipulator. This allows for a magnified and binocular view of the lesion, which is exposed using a laryngoscope placed in suspension. Note that a 4(X)-mm lens on the microscope provides adequate working distance between the microscope and the laryngoscope.
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. 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, as this maneuver often results in c o m m i s s u r e w e b formation. 8 Typical C 0 2 laser settings for such a procedure include using a 0 . 2 5 mm spot size at a working distance of 4 0 0 m m , 2- to 3-W power, and 0 . 5 - to 1.0-second pulse durations.

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, cave r n o u s , or mixed c a p i l l a r y / c a v e r n o u s lesions. T h e y may present in a pediatric or adult form; 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 . 6 T h e pediatric h e m a n g i o m a char-

Figure 9 - 2 . Iixample of the view obtained through the subglottiscope used for the patient in Fig. 9 - 1 . Note the red beam of the C 0 laser located at the inferior boundary of the lesion.
2

Figure 9 - 3 . Preoperative view of a 27-year-old patient with laryngeal papillomas involving both true vocal folds and the anterior false fold on the right. (Photo courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)

The Carbon Dioxide Laser in Laryngeal Surgery

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2

and the incision site i s then carefully outlined with the C 0 laser. 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 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 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. 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 . 2 5 - m m spot size with a 4 0 0 - m m lens, 0 . 5 - to 2 - W p o w e r , and pulse durations of 0.1 to 0.5 s e c o n d .

LARYNGEAL CYSTS
Figure 9-4. Two-week postoperative view demonstrating mild vocal fold edema, but the voice is significantly improved. (Photo courtesy of Robert W. Bastian. M.D., Loyola University, Chicago.) M u c u s - 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 - 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 . 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 . 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 . M a r supialization and ablation of the cysts lining m a y be att e m p t e d ; h o w e v e r , r e c u r r e n c e i s not u n c o m m o n . Laser settings for such a p r o c e d u r e include a 0 . 2 5 - m m spot size, 0 . 5 to 2 W, and a 0 . 1 - to 0 . 5 - s e c o n d pulse d u r a t i o n .
10

acteristically p r e s e n t s shortly after birth, 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 . 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, resulting i n a i r w a y obstruction. 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.'' 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 , 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 . 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 . 2 5 - m m spot size at a 4 0 0 - m m focal d i s t a n c e , 2- to 3 - W p o w e r , and 0 . 5 to 1.0-second pulse d u r a t i o n 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, 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.
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, o v e r t h e medial aspect of the vocal p r o c e s s . 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, g a s t r o e s o p h a g e a l reflux, or vocal a b u s e . 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. 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 , c h r o n i c throat c l e a r i n g , sore throat, or a g l o b u s s e n s a t i o n . Effective treatment usually includes rem o v a l o f t h e irritating s o u r c e , 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 , a s well a s s p e e c h therapy. W i t h l o n g - 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 - b a s e d g r a n u l o m a , 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 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, t h e C 0 laser i s ideal for surgical e x c i s i o n . 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 . 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 . 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 . 2 5 mm spot size with a 4 0 0 - m m lens, 0 . 5 - to 2 - W p o w e r , and a 0 . 1 - t o 0 . 5 - s e c o n d pulse d u r a t i o n .
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. 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 ) . P o l y p s m a y be fusiform, p e d u n c u l a t e d , hemorrhagic, o r g e n e r a l i z e d . 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 , c h r o n i c throat c l e a r i n g or c o u g h , cigarette s m o k e , or gastric acid a s sociated with g a s t r o e s o p h a g e a l reflux. Surgical intervention is r e c o m m e n d e d for i m m a t u r e , soft lesions failing c o n s e r v ative t h e r a p y , or for p o l y p s d e m o n s t r a t i n g fusiform, p e d u n culated, 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 . 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 , h e m o r rhagic p o l y p s . Vessels leading to the p o l y p a r e c o a g u l a t e d .
6 2

MALIGNANT NEOPLASMS
V o c a l fold h y p e r k e r a t o s i s , e r y t h r o p l a s i a , c a r c i n o m a in situ, 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

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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 , 4- to 6 - W power, with a 0.5to 1.0-second p u l s e duration. I n s u m m a r y , 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 , minimal s c a r r i n g , 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 . 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 , p r e m a l i g n a n t , and malignant lesions of t h e larynx, i n c l u d i n g laryngeal p a p i l l o m a s , h e m a n g i o m a s and cysts, vocal fold p o l y p s and g r a n u l o m a s , as well as vocal fold h y p e r k e r a t o s i s , erythroplasia, c a r c i n o m a in situ, 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 . With the developm e n t of m o r e sophisticated instrumentation, 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 , 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 .
2

using the C O , laser ( F i g s . 9 - 5 t o 9 - 9 ) . 2 W h e n c o m p a r i n g C 0 laser resection with irradiation for T , c a r c i n o m a s o f t h e glottis, t h e cure rates a r e e q u i v a l e n t . 1 1 - 1 3 V o i c e quality in select patients with T , 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 , 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, voice quality d e t e r i o r a t e s . 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 , 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. 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 , all in an outpatient setting. 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, glottic c a r c i n o m a s include a 0 . 2 5 - m m spot size at
2 2 14 2 2

Figure 9 - 5 . Preoperative view of a 57 -year-old patient with a T, squamous cell carcinoma involving the left true vocal fold after biopsy at an outside institute. This lesion is ideal for laser removal because of its position on the midcord, without involvement of the anterior commissure or vocal process. (Photo courtesy of Robert W. Bastian. M.D., Loyola University, Chicago.)

Figure 9 - 7 . Six-week postoperative view with near complete healing of the left vocal fold. (Photo courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)

Figure 9-6. Intraoperative view after removal of the lesion. The laser was used to outline the carcinoma with a 2- to 3-mm margin. After frozen section confirmation of clear margins the final defect included removal of the medial one third of the vocalis muscle. (Photo courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)

F i g u r e 9 - 8 . Six-month postoperative view with a mucosalized scar band extending across the original excision site. (Photo courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)

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 . 9 - 4 ) this mild true vocal fold e d e m a , but t h e voice is i m p r o v e d , both subjectively and objectively. focus of residual disease j u s t anterior to the process.

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patient h a s significantly N o t e small right vocal

T, Glottic Carcinoma
HISTORY T h i s is a 5 7 - y e a r - 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 . 9 - 5 t o 9 - 8 ) . Figure 9 - 9 . Example of how the laser is utilized to outline a small glottic carcinoma prior to removal. (Photo courtesy of Robert W. Bastian, M.D., Loyola University. Chicago.) EXAMINATION FINDINGS T h i s is a b i o p s y - 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. 9 - 5 ) . 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 , vocal p r o c e s s , ventricle, and subglottic regions are free of d i s e a s e . 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, c o n t a i n i n g a 4 0 0 - m m lens. Parameters A 0 . 2 5 - m m spot size. 4 - W average power, 0.5second pulse duration in a 10% duty cycle (superpulse mode). COMMENTS T h e lesion is carefully outlined (Fig. 9 - 9 ) with the laser, a small cuff of n o r m a l tissue is taken with t h e t u m o r , 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 - 6 ) . 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, every 2 m o n t h s for t h e next year, 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 .

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 . 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 .
2

Laryngeal

Papilloma

HISTORY This 2 7 - y e a r - 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 . 9 - 3 and 9-4). 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. 9 - 3 ) . 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 . 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 . A 4 0 0 - 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 . Parameters A 0 . 2 5 - m m spot size, 2 - W a v e r a g e p o w e r , 0.5- to 1.0-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 ) . 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 . 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.

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. 9 - 7 and 9 - 8 ) .

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 . Bastian, M . D . , from L o y o l a University, C h i c a g o , for u s e of the c a s e illustrations.

REFERENCES
1. Freche C, Jakobowitz M, Bastian RW. The carbon dioxide laser in laryngeal surgery. Ear Nose Throat J 1988;67:436-445. 2. Crockett DM, Reynolds BN. Laryngeal laser surgery. Otolaryngol Clin North Am 1990;23(l):49-66.

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 . 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. 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 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. 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 . 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 . " A d r i a n et a l . 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. H o w e v e r , 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.
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. Unfortunately, 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 - a l u m i n u m - 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 , 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 , a p i c o e c t o m y , and treatment o f small c a r i o u s c e r v i c a l lesions in teeth. 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. 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 .
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 . 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. 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.
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 , transmit, scatter, or reflect the light e n e r g y . 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). 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. 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 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. 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. 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. Fried e t a l . " ' d e t e r m i n e d t h e absorption and scattering coefficients, u s i n g w a v e l e n g t h s of 5 4 3 , 6 3 2 and 1053 nm. 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 . 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 , 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. 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. Fried et al. p l a c e d t h e e n a m e l s a m p l e , as well as d e n t i n , i n a n optically m a t c h e d solution. 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. 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 . 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 . T h e internal surface of t h e s p h e r e s are highly reflective, 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. T h e optically m a t c h e d solution, 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 , 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 . If it had not been used, t h e a i r - 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 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, 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 . 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.
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

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Lasers in Maxillofacial Surgery and Dentistry

sue. 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. B e c a u s e this is a very rapid action, it is e x p l o s i v e in n a t u r e . 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. 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. 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. 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 - 1 and in e n a m e l to be 1000 cm-1 . 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. 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 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. 1 0 - 1 6 ) . 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, 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 . 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. 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. 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. W i g d o r et a l . 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). E n Y A G h o l e s w e r e m a d e in the teeth. T h e output p o w e r of the laser w a s 1.5 W with an e n e r g y of 5 0 0 mJ per pulse at 3 Hz. A m a l g a m restorations were then placed in the ablation h o l e s . After 4 d a y s the teeth w e r e extracted and decalcified. 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. 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. Figure 1 0 - 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. 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. Figure 1 0 - 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. T h e laser defect can be seen as a depression in the dentin. 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. 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, 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. U n f o r t u n a t e l y , 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. H o w e v e r , if l o w e r e n e r g y levels a r e used, most of the light is transmitted a n d / o r scattered, 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 . Clinically this is significant, for if a laser w e r e used that h a s the potential for d e e p e r penetration, 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. 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, 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. 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 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. 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 . Sim u l t a n e o u s l y , 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 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 , 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 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. F r o m Fried et a l . ' s 1 1 ' 1 2 r e s e a r c h , laser light from the n o n c o n t a c t N d : Y A G laser (1.06 u.m) c a u s e s significant h e a t i n g in hard tissue ( d e n t i n , e n a m e l , and b o n e ) , 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. 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 . 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 . 9 4 - n m w a v e l e n g t h . 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 , 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 . 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 , it can ablate these hard (issues efficiently with very little heat production, thereby a v o i d i n g d a m a g e to t h e dental p u l p , which h a s very little heat tolerance. 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. 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. 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 . 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 . 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 - 1 .

Er:YAG laser holes on dog canine teeth.

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al tissue a p p e a r s n o r m a l . 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. 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. 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. F i g u r e 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 - i n d u c e d defect. 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. 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 . 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 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. 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. On a h i g h - p o w e r view ( F i g . 1 0 - 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 . 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. 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. 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 . 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 . F i g u r e 1 0 - 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 . 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 - 8 . 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. 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 . Photomicrograph of the dentin just beneath the E r Y A G laser hole. Note the increased dentin in the area beneath the laser hole. (X 100 H&E.) Figure 10-2. stain.) Normal pulpal and dentin histology. (X100 H&E

Figure 1 0 - 3 . Pulpal histology beneath an Er:YAG laser hole (right). (X100 H&E.)

Figure 10-5. Higher power view of the predentin layer just beneath the laser hole. Note the dark inclusions in the predentin. ( X 4 0 0 H&E.)

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Figure 10-6. Higher power view of the predentin layer in an area not affected by the laser. (X400 H&E.)

Figure 10-8. SEM photomicrograph of dentin ablated with an EnYAG laser (X 1200 longitudinal section).

Figure 10-7. SEM photomicrograph of dentin cut with a highspeed dental drill (X1000 longitudinal section). (All SEM photographs are courtesy of Dr. S. Ashrafi.)

Figure 10-9. SEM photomicrograph of dentin ablated with an EnYAG laser (X500 cross section).

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 . F i g u r e 1 0 - 9 is a cross section o f dentin treated with the E n Y A G laser. A g a i n , 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 . R e s e a r c h p e r f o r m e d by Visuri et al. from N o r t h w e s t e r n University (Evanston, 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. 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. T o prevent this i n c r e a s e in t e m p e r a t u r e , w a t e r w a s used as a c o o l a n t . B e c a u s e w a t e r a b s o r b s the 2 9 4 0 - n m w a v e l e n g t h very efficiently, 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 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. 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. 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 . 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 e n e r g y p e r pulse w a s varied and a pulse width of 2 5 0 u,s with an 800-p.m spot size w a s used. Figure 1 0 - 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. T h e lack of c h a r is evident. A p h o t o m i c r o g r a p h of the S E M (Fig. 1 0 - 1 1 ) of similar holes s h o w s well-defined holes in the e n a m e l . F i g u r e 1 0 - 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 - 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. 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. As noted in t h e g r a p h (Fig. 1 0 - 1 4 ) at high energy ( 6 2 6 m J / p u l s e ) 115 u.m of material w a s r e m o v e d per p u l s e . 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 . 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. 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. 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

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131

Figure 10-10. lack of char.

Ablation holes from an extracted tooth. Note the

Figure 10-13. 10-12.

Projected image of the impression from Figure

MEAN DEPTH PER PULSE pm/ pulse

Figure 1 0 - 1 1 . SEM photomicrograph of Er:YAG laser holes in the buccal surface of an extracted tooth.

