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Dated:-18-09-2013Lasers and Dental Implants: An Interview with Dr. Robert J.

Miller
Introduction
Dr. Robert J. Miller is a graduate of the New Yor !niversit" #ollege of Dentistr" and $ompleted a general
pra$ti$e residen$" at %lushing &ospital and Medi$al #enter. 'rior to attending dental s$hool( Dr. Miller
earned )a$helor of Arts and Master of Arts degrees in biolog". &e is a board $ertified Diplomate of the
Ameri$an )oard of *ral Implantolog"+Implant Dentistr" and is in private pra$ti$e in Delra" )ea$h at ,he
#enter for Advan$ed Aestheti$ and Implant Dentistr". Dr. Miller serves as $hairman of the Department of
*ral Implantolog" at the Atlanti$ #oast Dental Resear$h #lini$ in 'alm )ea$h( %lorida. You $an find out
more about Dr. Miller at: http:++www.robertmillerdds.$om+
Interview
Osseonews: Dr. Miller( do "ou believe that lasers have a pla$e in implant dentistr"-
Dr. Miller: If we $ompare the use of lasers to the traditional surgi$al approa$h using .$old surgi$al steel/(
lasers $learl" are the better $hoi$e. !sing a laser to perform implant surger" enables us to prepare the
implant site with minimal trauma to the hard and soft tissue. In fa$t( I would more properl" $hara$teri0e this
approa$h to surger" as atraumati$.
Osseonews: #ould "ou e1plain that a little further.
Dr. Miller: 2ith a laser( I $an target the tissue to be removed. I will not disrupt or damage the surrounding
tissue. ,he removal of both soft and hard tissue is pre$ise and minimall" invasive. You $annot a$hieve the
same results with a s$alpel blade.
Osseonews: Do "ou use a surgi$al guide stent to guide "our laser-
Dr. Miller: ,he patient gets a #one )eam 3olumetri$ ,omograhi$ s$an. I use this to generate a highl"
a$$urate surgi$al stent to pre$isel" guide the laser beam. ,his pro$edure is a$$urate to one tenth of a
millimemter 45.65 mm7. ,his is minimall" invasive dentistr" at its best.
Osseonews: &ow does the surgeri0ed tissue respond-
Dr. Miller: Another great benefit of laser surger" is that it $ompletel" re8engineers the wound healing
pro$ess. 2e ablate onl" the target tissue. 2e do not unne$essaril" damage ad9a$ent tissue. ,his redu$es the
$ompli$ations of wound healing. Laser surger" dramati$all" redu$es or eliminates the inflammator"
response. It also promotes the release of en0"mati$ inhibitors of the inflammator" pro$ess. Lasers have
ba$teri$idal properties whi$h virtuall" eliminate the problems of infe$tion. %inall" it stimulates the healing
of hard and soft tissue. ,he end result of this t"pe of surger" is stellar wound healing. ,here is nothing else
in this league.
Osseonews: 2hat is the potential for $ompli$ations-
Dr. Miller: :ver" surgi$al modalit" has the potential for $ompli$ations. )ut with this ind of laser surger"(
$ompli$ations are minimal be$ause we target spe$ifi$ tissue and sites with great a$$ura$".
%or e1ample( suppose I am doing an osteoplast" around the $ervi$al area of a tooth. If I inadvertantl" point
the laser at the tooth( I ma" affe$t the root surfa$e. I prevent this b" $arefull" dire$ting the laser energ". As in
the use of a high speed handpie$e( if "ou point the laser at non8target tissue( "ou will dire$t laser energ"
where "ou do not want it to go. 2ith $areful planning and 9udi$ious use( this 9ust does not happen.
Osseonews: 2hat t"pes of lasers do "ou use-
Dr. Miller: I $urrentl" use three lasers:
810 nm Diode Laser
940 nm Diode Laser
2780nm Er,Cr;YSGG laser [Erbium,Chromium;Yrium,S!andium,Gallium,Garne"
,he :r(#r:Y;<< laser 4)iolase ,e$hnologies7 $uts hard and soft tissue. It primaril" targets tissue that
$ontains water or h"dro1"apatite. You $an use this for man" purposes in$luding soft+hard tissue surger"(
preparing teeth for restorations( endodonti$s( and treatment of periodontal po$ets. ,his a$$ounts for about
=5> of the maret share for high level lasers.
Diode lasers target pigmented tissue or tissue $ontaining hemoglobin or o1"hemoglobin. It has little effe$t
on hard tissue. ,he ?@5 nm Diode laser $uts soft tissue lie a s$alpel blade and $an be used without an
anaestheti$. ,he =65 nm Diode laser is also a soft tissue laser and $an be used to biostimulate soft and hard
tissue. In published studies( laser treated osteotomies heal more Aui$l" and demonstrate a greater
per$entage of bone to implant $onta$t.
Osseonews: Dr. Miller( $an "ou give us an idea of some of the more important uses of lasers in dentistr"-
Dr. Miller: M" pleasure to do so. I hope that I $an give "our readers some idea of how useful lasers are in
man" areas of dentistr".
