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A review of laser applications in orthodontics

Article in International journal of orthodontics (Milwaukee, Wis.) · May 2014

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FEATURE This article has been peer reviewed.

A Review of Laser Applications in Orthodontics

By Yunlong Kang, BDS,MSOrth, AdvDipOrth; A.B.M. Rabie BDS, PhD, MSc, Cert Ortho, FHKAM, FCDSHK, Hon
FDSRCS; R.W.K. Wong BDS, MOrth, PhD, FRACDS, MOrthRCS, FHKAM, FCDSHK

Abstract: Laser technique now is widely applied in orthodontic treatment and proved to have many benefits. Soft tissue lasers can be
used to perform gingivectomy, frenectomy and surgical exposure of tooth with less bleeding and swelling, improved precision, reduced pain
and less wound contraction. Other laser applications include enamel etching and bonding and bracket debonding. Lower level lasers have the
potential effects of pain control and accelerating tooth movement. Clinicians must be aware of the safety issues and risks associated with laser
and receive proper training before the laser treatment is started.
Keywords: Laser; Orthodontics; gingivectomy; frenectomy; low-level laser; etching bonding; bone regeneration.

ntroduction prevention by Yamamoto and Sato. During the 1970s to 1980s,

The name “LASER” stands for Light Amplification
by Stimulated Emission of Radiation. A laser is
a device that can produce light by transforming
electrical energy into optical energy. To generate laser light,
atoms must be excited to a higher energy level and release their
energy in phase. It is a nearly parallel, monochromatic, and
coherent beam of light, which is opposite to ordinary lights.1
History of Laser
In 1917, Einstein published an article on the quantum
theory of radiation which is considered to be the basic concept
of laser technology.2 In early 1954, Townes, an American
physicist, first amplified microwaves by stimulated emission. An
acronym “MASER” which stands for Microwave Amplification
by Stimulated Emission of Radiation was used to describe the
device they invented.3 Four years later, Schawlow and Townes
extended maser techniques into the optical and infrared region
thus invented laser.4 In 1960, Maiman built the first working
laser with ruby as the active medium material.5
Soon after Maiman’s ruby laser was constructed, Goldman6
introduced laser technique into the medical field. Since then,
Goldman and other scholars published articles about different
kinds of lasers and their range of applications in medicine,
including dentistry. In 1964, he reported the impact of ruby
laser on dental caries.The results showed crater formation and
dentine fusion along with disappearance of dental caries.7 One
year later, he wrote another report about the effect of ruby laser
beams on teeth. This was the first report on laser applied to vital
teeth.8 Stern and Sognnaes9 also reported similar tooth enamel
changes subjected to ruby laser energy.
In 1964, Bell Laboratories developed the neodymium-
doped yttrium aluminum garnet (Nd:YAG) laser and carbon
dioxide (CO2) laser, researchers were able to extend laser
technique to both hard and soft tissues in the oral cavity. Ruby
laser was rarely used due to its large energy requirement and
collateral damage to other adjacent dental tissues. In 1980,
Nd:YAG laser was first reported to be used in dental caries
several papers were published regarding the application of CO2
laser in the treatment of hard and soft tissue lesions, periodontal
diseases and in oral surgery.10-13 Before 1990, the use of laser
in dentistry was limited being confined to a small group of
clinicians, until the development of a pulsed Nd:YAG laser by
Myers and Myers15 which allowed this technique to be widely
used in general dentistry.
Later, numerous types of lasers were developed (Holmium:
YAG, Erbium:YAG, Argon, Erbium yttrium scandium gallium
garnet) and applied to a range of dental areas including oral
surgery, preventive dentistry, orthodontics, pedodontics,
periodontology, oral pathology and oral medicine (Table 1).
Laser Technology
Basic Theory of Laser
According to the quantum theory of physics first described
by Niels Bohr,16 a photon which is the smallest unit of energy,
is released after an atom has absorbed another photon and is
excited. This phenomenon is called spontaneous emission.
Einstein2 further developed this theory. He added that
an excited atom may absorb a quantum of energy and then
release two photons. Two identical photons travel as a coherent
wave. More atoms will be excited by these photons which cause
further emission of additional identical photons resulting in an
amplification of light energy. Eventually, a laser beam will be
produced.17
Properties of Laser
Three unique properties of laser distinguish it from
ordinary light. Monochromaticity: The wavelength of light
emitted by laser is very narrow compared to conventional light
sources which emit light of a broad wavelength. Therefore,
instead of containing multiple colors, laser light has a single
specific color. Collimation: The beam of a laser has a constant
direction, size and shape while conventional lights diverge in all
directions. Coherency: All the light waves are identical in laser
light.