Figure 10-14. Table of ablation efficiency from the impression method in Figure 10-13.

Figure 10-12. ablation holes.

Dental impression from a tooth after Er:YAG

ablation surface. Figure 1 0 - 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 . 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. 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. 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 - 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 - s e c t i o n a l slice of d e n t i n . 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. 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 , including silver, z i n c , c o p p e r , and tin, 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 .

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Lasers in Maxillofacial Surgery and Dentistry

Figure 10-15. Laboratory setup for the study of dentin ablation.

Figure 1(1-17. Ablation holes created in dentin sections from extracted teeth with the E n Y A G laser.

Figure 10-16. laser.

Plume from dentin ablation with the E n Y A G

Figure 10-18. Ablation holes created in amalgam sections with the E n Y A G laser.

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 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 . 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 . 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. T h e ablation efficiency o f the laser w a s d e termined with and without water. 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 5 . 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. 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 . 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 - 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 . 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. 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.

Figure 1 0 - 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 . T h e hole on the right was cut without water. N o t e the char that was caused by the laser. 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 . It has a well-defined b o r d e r and no char is evident. 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, e n a m e l , amalg a m , and c o m p o s i t e ) w e r e very similar. Therefore, the composite ablation results are presented here as a s u m m a r y of the laser effects on the materials tested. Figure 1 0 - 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 . 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 w o e n e r g y levels w e r e used with and without water. 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. 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. The

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Figure 10-19. Ablution holes created in composite sections with the Er:YAG laser. With water (L); without water (R).

Figure 1 0 - 2 1 . Graph of the ablation rate as the fluence and water are varied.

other, 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 , in this a u t h o r ' s practice, 7 0 % would like a laser to be d e v e l o p e d that could replace the dental drill. 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 , a n d w h e t h e r a laser will be better tolerated by patients.

DENTAL CARIES SUSCEPTIBILITY

Figure 10-20. Graph of the temperature changes as the ablation progressed through the sample with and without water.

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 . 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 5C the p u l p m a y b e h a r m e d . 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 3C. 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. 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. As can be seen in the g r a p h , 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. 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 , 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 (9.0 to 11 p m ) on dental hard tissues and on denial c a r i e s susceptibility has been investigated. 2 0 - 2 3 T w o c o m p o n e n t s o f dental hard tissues, w a t e r and h y d r o x y a p a t i t e , 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 . 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 , which a r e close t o the main C O , e m i s s i o n of 10.6(H) nm. 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 , 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. 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 . 3 - to 1 0 . 6 - 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. 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 - 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 . 3 - and 9 . 6 - 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 . T h e y s u g g e s t that the l o w - 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 , 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 -

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b u r g , S w e d e n ) for the welding of dental implant supported bridges with a N d : Y A G laser. 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 . 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. 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 . 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 , 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 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. This method r e d u c e s distortion and therefore increases accuracy o f fit." T h e laser s y s t e m , d e v e l o p e d by N o b e l p h a r m a Industries, 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, which is then w e l d e d by t h e laser. 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, the welding must occur u n d e r an a t m o s p h e r e of argon gas. 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. 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 . 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 . As the metal c o o l s the t w o pieces of titanium j o i n together. 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 , 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, w h i c h can lead to a w e a k e r j o i n t . 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. Preliminary investigational work s u g g e s t s exciting areas of investigation for lasers in dentistry. 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. 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. 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 . The potential for laser a p p l i c a t i o n s in dentistry portends an exciting future.

tion by bacterial acids. T h e s e c h a n g e s are c a u s e d by a thermal effect; h o w e v e r , the authors state that the actual m e c h a nism of action is still not clear. 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 .

LASER DENTAL DECAY DETECTION AND OPTICAL PROPERTIES OF TEETH

Z a c h a r i a s e n et a l . and K o n i g et a l . 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 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. It is not u n d e r s t o o d w h y this o c c u r s , but the authors suggest it m a y be d u e lo the bacteria present in the lesion. 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. 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. 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 . r e v i e w e d the optical p r o p e r t i e s of teeth. 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. For instance, 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. 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. 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.
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. R e s e a r c h by Powell et al. 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 . 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 . Kelsey et al. 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 . B l a n k e n a u et a l , 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 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 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. 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.
3 0

REFERENCES
1. Stem RH. Sognnaes RF. Laser beam effect on dental hard tissues. J Dent Res I964;43(suppl to no. 5):873 (abstract 307). 2. Stern RH, Sognnaes RF. Goodman F. Laser effect on in vitro enamel permeabilily and solubility. J Am Dent Assoc 1966;78:838-843. 3. Lobene RR. Bhussry BR. Fine S. Interaction of carbon dioxide laser radiation with enamel and denlin. J Dent Rei 1968:47:311-317. 4. Goldman L. Hornby P. Meyer R, Goldman B. Impact of the laser on dental caries. Nature 1964:203:417.

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 . 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 . G o t h e n -

11

Phototherapy with Lasers and Dyes

Dan }. Castro, Romaine E. Saxton, 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. H o w e v e r , 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. 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 . T h i s t e c h n i q u e is simple and minimally invasive, with a potentially high effective c u r e rate and l o w morbidity. 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. 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 , ' superficial t u m o r s can be treated repeatedly by e n doscopically delivered laser fiberoptics. 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 . In the last t w o d e c a d e s , the field of p h o l o d y n a m i c therapy ( P D T ) has regained popularity, specifically since the introduction of lasers by M a i m a n , ' 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 , t h e current e x p e r i mental testing o f r h o d a m i n e - 1 2 3 , 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.
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 , 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 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. 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; three cures w e r e reported. 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. 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 - B e t z . 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 , proving that these c o m p o u n d s can induce systemic pholosensitization in m a n . Filially, 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. together with U V radiation, to treat psoriasis.
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 , i.e., 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. 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, w h i c h results in the destruction of this tissue.

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 ) . Both are used for eradication and i m a g i n g of c a n c e r s . E a c h of these potential applications will be r e v i e w e d .

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.'' 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 . After resolution of the sunburn the skin would return to its natural color. Reference to the use of a plant extract for the restoration of skin pigmentation w a s m a d e in 1400 B . C . , ' " and p h o t o t o x i c effects of psoralens w e r e described in 1250 A . D . "

Mechanisms

of Photooxyfienulion

M a n y c h e m i c a l s , including natural cell constituents, 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 . T h i s p r o c e s s , 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 . 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 , particularly m e t h i o n i n e , histidine. and t r y p t o p h a n ) , nucleic acid oxidation (primarily g u a n i n e ) , 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 ) . Photosensitized oxidation is initiated by t h e absorption of light by a sensitizer, w h i c h can be a d y e or p i g m e n t , a ketone or

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Lasers in Maxillofacial Surgery and Dentistry

of H P D and red light ( 6 3 0 n m ) , a w a v e l e n g t h selected for optimal activation o f H P D , w h i c h also allowed m a x i m u m penetration t h r o u g h tissue ( 1 - 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 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. In addition, 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. Lasers are o n e t y p e of light that can satisfy these conditions. 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 , including canc e r o f t h e l u n g , 2 3 , 2 4 b l a d d e r , 25 vagina and cervix, gastrointestinal tract, 26 p r i m a r y and metastatic skin c a n c e r s , and t u m o r s of t h e head and neck (laryngeal b a s e of tongue, palatal, and floor of m o u t h t u m o r s ) . 2 2 - 2 9 In a series of tum o r s treated with H P D and laser light, P D T has shown therapeutic effects. 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. At the s a m e e n e r g y level, 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 . H o w e v e r , therapeutic effectiveness varies according to e a c h lesion, e v e n in the s a m e patient. 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. 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 . 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. Pain is a n o t h e r c o m m o n side effect, particularly involving t h e c a l v a r i u m , 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 . 30 In addition. 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, which decreases its potential as a " t u m o r specific fluorescent d y e . " 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 . 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. A variety of other p h o t o c h e m i c a l l y active d y e s , such a s acridine o r a n g e , merc u r o c h r o m e , nitro-red. m e t h y l e n e blue, p s o r a l e n s , rose bengal, 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 . 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 .
17

q u i n o n e . o r a n a r o m a t i c m o l e c u l e . T h e sensitizer ( S e n s ) , b y c a p t u r i n g a photon, 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. 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 , t y p e I and t y p e II. that are a l w a y s in c o m p e t i t i o n . 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 , the reactivities of the substrate and sensitizer excited state, substrate c o n c e n t r a t i o n , and singlet o x y g e n lifetime. High sensitizer reactivity, high substrate reactivity and c o n c e n t r a t i o n , l o w o x y g e n c o n c e n t r a t i o n , and short singlet lifetimes favor the t y p e I m e c h a n i s m , w h i l e the o p p o s i t e factors favor the t y p e II.

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 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 . 1 7 , 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 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 , but until recently, 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 . 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 . 2 0 i n 1979. 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 , a t 4 0 2 , 5 0 7 . 5 4 0 , 5 7 3 . a n d 6 2 4 n m , all of w h i c h are in the visible s p e c t r u m of light. 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 .
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. 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. 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 , 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. In fact, the result of studies by H e n d e r s o n et a l . 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 . 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 , 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 , liver, 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 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. 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. M c r o c y a n i n e - 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

Phototherapy with Lasers and Dyes

patients with l e u k e m i a , l y m p h o m a , o r metastatic n e u r o b l a s t o m a . R h o d a m i n e - 1 2 3 ( R h - 1 2 3 ) ( F i g s . 11-1 and 1 1 - 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 . 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. 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, and e v i d e n c e for s i n g l e t - o x y g e n induced cell killings h a s been reported. 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 , 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. 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. U n l i k e H P D . 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. In addition, 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 . 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. F r o m histologic studies in transplanted urothelial t u m o r s , 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. 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 , the c h a l c o g e n a p y r i l i u m d y e s , 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. 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 , redox properties, f l u o r e s c e n c e yields, and hydrolytic stability. 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. H o w e v e r , 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, 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 , with an absorption m a x i m u m at 7 0 0 nm in saline. K o d a k Q - 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. 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 . P h e o p h o r b i d e , a chlorophyll derivative with a peak a b s o r p t i o n a t 6 7 0 n m . h a s b e e n e x a m i n e d recently b y Segclman.38
14

x 700.9

ABS 0.0527

Wfl UisiMe

MODE Scan

Figure 1 1 - 1 . Absorption spectrum of rhodamine dyes (Rh-123. Rh-6G. Rh-3G).

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. 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 . By a n a l o g y , 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 most likely many d y e s will be suitable, 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. For e x a m p l e , R h - 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. 11-3), melanoma, adenocarcinoma, l e u k e m i a , and l y m p h o m a cell lines."' 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 , on the o t h e r hand, is e x t r e m e l y efficient in leukemias, l y m p h o m a s , and n e u r o b l a s t o m a s , 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 37

RHODAMINE 123
Figure 11-2. Molecular structure of rhodamine dyes.

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 . First, d i o d e lasers are the most efficient and stable lasers available. S e c o n d , 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. 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. 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 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 - 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. 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 . Flexible fiberoptic cables of 2 0 0 u,m and s m a l l e r d i a m e t e r a r c currently available. 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 .

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 . 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 , laser d y e fluorescence, and d y e conjugated m o n o c l o n a l a n t i b o d y imaging.

CONCLUSIONS
Figure 11-3. Argon laser phototherapy of experimental P, squamous carcinoma tumors in nu/nu mice after sensitization with Rh123. Pretreatment (A2). immediately post-laser therapy (B2), I week (C2). and 10 weeks (D2) post-laser therapy. Complete cure is noted in the experimental tumors (Rh-123 + laser. D2) while continued growth is noted for control tumors ( D l ) . 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 a l o g o u s to antibiotic t h e r a p y , 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 . 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. W i t h the collaboration of p h o t o c h e m i s t s , physicists, t u m o r biologists, engineers, and c l i n i c i a n s , 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 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 , l o w e r s y s t e m i c toxicity, and d e e p e r tissue penetration. 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. 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 , laser fiberoptics, and m a g netic r e s o n a n c e - 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 - 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. 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 , c h e m i s t s , biologists, and p h o t o c h e m i s t s , 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 then tested clinically. D y e s with h i g h e r affinity for specific n e o p l a s m s , with rapid m e t a b o lism, 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 . 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, 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. 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 , 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, redox p r o p e r t i e s , 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 .

Phototherapy with Lasers and Dyes

d y e fluorescence, 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 . 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 , be linked to photosensitizers, and then be injected into p a t i e n t s with cancer. 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 - 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 - p o w e r laser e m i s s i o n via interstitial fiberoptics. 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 . 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 , 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 , U C L A School o f Medicine. N I H grant # U S H H S D C 0 0 3 1 , a n d N I H grant # C A 6 5 0 5 3 - O l R . the Elsa P a r d e e F o u n d a t i o n , t h e D u P o n t Merck, E - Z E M , Inc., L a s e r s c o p e , R e s o n a n c e T e c h n o l o g y , O h m c d a , Inc., T r i m e d y n e , Valley L a b . Inc., I n - V i v o R e search Inc., G E Medical S y s t e m s , 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 . R . C . , BP 3-94801 Villejuif Cedex, France). 18.

141

11. 12. 13.

14. 15.

16. 17.

19.

20.

21.