#n!o$erin% im&lans in Sa%e '' sur%er() *his &ro!edure is araumai! and hel&s o &re$en !resal
bone remodelin%
+e!onourin% %in%i$al issue and s!ul&in% emer%en!e &ro,ile ,or &roshei! !om&onens
+aisin% sur%i!al ,la&s
-sseous re!onourin%
Creain% &araboli! issue ar!hie!ure) *his !an be done &re.o&erai$el( or &os.o&erai$el( a,er
im&lan &la!emen
/one har$esin% ,or blo!0 %ra,s
Laeral 1all sinus %ra, 1indo1s
+id%e s&liin% ,or e2&ansion
Disra!ion oseo%enesis
Debridin% e2ra!ion sies ,or immediae im&lan &la!emen) Sin!e laser sur%er( is ba!eri!idal,
in,e!ed im&lan sies !an be relie$ed o, &aho%eni! ba!erial load and a&i!al %ranulomas
3blain% diseased 4un!ional e&ihelium
/iosimulaion ,or so, and hard issue healin%
+emo$in% !al!ulus and &la5ue ,rom im&lan sur,a!es 1ihou dama%in% he im&lan ,i2ure or
!om&onens)
*reamen o, &eri.im&laniis
Osseonews: #an the laser be used to remove failing implants-
Dr. Miller: ,his is a ver" important use for lasers. In $ases lie this we want to remove the implant with
minimal damage to the ad9a$ent soft and hard tissues. ,his is far better than using the traditional approa$h of
trephining the implant bod".
It is important to note that the laser approa$h will be atraumati$. 2e will not damage the ad9a$ent bone or
soft tissue. 2e will not overheat the surrounding bone whi$h would $ause problems postoperativel". ,he site
will not be $ontaminated with titanium fragments or filings be$ause we are not going to $ut the implant or
grind it. ,he laser energ" has ba$teri$idal properties whi$h will eliminate pathogeni$ ba$teria from the site.
After removing the implant and debriding the site( we $an stimulate the healing of the soft and hard tissues.
,he laser $onfers ultimate $ontrol of the operating field whi$h is $riti$al in $ases lie this.
Osseonews: 2hat is the best sour$e of training in laser dentistr"-
Dr. Miller: I re$ommend the 2orld #lini$al Laser Institute 42#LI7 at http:++www.learnlasers.$om+. ,his is
the largest laser training institute in the !nited ;tates. I would also re$ommend the A$adem" of Laser
Dentistr" at http:++www.laserdentistr".org+. It is important that "ou learn how to use the laser before "ou start
using it in $lini$al pra$ti$e. ,hese both offer e1$ellent training programs.
In :urope I re$ommend the International ;o$iet" for *ral Laser Appli$ations http:++www.sola8int.org+. I am
a member of the ;*LA :1e$utive )oard.
OsseoNews: Dr. Miller( thans for "our time.
Interview conducted by:
<ar" J. Baplowit0( DD;( MA( M :d( A)<D
:ditor8in8#hief( www.osseonews.$om
Cone /eam C* 'ma%in%, Denal 'm&lan 'ner$ie1s, Laser Denisr(, Sur%i!al Guides ,or 'm&lan 6la!emen
78 Commens
35 thoughts on Lasers Role in Implant Dentistry: An Exclusive
Interview
1) Javier Higuera sa(s9
:ul( 71, 2007 a 9944 &m
I use lasers sin$e 6???. I use :r:YA< for hard tissues and ;urgi$al Diode for soft tissues.
I ussuall" mae the in$ission with the Diode Laser without flap( no pain( no infe$tion and atraumati$.
I also use a ,herapeuti$ Laser after implant surger" to minimi0e postoperative pain and stimulate
osseointegration
,he future of dentistr" is in Lasers.
)est Regards to ever"one at *sseonewsC
2) Johndds sa(s9
:ul( 71, 2007 a 10974 &m
I am a 'eriolase owner. I $anDt sa" it has been good for m" implant side of m" pra$ti$e sin$e we now
are helpng people eep their teeth. I have posted some E8ra"s of F of m" $ases here. ,hese are 9ust
E8ra"s but the 'erio 'robings are even more in$redible
http:++ddsgadget.$om+implant$ases+-$atGH?
I L*3: the 'eriolase
7) 6in%ba!09 'm&lans and Lasers ; *he Denal 'm&lan /lo%
4) Dr. Mehdi Jafari sa(s9
3u%us 2, 2007 a 8920 am
,itanium as a metal e1hibits refle$tivit" to in$ident light energ". 2ith regard to the wavelengths of
$urrent lasers( the refle$tivit" is lowest in the range H=58?55 nm( rising as the wavelength in$reases
towards 65(I55 nm 4Re$hmann '( ;adegh &( <oldin D( &ennig ,. ;urfa$e morpholog" of implants
after laser irradiation. Dts$h JahnKr0tl J L555M NN: FH6OFHI7.,his would suggest that shorter
wavelengths are most damaging( as the low refle$tivit" would allow greater heat effe$ts to build up.