IJO VOL. 25 NO. 1 SPRING 2014 47

 Basic Components of Laser the target tissue depends on the laser wavelength, emission mode and tissue
A laser device basically contains three major characteristics.18,168
parts: an optical resonant which consists of more There are several photobiological effects of dental lasers: Photothermal
than two mirrors, an active medium (gas, dye, effect of laser is the transformation of light into heat. Surgical incision,
solid-state electronic device or semiconductor) and excision and ablation with precision and hemostasis are results of the
an external energy source (pump source). photothermal effect. Laser chemical reactions such as curing composite resin
The external energy sources usually involve and breaking the chemical bonds can be stimulated by laser which is the result
a flash-lamp or electricity to excite the active of photochemical effects. The photoacoustic effect of laser can produce a shock
particles in the active medium in order to produce wave, which can explode the tissue, create an abraded crater. This is beneficial
stimulated emission. Photons are then released for dental hard tissue procedures. Laser has a biostimulating effect which causes
from the active medium and amplified by mirrors rapid wound healing and pain relief, an increase in collagen growth and the
in the optical resonant and eventually emerge as generation of an anti-inflammatory effect.59,169,170
laser light.
Types of Dental Lasers
Laser Delivery System and Emission Mode Lasers applied in dentistry are named after the chemical elements,
A laser beam must be delivered to the target molecules or compounds that compose the active medium which is stimulated.
tissue in a precise and ergonomic manner. There There are six basic types of lasers now are used in dentistry. Their name,
are two main delivery systems available for dental
Table 1.History
Table 1. Historyof of Laser
Laser Development
Development
laser.
A hollow tube-like wave guide with interior Year Name Development of Laser
mirror. The laser beam is reflected by the mirrors 1917 Einstein2 On the Quantum Mechanics of Radiation
along the wave guide and exits through a hand- 1954 Townes3 Invention of MASER
piece. The beam works on the tissue in a non- 1958 Schawlow and Townes4 Invention of LASER
contact fashion (not direct physical contact with 1960 Maiman5 Built the first working laser
1963 Goldman6 Introduced laser into medical field
the tissue). CO2 laser is delivered with this system.
1964 Goldman7 Reported impact of laser beam to dental caries
Glass fiber-optic cable. Glass fiber cable with
1964 Bell Laboratories Nd:YAG laser and CO2 laser were developed.
different diameters (200u to 1000u) can be used Extended the application of laser into soft tissue
to deliver a laser beam. It is encased in a sheath, 1980 Yamamoto and Sato14 Nd:YAG laser was first reported to be used in
very fragile and can not be bent into a sharp angle. dental caries prevention
This system can be used in both contact 1989 Myers and Myers15 Development of a pulsed Nd:YAG laser, made
application of laser in general dentistry possible
(touch the tissue directly) and non-contact
fashion, but it is mostly used in contact fashion in 1990- Ho:YAG, Er:YAG, Argon, Er:YSGG and other types of laser were invented.
Laser has been widely applied in dentistry
oral surgery. Nd:YAG, diode and erbium lasers are
delivered with this system. TableTable
2. Summary ofdental
Dental
2. Summary of lasersLasers
A laser device emits light energy by three
modes. In continuous wave, the laser beam is Name Active medium Wavelength Character Application
CO2 Laser18-19 Gas-active, CO2 10600nm Well absorbed by water; Soft tissue surgery;
emitted at a constant power level (argon, diode Highest absorption in Enamel surface
and CO2). Another mode involves the periodic hydroxyapatite; modification
Non-contact mode
alteration of the laser energy being on and off Nd:YAG Solid active, crystal 1064nm Absorbed by water and Soft tissue surgery;
in a short amount of time (diode, CO2), this is Laser20 of yttrium-aluminum- pigment tissue(hemoglobin); sulcular debridement
garnet doped with Good hemostatic abliliy; and remove surface
called gate-pulsed mode. The last mode is named neodymium Slightly absorbed by dental carious lesion
hard tissue
free-running pulsed mode, where a large quantity Contact mode
of energy is released for a short period of time Diode Solid active, solid- 800-980nm Well absorbed by pigment Soft tissue surgery;
Laser18,22 state semiconductor: tissue and water; Poorly sulcular debridement
followed by a relatively longer time during which aluminum, gallium absorbed by dental hard
the laser is off (Nd:YAG, erbium and Ho:YAG). and arsenide tissue;
Contact mode with small size
instrument
Laser biological effects Argon Laser21 Gas active, argon 488nm; 488nm active Light curing dental
514nm camphoroquinone; materials;
When laser light hits the target tissue, four 514nm absorbed by red Sulcular debridement
pigment tissue; and highly
types of interactions occur: reflection, transmission Poorly absorbed by dental vascularized lesions
and scattering and absorption. Reflection occurs hard tissue Caries detection
Er,Cr:YSGG Er,Cr:YSGG : solid Er,Cr:YSGG Highest absorption in water; Caries removal and
when the beam redirects itself away from the tissue and Er:YAG active, crystal of 2790nm high affinity for tooth preparation;
surface which results in no effect on the target. Laser18,21 yttrium-scandium- Er:YAG hydroxyapatite Soft tissue surgery
gallium-garnet doped 2940nm
When the laser energy passes through the tissue with erbium and
and has no effect on the target tissue, transmission chromium
Er:YAG: solid active,
occurs. Scattering tends to transfer heat produced crystal of yttrium-
gallium-garnet doped
by laser beam to the adjacent site which weakens with erbium
the laser energy. The absorption of laser energy Ho:YAG Solid active, crystal 2120nm Absorption by water; Soft tissue surgery
Laser18 of yttrium- Poorly absorbed by pigment
by the target tissue is the primary and desirable aluminum-garnet tissue and dental hard tissue
effect of laser. The amount of energy absorbed by doped with holmium

