Laser in Operative Dentistry

The introduction of LASERs( Light amplification by the stimulated emission of

radiation) in the field of prosthodontics is one of the important technological advancements
that have replaced many conventional surgical and technological procedures and is able to
replace the dental handpiece .

Components of the LASER tube:

● Active medium
● Pumping machine
● Optical resonator
● Delivery system
● Control panel
● Focusing lens

Active medium:

Material either naturally occurring or man-made that when stimulated emits

LASER light this material may be either a gas (e.g: Argon or CO2) or a crystal (e.g: YSGG doped
with Er and Cr, YAG crystal doped with Er or Nd) or a solid state semiconductor (AiGaAs,
InGaAs, diode). The active medium is positioned within the LASER cavity (an internally
positioned tube with mirrors co-axially positioned at each end surrounded by the external
energizing input, or pumping mechanism

Pumping machine:

The man-made source of the primary energy that excites the active
medium. This is usually a light source either a flash light or arc light or an
electromagnetic coil. Energy from this primary source can be absorbed by the active
medium resulting in the production of LASER light by the process of stimulated
emission.

Optical resonator:

LASER light produced by the stimulated active medium is bounced back and
forth through the axis of the LASER cavity using two mirrors placed parallel to each
other at each end thus amplifying the power. The distal mirror is totally relective, the
proximal mirror is selectively transmissive allowing light of sufficient energy to exit the
optical cavity. The parallelism of the mirrors ensure that the light is collimated.

Cooling system:

Since heat production is a by-product of LASER light propagation, a co-axial

cooling system is used which may be air-assisted or water-assisted. It represents the
bulkiest part of the laser system

Control panel:

It allows the variation in the power output with time, above that defined by the
pumping mechanism frequency and other facilities may allow wavelength change.

LASER-tissue interaction:

1. Reflection: The beam redirects itself off the tissue surface without any effect on the target
tissue.
2. Transmission: Laser beam enters the medium and emerges distally without interacting with
the medium i.e.no effect on the target tissue.
3. Scatter: Result of light scattering is a weakening of laser energy producing no effect on target
tissue.
4. Absorption: The incident energy of the beam is absorbed by the medium and transferred
into another form of energy. Absorption is the most important interaction. Each wavelength
has specific chromophores that absorb their energy. This absorbed energy is converted into
thermal and and/or mechanical energy that is used to perform the work desired. Near infrared
lasers like diodes and Nd:YAGs are mostly absorbed by pigments such as hemoglobin and
melanin. Erbium and CO2 lasers are predominantly absorbed by water, with erbium
wavelengths also exhibiting some hydroxyapatite absorption. Absorption requires an absorber
of light, termed chromophores, which have a certain affinity for specific wavelengths of light.
Example : Melanin and Heamoglobin (in soft tissues) have affinity To Diode laser
Water (in soft tissues and hard tissues) and hydroxyapatite (in hard tissues) have affinity to
Erbium laser.

Depending on the clinical situation, dentists need different laser wavelengths

and irradiation parameters to obtain distinct effects on the same tissue.

Clinical applications of LASER in conservative dentistry:

 It is important to know that LASER has never been the “magic wand” in
medicine and dentistry.Clinicians need to understand all the LASER principles in order to
take full advantage of the features to provide safe and effective treatment.
1. Diagnostic laser
2. Cavity preparation & caries removal
3. Laser Bleaching
4. Pulp Capping
5. Gingival Care

1. Diagnostic Laser:

Diagnodent is used to detect incipient caries by “ Laser Induced

Fluorescence”. When the laser irradiates the tooth, Bacterial
metabolites show fluorescence after irradiation with laser.
Carious teeth show more fluorescence compared to healthy tissue.
Carious tooth structure exhibits fluorescence proportionate to the
degree of caries .

2. Cavity preparation & caries removal:

The mechanism of dental hard tissue removal by laser in a

thermomechanical process called “Photo-thermal ablation”.

By understanding the chemical composition of the target

tissue; dentine contains higher percentage of water than
enamel so Er:YAG laser can ablade dentine faster than enamel
as well as carious tissue faster than sound tooth structure.
Erbium lasers are the only hard tissue wave length available
commercially. Its inherent absorption qualities allow erbium
laser to ablade tooth structure. Also they are unique in that
they are the only lasers that can cut both hard and soft
tissues.