&owever( there is eviden$e to suggest that the diode wavelength group delivered in low power #2
values 468L 2atts average power7( $ause minimal damage to the implant or surrounding bone. ,his is
e1plained b" the fa$t that the Nd: YA<( :r(#r:Y;<< and :r:YA< emission modes 4%R'7( result in
high pea power values and heat produ$tion more than several hundred degrees #elsius. Laser use in
implantolog" has been histori$all" $ontroversial. 2hilst there is a general a$$eptan$e that lasers are
$apable of a$$urate $utting of materials and tissue( there is no eviden$e8based advo$a$" as to the use
of an" laser wavelength in produ$ing a full"8prepared osteotom" site for the pla$ement of root8form
dental implants. &owever( there are some reports of the use of erbium YA< and erbium Y;<< lasers
to establish a $ontrolled in$ision of overl"ing gingival tissue and to initiate a brea$h of the $orti$al
bone plate( prior to the use of $onventional implant drills. ;u$h te$hniAues( although intrinsi$all"
$orre$tl" based on predi$table laser8tissue intera$tion( run the ris of septi$ism amongst
pra$titioners more allied to a $onventional surgi$al approa$h to implant pla$ement. 2ith all other
predisposing fa$tors addressed( the fundamental e" to su$$ess in implant surger" is the apposition
of normal healing bone onto the implant surfa$e. 2hile using a laser beam around an implant(
demands a te$hniAue whereb" the lo$al temperature does not e1$eed @H degrees $entigrade( whi$h is
$lini$all" hard to prove. An" therapeuti$ use of lasers in implant dentistr" must address this fa$t that
the prime intera$tion in laser use results in the $onversion of in$ident ele$tromagneti$ energ" into
heat energ". As far as the $lini$ian is $on$erned( the possibilit" of implant surfa$e damage arising
from in$ident laser light must be avoided b" an" means( and the soft and hard tissues around it as
well.
8) Bret Dyer sa(s9
3u%us 8, 2007 a 8988 &m
Dr. Miller I en9o"ed "our interview. *n the Auestion of erbium lasers $reating thermal damage on
implants and the ad9a$ent tissue( that has been evaluated. A pubmed sear$h will reveal arti$les b"
;$hwar0( Matsu"ama( and others that demonstrate in vitro that erbium lasers $reate a bio$ompatable
surfa$e on implants for fibroblasts and osteoblast. In vivo studies have also demonstrated no thermal
effe$t to the implant or the ad9a$ent tissues. Rather an" solid instrument $ontaminates and alters the
implant surfa$e negativel". #hemi$al treatments have not been shown to $reate predi$table
debridement or bio$ompatibilit". ,o date( the most effe$tive and the safest wa" to treat an
ailing+failing implant is with an erbium laser. Dr. MillerDs stud" demonstrated that laser e1posure of
implants before restoration prevents future bone loss around the ne$ of the implant. #ontouring the
sul$us around an implant before final seating of the abutment and restoration prevents pressure
ne$rosis and preserves the papillae.
Indeed using $onventional drills $reates a $on$ern for temperature rising in the bone during
implantation. !sing a drill or dis for bon" e1pansion pro$edures is mu$h more liel" to damage
ad9a$ent $orti$al bone than a laser in$ision through bone. ,his has also been shown in the literature
4loo up Bimura( 2ang( and a host of others7.
I would be $on$erned about $reating an osteotom" with a laser. Not from a thermal standpoint. More
from a pre$ision point of view.
<) Robert J. Miller sa(s9
3u%us 8, 2007 a 9912 &m
In a re$ent published stud"( I $ompared the traditional $hemotherapeuti$ modalit" of treating the
ailing implant to laser debridement 4.,reatment of the #ontaminated Implant ;urfa$e !sing the
:r(#rMY;<< Laser/( Implant Dentistr" L55@M@(6IN86H5. :rbium based lasers are demonstrabl"
superior to $itri$ a$id as proposed b" Roland Meffert for the past de$ade. 2e have shown that the
:r(#r laser $an be safel" used dire$tl" on the implant surfa$e( and has the $apabilit" to remove an"
adherent material( in$luding appositional plasma spra"ed surfa$es be$ause of its high absorption
spe$trum in &A. In other studies( in$luding one presented at the re$ent ;*LA $onferen$e in
)elgium( resear$hers at the !niversit" of 3ienna 4)eer( ;$hoop( Morit07( showed that erbium lasers
a$tuall" D:#R:A;: the temperature of the surfa$e of the implant over time. *n the other hand(
NdMYA< is $ontraindi$ated on the implant surfa$e be$ause of its high thermal $oeffi$ient O it melts
the implant surfa$e and $an fuse $over s$rews. Refle$tivit" is N*, a valid measure of temperature
$oeffi$ient( but rather the pulse mode and wave shape of the laser energ".
2ith regard to preparation of the osteotom"( in thin ridges( where drills ma" fra$ture thin fa$ial
plates( the laser is an ideal modalit" for prote$ting thin bone" plates and preparing them for implant
pla$ement or further e1pansion with $hisels+osteotomes.
7) DR Stewart Rosenberg sa(s9
3u%us 9, 2007 a 9947 am
I read with interest the e1$ellent interview with Dr. Robert Miller and was about to $omment last
night when we had a power outage. I was pleasantl" surprised this morning to see the posts b" Dr.