48 IJO VOL. 25 NO. 1 SPRING 2014

wavelength, characters and functions are listed Table
Table 3. 3. Laserapplications
Laser applications in orthodontics
in orthodontics
in Table 2.
Category Application Type of Laser Advantage
According to the energy output and focus, *Nd:YAG, diode ;
51-52

lasers can also be classified into three groups: Gingivectomy, gingivoplasty CO2
43,46,48
; Less bleeding
Er:YAG, Er,Cr:YAGG53-56 good hemostasis+; reduce
high, medium and low power. Soft pain and swelling
66,68,85
;
tissue Precise incision#; less
Frenectomy *CO252,62-63, Er:YAG56,67-68;
management
Laser Application in Orthodontics Nd:YAG, diode
56,64-66 wound contraction and
scar formation87; reduce
Laser was invented and has been used in healing period88-90
Impacted tooth exposure *Er:YAG, Er,Cr:YAGG 56,73;
oral and oral maxillofacial surgery for more than CO272, Nd:YAG, diode40
three decades.23 It is a relatively new technique 104-107
Enamel etching, bracket Er:YAG, Er,Cr:YAGG More acid resistant111;
that has been introduced into orthodontics Hard bonding less microleakage112
within the last twenty years.24-25 It soon gained tissue
management Bracket debonding CO2121-125, Nd:YAG126-127, Avoid enamel fracture
its place in solving a variety of problems relating Er:YAG128-129, Tm:YAG130
to orthodontic treatment ranging from ceramic
Pain control Low-level lasers141-144: Reduce pain during tooth
bracket debonding26 and enamel surface GaAlAs, GaAlAs diode(twin movement135-139
etching27 to mucogingival surgery.28 Lasers with Miscellaneous laser)
different wavelengths can manage both hard and Tooth movement Low-level laser156-158 Increase the rate of tooth
soft tissue problems. Moreover, low level lasers movement
were reported to be beneficial in pain control Accelerate midpalatal
induced by orthodontic arch wire placement.29 Bone healing after Low-level laser181-185 suture opening and
expansion improve bone
Summary in Table 3. regeneration 182