REFERENCES
22. 1. Muiman TH. Stimulated optical radiation in ruby. Nature 1960; 187:493-494. 2. Policard A. Etudes sur les aspects offerts pas des lumeur experimentales examinee a la lumiere de woods. CR Sac Biol (Paris) 1924:91:1423. 3. Castro DJ. Saxton RE. Fetterman HG. Castro DJ. Ward PH. Rhodamine-123 as a new photochemosensitizing agent with the argon laser: "Non-thermal'" and thermal effects on human squamous carcinoma cells in-vitro. Laryngoscope I987;97(5):554-56I. 4. Castro DJ, Saxton RE. Fetterman HR. Ward PH. The effects Of argon lasers on human melanoma cells sensitized with Rhodamine-123 in-vitro. Am J Otolaryngol 1988;9( I): 18-29. 5. Castro DJ. Saxton RE. Fetterman HR. Ward PH. Phototherapy with the argon laser on human melanoma cells "sensitized" with Rhodamine-123: a new method for tumor growth inhibition. Laryngoscope 1988:98(4):369-376. 6. Castro DJ. Saxton RE, Fetterman HR. Castro DJ, Ward PH. Biostimulalion of human carcinoma cells with the argon laser: a previously unreported potential iatrogenic effect of lasers. Laryngoscope 1987;98:109-116. 7. Castro DJ. Saxton RE, Fetterman HR. Castro DJ. Ward PH. Biostimulative effects of Nd:YAG Q-switch dye on normal fibroblast cultures: study of a new chemosensitizing agent for the Nd:YAG laser. Laryngoscope 19K7:97( 12): 1454-1459. 8. Gaffncy DK. Sieber F. Binding of merocyanine 540 by cells labeled with anthroyloxy fatty acids. Photochem Photoblol 1990;49 (suppl):315. 9. Forrest JB, Forrest HJ. Case report: malignant melanoma arising during therapy for vitiligo. J Surg Oncol 1980;13:337-340. 10. Whitney WD. Atharva-veda Samhita. (Translation and notes).

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Harvard Oriental Series, vol 7. Cambridge: Harvard University Press. 1905. Ibn El-Bitar. Mofradai Al Adwiya. Cairo: Egyptian Government Press, 1877; 1:4. Finscn NR. Neue untcrsuchugen uber die einwirkung dess lichtcs auf die haut. Mitt Fisen Instil 1900; 1:8. Jesionek A. Tappeiner HV. Zur behandlung de hautcarcinome mil fluoresierenden Stolle. Dtsch Arch Klin Med 1905;82:223-227. Haxthauscn H, Hausmann W. Die lichterkrankugen der haul. Vienna: Urban and Schwur/enberg. 1929. Meyer-Belz F. Untcrsuchugen iiber die biologische (photodynamische). Wirkung des Hamnloporphyrins und anderer derivate des blut-und gallenfarbstoffs. Dtsch Arch Klin Med 1913:112:476-503. Gocckerman WH. Treatment of psoriasis. North West Med 1925;24:229-231. Dougherty TJ. Kaufman JE. Goldfarb A. et al. Photoradiation therapy for the treatment of malignant tumors. Canter Res 1978;38:2628-2635. Dougherty TJ. Lawrence G. Kaufman JH. et al. Photoradiation in the treatment of recurrent breast carcinoma. J Nail Cancer Inst 1979:62:231-237. I lay ..ia Y. Dougherty TJ. Lasers and hematoporphyrin derivative in cancer. In: Hayata Y, Dougherty TJ. eds. Cancer. Translation by Barron P. New York: Igaku-Shoin. Tokyo; 1982:1-114. Chang CT. Dougherty TJ. Photoradiation therapy: kinetics ol thermodynamics of porphyrin uptake and loss in normal and malignant cells in culture. Radial Res 1978;74:498-499. Henderson BW, Bellnier DA. Ziring B. Dougherty TJ. Aspects of the cellular uptake and retention of hematoporphyrin derivative and their correlation with the biological response to PRT in vitro. In: Kessel D. Dougherty TJ. eds. Porphyrin Photosensitizaiion. New York: Plenum Press; 1983:129-138. Gomer CJ. Dougherty TJ. Determination of | 3 H | and | I9C| hematoporphyrin derivative distribution in malignant and normal tissue. Cancer Res 1979:39:146-151. Balchum OJ. Doiron DR. Huth GC. Photoradiation therapy of endobronchial lung cancers employing the photodynamic action of hematoporphyrin derivative. Laser Surg Med 1984;4:13-30. Hayata Y. Kato H. Konaka C. et al. Photoradiation therapy with hematoporphyrin derivative in early and stage I lung cancer. Chest 1984:86:169-177. Benson RC. Kinsey JH, Cortese DA, et al. Treatment of transitional cell carcinoma of the bladder with hematoporphyrin derivative phototherapy. J Urol 1983:130:1090-1094. Hayata Y. Kato H. Okitsu H, et al. Photodynamic therapy with hematoporphyrin derivative in cancer of the upper gastrointestinal tract. Semin Surg Oncol 1985:1:1-11. Keller GS. Doiron DR. Fisher GU. Photodynamic therapy in otolaryngologyhead and neck surgery. Arch Otolaryngol 1985:111:758-761. Gluckman JL, Waner M. Shumrick K. Photodynamic therapy: a viable alternative to conventional therapy for early lesion of the upper aerodigestive tract. Presented at the Joint Meeting of the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons entitled, "Current Research and Clinical Concepts in Head and Neck Cancer," Dorado. Puerto Rico. May 5. 1985.

29. Kinsey JH. Cortese DA. Neel HB. Thermal considerations in murine tumor killing using hematoporphyrin derivative phototherapy. Cancer Res 1983;43:1562-1567. 30. Gregory RO. Goldman L. Application of photodynamic therapy in plastic surgery. Laser Surg Med 1986;6:62-66. 31. Ricsz P. Krishna M. Phthalocyanines und their sulfonated derivatives as photosensitizers in photodynamic therapy.

12

Laser Photothermal Therapy for Cancer Treatment

Dan J. Castro, Romaine E. Saxton, 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 . 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. 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 . 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. 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, 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 , 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 . In addition, 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, its effects are p r e d i c t a b l e , r e p r o d u c i b l e , and c o n t r o l l a b l e . Its nonionizing characteristic simplifies safety r e q u i r e m e n t s . With the increasing cost of health c a r e d u r i n g t h e past 20 years, 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 . 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. 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 , 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 , resulting in r e d u c e d morbidity, accelerated functional r e c o v e r y , 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, radio 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 2 - 1 ) . 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 , its p h y s i o l o g i c effects, 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 .

a v a i l a b l e s e v e r e l y limits its utility, 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 . 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 . 4 and Z h o u et a l . for the treatment of liver t u m o r s . 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 . 4 , 5 D r i t c h i l o et a l . 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, b u t t h e effect on survival w a s not clear. Livraghi et a l . 7 an d S h i n a e t a l . 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 , w h i c h w a s associated with few complications and produced tumor necrosis. This method, h o w e v e r , 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 . 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; 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, which limits r e p e a t e d treatment, 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 . 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 , 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

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, ultrasound, m i c r o w a v e , or laser e n e r g y . 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. 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. H o w e v e r , 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 . 1 2 - 2 ) . 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 , infrared t h e r m o g r a p h y , and histologic a s s e s s m e n t , 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 . S i n c e t h e m i d - 1 9 7 0 s , 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 . " I n 1985 S v a a s a n d e t a l . 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 . 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 l u m i n u m - 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 . M a t t h e w s o n e t a l . used a single N d : Y A G laser fiber at l o w p o w e r ( 1 - 2 W ) , 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), 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 . H a s h i m o t o e t a l . 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 - 1 7 1 8

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I 44

Lasers in Maxillofacial Surgery and Dentistry

Figure 1 2 - 1 . (A) Interstitial Nd:YAG laser treatment of a recurrent midline neck squamous cell carcinoma guided by ultrasound. (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. (C) The Nd:YAG laser is then turned on while the ultrasound monitors the tissue effects, demonstrating a transient hyperechoic signal during energy deposition.

difluser fiber tip to treat liver t u m o r s with evidence of reduction of t u m o r size. G o d l e w s k i et a l . 1 9 , 2 0 used high-powered N d : Y A G of up to 100 W. of 1-second duration to produce areas of vaporization and necrosis of 16 to 22 mm in the porcine liver. However, the high power density at the distal end of the optical fiber resulted in frequent tip d a m a g e , burning, nonuniform distribution of laser energy, and poorly reproducible tissue effects. T h e recent introduction of synthetic sapphire p r o b e s , 2 1 which h a v e high melting points (202O-2050C). greater tensile strength, 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 - i n d u c e d hyperthermia in a d o g m o d e l . 2 1 , 2 2 Daiku/.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 , 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 - o p t i c c o u p l i n g s y s t e m s , which a l l o w t h e insertion of multiple fibers. T h i s c o n c e p t , while attractive, has p r o v e d difficult to a c h i e v e in practice.

Figure 1 2 - 2 . T2-weighted image of three in vivo laser lesions made at 2(X)() J in (he normal muscle of a rabbit. Lesions were produced using 5 W X 400 sec. 10 W X 200 sec. and 20 W X 400 sec. Concentric layers of signal intensity change correspond to coagulated (dark) and interstitial edema (bright and diffused) zones. At the core of each lesion is the center filled with interstitial fluid. Mood, or air.

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 , p h o t o m e c h a n i cal, and p h o t o t h e r m a l . 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

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. 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, 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. 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 ) , a n d short laser pulses ( 1 0 -6 second or less), which p r o d u c e shock w a v e s and p l a s m a s . Such effects occur, for e x a m p l e , w h e n a laser is o p e r a t e d in the Q - s w i t c h e d m o d e . 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. 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, (2) p h o t o a b l a t i o n . 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 . 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 , 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. 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 , 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 . In addition this t e c h n i q u e is slow, c u m bersome, and difficult to a p p l y . In photoablation. t h e tissue is rapidly h e a t e d to a r a n g e of 60 to 100C w h e r e visible w h i t e n i n g is seen, indicating thermal c o a g u l a t i o n . 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 , irreversible alteration of proteins and other biologic m o l e c u l e s , o r g a n e l l e s , m e m b r a n e s , cells, 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 . Most of these alterations are due to thermal denaturation of structural p r o t e i n s , although m e m b r a n e rupture m a y result from alterations in lipids. By this definition, 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. T h i s p r o c e s s is easier and faster to d e liver and control in tissues. W h e n tissue t e m p e r a t u r e is raised a b o v e 100C, 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. 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." W a t e r loss results in tissue desiccation, which radically c h a n g e s the optical characteristics of tissues and their absorption efficiency of infrared lasers. In addition, w a t e r loss reduces the thermal conductivity and specific heat of tissues. Black char, yellow flames, 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.

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 . 5 C , 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 . T h i s h e a t - 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. B i c h e r and B r u l e y , 2 3 Dethlefse n and Dewey. 24 D i e t z e l , 2 5 H o r n b a c k . 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 . A d r i a m y c i n . and cis-platinum is enh a n c e d by heat treatment (T = 4 0 - 4 2 . 5 C ) . 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 42.5C b e c a u s e cells die after heating in a t i m e - t e m p e r a t u r e - and cell c y c l e - d e p e n d e n t m a n n e r . 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. 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 . 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 . with heating t i m e s b e t w e e n 1 second and several h o u r s . 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 1C 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 . 3 2 I n addition, h y p e r t h e r m i a inhibits D N A replication and D N A and protein synthesis, 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 . 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 , an elevated rate of m e t a b o lism is s e e n , w h i c h is followed by an inhibition in energy production in m o s t c e l l s . 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, 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. T u m o r cells are preferentially killed in the S-phase d u r i n g hyperthermia, 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 , acidity, and e n e r g y d e p r i v a t i o n . 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, which m a y be p o o r and sluggish in t u m o r s . In addition, 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 , 3 3 , 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. 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 . T h e Iherm a l distribution in tissues, t h e rate of t e m p e r a t u r e rise, 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 , specific heat s o u r c e , blood perfusion rate, tissue extinction coefficient, h e a t losses at e x p o s e d surfaces, and incident energy density. F a c t o r s such as optical w a v e l e n g t h s , heating conditions at the surface, 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 . C o o l i n g at t h e surface, for e x a m p l e , 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, 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. In most t u m o r s , 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 . H o w e v e r , 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 , it m a y reduce its c h e m o t h e r a p y a n d / o r ra-

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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 . T h e r e fore, 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. 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. T h e intercellular s p a c e b e c o m e s h y p o x i c , acidic and d e p r i v e d of nutrients, which further e n h a n c e s the c y l o c i d a l effects of hyperthermia, 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 .

IMAGING-GUIDED MINIMALLY INVASIVE THERAPY

T h e c o n c e p t of i m a g i n g - 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 , 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.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 . 4 2- 5 2 T h e availability o f o b l i q u e and multiplanar i m a g ing capabilities, a lack of ionizing radiation, high tissue contrast anil resolution, the a b s e n c e of b e a m - h a r d e n i n g artifacts from b o n e , 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. 1 2 - 3 ) . H o w e v e r , 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 . T h e high m a g n e t i c f i e l d (1.5 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 . 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 - 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 1.5 T S i g n a ( G E Medical S y s t e m s , 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. 1 2 - 4 ) . A series of 55 p a t i e n t s w e r e treated o v e r a 6 - y e a r period ( 1 9 8 8 - 1 9 9 4 ) a t t h e U C L A School o f M e d i c i n e , u s i n g the c o n c e p t of i m a g i n g - g u i d e d m i n i m a l l y i n v a s i v e therapy. 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, d y s p h a g i a , d y s p n e a , and b l e e d 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 , l o cated in different a n a t o m i c sites within t h e head and neck. 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 - 1 ) , 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. 12^+). 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 - a l u m i n u m - 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 - 3 . (A) Presurgical 3D-MR1 of a patient with an unresectable recurrent submental carcinoma. Based on laser dosimetry study presurgical planning of the needle, introduction and position is made on the screen. (B) Presurgical MR images of the same patient showing the needles in the tumor during energy deposition.

toablate the t u m o r 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 . Ninety percent of the patients w e r e treated o n a n outpatient b a s i s , 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, with a m e a n of t w o treatments. In 50 to 8 0 % o f the patients, 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. 1 2 - 5 ) . 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 , histology, and g r o w t h rate. S m a l l e r , s l o w - g r o w i n g , m o r e differentiated t u m o r s were
2

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147

Figure 12-4. Setting of the MR suite showing the GE Signa MR magnet (A), the operator console (B). the Laserscope KTP:YAG laser, which is kept outside the magnet (C). the Coherent power meter and detector head (I)), the l.uxtron tluoroptic thermometer ().