D"er and Miller des$ribing the literature relating to the use or :rbium lasers in implantolog" that I
was about to Auote. ;o I now I need onl" sa" that I agree with Dr. MillerDs and D"erDs dis$ussions
$ompletel". As a pioneer in the use of dental lasers going ba$ to 6?=N I have . after using ever"
wavelength available settled on the :r(#r:Y;<< laser as m" laser of $hoi$e $oupled with a diode for
biostimulation to "ield dramati$all" faster healing and la$ of post operative seAuela. &aving read
Dr.MillerDs arti$le on treating failing implants in L55@ I have been using the te$hniAue des$ribed with
remarable su$$ess to save implants I believe would have been lost using an" other te$hniAue. ,he
:r(#r:Y;<< has been demonstrated in the literature to a$tuall" der$rease pulpal temperature b" L
degrees when used for $avit" preparations and ane$dotall" in numerous in$iden$es in our pra$ti$e
over the last few "ears I have seen onl" positive results $lini$all" on implants. ,hat would not be the
$ase with .hot/ $utting lasers su$h as #*L( Nd:YA<( Argon. or diodes in a $utting mode.
I have also witnessed personall" Dr. Norberto )erna( of Rome( Ital"( perform a $omplete osteotom"
and immediate implant pla$ement using an :r(#r:Y;<< laser and a series of patented 9igs or guides .
And he did it without lo$al anesthesiaCCCC
,he laser is also wonderful as a laser ostoetome to aid in the atraumati$ e1tra$tion of anterior teeth
prior to implant pla$ement to avoid fra$ture of the thin bu$$al plate of bone. I have several $ase
studies using this te$hniAue soon to be published.
In $losing I applaud Dr. Miller for his innovations in the use of lasers in implantolog". &Is efforts
have made it mu$h easier( more predi$table( and far less un$omfortable to a$hieve e1$ellen$e in our
implant $ases.
8) johndds sa(s9
3u%us 9, 2007 a 1947 &m
DR ;tewart Rosenberg ;aid
,hat would not be the $ase with .hot/ $utting lasers su$h as #*L( Nd:YA<( Argon. or diodes in a
$utting mode.
:ven though the 'eriolase is an Nd:Yag it has a dut" $"$le of .L> that means that it is off for over
??.=> of the time. ,his allows the tissue to rela1 and $ool. 'eriolase owners have found the LANA'
proto$ol helps with peri implantitis.
9) Robert J. Miller sa(s9
3u%us 9, 2007 a 8920 &m
Dr. Rosenberg $orre$tl" states that in .$utting mode/( the Nd:YA<( #*L( Argon and diode lasers are(
in fa$t( high thermal $oeffi$ient lasers. ,his supports m" thesis that it is pulse and wave form that
determines the thermal $oeffi$ient of laser energ"( not wavelength. As we be$ome more astute with
regard to laser intera$tion with both hard and soft tissue( we will be able to titrate the affe$t of
targeted mon$hromati$ energ". ,he bod" of nowledge with regard to lasers in dentistr" and
medi$ine is now @5 "ears old. *ur abilit" to target spe$ifi$ tissue and to biomodulate metaboli$
pro$esses has finall" mat$hed our enthusiasm in the use of this modalit". #ontrol of periodontal
disease( true ba$terio$idal ill( biostimulation( non8surgi$al po$et redu$tion( and a host of parallel
pro$edures will help us to rewrite the te1tboos on treatment of dental disease. 2e meet the
reAuirements for both eviden$e8based and minimall" invasive dental treatment. If "ou have not "et
attended a laser program( itDs time to give this modalit" serious $onsideration. RJM
10) Horneman sa(s9
3u%us 12, 2007 a 10928 am
I wonder or dr Miller does his whole implantbedpreparation with the laser or 9ust the pilot drilling-. I
use the er8"ag laser onl" for pilotdriling( but I lie to now in whi$h wa" "ou $an do the whole
preparation with the laser. Is the tri$ in the template "ouDve let fabri$ated. I also use the diode laser
for $utting the gingiva. ,he" advise me to use a hot tip( be$ause the laserenerg" wouldnDt travel to
deep into the surrounding tissues due to de $arbonisation. )ut most of the $lients feel pain 4 as a
result of the $arbonisation7 and I have to use anestheti$s. I use the diode laser in a $ontinuous wave
setting. Is it better not to use a hot tip and use a $hopping setting-
,. &orneman
11) Dr. Mehdi Jafari sa(s9
3u%us 12, 2007 a 10907 &m
A group of investigators studied the appli$ation of :rbium: YA< lasers for se$ond8stage implant
surger". ,went" patients were studied with a total of N5 implants in whi$h osseointegration was
$omplete. ,he sub9e$ts were divided into two groups: a $ontrol group 465 patients with LN implants7(
sub9e$ted to $onventional se$ond stage surger"M and a group of 65 sub9e$ts 4also with LN implants7
treated with the :r: YA< lasers at se$ond stage implant surger". ,he use of :r: YA< lasers obviated
the need for lo$al anesthesia and minimi0ed postoperative pain and time needed before starting the
se$ond stage. 2ith regard to surgi$al duration( Aualit" of hemostasis( and su$$ess in implant
treatment( N* DI%%:R:N#:; were reported. In the se$ond stage of implant surger"( different t"pes
of laser have been used( taing advantage of their ba$teri$idal effe$tM disadvantages arise from
indu$ing damage to the implant surfa$e and adverse thermal effe$ts. ,he" $on$luded that advantages
afforded b" laser treatment in$lude te$hni$al simpli$it"( the possibilit" of obviating lo$al anesthesia(
absen$e of postoperative pain and edema( and $omplete tissue healing( thus fa$ilitating faster
prostheti$ rehabilitation( but the" insisted that the des$ribed te$hniAue $an be used in all $ases
:E#:', situations where estheti$ $onsiderations prevail in anterior areas( or in the event of a la$ of
eratini0ed gingiva surrounding the implant. 4Josep Arnabat8DomPngue0( et al. IN, J *RAL
MAEILL*%A# IM'LAN,; L55FM 6=:65@O66L7.