Soft Tissue Management PS. *most popular; +

Soft tissue abnormalities often occur
before, during and after orthodontic treatment.
The three main clinical situations associated
with orthodontic therapy include gingival
overgrowth,30-33 abnormal frenum34-35 and
impacted teeth.36 Therefore surgical procedures
such as gingivectomy, gingivoplasty, frenectomy
and surgical exposure of impacted teeth are
most commonly required to solve the above
problems. According to previous studies,
soft tissue lasers can replace the conventional
scalpel to perform these operations with
enhanced precision, better hemostatic ability,
faster wound healing and less pain. Various
soft tissue lasers that were used for intraoral
soft tissue procedures were reported by case
reports and uncontrolled clinical studies, among
which the diode, CO2 and Nd:YAG, are the
most dominant ones. Recently, Er:YAG and
Er,Cr:YAG gained more attention in their
application in soft tissue surgery.13,37-40
Gingival enlargement can affect
orthodontic therapy from the beginning of
bonding brackets to the final finishing stage.
The etiology of gingival overgrowth can be
divided into two categories; drug induced41
(phenytoin, ciclosporin and calcium channel
blockers), and plaque accumulation with
mechanical stimulation.4 Enlarged or irregularly
contoured gingival margins tend to change
the crown height and shape which in turn
change the tooth proportion.43 Therefore,
many clinicians find it difficult to accurately
place the bracket on the clinical crown center.
Sometimes it may not be possible to bond the
brackets. During orthodontic treatment, teeth
IJO VOL. 25 NO. 1 SPRING 2014
39,43,47-48, 53,63,76-79; #
40,43,74,80-81
disproportionality caused by gingival overgrowth makes it hard for clinicians
to correctly evaluate and judge the axial inclination of the teeth, leading to an
unsatisfactory finishing and compromised esthetic result.
Gingivectomy and gingivoplasty are required for the correction of problems
brought by gingival enlargement. CO2 laser has long been considered a favorite
tool for oral surgery because its wavelength is well absorbed by soft tissue, since
it is mostly composed of water. In the 1980s, CO2 laser started to be used by
periodontists to perform gingivectomy on patients with drug-induced gingival
hyperplasia.13,44-45 Later, CO2 laser was widely used by dentists to remove excessive
gingival tissue for both functional and esthetic reasons.43,46,48,51-52 CO2 laser was
reported to have many benefits when used in orthodontic treatment. Advantages
include less bleeding and pain, less wound contraction and scarring, minimal
post-operative discomfort, reduced treatment time and fixed appliance could be
fixed immediately after the surgical procedure.46-48 However, because CO2 laser
energy is also well absorbed by hydroxyapatite (tooth enamel); there is a risk that
temperature changes caused by laser energy delivery may compromise the dental
pulp49 or result in etching or pitting of the enamel.50
Nd:YAG and diode lasers are more popular among clinicians in orthodontics
and esthetic dentistry. They have the advantages that are similar to what CO2
laser has. They are more suitable for gingivoplasty because they are used in a
direct contact mode which provides optimum control for esthetic surgery.51
It is also reported that they have improved hemostatic ability.52 Wavelengths
of them are not well absorbed by dental hard tissues, therefore these lasers are
safe to apply adjacent to teeth. Tony NF.,173 in a randomized trial, compared a
group of patients receiving diode laser gingivectomy adjunct with non surgical
periodontal treatment to a control group receiving only non surgical periodontal
treatment after orthodontic treatment. The result of this research shows that
laser gingivectomy using diode laser can quickly resolve gingival overgrowth and
control gingival inflammation more effectively.
Er:YAG and Er,Cr:YAGG lasers can work both on soft and hard tissues
because both of their wavelengths are absorbed by water and hydroxyapatite.
However, they are mostly used for caries removal and tooth preparation instead
of soft tissue surgery due to their high affinity to enamel and relatively poor
coagulation ability. Few reports have been published regarding the application
49