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 . 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 ) . 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 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 . 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 . 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. 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 . 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 . 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 . After o b t a i n i n g appropriate informed c o n s e n t , 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. 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, 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 1:100,000 e p i nephrine. Based upon the t u m o r v o l u m e to be treated, a variable n u m b e r of 16-gauge M R I - c o m p a t i b l e needles (EZ - E M . Inc.) 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 . MRI (5 patients) or U T Z (25 patients) (Fig. 1 2 - 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 , 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.

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 . 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. 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 . As tissue photoablation o c c u r r e d , the t u m o r m a s s w a s frequently irrigated with normal saline and suctioned ( F i g . 1 2 - 1 ) . 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 , d e b u l k it, 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 . T h e initial t u m o r v o l u m e as calculated by 3 D - 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 . 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.
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, breast, kidney, and prostate. 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, 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 . In addition, b e c a u s e laser light is n o n i o n i z i n g , 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. 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-

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radio frequency, m i c r o w a v e s , c r y o t h e r a p y , ethanol injection, or interstitial radioactive seed implantation. 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, o u t p a t i e n t basis. 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 , 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 , U C L A School o f M e d i c i n e , N I H grant # U S H H S D C 0 0 3 1 , and N I H grant # C A 6 5 0 5 3 - O l R , t h e Elsa P a r d e e F o u n d a t i o n , DuPont M e r c k , E - Z - E M , Inc., L a s e r s c o p e , R e s o n a n c e T e c h n o l o g y , O h m e d a , Inc., T r i m e d y n e , Valley L a b , Inc., In-Vivo Research Inc., G E Medical S y s t e m s , 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 . R . C . , B P 3-94801 Villejuif Cedex, France).

REFERENCES
1. Breasted JH. The Edwin Smith Surgical Papyrus, vol 1. Chicago: University of Chicago: 1930. 2. Milne JS. Surgical Instruments in Greek and Roman Times. Oxford: Clarendon Press; 1907. 3. Wagner von Jauregg J. Gutachten der Wiener Medizinischen Fakultaet. Jahrb Psychiat Neurol 19I7-18;38:1^18. 4. Ravikumar TS. Kane R, Cady B, et al. Hepatic cryosurgery with intraoperative ultrasound monitoring for metastatic colon carcinoma. Arch Surg 1987; 122:403-409. 5. Zhou XD, Tang ZY, Yu YQ, Ma ZC. Clinical evaluation of cryosurgery in the treatment of primary liver cancer (report of 60 cases). Cancer 1988;61:1889-1892. 6. Dritchilo AE, Grant EG, Harter KW, et al. Interstitial radiation therapy for hepatic metastases: sonographic guidance for applicator placement. Am J Roentgenol 1986;164:275-278. 7. Livraghi T, Salmi A, Bolondi L, et al. Small hepatocellular carcinoma: percutaneous alcohol injection results in 23 patients. Radiology 1988; 168:313-317. 8. Shiina S, Yasuda H, Muto H, et al. Percutaneous ethanol injection in the treatment of liver neoplasms. Am J Roentgenol 1987;149:949-952. 9. Cummins L, Nauenberg M. Thermal effects of laser radiation in biological tissue. Biophys J 1983;42:99-102. 10. Welch AJ. The thermal response of laser irradiated tissue. IEEE J Quant Electron 1984;20:1471-1484. 11. Dougherty TJ, Lawrence G, Kaufman JH, et al. Photoradiation in the treatment of recurrent breast carcinoma. J Natl Cancer Inst 1979;62:231-237. 12. Dougherty TJ, Kaufman JE, Goldfarb A, et al. Photoradiation therapy for the treatment of malignant tumors. Cancer Res. 1985;38:2628-2635. 13. Svassand LO, Boerslid T, Oeveraasen M. Thermal and optical properties of living tissue: application of laser-induced hyperthermia. Lasers Surg Med. 1985;5:589-602. 14. Bown SG. Phototherapy to tumors. World J Surg 1983;7:700-709. 15. Matthevvson K. Barr H, Tralau C, Bown SG. Low power interstitial Nd-YAG laser photocoagulation; studies in a transplantable fibrosarcoma. Br J Surg 1989;76(4):378-381. 16. Matthewson K, Barton T, Lewin MR, et al. Low power interstitial Nd-YAG laser photocoagulation in normal and neoplastic rat colon. Gut 1988;29:27-34.

Figure 12-5. Pre- (A) and post- (B) 3D-MR images on a patient with a large base of skull carcinoma that was treated using the concept of imaging-guided surgery. 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, breast, k i d n e y , prostatic m a s s e s , and single-level d i s k d i s e a s e s . 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 , 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. In t h e future, 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 , liver, c h e s t , a b d o m e n , all t u m o r m e t a s t a s e s , and other p a t h o l o g i c c o n d i t i o n s . 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 , 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 .

13

Laser-Assisted Temporomandibular Joint Surgery

Steven ]. 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 ) . 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 . 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. As its usefulness for the treatment of internal d e r a n g e m e n t s , particularly n o n r e d u c i n g d i s k displacement (closed lock), h a s b e c o m e generally a c c e p t e d , 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. 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 , ' 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 . 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, triangulalion, 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 . 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 , 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). Fortunately, 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 . C o n s e q u e n t l y , 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 . Instruments for incising, s c u l p t i n g , 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. H o w e v e r , they r e m a i n e d inefficient. 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 . 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.
1 2 3,4

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 . ' 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 , 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, excellent a c c e s s , 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. Lasers, particularly the h o l 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 ( H o : Y A G ) laser emitting at 2 1 9 2 n m , 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 , s y n o v i u m , o r b o n e . 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 .
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 , 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 . 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 , which is well below the thermal relaxation time for m o s t tissues with high w a t e r content. 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. In fact, 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 = 1.2-22.6F) 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. 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 . 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 0.3 m m . it r e m o v e s tissue precisely. 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 , there is very little u n w a n t e d thermal d a m a g e lateral to the vaporization crater. N e v e r t h e l e s s , 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 0.1 to 1.0 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. 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 0.4 to 0.6 m m , 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 52

Lasers in Maxillofacial Surgery and Dentistry

0.7 to 1.8 m m . 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. 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 . Several f i b e r delivery m e t h o d s are available. 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 . 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 . 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. 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 .

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. 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 , and a diagnosis of nonreducing T M J disk displacement (closed lock) w a s m a d e . 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 . 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 . " 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 r e w a s no pain on the left s i d e . 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. There were no joint sounds or crepitus. 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 . 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. 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 . T h e left j o i n t w a s n o r m a l . 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 . 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 . 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 . 1 3 - 1 ) , 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 . " 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. T h e laser w a s set at 8 W o u t p u t p o w e r , pulsed m o d e at 5 Hz. T h i s resulted in a b l o o d l e s s releasing incision (Fig. 1 3 - 2 ) . 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. A res o r b a b l e s u t u r e , O - P D S E t h i c o n , 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. 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 . P o s t o p e r a t i v e l y , 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. 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 . 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, w h i c h w e r e not p r o b l e m a t i c for her. 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 . S h e r e m a i n s pain free and functional since t h e n .

Figure 1 3 - 1 . Anterior and medial dislocation of TMJ mensicus. Retrodiscal tissues are shown stretched over posterior portion of condylar head.

Figure 13-2. Bloodless releasing incision created through synovium and superior aspect of lateral pterygoid muscle using the Holmium:YAG laser.

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 . 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 . 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 . 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 . 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. 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. S h e had m a n d i b u l a r retrognathia with a d e e p bite. 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 . T h e r e w e r e no areas of defined m u s c l e tenderness. 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. 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 . T h e left s i d e w a s n o r mal. 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 . 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 . " A large disruption in the m e n i s c u s w a s seen ( F i g . 1 3 - 3 ) . 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 . C o n s e q u e n t l y , 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 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. 1 3 - 4 ) . 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 , 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. 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. B l e e d i n g w a s m i n i m a l , 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 . After c o m p l e t i n g the m e n i s e c t o m y (Fig. 1 3 - 5 ) , the joint w a s inj e c t e d with a 0 . 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 , and the patient r e c o v ered uneventfully. 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 . 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 . 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. 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 .
2 4

Figure 1 3 - 3 . Large perforation of meniscus with visible deformed condylar head.

Figure 13-4. Resection of residual perforated meniscus using the Holmium:YAG laser.

Figure 13-5. Completed laser-assisted menisectomy: View of intact cartilidge over deformed condylar head.

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 . 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 , removal of the m e n i s c u s with conventional shavers, and rotary i n s t r u m e n t s is tedious and inaccurate. In

Laser-Assisted Temporomandibular Joint Surgery

contradistinction, 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 . In addition, 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, it m i n i m i z e s scuffing of c o n d y l a r surfaces. B e c a u s e t h e depth of tissue penetration is usually only 0.4 to 0.6 m m . ablation is readily confined to the a b n o r m a l menisc u s , 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 . C o n s e q u e n t to its excellent h e m o s t a t i c properties, 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. Lasers are safe and effective w h e n standard p r e c a u t i o n s are taken. T h e H o : Y A G laser is a m a z i n g l y versatile, 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. 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.

155

REFERENCES
1. McCain JP, De la Rua H. Principles: practices of operative arthroscopy of the human temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989:1:135-151. 2. McCain JP. Puncture technique and portals of entry for diagnostic and operative arthroscopy of the temporomandibular joint. Arthroscopy 1991:2:221-232. 3. McCain JP. An Illustrated Guide to TMJ Arthroscopy. And o v e r . M D : Dyonics; 1987. 4. .Sanders B. TMJ Internal Derangement and Arthrosis: Surgical Atlas. St. Louis: Mosby; 1985. 5. Hendler BH. Ciatcno J. Mooar P. et al. Holmiuin:YAG laser arthroscopy of the temporomandibular joint. J Oral Maxillofac Surg 1992:50:931-934. 6. Koslin MG. Martin JC. The use of the holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac Surg 1993:51:122-123. 7. Koslin MG. Arthroscopic Laser Debridement of Perforated Articular Disc Using the Versa Pulse Surgical Laser. Palo A l t o C A : Coherent. 1992. 8. Tarro AW. Arthroscopy: A Diagnostic and Surgical Atlas. Philadelphia: J.B. Lippincott: 1993.

14

Endoscopic Sinus Surgery: A Significant Adjunct to Maxillofacial Surgery

Jeffrey J. Moses, Claus R. 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. As enhanced awareness of the importance of the patency of the osteomeatal unit ( O M U ) grew, it has b e c o m e evident that some cases of postoperative sinusitis occurred consequent to midfacial orthognathic surgery. High-level septal deviations could lead to distortion of the middle turbinate on the convex side of the septum, which laterali/.es the uncinate process and hiatus semilunaris of the infundibular outflow pathway, which subsequently also b e c o m e s tortuous. T h e s e anatomic alterations predispose to the development of postoperative sinusitis. 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, 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 . If s y m p t o m s arise, 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 , allogeneic, and alloplastic materials placed adjacent to the sinus during surgery. Most i m p o r t a n t l y , 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 , 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 .

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 , 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 . W i t h increasing familiarity and s o p h i s t i c a t i o n , 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. 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. 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. 1 4 - I ) . 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. B e l o w I 8 C and 50% h u m i d i t y , i m p a i r m e n t o c c u r s . If contact occurs bet w e e n m u c o s a l surfaces, 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 , 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. 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 . 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. Messerklinger (A, 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 , c o n centrating on the m a x i l l a r y , e t h m o i d a l , and frontal s i n u s e s . In contrast, 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 , 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 . For t h e

Figure 1 4 - 1 . Coronal view of paranasal sinuses. Arrows indicate direction of normal ciliary directed mucous flow toward natural ostea.

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B
Figure 14 -2. (A) Diagram of stylistic oslca lumen of greater than 2.5 mm diameter indicating healthy cilia and aeration. (B) Diagram of cross section of ostca lumen with less than 2.5 mm diameter indicating paralysis of ciliary motion and inadequate aeration potential due to mucous stagnation.

Structurally, 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 , frontal, and maxillary sinuses within the hiatus s e m i l u n a r i s which, along with the middle turbinate, occupies the m i d d l e m e a t u s . O s t i a d i a m e t e r s less than 2.5 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. I 4 - 2 A . B ) . A d d i t i o n a l l y , 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 , 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 , resulting in c h r o n i c sinus disease. 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 , and location and patency of the ostia and O M U (Fig. 1 4 - 3 ) . 1. 2. 3. 4. Lamina p a p y r a c e a Anterior e t h m o i d Infundibulum Uncinate process 5. 6. 7. 8. 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. Additional tests such as those of M u e l l e r and Cottle (Smith and N e p h e w Richard, Inc.. 7 4 5 0 B r o o k s Rd., M e m p h i s , T N 3 8 7 7 6 U S A ) to a s s e s s the nasal valve, 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. A n y d e v i a t i o n s of t h e s e p t u m , laterally or in a vertical to inferior S - s h a p e d fashion, should be noted. 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. 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. Cross-sectional coronal diagram of normal structure in the nose and osteo-meatal complex.

layer i m m e d i a t e l y adjacent lo the cilia, stasis o c c u r s , p r o viding a culture m e d i u m for bacterial infections. T h u s , 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, 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. Infundibular m u c o s a l s w e l l i n g induced by alterations in airflow patterns, 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, similarly impairs mucociliary function.