12) Dr. Mehdi Jafari sa(s9
3u%us 17, 2007 a 1297< am
,he appli$ation of high8energ" lasers in dentistr" reAuires spe$ial $onsideration of potential riss of
inadvertent tissue and material damage. 2ith regard to the treatment of periimplantitis( the riss
relate to possible implant surfa$e alterations and e1$essive heat generation in the peri8implant bone.
,he diode laser is the onl" laser t"pe whi$h( irrespe$tive of the power densit"( does not adversel"
influen$e stru$tural implant surfa$e $hara$teristi$s 4Breisler( Me t al. 4L5567 :ffe$t of the Nd: YA<(
&o: YA<( :r: YA<( #*L and <a Al As laser irradiation on surfa$e properties of endosseous dental
implants. Medi$al Laser Appli$ations 6I: 6NL7. ,his is not a result of its spe$ifi$ wavelength( as the
refle$tion $apa$it" of titanium for light of =55 nm is even lower than for light of 65I@ nm 4Nd:YA<7(
L655 nm 4&o:YA<7( L?@5 nm 4:r:YA<7( and 65 I55 nm 4#*L7( leading to higher energ" absorption
4Re$hmann( ' et al. 4L5557 Jur *berflK$henmorphologie von Implantaten na$h Laserbestrahlung.
Deuts$he JahnKr0tli$he Jeits$hrift NN: FH6OFHI7. 'ulsed lasers 4YA< and #*L lasers7 with
$onsiderable energ" peas are $apable of generating power densities higher than 65I 2+$mL(
indu$ing plasma formation 4so8$alled photoplsmol"sis phenomenon7 and alteration of light refle$tion
in the superfi$ial la"ers of metals 45.6O6.5 Qm7. ,hese e1tremel" high temperatures rea$hed during
this pro$ess( however( are( to a large e1tent( restri$ted to the area of laserOmetal intera$tion. A slow
but stead" warming of the metal bod" $an be observed and $onsiderable temperature elevations $an
be re$orded even in remote parts of the ob9e$t. Regarding the biologi$al effe$ts of e1$essive heat
generation( it must be taen into $onsideration that this pro$ess might impair wound healing.
Moreover( possible laser effe$ts on implant surfa$es with regard to ba$terial re8$oloni0ation and new
$ellular atta$hment reAuire further resear$h.It is feasible that( similar to the influen$e of different
sterili0ation pro$esses( lasing titanium or h"dro1"apatite surfa$es might affe$t new adhesion of
periimplantitis8relevant pathogens.
17) Robert J. Miller sa(s9
3u%us 17, 2007 a 8972 &m
,o Dr. &orneman: 2e will o$$asionall" use the :r(#r laser to perform our $omplete osteotomies in
D@ bone to prevent mi$rofra$turing of the thin trebe$ulae. Most of the time( however( we use it to
start the ostetomies( preserve the fa$ial plates b" doing a .D/ shaped preparation with the flat
towards the fa$ial and then e1panding the ridge. 2ith regard to "our diode laser( the reason "our
patients need anaestheti$ is that "ou are using it in $ontinuous wave mode. 2ith the proper pulsed
mode( "ou will get thermal rela1ation( e1$ellent $utting( hemostasis( and a la$ of $arboni0ation
whi$h allows "ou to travel deeper in the tissue. Also( the sele$tion of diode wavelength 4=65( ?@5(
?=5nm7 will also mae a differen$e with regard to hemoglobin and o1"hemoglobin $ontaining
tissues. 2e use a ?@5nm for $utting and =65nm for photobiomodulation.
14) Robert J. Miller sa(s9
3u%us 17, 2007 a <902 &m
I am familiar with the studies "ou Auote. Dr. Arnabat is a $lose personal friend of mine and I was
present when he presented his paper on Lnd stage un$overing of implants using lasers. &owever( the
$on$lusion he rea$hed was flawed. ,his is be$ause in all $ases the" ablated the healed atta$hment
apparatus around the ne$s of the implants. ,his $auses api$al reatta$hment of the 9un$tional
epithelium whi$h results in a violation of biologi$al width and resultant $restal bone remodeling.
2hen he looed at our studies and modified his te$hniAue to avoid traumati0ing the mature hemi8
desmosomal atta$hment( he had ):,,:R results using the laser. &e now le$tures on using our
te$hniAue and is publishing his new stud".
2ith regard to using lasers in the aestheti$ 0one( it is demonstrabl" superior to traditional surgi$al
te$hniAues. ,his is be$ause we dramati$all" redu$e or eliminate the inflammator" response. ,his
prevents the produ$tion of matri18metalloproteanases 4$ollagenase( gelastase( elastase( protease7
whi$h brea down soft tissue( $ause edema+er"thema( and have an osteopromotive effe$t on
osteo$lasts. Lasers will remove tissue fragments+smear la"er( have ba$terio$idal properties( and have
a biologi$al stimulator" affe$t of hard+soft tissue 4photobiomodulation7 whi$h $omes from the
orthopaedi$ literature.