Figure 1A: A 12-year-old orthodontic patient with gingival
hyperplasia. Figure 1B: Gingivectomy performed with
erbium laser under local anesthesia. Figure 1C: One
month after the treatment. Courtesy Dr. Fred S. Margolis.
Figure 2: A - The upper labial frenum is extended to
the palatal inter-incisal area causing upper diastema.
the labial area without local anesthesia under pai- free
parameters. Figure 2D: Ten days post-treatment would
healing assessed. Courtesy Dr Panagiotis Kafas.
of Er:YAG and Er,Cr:YSGG lasers in intraoral soft tissue
surgery.53-56 More interest has been directed to the Er,Cr:YSGG
laser because it is an energy system specific to dentistry.57 In
a recent study by Thongdee et al171 which assessed the effect
of laser on the treatment of orthodontic-associated gingival
overgrowth yielded promising results. Gingivectomy was carried
out with the Er,Cr:YSGG laser. 22 patients were involved in this
study, 168 tooth areas of gingival overgrowth were measured
with minimum probing depth of 3mm. Immediately after
surgery, the average probing depth was reduced to an average
of 1mm. Post-operative follow up had been conducted with
intervals at 2 weeks and 1, 2, 3, 6 and 12 months. After one
year, the probing depth averaged 1.4mm.
Hypertrophic labial frenum which remains inserted in the
free gingival margin or on the palatine papillae causes a midline
diastema.58 This type of low frenum can impede the insertion of
temporary anchorage devices which are used for the intrusion
of upper incisors in the case of gummy smile. A short lingual
frenum may cause ankyloglossis, and lead to problems such
as atypical swallow, disproportional lower jaw growth and a
lower midline diastema.60-61 Frenectomy with lasers of different
wavelengths has been reported by previous authors. CO2 laser
is an ideal tool for intraoral surgery involving large amounts
of soft tissue or dense fibrous tissues. It is a popular choice
for frenectomy because of its high absorption by oral mucosal
tissues, which contain 90% water. This laser works well in both
soft and hard tissues.52 Comparing to the conventional scalpels,
it causes less pain and swelling and has fewer postsurgical
complications. It reduces postoperative bleeding and also
promotes better healing.62-63
50
Nd:YAG and diode lasers are also used
in frenectomy by many clinicians with cases
reporting similar benefits as CO2 laser.56,64-66
Nevertheless, the application of Nd:YAG and
diode lasers on labial frenectomy is limited.39,52
Their wavelengths are not well absorbed by
dental hard tissues. They operate in a continuous or interrupted-
continuous wave mode which promotes high thermal side
effects. Therefore, Nd:YAG and diode lasers cannot be used in
direct contact with bone where one end of the labial frenum
fibers are attached. But in lingual frenectomy, diode laser was
reported to be useful due to its small size and low cost.28
Er:YAG laser is well absorbed by hard tissue and water and
operates in a pulsed wave mode, promoting efficient ablation of
hard tissue with minimal thermal effects. Since the Er:YAG laser
has these characteristics, it should be used in conjunction with
the Nd:YAG or diode laser for labial frenectomy. Er:YAG laser
was also reported to induce an analgesic effect56 and require less
or no local anesthesia.67-68
Impacted teeth can be aligned into position by orthodontic
force following surgical exposure.69 Surgical exposure of
impacted teeth is not uncommon in everyday orthodontic
treatment.70 Laser techniques are especially beneficial when
applied to perform surgical exposure of teeth which are either
impacted at a mucogingival or bone level. Surgical exposure
performed by laser is quick, clean and painless. A dry field
without contamination of blood results after laser surgery,
making it easier to directly bond a bracket on the exposed
tooth.71 However, a incidence of subcutaneous emphysema
following tooth exposure with laser was reported recently.172
Various laser wavelengths including erbium, diode, Nd:YAG
and CO2 lasers were used to perform this procedure by previous
studies.40,56,72 Erbium gained more interest from clinicians
because it is able to cut both soft and hard tissues, thereby
being able to expose teeth at bone level.73 It also has the effect
of enamel etching which facilitates the bonding of orthodontic
accessories immediately after surgery.56 The enamel etching effect
of laser will be discussed in the next part of this article.
Advantages and Disadvantages of Soft Tissue Lasers
Main advantages of using lasers in soft tissue procedures had