Endoscopic Sinus Surgery

d i e turbinate. 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 . Le Fort I o s t e o t o m y m a y alter airflow patterns, 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 . In addition, 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 , 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. 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, thereby n a r r o w i n g its lumen to less than 2.5 m m , which leads to a cessation of ciliary m o tion that blocks O M U function. 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 , 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. 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 , h y p e r t r o p h i c t u r b i n a t e s , and s y m p t o m a t i c O M U b l o c k a g e . 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 , 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.

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can be utilized for e n d o n a s a l soft tissue ablation, p h o t o c o a g u l a t i o n , a n d t u r b i n o p l a s t y w h e n indicated. Settings of 10 W of p o w e r and h i g h - s p e e d p l u m e e v a c u a t i o n a r e utilized. T h e C 0 laser ( L u x a r C o r p o r a t i o n , 7 9 2 0 6 North C e n t e r P a r k w a y , B o t h e l l , W A 9 0 8 7 7 - 8 2 0 5 ; L X 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 , and c o n v e n i e n t tips are availa b l e for directed b e a m localization. On selected c a s e s , 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 . 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 , inhibiting access to the hiatus s e m i l u n a r i s , u n c i n a t e process, and infundibulum. O t h e r w i s e , 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 , w h i c h o b s t r u c t s vision.
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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. First, 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 . 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 - 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. 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 , 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. 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 , 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 . 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 . After its identification, 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 (3.0 mm plus) is a c h i e v e d . 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 - 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 .
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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. A R i c h a r d ' s 3 0 angled e n d o s c o p e o f 3 . 5 - o r 4 . 0 - m m d i a m e t e r i s u s e d , 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 . A s i m p l e setup of instrumentation is preferred by t h e author; 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. 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 - B l a k e s l e y forceps, 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 . If required, 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 - c u t t e r " a n d m e d i u m r e verse biting instruments. A c u r v e d o s t i u r 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. 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 , # 1 0 F r e n c h c a t h e t e r t u b i n g , and irrigation. L a r g e r m u c i n o u s s t r u c t u r e s , such a s e n g o r g e d turbinates o r intranasal p o l y p 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 . " Occasionally, 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, 0 . 5 % b u p i v a c a i n e with e p i nephrine 1:1(X),000, and timed nasal cottonoid p a c k i n g soaked with 4% c o c a i n e . 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 - a l u m i n u m - 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. If not available, insulated e l e c t r o c a u t e r y should be accessible. T h e H o : Y A G laser ( N e w S t a r L a s e r s , 7 7 8 0 2 K e m p e r Rd., A u b u r n , 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
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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 , turbinate hypertrop h y , o r p a r a d o x i c a l turbinate m o r p h o l o g y , 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 . In these c a s e s , both the " t h r u - 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. F o l l o w i n g these p r o c e d u r e s , a F E S S silicone stent, bacit r a c i n - c o a t e d Telfa strip, 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. If s e p t o p l a s t y w a s p e r f o r m e d , its m u -

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In certain c a s e s mucosal w e b s a n d / o r shelf-life plicae, which m a y inhibit p h y s i o l o g i c m u c o u s flow, m a y also be present and r e q u i r e lysis. T h e m a x i l l a r y - a n t r a l t r o c h a r - 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 , tooth or foreign b o d y r e m o v a l s , 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 . 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 .

c o s a is r e a p p r o x i m a t c d with 4 - 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 . 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, such as t h e H o s a k a w i n d o w (Fig. 144). 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, 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. 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 . T h i s is a c c o m p l i s h e d using an e n d - c u t t i n g b o n e r o n g e u r , 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, 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. 1 4 - 5 ) . T h e status of b o n e healing, fixation h a r d w a r e , h y d r o x y a p atite, 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 .

COMPLICATIONS AND POSTOPERATIVE CONSIDERATIONS

O c c a s i o n a l l 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 . F o l l o w - u p antibiotics are given routinely with all patients. 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 . 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.

CASE ILLUSTRATIONS Case 1

T h i s is a 4 2 - y e a r - o l d m a n status p o s t - 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 , septoplasty, and partial t u r b i n e c t o m i e s . 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, vertical m a x i l l a r y hyperplasia and retrognathism, 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. 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, and severe septal spurs and d e v i a t i o n s . 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 . W i t h i n 2 to 3 w e e k s after surgery, the patient reported a large tissue obstruction of the right nasal p a s s a g e w a y . 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. A large ( 2 - 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. 1 4 - 6 ) . 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 , followed by H o : Y A G laser ablation of soft tissue tags r e m a i n i n g . Pathologic confirmation of p o l y p s and the m u c o u s - 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 . P o s t o p e r a t i v e intranasal steroids w e r e applied, 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 .

Figure 14-4. Diagram of a down fractured maxilla at the Lc Fort 1 level indicating view of notches (Hosaka Window) placed in the lateral nasal wall.

Figure 14-5. Placement of endoantral cannula and endoscope through a "Hosaka Window" approach.

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Figure 14-6. Coronal CT scan of patient (Case 1) having a large Concha Bullosa and nasal polyp in right nasal parragenay.

T h i s is a 5 4 - y e a r - o l d w h i t e w o m a n w h o presented status p o s t - 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 . S e g m e n t a l Le Fort I o s t e o t o m i e s , 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 . T h e maxillary nasal sinuses had p o l y p s p r e s e n 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 . S e v e r a l years later, 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 . 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. A d d i t i o n a l l y , 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. B l o c k a g e of the O M U w a s noted on the left side (Fig. 14-7). 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 . 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 . and C 0 laser-assisted uvulopalatoplasty, which was accomplished.
2

Case 3
T h i s is a 3 5 - y e a r - 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 ) . 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 , sagittal split r a m u s o s t e o t o m y , t u r b i n e c t o m i e s , and septoplasty. 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 . 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 , 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 . 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 . 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 , 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. 1 4 - 8 ) . 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 ) . 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 , s y n e c h i a l lysis, 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. Coronal CT scan of patient (Case 2) showing Concha Bullosa, obstructed OMU. and evagination of inferior turbinates into the maxillary antrum.

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.

Figure 14-8. Coronal CT scan of patient (Case 3) with OMU blockage and synechial web obstruction of the maxillary oslea.

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i n f u n d i b u l u m . 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. 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 , 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, 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, 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.

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. 1 4 - 9 ) . 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 . 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. 1 4 - 1 0 ) . In o u r e x p e r i e n c e , 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 . 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, 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, 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 , 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 . 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. 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 - 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. With the a d v e n t of office-based e n d o s c o p i c instrumentation, 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 , p o l y p s , and O M U blockage, 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. 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 . 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 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 , combined with intranasal u s e of laser-assisted turbinoplasty and soft tissue lysis, 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 .

Figure 14-9. Endoscopic view of maxillary antral wall showing step and hardware entrance into the maxillary sinus.

REFERENCES
1. Heetderks DL. Observations on the reactions of normal nasal mucous membrane. Am J Med Sci. 1927; 174:231. 2. Hilding AC. The role of respiratory mucosa in health and disease. Man Med. 1967; 50:915-919. 3. Holliday RA. Shiptner BA. Avoiding complications of endoscopic sinus surgery: analysis of coronal, axial, and sagittal computed tomographic images. Operative Tech Otolaryngol Head Neck Surg. 1995; (3):149-157.

Figure 14-1(1. 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.

15

Laser Biostimulation: Photobioactivation, A Modulation of Biologic Processes by Low-Intensity Laser Radiation

Joseph S. 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, sun, and healing. Greek and R o m a n p h y s i c i a n s , C e l s u s and G a l e n for e x a m p l e , 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 , arthritis, and a s t h m a . 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 .C. 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. 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 , 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, poor diets, long h o u r s in dark w o r k p l a c e s , and few opportunities for a d e q u a t e e x p o s u r e to sunlight. 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 , rickets, e d e m a , r h e u m a t i c arthritis, and d e p r e s s i o n , for which s u n bathing w a s often prescribed as a c u r e . 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.
ULTRAVIOLET (UV) THERAPY

clinical research and the potential for harmful effects from UV e x p o s u r e , 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 , although not universally a c c e p t e d , for stimulation of w o u n d healing in ulcers, boils, and c a r b u n c l e s , and for treatment of acne vulgaris and neonatal j a u n d i c e w h e n used cautiously and prudently.
1,2

L A S E R S I.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. S i n c e that time, medical a p plications of the intense, c o h e r e n t , 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, d y e , and g a s lasers h a v e multiplied. Shortly after the introduction of this new source of light, 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. With the availability of o t h e r lasers, 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. 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, a n infrared ( I R ) emitter a t 10,600-nm w a v e l e n g t h , 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, d e r m a t o l o g y , plastic s u r g e r y , g y n e c o l o g y , o p h t h a l m o l o g y , oncology, oral and maxillofacial s u r g e r y , o t o l a r y n g o l o g y , and general s u r g e r y .
2

Al the turn of the 2()th c e n t u r y , 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. By t h e 1930s, 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, r h e u m a t o i d arthritis, h e m o p h i l i a , and herpes zoster. 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 , at that t i m e , 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 , dietary s u p p l e m e n t s , etc. 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 . 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. 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 . 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. 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. M a n y of the most c o m m o n of these solid-state near-IR lasers

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ministration ( F D A ) approval for n e w medical d e v i c e s a s safe and effective. 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. Until such e v i d e n c e is p r e s e n t e d , 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.

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 ) , w h i c h p r o d u c e s radiation of 8 2 0 - to 9 0 4 - n m w a v e l e n g t h s . 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. H e l i u m - 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. T h e s e lasers emit light primarily at 6 3 2 . 8 - 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. 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 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. Similarly, 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 - w i n e stains. 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 . 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 . 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 . 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 , which involve protein d e n a t u r a t i o n , c o a g u l a t i o n , 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. T h e e x t r e m e ultraviolet radiation of h i g h - 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 , resulting in ablation relatively free of t h e r m a l effects.
LOW-INTENSITY LASER THERAPY

Clinical Areas of Application

L o w - 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. P h y s i o t h e r a p y a. W o u n d h e a l i n g b. Soft tissue injuries C. Pain relief d. Arthritis 2. 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. Activation of bone growth 3. V e t e r i n a r y practice a. Pain relief b . W o u n d healing c. T r e a t m e n t of respiratory tract infections d. R e v e r s a l of n e u r o p r a x i a e. I m p r o v e m e n t of foot g r o w t h in horses 4. Laser acupuncture a. b. c. d.

CONTROVERSY
S i n c e M e s t e r s initial work, 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 early reports of L I L R - 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 . E v e n w h e n translated, (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 , protocols that w e r e not blinded or c o n t r o l l e d , and Hawed m e t h o d o l o g i e s . In particular, the specifications of L I L R research w e r e inconsistently presented, 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 . As t h e field h a s m a t u r e d , the rigor of reporting has i m p r o v e d , leading to m o r e credible and reliable results. 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, 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 . 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. 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 . 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. T r e a t m e n t t i m e s a r e typically short ( ^ 3 0 s e c ) , 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 .
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 , 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 . 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 , including intensity, b e a m profiles, polarization, 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 , what w e r e the pulse c h a r a c t e r i s t i c 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 .
8,0

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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 .

c a u s e s " s h o w e d significant beneficial results. 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 . 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 - 1 . 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, particularly in its e a r l y p h a s e s . T h e s e effects m a y d e p e n d o n the species o f animal used. L o o s e - s k i n n e d a n i m a l s such a s rabbits, rats, 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 , 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 . T h e r e a r e , h o w e v e r , 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 .
12 14 1 5

A.
1. 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 - 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. 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 . A n u m b e r of w e l l - d e s i g n e d and controlled studies find pain lessened, s w e l l i n g d i m i n i s h e d , 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 . H o w e v e r , b e n e f i t s m a y b e limited. 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, l e u k o c y t e c o u n t s , platelet a g g r e g a t i o n , and C reactive protein c o n c e n t r a t i o n s , 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 , 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 l a t i o n s h i p of these factors to clinical effectiveness is still unclear. A multicenter, 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. 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, patient selection, and benefit. A n o t h e r w e l l - 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 . 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 , if a n y , w e r e t o o limited to justify c o n t i n u a t i o n .
6,8

2. Polarization 3 . B e a m m o d e and profile a. TEM,,,,gaussian b. Multimode c. Homogeneous 4 . B e a m temporal t y p e a. C W b . Pulsed

B.
1. 2. 3. 4. 5. 6.

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. 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.