It’s an explosive water mediated tissue removal process according to

the following steps;
● Fast heating of the subsurface water confined by hard tissue
matrix
● High molecular vibration
● Followed by high subsurface pressure higher than the strength
of the above tissue
● Explosion of tissue due to material failure and hence material
removal occurs
During irradiation water cooling is required to reduce the
increase in temperature and improve the ablation rate during
cavity preparation to avoid odontoblatic alterations and
inflammatory response in the pulp chamber beneath the
preparation.
Cavity preparation using Er:YAG laser takes more time
compared to rotary cutting instruments. Low noise and
vibration elimination as well as the eliminating in some cases
the need for local aneathesia.

At Enamel level:

During cavity preparation, ablation of sound enamel by Er:YAG

laser promotes cavities with rough enamel margins, irregular
and rugged walls, a chalky surface and the depth is dependent
on the energy density and pulse width. High energies over 300
mJ may induce subsurface damage into enamel which might
lead to poor marginal adaptation and hence high degree of
microleakage.
Low energies for finishing can be used for better adaptation
results. Microleakage is almost the same when cavities are
prepared with both laser and burs when low enery is used.
The problem with low energy is that it requires very long
treatment time

At Pulp level:

No evidence of either odontoblastic alteration, inflammatory

response beneath the preparation, or pathological changes
underlying deep cavity preparations.
 The use of high speed drills for cavity preparation promotes
smooth enamel and dentine cavities with smooth internal
walls.

Sometimes it’s difficult to promote the selective ablation of

infected dentine in order to preserve the affected dentine.
This depends on the experience of the operator added to the
use of manual instruments using the tactile sensation for
correct diagnosis of remaining tissue as well as manual
excavation of carious dentine as well as the selective use of
round bur low speed.

3. Restoration removal:

Laser can’t be used for removal of amalgam, gold or ceramic restorations due to the low
absorption of these materials as well as the reflection of the laser light that might cause
damage either intraorally to the patient or to the operator’s eyes. Laser is effective in ceramic
veneers removal due to the low thickness of veneers. Laser energy is transmitted through
veneer thickness causing the bonding interface to degrade by laser energy.

4. Bleaching:

The objective of the laser bleaching is to achieve the ultimate power

bleaching process using most efficient energy source while
avoiding any adverse effect. Laser can enhance bleaching by
photo-oxidation of colored molecules in the teeth or by
interaction with the components of the bleaching gel through
photochemical reaction. Both diode and Erbium laser can be used
for bleaching

5. Pulp capping:

It was suggested that laser can be used for direct pulp capping this
has been based on the following;
 Laser can create a fine area of hemostasis creating a very thin layer of
superficial coagulation below which injury can be reversed by creating
a place for migration of inflammatory cells and fibroblasts that
contribute to the formation of dental bridge

This procedure is not safe nor easy as pulp tissue might be damaged
thermally. This might be due to the creation of thicker and deeper
layer of coagulation resulting in necrosis. This is also dependent on
inappropriate laser power, time or technique.

6. Gingival care :

In restorative dentistry, the health of gingiva is mandatory for success

of all the clinical steps. Laser use for gingival care during operative
procedures is associated with drier operative field through improved
hemostasis with better visibility as well as it’s associated low
postoperative inflammation and decreased patient’s discomfort.
The use of laser for gingival care indications range from access to
esthetics. Gingivectomy can be used when suprabony pockets are
present or enlarged fibrotic gingiva.

When scalpel procedures must be avoided in a patient with

coagulation considerations laser allows surgery to proceed without
compromising the patient’s overall health with anticoagulant therapy
becoming much less of an issue during the treatment.

Both Erbium and diode laser demonstrate wound healing that is

either comparable with that achieved after use of conventional
scalpel blade or somewhat accelerated. If the objective is soft tissue,
the diode laser is sufficient. However to alter underlying osseous
structure erbium is the only laser receiving clearance from FDA for
osseous resection.

7. Laser frenectomy

Frenectomy is the complete removal of either the labial or lingual

frenum . This procedure can be accomplished either with routine
scalpel technique or by using laser. The conventional technique
 involves excision of the frenum by using scalpel with the routine risks
like bleeding and patient compliance. Laser offers many advantages
over scalpel procedures like shorter duration,simplicity of the
procedure lesser pain and scarring.

8. Laser depigmentation:

Racial pigmentation can be removed either by a surgical procedure

where the pigments are removed either with traditional surgical
procedure or with laser. Laser offers better handling, hemostasis and
shorter time.