been summarized by previous articles:40,74-75
Less bleeding during surgery and excellent postoperative
hemostasis. This is confirmed by the majority of the
previous papers, which are mainly case reports with some
uncontrolled studies. It is considered to be one of the major
advantages of lasers. A clear dry operation field can be
achieved due to less bleeding.39,43,47-48,53,63,76-79
Precise incision control because of less bleeding and a
clear dry field during surgery. In contrast, bleeding usually
compromises the accuracy of incisor when scalpel is
used.40,43,74,80-81
Reduced pain and swelling during and after laser
surgery. Pain reduction is another major advantage.
Several animal and randomized controlled clinical
studies63,65,82-84 have compared the level of pain produced
by laser and scalpel surgery. Most of the results indicated
a dramatic reduction in post-operative pain with laser
surgery. There were even reports of diode and erbium
IJO VOL. 25 NO. 1 SPRING 2014
 laser surgeries performed without local anesthesia.66,68,85
However Strauss et al86 revealed no statistically significant
difference in the frequency and intensity of pain or the
temporal distribution of pain after CO2 laser and scalpel
biopsies.
Less wound contraction, scar formation and reduced
healing period. The wound produced by laser surgery
was reported to have little contraction, less collagen
formation and fewer myofibroblasts.87 Other studies
demonstrated shorter healing time and less scar formation
with laser.88-90 Controversy arose after some researchers
reported that wound repair was equivalent between laser
and scalpel or electrosurgery in the later stages.91-93 Some
studies showed that laser created more tissue damage than
scalpel, with delayed wound healing.94-96 These studies
included inconsistent parameters such as wavelength,
frequency, time of exposure and power, which affect the
response of tissues and duration of healing.
Although there are a number of uses for soft tissue laser
in orthodontics, it is not as well accepted as conventional
techniques. One of the possible reasons may be lack of solid
evidence to support the reported benefits of laser in soft tissue
procedures. Is laser superior to the conventional scalpel? Can
laser achieve same results? What are the long term effects
of laser surgery? Answers to these questions are conflicting.
The existing studies were mostly case reports, uncontrolled
studies and animal histological studies. It is difficult to make
a clear conclusion based on this data. Only a limited number
of randomized controlled clinical studies were conducted
on patients’ perception of laser compared to conventional
techniques, and observing the short and long term results of
laser surgery. In the future, more RCTs are indicated to provide
solid support for laser.
Enamel Etching and Bracket Bonding
The bonding of brackets on the surface of a tooth requires
the penetration of bonding material into the etched enamel.
Enamel etched with 37% phosphoric acid achieves a high
level of bonding strength.97 However, demineralization caused
by acid etching leaves the enamel surface susceptible to acid
attack in the oral environment, leaving the tooth prone to
caries. In addition, the procedures required for acid etching are
complicated and time consuming.98 Laser etching has become a
Figure 3: Canine exposure performed with diode laser,
Courtesy Dr Antonio Gracco.
IJO VOL. 25 NO. 1 SPRING 2014
possible alternative to acid etching in the recent years. Etching
with laser can produce microirregularities that are suitable for
resin penetration.99 The shear bond strength of lased tooth
is similar to those treated by acid etching.174 There are fewer
steps in the etching procedure making it easier to handle. The
acid resistant effect of laser is superior to conventional acid
etching.100
Laser etching was introduced into orthodontic bonding in
the 1990s. Initially, Nd:YAG laser was used to etch the enamel
surface. The results of laser etching showed compromised
bonding strength, longer bonding time and more discomfort
than conventional acid etching. Nd:YAG laser was considered
an ineffective pretreatment of bonding bracket to enamel.101-103
As the previous studies indicated, Nd:YAG laser is more suitable
for soft tissue procedures. Application of Nd:YAG laser on
dental hard tissue is ineffective and also has thermal side effect
which can cause discomfort to the patient and is harmful to
dental pulp.39,52 Er:YAG and Er,Cr:YAG lasers can be used for
both soft and hard tissue procedures without creating a thermal