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. 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, 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 , w h i l e only 8% remained unhealed. The average healing time was 12 to 16 w e e k s . 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 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, t h e interpretation of the p u b lished information p r e s e n t s difficulties. 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, w h i c h is t h e localized p r i m a r y response, 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 . By radioactive labeling of cellular c o m p o n e n t s , M e s t e r and his s o n s , o v e r a 2 0 - y e a r p e riod, 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

168

Lasers in Maxillofacial Surgery and Dentistry

I able 15-1. 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

0.5. 1.4. 5. 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. 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

Every 3rd day X 4

Haina (1981)

Rat
w

Open skin

Granulation tissue formation Rate of wound closure and collagen synthesis Wound area, effect of eschar removal. tensile strength Wound area Wound area Wound area Wound area

HeNe 633 nm

50

0.5. 1.5. 4. 1 0 . 2 0 4 , 10. 20

Once daily

Kuna (1981)"'

Rat

Open skin

HeNe 633 nm

45

Once daily

Surinchak (1983)"
' I I " '-I'..1

Rabbits

Open skin

HeNe 633 nm

Variable

1.1

22
4.5 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 0.96 2 I.I

Every 3rd day 2X daily 2X daily

None

Rats Guinea pig Pig Guinea pig Mice

Open skin Open skin Open skin Open '.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 - 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. action potential increased and degeneralion reduced None, except increased tensile strength Size decreased. no other difference, but fibroblasts and collagen aligned Increased rate of healing. decrease in LDLs Increased SOD

Hunter (1984)'" McCaughan (1985)* Mesicr (1985)

45

Wound area. Ruby 694 nm cellular content of granulation tissue Wound area. collagen content, tensile strength Procollagen levels Wound area, tensile strength, collagen content Wound area, action potential, neuron degeneration HeNe 633 nm

Abergel (1987)* Abergel (1987)*' Lyons (1987)

47

Mice

Open skin

4.05

1.22

Every other day 3X weekly Every other day Daily for 20-21days

Pig Mice

Open skin Open skin

HeNe 633 nm HeNe 633 nm

1.56 4.05

0.6 1.22

Rochkind (I989) *
4

Rats

Open skin. burns. peripheral andCNS

HeNe 633 nm

N/A

7.6 10 10

Braverman (1989)*

Rabbils

Open skin

Wound area, tensile Strength, epidermal thickness, collagen area Size, tensile strength. energy absorption. strain

HeNe 633 nm and infrared

N/A

1.65 HeNe 8.25 IR

N/A

Enwemeka (1990)'

Rabbits

Tendons

HeNe 633 nm

N/A

1.2.3.4, 5mJ/cm

Daily
2

/arkovic (1991)"

Mice

Open skin

Wound area, serum lipoprotein content

GaAs 830 nm

50-W pulses

N/A

210 seconds daily, 7 days

Rossetti (I99I)'

Rat
2

Brain

Superoxide dismulase

HeNe 633 nm

1.08

N/A

Laser Biostimulation
T a b l e 152.
K i l l KI.NCI LASER 830 633 TREATMENT 60 mW CW and pulsed 0.9 mW. 9 0 s. CW X 3 pw. 3/52. 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. strength, etc.

1DIAGNOSIS RA pain OA thumb pain

\1. 1 1 1 1 1 1 ct Jl.
(1987)" H.i.l.iid et ul. (1987)
54

Bicglio el al. (1987)" Bliddal el ill. (1987)*' Burgudjieva et al. (1985)" Choi cl al. (I986) *
5

633

Radicular pain

+ ve*

Report

inflamm phase: ?ncural/vasc mechanisms + EMG etc; ?systemic effect*

633 633 904

10 mW, 5 min. X 3 pw. 3/52. T T <1 mW.60s. X 2 pw. Acu

7

RA pain Postop pain (gynecologic) Painful elbow Tri neuralgia Sports injuries

17 179 1 106 62

ns +ve 67* +ve 90%*

VAS* Report Report* Report Scotl/VAS**

[FLA]
*+glucocorticoid excretion [F1.AI Cumulative effect *25%; placebo. ** +thermography

Duhenko ct al. (1976)"

Emmanouilidis 820 and Diamantopoulos (1986)

60

l5mW.90s. CW. X 5 pw. 2/52. T 3 mW. 5 min. 4000 Hz, T. x3pw.2/52

England ct al. (1989)"' Galpcrti cl al (1987)"' Gartner cl al. (1987)"

904

Tendinitis

30

+ve*

VAS**

*p<

.001; **+goniomelry

633 IR

< 6 0 s . <7.2J/cm

PA pain AS. PA, LBP.etc. Locomotor pain

60 546 200

+ve 87%

Quest Report* Numeric * +functional; cumulative effect Comparative sludy: .'analysis *+X-ray invest crossover study: *+drug intake *46% "effective / 34% fair
-

10-20 min, X5pw,4/52.T < 2 5 mW. vartime. CW. x 5 p w , T 5 - 2 0 min. x5pw,T 0.3 mW. 30 min. 250 Hz. X 5 pw. T X URx.T
7

Glykofridis 633; and Diamantopoulos 660- 950 (I987)

M

N*

+ve

Gussetti el al. (1986)" Jensen et al. (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

SO' 'i nil 79%* +ve -l-ve* +ve**

Report* Report* Numeric Report Adapt V A S

7

Kalsclal. (1985)"" 633 Krcc/i and Klinger (1986)"" 633 633/IR*

1
N N

[FLA], 'sialadenitis
*/><.00l, max post 1 h; effects 9.6 ii combination preferable; ** + grip strength, etc. |FLA| 'versus alternatives [Ab]

2 mW. 3 0 s. 100 Hz. 1 Rx. Acu 10 min, 15/365. T

Y Y

1 .onaiiiT
(I986) " Lukashcvich (1985)" Martinof^S?)
72 7

633 CO,

T 5 mW. CW?. <20min. X5pw. 3/52. N + T

PHN Mastalgia

150 50

+ve* 32%

Report Keele/Lasa/ Map Numeric*

Mayordomo cl al. (1986)" Mester and Mesicr (1987)" Morselli el al. (1985a)
75

co

< 2 5 W. scan. CW. Locomotor pain 5 - 1 0 min, X2 pday 50 mW < 2 5 W scan. CW. 5 - 1 0 min. X 3 pw Wound pain OA pain

82
7

N
7

;lt80% +ve >70%*

* + thermography |Ah|

Clust CO,

200

[Ab], *62% acute effect; effects cxlend>l h [Ab] |Ab| *+thermography [Ab] * +thermography; .'placebo: 10-citi distance [Ab]

Morselli et al. (19856)'* Roumeliotis et al. (1985)

77

co

< 2 5 W . scan. CW?; Sports injuries 10-15 min. X2 pday 15 m W . C W . < 2 5 min. X5pw. 2/52. T < 3 0 s/pt, < 7 min. T P + Acu < 3 0 m W . 1200 Hz. 15 min, 10/365. T
7

>I0 0 31

+ve +ve

Report VAS*

820

Snorts injuries

Shiroto ct al. (I986) '

7

830 633; 904

Various pain Tcndinopalhies

160 0 64

N Y

N Y

85% ns

Report Numeric*

Sicberl ct al. (I987) *

7

Simunovic(l987)"" 633 TernovoylP^)"

1

Oral pain Locomotor pain

633

T + TP

400

+ve +ve

Report Report*

[FLA]

170

Lasers in Maxillofacial Surgery and Dentistry

T a b l e 15 -2. Examples of laser-mediated analgesia (continued)

<; 11 K : \ i i Vidovich el al. (1987)

B

LASER

TREATMENT 1 mW

DIAGNOSIS RA pain

N 272 36

El'T 75% 73%

Ml

A M Kl

COMMENTS |Ab] * + drug intake, etc. Chronic effect, * + 5 IIIAA */><.0()l. **+drug intake | A b ] . *+drug intake [Abl. *+drug intake

co
M

VAS* VAS*

Walker (1983)

633

1 mW, < 3 0 s . 20 Hz, Chronic pains X 3 p w , 10/52. N + T 1 mW, X 3 pw. 10/52 6 0 s , 1000 Hz. 30 mW, Acu RA pain OA pain hands Minor surgery

Walker el al. (1986)" Willner e! al. (1985)" Zhou Yo Cheng (1987)

633 904 C0

64 67 40

Y Y

+ve* 62% 95%

VAS** MPQ* Report*

D. double-blind; P. placebo-controlled; BIT, efficacy; Measure, pain measurement method used; RA. rheumatoid arthritis; |Ab|, abstract; pw, per week, e.g.. 3/52 = 3 weeks; T. topically applied to lesion; ns, nonsignificant findings; ROM, range of movement; N, applied to nerves/nerve r<x>ts; VAS, visual analogue scale; EMG, electromyography; |FLA|, foreign language abstract; Acu. applied to acupuncture points; Tri, trigeminal; PA, periarthrilic pain; AS, ankylosing spondylitis; l.BP. low back pain; Rx, treatment; OA, osteoarthritis; PHN. postherpetic neuralgia; Scan laser used in conjunction with scanning

1. 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. 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 - 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 . 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 . 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 . 2 . 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 , 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 , s h o w e d a significant increase in c o l l a g e n fibers, 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 . 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 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 - 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. 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 . 3 . 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, b l a s t - 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 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. 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 . 4 . 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 . In t h e treated w o u n d s , 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 . 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 .
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, motility, p h a g o c y t o s i s , i m m u n e r e s p o n s e , and respiration. 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 , cell g r a n u l e r e l e a s e , cell motility, m e m b r a n e potential, cell b i n d i n g affinities, n e u r o t r a n s m i t t e r release, 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 , p h a g o c y t o s i s , a d e n o s i n e triphosphate ( A T P ) s y n t h e s i s , intercellular m a t r i x , and p r o s t a g l a n d i n synthesis. R e c e n t l y , 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, but not to p r o l i f e r a t i o n . 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 . 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. 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 . 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 , 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 . 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. 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, alter cellular s i g n a l i n g , or increase production of A T P , 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. 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 . 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 , 6 3 0 , 6 8 0 , 7 6 0 , a n d 8 2 0 n m . H o w e v e r , 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.
6,8 17 8 19 2 02 1 2 2

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 , 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 . 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 . C y t o c h r o m e s A - A 3 and c o p p e r c o m p l e x , or c y t o c h r o m e o x i d a s 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 . 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 . 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. B e c a u s e of the low a b s o r p l i v i t i e s , 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. T h e s e factors only serve to further o b s c u r e an already confused area of research. 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 .

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 . 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 . A l s o , 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 , 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.

sis

c o n v e r s i o n into h i g h - e n e r g y p h o s p h a t e ( A T P ) . 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 , inhibiting electron transport, or a n a e r o b i o s i s , 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, 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 . For e x a m p l e , 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, 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. 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 u s , 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 .

T h u 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 . H o w e v e r , 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; 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 . 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 , 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. T h u s , the initial and short-term effect of LILR cannot be a result of direct stimulation of t h e A T P production. 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 . ' 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 . 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 . ' ' 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 .
3 0 , 3 1

28,2

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 . 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. 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 . 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 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 . 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. 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 , 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 , incoherent s o u r c e 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 . H o w e v e r , 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.

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 , along with the e m e r g e n c e of n e w , active media and w a v e l e n g t h s . In addition, 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. W i t h these i m p r e s s i v e a d v a n c e s , potential h a s increased for further clinical application of lasers in surgery and m e d i c i n 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 . 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, which facilitates laser t i s s u e - w e l d i n g . 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 . T h e s e included the large size and cost of e q u i p m e n t , lack of portability, 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 . 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 , 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 , a d d s to the confusion in this field. 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 s y s t e m s h o u l d be c o m p a c t , reliable, i n e x p e n s i v e , and easy t o use. T o a c h i e v e these ideals, 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 - a l u m i n u m - 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 . 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. 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 , portable, and relatively i n e x p e n s i v e . D y e - 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 - p o w e r lasers. At t h e s a m e t i m e , 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, especially for a e r o s p a c e and military applications (see C h a p t e r 17). Laser tissue fusion is being investigated as an alternative to surgical closure with s u t u r e s . 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 , 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. 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, g r e a t e r speed, e a s e of u s e , 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. It also a l l o w s w e l d e d tissue the ability to g r o w , 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 , it offers a c o m p l e t 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 .
2 1

especially w h e n g l u e reinforcement is a d d e d . 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 - 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, using indocya nine green d y e - 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 - n m diode laser.*

DEVELOPING FRONTS
As with laser p h o t o a b l a t i o n . laser tissue fusion requires training, 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 . 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. 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. 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 . M o r e importantly, 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, e x p o s u r e d u r a t i o n , duty cycle) tends to provide a more uniform result, 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 . 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 . T h i s further p r o v i d e s selective localization of the laser e n e r g y , 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 . In addition to forming stronger b o n d s , 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 . M o r e o v e r , 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. T o a c h i e v e d y e - e n h a n c e d p h o t o a c t i v a t i o n , 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 . 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. 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 - n m solid-state d i o d e l a s e r . T h e 8 0 8 - 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. In addition, 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, b e c a u s e the latter d o e s not a b s o r b within the
7 1

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176

Lasers in Maxillofacial Surgery and Dentistry

laser-fusion skin repair without any l o n g - 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 . " ' 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 , laser was reported by D e w et a l . " in 1982. T h e e l e c t r o p h y s i o l o g y . a x o p l a s m i c transport, 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. 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 . 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. 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 , forming a n e u r o m a with i n c o m p l e t e reinnervation. 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, silicon, g l a s s , and fibrin g l u e . 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 . 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*. pulse d u r a t i o n 2 0 0 m s . spot size 0.5 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 ) . T h e y noted e n h a n c e d , 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 . 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 , with actual interdigilation of the layered fibrils o c c u r r i n g , 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. M o r e o v e r , 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. 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. T h e y used a single slay suture, w h i c h w a s later r e m o v e d , 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 , c o n d u c t i o n velocity, axon fiber density, 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 . Notably, 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 , 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. 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 . A g a i n , 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. Potentially, 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. 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. Further work in this a r e a is clearly n e e d e d , 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 . 16-1 to 1 6 - 4 ) .
2 1

8 0 8 - n m w i n d o w . C l e a r l y , 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 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 . T h e o r e t i c a l l y , 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 , 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 . H o w e v e r , o b t a i n i n g fibrinogen for clinical u s e is p r o b l e m atic, 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.