2ith regard to peri8implantitis treatment( a high thermal $oeffi$ient is not ne$essaril" bad. ,he first
published reports were using a #*L laser. ,he high spot energ" a$tuall" $auses a deepening of the
titanium o1ide la"er whi$h( when used in invitro studies( a$tuall" in$reases the wettabilit" of the
implant surfa$e( a good thing when tr"ing to .reintegrate/ an implant. 2hen an implant surfa$e is
.surgi$all" $lean/( it offers the best interfa$e for bone regrowth. You M!;, graft these sites or "ou
will get soft tissue reatta$hment rather than reintegration. You re$reate the .ailing/ implant whi$h( if
a pathologi$ pro$ess reo$$urs( Aui$l" progresses to a .failing/ implant. And last( none of the studies
"ou Auote in$lude the :r(#r:Y;<< laser. At LH=5nm( it is the best $ombination of power( hert0 rate(
pulse form( and tip sele$tion for both hard and soft tissue surger". =5> of the world maret for dental
lasers after L5 "ears speas for itself.
18) Jason Luchtefeld DMD sa(s9
3u%us 14, 2007 a 2927 &m
what were the parameters of Nd:YA< when used to fuse the implant-
thans.
1<) Robert J. Miller sa(s9
3u%us 14, 2007 a 8904 &m
,he original Nd:YA< studies were done in a $ontinuous wave mode. 2hile this is fine for soft tissue
ablation( it has an e1tremel" high thermal $oeffi$ient on the implant surfa$e and $an fuse $over
s$rews to the implant bod" 4Roland Meffert( 2#*I( L55F7. %ortunatel"( the new ND:YA<s have a
pulsed mode as well. At the ;*LA $onferen$e in )ruges( )elgium last "ear( a paper was presented
on using the Nd:YA< for Lnd stage implant re$over". L*2 power and pulsed mode to mitigate the
thermal effe$ts on the $over s$rew.
17) Higuera Javier sa(s9
3u%us 14, 2007 a 11907 &m
Dr. Miller( I use Diode Laser for Lnd stage implant re$over". ItDs ama0ing the wa" gingival tissue is
vapori0ed without bleeding and without retra$tion. I have man" do$umentated $ases and I have made
several e1perien$es whi$h I will publish ver" soon.
18) 6in%ba!09 denisr( = /lo% 3r!hi$e = *ai1an Denisr(
19) Robert J. Miller sa(s9
3u%us 1<, 2007 a 10972 am
I refer "ou to the studies b" Dr. Norberto )erna in Rome( Ital". &e has patented a $ad milled devi$e
$ontaining rings of var"ing dimensions that a$t as a guide for the laser tip. An appropriate tip length
is sele$ted and the tip follows the $on$entri$ outline of the ring to depth. It must be noted( however(
that laser prepared osteotomies are N*, as a$$urate as drill prepared. &owever( laser osteotomies
$ontain no smear la"er( so the $ataboli$ phase of bone( mitigated b" bone fragments( is less
pronoun$ed. It will help to prevent fra$ture of thin ridges and( as published in the literature 4<
Romanos( et al7( there will be greater bone to implant $onta$t in laser prepared osteotomies.
20) johndds sa(s9
3u%us 19, 2007 a 7941 am
Dr. Miller
I was thoroughl" impressed with "our le$ture at the 2#MID. Ni$e photograph".
21) Lance sa(s9
Se&ember <, 2007 a 8978 am
I am $on$erned with "our dis$ussion of treatment of ailing+failing implants. Are "ou referring to old
$"lindri$al implant t"pes- &opefull" "ou are not taling about perimplantitis around s$rew t"pe
implants. If so( there is a problem with the implant installation te$hniAue(possibl" over heating the
bone or altering the implant surfa$e. 'eriimplantitis is reall" a thing of the past and was related to
rough surfa$e bullet shaped implants. ,his is wh" the" are off the maret.
22) Robert J. Miller sa(s9
Se&ember 8, 2007 a 7979 am
3irtuall" all of the peri8implantitis treatment we have performed over the last few "ears using lasers
has been on endosseous s$rews. ,he biologi$ pro$ess that leads to the ailing+failing implant $an
o$$ur regardless of the ar$hite$ture and surfa$e t"pe. &ow often do "ou see several millimeters of
$restal bone remodeling around healed implants- ,his atta$hment of soft tissue to the roughened
bod" predisposes the implant to further breadown well after healing. 2e are starting to see the first
big waves of failure of implants N8H "ears after full loading and fun$tion. ,he idea that peri8
implantitis is a thing of the past is an absurd notion. %or those of us who have been pla$ing implants
for an e1tended period of time( we are starting to see our late failures of our $ases. ,hese $ases( in the
earlier stages( $an be ideal $andidates for repair. Not addressing this slow(stead" progression of bone
loss is to $onsidered as supervised negle$t.
27) Robert J. Miller sa(s9
Se&ember 27, 2007 a 1297< am
Just returned from the International ;o$iet" for *ral Laser Appli$ations 4;*LA7 in <reat )ritain.
*ur $olleagues from the !niversit" of 3ienna 4Morit0( )eer( ;$hoop7 presented a stud" that
definitivel" shows that lasers are now the number one indi$ation for treatment of peri8implantitis.