MECHANISM
T h e exact m e c h a n i s m of tissue fusion is not clear. 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. 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 . 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 . 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 . N e v e r t h e less, 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 . O v e r a l l , 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. In this s e n s e , 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.
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. 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. In g e n e r a l , l a s e r - 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. 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. M o r e o v e r , fibrinogen g l u e is reabsorbed w i t h o u t a foreign b o d y reaction, in c o n t r a d i s tinction to the c a s e w h e n sutures are used. S t u d i e s of stressstrain analyses reveal similar strength in laser-repaired v e s s e l s . ' 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. T h e y are s i m p l e r to weld, 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. 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, 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 . Increased c o l l a g e n formation w a s found, with greater strength of

Tissue Fusion

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Figure 1 6 - 1 . Rat sciatic nerve. Nerve transected and then fused with KIO-nm dye laser. CW at 680 mW for 20 seconds. 660-u.m spot size. (I0X.) (Courtesy of Lewis dayman. D.M.D.. M.D.)

Figure 1 6 - 4 . Rat sciatic nerve. CW COo laser. 600-p.m spot size, P = 0.4 W. PW = 0.2 sec. Six weeks: nerve continuous. (S100 stain.) Partial neuroma at site of stay suture. (25X.) (Courtesy of Lewis dayman. D.M.D.. M.D.)

Figure 1 16-2. 6 - 2 . Sciatic Sciatic nerve nerve at at 6 6 weeks. weeks. Dense Dense staining staining vertical vertical band indicates persistent scar. (50X.) (Courtesy of Lewis dayman. D.M.D.. M.D.) M.D.)

Figure 1 6 - 5 . Six weeks. Healing complete. Minor disturbance of axonal architecture. (S100 stain.) (25X.) (Courtesy of Lewis dayman. D.M.D., M.D.)

REFERENCES
1. Bass LS, Ozc MC. Auteri JS. et al. Laparoscopic applications of laser-activated tissue glues. Proc SPIE 1991; 1421: 164-168. 2. Frazier OH, Painvin GA, Morris JR, et al. Laser-assisted microvascular anastomoses: angiographic and anatomopathologic studies on growing microvascular anastomoses: preliminary report. Surgery 1985;97:585-590. 3. Oz MC. Johnson JP. Parangi S, et al. Tissue soldering using indocyanine green dye enhanced fibrinogen with the near infrared diode laser. J Vase Surg 1980; 11:718-725. 4. Dew DK, Hsu TM, Hsu LS, ct al. Laser assisted skin closure at 1.32 microns: The use of a software driven medical laser system. Proc SPIE 1991; 1422:111 -115. 5. Grubbs PE, Wang S, Marini C. et al. Enhancement of C 0 laser microvascular anastomoses by fibrin glues. J Surg Res 1988;45:112-119. 6. Poppas DP, Schlossburg SM, Richmond IL, et al. Laser welding in urethral surgery: improved results with a protein solder. J Urol 1988:139:415-417.
2

Figure 1 6 - 3 . Same rat. Residual histologic signs of thermal damage and incomplete nerve healing still present. (250X.) (Courtesy of Lewis dayman. D.M.D.. M.D.)

17

Laser Application in Microgravity, Aerospace, and Military Operations

Paul C. Kuo, Michael D. 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, but not e l i m i n a t e d , d u e to m i c r o g r a v ity. T h e need for surgical repair is clear. 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 , but it is difficult to c o n t r o l , c o n t a i n , and collect fluids, and there is a tendency for arterial blood to scatter.
1,2

T h e first use of a C O , 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. 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. 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 . Furthermore, 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. 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 . In this light, 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 , reliable, r e - 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, weightless s p a c e e n v i r o n m e n t s .
7

w e a t h e r e x t r e m e s , vibration, and shock. 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. Biological d r e s s i n g and d y e - 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, w h e n d e v e l o p e d , 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 . As previously discussed, 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, r e p r o d u c i b l e results, particularly in unskilled h a n d s with less surgical e x p e r t i s e . C u r r e n t l y , 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. 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 , 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 .

REFERENCES
1. Gardener RM. Ostler DV. Nelson BD. et al. The role of smart medical systems in the space station. Int J Monit Comp 1989:6:91. 2. Nelson BD. Gardener RM. Ostler V, et al. Medical impact analysis for the space station. Avial Space Environ Med 1990:61:170. 3. Markham SM. R(xk JA. Deploying and testing an expandablesurgical chamber in microgravity. Avial Space Environ Med 1989:60:76. 4. Rock JA. An expandable surgical chamber for use in conditions of weightlessness. Avial Space Environ Med 1984:55:403. 5. Yaroshcnko. GL. Terentyn VG. Mokov MD. Characteristics of surgical intervention under conditions of weightlessness. Voen-MedZH 1967:10:69. 6. Space Life Sciences: A status report. Offices of Space Science and Applications. NASA 1990;Feb:5. 7. Colvard MC. Kuo PC, Caleel R, et al. Laser surgery procedures in the operational KC-135 aviation environment. Avial Space Environ Med I992;63:619. 8 Keipert AG. Garber DD, Colvard MD. Field Medical Laser System (FMLS) for the Special Operations Command. Kirkland AFB. New Mexico. Phillips Laboratory Laser and Imaging Directorate, Airforce Material Command. 1994.

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 . 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. R e c e n t l y , a small, totally r e c h a r g e a b l e , N : - 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 , 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. To be effective, these miniaturized units s h o u l d be configured with pre-set. 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 . In addition, they must be extremely lightweight, small, and rugged to withstand
8

179

Transoral Resection of Oral Cancer

Figure 7-15. One year. Hull range of motion of tongue. S p e e c h is normal as it has been since the s e c o n d postoperative month. Patient has been in regular c a n c e r surveillance protocol s i n c e month 3.

Figure 7-16.

Note

norma! range o f motion o n tongue

Figure 7-17.

S p e e c h and s w a l l o w i n g were normal. Patient had

DO e v i d e n c e of disease at 3 years.

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 . RSPup 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

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

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. M a y also be a carbonized region. / 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. 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. 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.

c h a n g e s with the square of its radius, a d o u b l i n g of the spot size, w h e n the b e a m is d e f o c u s e d , will result in a fourfold d e c r e a s e in p o w e r density. T h e r e f o r e , w h e n the laser is used in the d e f o c u s e d m o d e , t h e b e a m g e o m e t r y is flattened out, which permits controlled ablation of tissue to occur. 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. 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.

Index

Ablation of dentin, 127-133 of recurrent tumor. I OK tissue destruction, planes. 25-31 argon laser. 28. 29-31 technique. 29-30 diascopy. mucosa compressed. 30 first plane. 25-26 intralesional photocoagulation. 30-31 labiobuccal vestibule, vascular malformation, 29 Nd:YAG, 27-28 contact laser probe tip. 28 postoperative care. 27 second plane, 26 third plane. 26-27 Absorption, of light, composite tissue, 7 Absorption length, defined, 183 Absorption spectrum, rluxlamine dyes, 139 Aerospace, laser application in. 179 Aesthetic surgery, skin resurfacing in, 79 Analgesia, laser-mediated. 167, I69t-170t Anesthesia, general, avoiding, transoral resection. oral cancer. 87 Argon laser, 28t. 29-31 complications, 33-35 telangiectasias, scarring after, 34 frequency-doubled Nd:YAG laser, 4 nonconlact. 32 skin penetration, inadvertent. 33 technique. 29-30 telangiectasias, scarring after treatment, 34 Bean profile. CO, laser, transverse, cross section, 24 Buccal mucosa nodular leukoplakia, 38 prencoplasia. 50-51 cpithclialization, 51 first raster, 50, 51 mucosa, healing, 50 postoperative, 51 second raster. 51 proliferative granulation tissue. 107 transoral resection, oral cancer. 102-103 Carbon dioxide laser. See CO, laser Caries, dental, susceptibility, lasers and. 133-134 Characteristics, of lasers, 3t Chromophorc, laser, matched, 182 C 0 laser. 2-4, 19-25 advantages of. 19-20 articulated arm. 20 basis for use of, 20-22. 28t beam geometry. 24-25 profile, transverse, cross section, 24 disadvantages of, 20 energy, 23 cxcisional procedures. 65 Ouence. 23
2

Gaussian distribution, energy, 24-25 handpiece. 20 incisional procedures, 63-65 frenectomy, 63-64 vestibuloplasly, 64-65 irradiance, 22-23 laryngeal surgery. 121-126 Learner's curve. 23-24 microslad. 20 Nd:YAG, transoral resection, oral cancer, 87 power density, 23, 23t tissue effects and, 23t preneoplasia. oral cavity. 39-41 outline of lesion with. 42 transoral resection, oral cancer, 87 tumor debulking. transoral resection, oral cancer. 108 uvulopalatoplasty. 111-120 as vaporization instrument, 72 W/cm2, 23. Coagulation necrosis, zone of. defined. 182 Components, of lasers, 3 Contact laser surgery, overview, 8-9 Decay detection, dental, lasers and, 134 Dental caries, susceptibility, lasers and. 133-134 Dentin ablation, laboratory setup, laser. 132 histology, 129 Dentistry, lasers in. 127-135 ablation. 127-133 decay detection. 134 dental caries, susceptibility, 133-134 dentin ablation Er:YAG laser, plume from. 132 laboratory setup. 132 histology. 129 ErYAG, canine teeth, hole. 128 extracted t<x>th. ablation holes, 131 hard dental tissue ablation, 127-133 materials processing, 134 pulpal histology, 129 Deoxyribonucleic acid. See DNA Diascopy. mucosa compressed, 30 Diode laser. 4-5 DNA organization, papillomas, 55, 57 Duty cycle, defined, 183 Dyes, phototherapy with, 137-142. 139 definitions, 137 hematoporphyrin derivatives, 138 history. 137 light sources. 139-140 overview, 140-141 photodiagnostic imaging, 140 photodynamic therapy, 137-140 photooxygenation, mechanisms of, 137-138 photosensitizes. 139-140 rhodamine dyes absorption spectrum, 139 molecular structure, 139

Ear tag, excision, 68 ED. Set Fluence Electrical hazards, laser surgery, 16 Electromagnetic spectrum, 2 Endoscopic sinus surgery. 157-163 case study, 160-161 complications, 160 "Hosaka window" approach. 160 instrumentation. 159 overview. 161-162 paranasal sinuses, coronal view of, 157 postoperative considerations, 160 preoperative examination. 158-159 rationale. 157-158 technique, 159-160 Energy defined. 183 density. See Fluence Energy state, diagram. 2 Epulis fissuratum, 81 Erbium, yttrium-aluminum-garnetl. See Er:YAG laser Jt Erthroplakia, ventral tongue, prencoplasia, 38 Er:YAG laser, 35 " canine teeth. 128 dentin ablation, 132 Extinction coefficient, defined. 183 length, defined, 183 Facial nevi, 78 Facial telangiectasias. 34 Fibrin coagulum. prencoplasia. oral cavity, 41.43 Fibrocpithelial hyperplasia, palate, 75-77 Fihroepithelial polyp, excision, 67 Fibroma, excision, 66 Fire hazards, laser surgery. 14-16 Fluence. defined. 183 Free-beam lasers. 8-9 contact laser surgery, vs. nonconlact. 8 modification, 8-9 transoral resection, oral cancer, 86 Frenectomy. with CO, laser. 63-64 General anesthesia, avoiding, transoral resection, oral cancer, 87 Gingiva grafting, 70 hypertrophy, 73 severe, 74 lingual, leukoplakia. 48-49 Goggles patient protection with, 33 wavelength specific, 14 Handpiece, CO; laser. 20 Hazards, laser surgery. 11-16 electrical hazards, 16 fire hazards. 14-16 judgment errors. 11-12 optical hazards, 12, 13-14

185

186

Index
Laser, overview, 1-5 argon, frequency-doubled Nd:YAG laser, 4 characteristics, 3t chromophorc, matched, 180 CO, laser, 2-4 components, 3 diode laser, 4-5 Ho:YAG laser. 4 Nd:YAG laser, 4 Laser biostimulation, 165-172 analgesia, laser-mediated, 167, I69t-I70t background, 165-166 cellular effects, 167-171 cellular processes, exposure to, timing. 171 controversy, 166-167 current research, 167-171 exposure to cellular processes, timing, 171 heliotherapy. 165 laser parameters. 167 low-intensity laser therapy. 166 overview. 165-166 parameters. 167 repetition rates, effects of, 171 research, 171 ultraviolet therapy. 165 in vivo animal experiments. 168t wavelengths, simultaneous, multiple, effects of exposure to, 171 wound healing. 167, I68t Laser handpiece, positioning, prencoplasia, oral cavity, 45 Laser pulse, defined. 183 Laser tissue effects, photolhermal therapy, 144-145 Learner's curve. CO, laser, 23-24 Leukoplakia, prencoplasia. oral cavity, 43-44 Light absorption, composite tissue, 7 lasers and. overview, 1, 2 in medicine, therapeutic use of. See also Photobioactivation overview, 165-166 sources of, phototherapy and. 139-140 tissue, interactions, 6 Lingual gingiva, leukoplakia. 48-49 ablation. 48 front surface mirror, to redirect beam, 48 postoperative, 49 sulcus, ablation, 48 Lip. dysplastic leukoplakia. 45-47 Meniscus, anterior, medial dislocation of, temporomandibular joint surgery, 153 Microgravity, laser application. 179 Military operations, laser application, 179 Mouth, floor of. transoral resection, oral cancer, 90-93.94-95 aftercare. 95. lingual anterior mandibular gingiva. 94-95 technique 90-93. 94 Mucocele, 82-83 aphthous stomatitis, 82-83 benign pigmented lesions, 82 Nd:YAG laser. 4, 27-28 argon, frequency-doubled, 4 CO, transoral resection, oral cancer, 87 contact laser probe tip, 28 retinal burns, 12 Necrosis, coagulation, zone of, defined, 184 Nonapneic snorers, 114-115 Obstructive sleep apnea syndrome, 115. See also Sleep apnea syndrome Optical hazards, in laser surgery, 12, 13-14 Oral cavity, preneoplasia, 37-53 buccal mucosa, 50-51 epithelialization, 51 first raster. 50. 51 mucosa, healing, 50 postoperative, 51 second raster. 51 CO, laser, 39-41 outline of lesion with, 42 duct, lesion over, 40 erthroplakia, ventral tongue, 38 fibrin coagulum. 41. 43 healing. 43 laser handpiece, positioning, 45 laser wound, soft tissue. 41 leukoplakia, 43-44, 48^*9 lingual gingiva, 48-49 lip dysplastic leukoplakia, 45 leukoplakia, with dysplasia. 45-47 mouth, 48-49 front surface mirror, to redirect beam, 48 lingual gingiva, ablation, 48 postoperative, 49 sulcus, ablation, 48 multicentricity, 38 nodular leukoplakia, buccal mucosa. 38 palate, papillary hyperplasia of. 42 reepithelialization complete. 43 results, 43 surgical technique, 41-42,43 tongue, leukoplakia, 52 debris removed, 52 surface reepithelialized, 52 tongue blade, spot size, 40 vaporization, tissue over duct. 40 vital staining. 37-39 Palate papillary hyperplasia of. 42 postoperative tonsillar hypertrophy, 104, 104-105 Papilloma, 55-62 carbon dioxide laser. 58 clinical, laboratory evaluation, 57-58 epithelial hyperplasia, lateral tongue. 58 gingival site. 59 infection, pathophysiology of. 57 active expression phase. 57 inoculation, 57 laryngeal. CO, laser. 125 examination findings, 122. 125 healing sequence. 123. 125 history. 122-123, 125 laser type. 125 parameters, 125 treatment. 125 Up no recurrence. 59 site, 59 virology, 55-56 DNA organization, 55, 57 taxonomy, 55, 56 viral genetic function. 55 Papillomatosis, renal transplant recipient.
(,l> 61

Hazards, laser surgery (Continued) plume hazards. 16 skin hazards. 12-14 Heliotherapy. 165 Hemangioma laryngeal, CO, laser. 122-126 malformation. 71 subglottic. CO, laser. 122-126 Hematoporphyrin derivatives, 138 Histology, pulpal. 129 History, of lasers, I Holmium. yltrium-aluminum-garnctt. See Ho: YAG laser "Hosaka window" approach, endoscopic sinus surgery. 160 Ho:YAG laser. 4, 35 temporomandibular joint surgery', energy levels for, 35t Human papillomavirus, 55-62 carbon dioxide laser. 58 epithelial hyperplasia, lateral tongue. 58 evaluation, clinical, laboratory, 57-58 infection, pathophysiology of, 57 active expression phase, 57 incubation phase. 57 inoculation. 57 virology, 55-56 DNA organization, 55,57 taxonomy, 55, 56 viral genetic function, 55 Hyperthermia, biologic effects. 145-146 Imaging-guidcd minimally invasive therapy. photolhermal therapy. 146-148 Impacted teeth, exposure of, 69 Incubation phase, papillomas, human papillomavirus. 57 Inoculation, papillomas, human papillomavirus, 57 Intralesional photocoagulation. 30-31 Irradiance CO, laser, 22-23 defined, 183 Judgment errors, in laser surgery. 11-12 KTP laser. See Argon, frequencv-doublcd Nd:YAG laser I^ibiobuccal sulcus, vascular malformation of, 33 luibiobuccal vestibule, vascular malformation, 29 Laryngeal hemangiomas. CO. laser. 122-126 laryngeal surgery, CO, laser. 121-126 case presentations, 125 cysts, laryngeal, 123 granuloma. 123 hemangiomas, laryngeal, subglottic. 122-126 laryngeal hemangiomas, 122-126 neoplasms, malignant. 123-125 papilloma. 121-122, 125 examination findings, 122, 125 healing sequence, 123, 125 history. 122-123. 125 laser type. 125 parameters. 125 treatment. 125 Reinke's edema. 123 T, glottic carcinoma. 125 examination findings. 124. 125 healing sequence, 124, 125 history. 124. 125 laser type. 125 parameters, 125 treatment, 125 vocal Ibid polyps. 123

maxillary alveolus, palate, after treatment. 60 recurrent disease, 61 Paranasal sinuses, coronal view of, 157 Photobioactivation. 165-172 analgesia, laser-mediated, 167. 169-1701 background, 165-166 cellular effects, 167-171 controversy, 166-167 current research, 167-171

Index
exposure to cellular processes, liming. 171 heliotherapy. 165 laser parameters. 167 low-intensity laser therapy. 166 parameters. 167 repetition rates, effects of. 171 research. 171 ultraviolet therapy. 165 wavelengths, simultaneous multiple, effects of exposure to, 171 wound healing. 167. I68t Photodiagnostic imaging. 140 Pholodynamic therapy. 137-140 Photooxygenation. mechanisms of. 137-138 Photosensitizers. 139-140 Phototherapy with dyes. 137-142 definilions. 137 dyes. 138-139 hematoporphyrin derivatives. 138 history. 137 light sources. 139-140 overview. 140-141 photodiagnostic imaging. 140 pholodynamic therapy. 137-140 photooxygenation. mechanisms of. 137-138 photosensitizers. 139-140 rhodamine dyes absorption spectrum. 139 molecular structure, 139 Photothernial therapy, cancer. 143-149 background. 143-144 hyperthermia, biologic effects. 145-146 imaging-guided minimally invasive therapy. 146-147. 48 laser tissue effects, 144-145 overview. 147-148 Pigmented lesions, benign. 82 Plume hazards, in laser surgery. 16 Power, defined. 183 Prencoplasia, oral cavity. 37-53 buccal mucosa. 50-51 epithelialization, 51 first raster, 50,51 mucosa, healing, 50 postoperative. 51 second raster. 51 CO, laser. 39-41 outline of lesion with. 42 duel, lesion over. 40 erthroplakia. ventral tongue, 38 fibrin coagulum, 41, 43 healing. 43 laser handpiece, positioning. 45 laser wound, soft tissue. 41 leukoplakia. 43-44. 48-49 lingual gingiva. 48-49 lip leukoplakia, with dysplasia. 45-47 mouth. 48-49 front surface mirror, to redirect beam, 48 lingual gingiva, ablation. 48 postoperative. 49 sulcus, ablation, 48 multicentricity, 38 nodular leukoplakia, buccal mucosa. 38 palate, papillary hyperplasia of, 42 rccpitheliali/ation complete. 43 results. 43 surgical technique. 41-42,43 tongue, leukoplakia, 52 debris removed, 52 surface reepithelialized, 52 tongue blade, spot size. 40 vaporization, tissue over duct. 40 vital staining. 37-39 PRR. See Pulse repetition rale Pulse repetition rate, defined. 183 width, defined. 183 Reinke's edema. CO, laser, 123 Renal transplant recipient, papillomatosis, 60-61 maxillary alveolus, palate, after treatment. 60 recurrent disease. 61 Retinal burns. Nd:YAG-induced, 12 Rhinophyma, 80 Rhodamine dyes absorption spectrum. 139 molecular structure, 139 Safety, with laser. 11-17 goggles, wavelength specific, 14 hazards, laser surgery. 11-16 electrical hazards, 16 fire hazards, 14-16 judgment errors, 11-12 optical hazards. 12. 13-14 plume hazards. 16 skin hazards. 12-14 retinal burns, Nd:YAG-induced, 12 Sciatic nerve, tissue fusion, 177 Skin hazards, in laser surgery, 12-14 resurfacing, in aesthetic surgery. 79 Sleep apnea syndrome, laser-assisted uvulopalaloplasty. 111-120 contact Nd:YAG. 119 incisions. 117 indications, 111 multiple sessions. 113 "multiple-stage" technique. 112-113 one stage. 114 operative outcome. 114 overview, 116 procedure, description. 112-114 "single-stage" technique, 113-114 uvulopalatopharyngoplasty, compared. 111 Snoring, uvulopalatoplasly. 111-120 contact Nd:YAG, 119 indications, 111 laser-assisted UPPP. 112 LAUP multiple sessions. 113 one stage. 114 "multiple-stage" technique. 112-113 nonapneic snorer. 114-115 operative outcome. 114 overview. 116 procedure, description. 112-114 "single-stage" technique, 113-114 uvula, vertical incisions, 117 Soft tissue excision. 63-83 clinical laser application, overview. 63 CO, laser excisional procedures, 65 incisional procedures, 63-65 frenectomy, 63-64 vcslibuloplasty, 64-65 as vaporization instrument. 72 combination uses. 80 rhinophyma. 80 complications. 83 ear tag. 68 epulis lissuratum. 81 facial nevi, 78 fibrocpilhelial hyperplasia, palate. 75-77 fibroepithelial polyp, 67 fibroma. 66

187

gingiva grafting. 70 hypertrophy. 73 severe, 74 hemangiomas malformation. 71 impacted teelh, exposure of, 69 mucocele, 82-83 aphthous Momaritis, 82-83 benign pigmented lesions, 82 skin resurfacing, in aesthetic surgery, 79 vascular malformation, 71 wound care. 83 Spot size, defined. 183-184 Stomatitis, aphthous. 82-83 Subglottic hemangioma, CO, laser. 122-126 Sublethal unjury. zone of, defined, 184 Submandibular duct, transoral resection, oral cancer. 88 Surgical lasers, physical considerations. 1 -9 contact laser surgery. 8-9 electromagnetic spectrum, 2 energy state, diagram, 2 free-beam lasers, 8-9 contact laser surgery, vs. noncontact. 8 modification. 8-9 history. I light, 1,2 absorption, composite tissue, 7 tissue, interactions, 6 overview. 1-5 argon, 4 characteristics. 3t CO, laser, 2-4 components, 3 diode laser, 4-5 Ho: YAG laser, 4 Nd:YAG laser, 4 power/depth, 7 temperature/depth. 7 temperature gradients, in tissue. 5 thermal laser-tissue effects. 5-7 T, glottic carcinoma, C 0 laser, 125 examination findings. 124, 125 healing sequence 124, 125 history, 124, 125 laser type. 125 parameters, 125 treatment. 125 Telangiectasias. 34 Temperature gradients, in tissue, 5 Temporomandibular joint surgery. 151-155 case study, 153. 154 Ho:YAG laser. 151-152 meniscus, anterior, medial dislocation of. 153 overview. 154-155 Thermal laser-tissue effects, laser, 5-7 Thermal relaxation time, defined. 184 Tissue fusion. 173-176 mechanism. 174 sciatic nerve. 175 in vivo studies. 176-177 light absorption, 7 interactions, 6 temperature gradients in. 5 Tongue, leukoplakia. 52 debris removed. 52 surface reepithelialized. 52 Tongue blade, spot size, 40 Tonsillar hypertrophy, postoperative, transoral resection, oral cancer, 104-105 Tooth. See also Dentistry impacted, exposure of. 69
2

188

Index time at operation. 88 tongue cancer, primary closure. 99 contact Nd:YAG laser scalpel. 100-101 free beam CO 96-98 motion, restricted, 106 tonsillar hypertrophy, postoperative, 104-105 tumor debulking, CO, laser, 108 Tumor debulking. CO, laser, transoral resection, oral cancer. 108
:

Transoral rcsoclion. oral cancer. 85-109 buccal mucosa. 102-103 with proliferative granulation tissue. 107 CO, laser. 87 vs. contact Nd:YAG. 87. 89 free beam. 86. 96-98 tumor debulking. 108 complications. 88 consequences, 87-88 contact Nd.YAG. 87 dry field. 86-87. 101 general anesthesia, avoiding. 87 surgical protocol, 87 mouth, floor of. 90-93.94-95 aftercare. 95 lingual anterior mandibular gingiva. 94-95 technique 90-93,94 palate, postoperative tonsillar hypertrophy. 104-105 proliferative granulation tissue buccal mucosa, 107 submandibular duct, 88 surgical cases. 89 survival. 85-86

operative outcome. 114 OSAS patients. 114 overview, 116 personal series, results of. 114-115 procedure description, 112-114 "single-stage" technique, 113-114 uvulopalatopharyngoplasty, compared. 111 Vaporization, zone of. defined. 184 Vascular malformation. 71 labiobuccal sulcus, 33 Vcstibuloplasty, with CO, laser. 64-65 Viral genetic function, papillomas. 55 Virology human papillomavirus, 55-56 papillomas. 55-56 Vocal fold polyps, C 0 laser, 123
2

Ultraviolet therapy. 165 UV. See Ultraviolet therapy Uvulopalatoplasty, 111-120 case study. 116 contact Nd:YAG, 119 incisions. 117 indications. 111 I.AUP multiple sessions, 113 one stage, 114 "multiple-stage" technique. 112-113 nonapneic snorers. 114-115 obstructive sleep apnea syndrome. I IS

Wound healing, photobioactivation and, 167, I68t Zones of coagulation necrosis, defined. 184 of sublethal unjury. defined. 184 of vaporization, defined. 184