,heir $ontrolled studies and :;:MDs are beautifull" done and there should be no doubt that ablative
laser te$hniAues are demonstrabl" better than all previous modalities in surgi$all" debriding the
implant surfa$e in preparation for grafting.
24) drs. ! sa(s9
>o$ember 11, 2007 a 8918 am
I than "ou for the e1planation for the diode =65 nm. I have also an er8"ag laser and I am stimulated
b" "our interview to use this for rigde splitting(et$. ,ill now I 9ust used it to de$ontaminate implants
in $ase o peri8implantitis( removing third molars and rese$tion of the roottips( with ver" good
woundhealing in even infe$tiious sites. ,his is another well$ome treatment modalit". In m" $ountr"
lasers arenDt mu$h of a $hoi$e in treatments( but I love to use them.
28) Robert J. Miller sa(s9
>o$ember 11, 2007 a <949 &m
Just returned from the 2orld #lini$al Laser Institute $onferen$e in London. *utstanding le$tures on
the use of both :rbium and Diode lasers in endodonti$s. ,he LH=5nm laser is used to remove the
smear la"er following instrumentation using their photoa$ousti$ properties( and the =658?=5 diodes
ill pathogens at depth in hard to obturate a$$essor" $anals( in$luding the most hard" ent. fae$alis.
,he indi$ations for surger"( periodontal therap"( restorative( and endodonti$ dis$iplines 9ust eeps
growing. ,ime for $lini$ians to give this modalit" a ver" serious loo. *ver LN55 peer8reviewed
publi$ations to date on 'ubMed.
2<) "lie#ictor sa(s9
>o$ember 18, 2007 a 8918 &m
,o Dr Robert Miller(
what about the use of laser beam to remove the gingival h"perpigmentations -
27) drs. ! sa(s9
>o$ember 18, 2007 a 4921 &m
2ith lasers "ou $an remove the h"perpigmentations. ,he diodelasers parti$ular rea$t ver" good withe
melanine( but with the $orre$t settings "ou $an use other lasers as well
28) Robert J. Miller sa(s9
>o$ember 20, 2007 a 8920 &m
I refer "ou to a the wor b" Dr. <i0em )er of Anara( ,ure". In a published stud"( the
:r(#rMY;<< laser is used for depigmentation without the need for anaesthesia. You ma" also use
diode lasers( as the" have high absorption in pigmented tissue. )e prepared to use anesthesia as the"
have a relativel" high thermal $oeffi$ient. You must remove the melano$"te $ontaining epithelial
0one or repigmentation ma" o$$ur. *n$e this 0one has been $ompletel" ablated( depigmentaton is
permanent. RJM
29) dr ! sa(s9
>o$ember 22, 2007 a 8907 &m
2hat about post8operative pain- Is the erbiumlaser in this $ase better then the diodelaser- I agree
with RJM in the use of anestheti$s when "ou use a diodelaser( be$ause this is a thermal laser and not
a waterlaser where all the energ" will beabsorbed b" water. In m" e1perien$e the diodelaser is more
ease( be$ause it targets the right $ell8line and in the $ase of ther erbiumlaser "ou rmeove as mu$h
tissue as needed till "ou remove the right la"er of $ells. ;o with the use of the diodelaser I hope I
target the right $ells more then the other $ells. 2hat is "ou Idea about this-
70) Dr. Mehdi Jafari sa(s9
>o$ember 27, 2007 a 2929 am
:1$ision of benign or at"pi$al pigmentations $an leave noti$eable s$ars in $osmeti$all" sensitive and
even other sites and a pat$hwor of eviden$e in some patients. )oth $ongenital and a$Auired
melano$"ti$ h"pera$tivities or pigmentations have been treated with argon( rub"( ale1andrite( Nd:
YA< and ver" seldom( diode lasers( although the latter remains $ontroversial. ,he long8term effe$ts
of laser irradiation on melano$"tes is unnown( as is laser RdebulingD of $ongenital melano$"ti$
naevi 4#MN7 in relation to the ris of malignant melanoma. :ven after multiple treatments of them(
most lesions show repigmentation. ;ubseAuent e1$ision for histologi$al e1amination( freAuen"l"
shows fibrosis and a de$rease in melano$"tes.Introral pigmentations ma" be intrepithelial and+or
within the Lamina 'ropria. As with postinflammator" h"perpigmentation( laser therap" is
unpredi$table and ma" daren lesions.2hile using lasers on melanin pigmented oral lesions
4espe$iall" the heat generating ones7( the $lini$ian should alwa"s be aware of future meta8 or
neoplasti$ $ellular a$tivities at that site.
71) Robert J. Miller sa(s9
>o$ember 2<, 2007 a 498< &m
Argon( rub"( and ale1andrite lasers are no longer used for soft+hard tissue pro$edures. ,he onl" use
toda" for the Argon laser is for $uring of $omposite. You mention the use of lasers for
depigmentation and then mention removal of nevi. ,hese are two definitivel" different lesions( with
pigmentation being a variant of normal tissue( while nevi are $onsidered b" man" pathologists as
pre8malignant. If the melano$"te 0one in normal pigmented tissue is ablated( depigmentation is
permanent. ,he onl" wa" pigmentation $an return is if there is in$omplete removal of
melano$"tes.Diode lasers have an affinit" for melanin $ontaining tissue and preferentiall" ablate
them. &owever( the manner in whi$h the diode tip is brought a$ross the tissue bed leaves a tissue
plane that is relativel" uneven. ,his ma" result in in$omplete ablation of the melano$"te 0one and
repigmentation. *n$e again( "ou did not mention the lasers that represent the largest number of
instuments being used toda"M the erbium famil" and super8pulsed #*L.2ith regard to the
:r.#rMY;<< laser( there is pure ablation without a thermal $oeffi$ient. ,he formation of a fibrous
la"er is s$arring of the tissue and results from a thermal intera$tion. ,he histolog" of the :rbium
treated mu$osal 0ones shows no eviden$e of s$arring and a normal epithelial 0one+thi$ness after
healing.
72) Dr. Mehdi Jafari sa(s9
>o$ember 29, 2007 a 9910 am
<ingival h"perpigmentation is $aused b" e1$essive melanin deposition b" the melano$"tes mainl"
lo$ated in the basal and suprabasal $ell la"ers of the epithelium. ,he melano$"tes are dendriti$ $ells
unatta$hed to the surrounding epithelial $ells that behave as uni$ellular e1o$rine glands.A$tivated
melano$"tes $onvert t"rosine to melanin( whi$h is transferred to the basal and pri$le $ell la"ers.
Most of the melanin and melano$"tes are $on$entrated in the basal la"er and among the epithelial
$ells lo$ated dire$tl" above it( and the laser beam vapori0es the various epithelial levels as far as the
basement membrane.%urthermore( the pain and disturban$e $aused b" the pro$edure( ma" hinder the
$omplete removal of the pigmented gingiva.Laser ablation of gingival melanin pigmentations ma"
lead to devitali0ation of the ad9a$ent teeth( gingival re$ession( damage to the underl"ing periosteum
and bone( dela"ed wound healing( and loss of enamel. ,he $ompli$ations ma" be due to the thermal
effe$ts of the heat generating lasers4e.g. diode laser7( whi$h is reported to sometimes e1tend at tissue
depth into the Lamina propria( resulting in a large volume of $oagulated tissue.In $ontrast to the
alveolar mu$osa( depigmentation of the atta$hed gingiva reAuires repeated passes of the laser beam
over the surfa$e and+or within various treatment sessions.Repigmentation is a ma9or $on$ern in the
treatment of gingival melanin pigmentation. ,he re$urren$e rate varies with regard to the treatment
modalities and the duration of follow8up.Naamura et alSY. Naamura( M. &ossain( B. &ira"ama and
B. Matsumoto( Lasers ;urg Med LN 46???7( pp. 6@5O6@HT reported that there was repigmentation in
four of their seven $ases( almost eAual to the preoperative state( at L@ months. ,o prevent the
re$urren$e( the gingival tissue should be $leared of melanin entirel" in$luding free gingiva and
interdental papilla sin$e repigmentation starts as a result of migrating melano$"tes from free
gingiva.Man" $lini$ians believe that adeAuate tissue removal ma" not be possible at the gingival
margins and interdental papillar" region due to $lose pro1imit" of the ad9a$ent teeth( whi$h ma" be
damaged b" the laser beam. ,hese limitations have led to in$omplete vapori0ation of the pigment in
su$h deli$ate areas( whi$h tend to promote repigmentation.
77) dr ! sa(s9
De!ember 7, 2007 a 2942 &m
I agree with dr. miller the use of diodlasers in endodonti$s is greatC )ut "ou need the right
wavelength. ,he diodlaser with =65 nm will appro1imatel" goes to the same depth as the ND8"ag
and gives "ou ver" good results. ,he ?=5nm diodlaser will not $ome ver" deep into the dentin. ;ee
some resear$h done on this topi$ b" dr <uttne$ht <erman".
74) Robert J. Miller sa(s9
De!ember 28, 2007 a <917 &m
I am not aware of an"one using the diode laser for gingival depigmentation an"more. ,he standard
for this pro$edure is an :rbium based laser. ,his is be$ause pure ablation( rather than $oagulation( is
far more effe$tive at the lamina propria level than an" other wavelength. 3apori0ation is an older
$on$ept( as eviden$ed b" the sour$es "ou Auote( and results in a grossl" uneven tissue plane. ,his is
wh" previous attempts at depigmentation met with mi1ed results. ,issue temperature does not
mitigate the su$$ess of this pro$edure. Rather( it is the effi$a$" of melano$"te removal that di$tates
su$$ess. A pubmed $he$ of the $urrent literature indi$ates this. ,here is absolutel" no eviden$e of
devitali0ation of teeth subseAuent to depigmentation using the :r(#rMY;<< laser and the su$$ess
rates are outstanding. 3apori0ation at an" wavelength is no longer an a$$epted paradigm and
indi$ates a la$ of nowledge of the $urrent state of the art. RJM
78) vaughan dentist sa(s9
:ul( 18, 2010 a 8982 &m
Lasers are be$oming more popular in dental pra$ti$es and are repla$ing blades to perform implant
and periodontal surger". Dental lasers provide a $leaner $ut and less bleeding.
#omments are $losed.
; ?uli&le S!lerosis 9 Conraindi!aion ,or 'm&lans@
Denal 'm&lan 6aien 1ih Diabees@ =
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