side effect. After the introduction of Er:YAG and Er,Cr:YAG
lasers, etching by laser has become more effective. The shear
bond strength of tooth surface etched by Er,Cr:YAG laser is
comparable to those prepared by acid and reaches an adequate
level.104-107 However, some researchers disagree with the above
findings.108,109 The conflicting findings are probably due to
different power output and experimental design among different
studies. Acid resistant effect of laser etching is superior to
phosphoric acid. Aside from the bond strength, laser etching is
useful when applied in immediate bonding on surgical exposed
teeth without acid etching.56
The calcium-phosphate ratio of the enamel can be modified
after laser irradiation leading to the formation of more stable
and acid-proof compounds. It is similar to the effect of fluoride
on enamel.100,110 Some studies have proven that enamel prepared
by laser irradiation is more acid resistant than acid-etching. Kim,
et al111 reported an in vitro study, where enamel was treated by
Er:YAG laser and found to be more resistant to acid, than that
treated by conventional acid etching. Hamamci, et al.,112 found
less microleakage of brackets bonded by etching with Er:YAG
and Er, Cr:YAG lasers than acid etching. Noel, et al.,113 studied
the acid resistant effect induced by Argon laser.
Even though laser etching has many advantages over
conventional methods, it is not yet a routine procedure
adopted in orthodontic bonding. Compared to acid etching,
the unpredictable bonding results of laser are probably one of
the reasons that has slowed the acceptance of laser etching in
orthodontics.
Bracket Debonding
A major concern of brackets debonding in orthodontics
is the risk of enamel damage.114-117 The occurrence of enamel
fracture is relatively higher with ceramic brackets because of
the high bond strength.118-119 In order to reduce the risk of
enamel fracture, a debonding technique that requires less force is
needed.
Laser irradiation can soften the composite resin by heating
the brackets, help reducing the force required for debonding.
The mechanism of laser debonding includes: thermal softening,
thermal ablation or photoablation. Thermal softening occurs
51
 when laser with low power density irradiates the brackets until
the resin softens. The brackets will slide off the tooth surface
with gravity. Thermal ablation and photoablation vaporize
the resin when its temperature is raised quickly by high power
dentity lasers. The resulting bracket can be blown off the tooth
surface.120,131
Different types of lasers (CO2,121-125 Nd:YAG,126-127
Er:YAG,128-129 Tm:YAG,130) brackets (monocrystalline and
polycrystalline) and adhesive materials (Methyl Methacrylate
MMA and Bisphenol A-Glycidyl Methacrylate Bis-GMA)
were used to study the effect of laser in debonding brackets
debonding. Most of the studies showed the benefits of laser
debonding; more time efficient, significantly reduced debonding
force and enamel damage. However, potential safety concerns
have also been reported. The increase of pulp temperature and
potential hazard to tooth vitality resulting from laser heating
is the main concern of clinicians. According to Zach and
Cohen,132, the pulp can only tolerate an increase of 5.5oC in
intrapulpal temperature. Overheating will harm the pulpal
tissue. Most of the previous studies had been carried out to
evaluate the thermal effect of laser on pulp temperature and
determine factors that cause temperature rise. Key factors
include types of lasers and brackets, duration of heating, energy
level and methods.122, 126, 129 It was also reported that different
resins have varied reactions against certain types of lasers.133 The
conclusions of these studies indicate that the temperature change
will remain within the safety threshold if the appropriate laser
can be chosen and the application duration and method can be
precisely controlled.
Pain Control
Tooth movement is often associated with pain, especially
within the first 7 days after force applied.134 Low-level laser
therapy (LLLT) has been shown to have analgesic effect in a
variety of therapeutic procedures.135-139 LLLT is a new technique
and is defined as the laser treatment in which the energy output
is low enough that the temperature of the applied area will not
rise above body temperature.138 The mechanism of pain relief by
LLLT is not yet well established. The analgesic effect is believed
to be attributed to its anti-inflammatory and neuronal effect.140
Table 4. Laser Safety
Hazard - Causes and Protection
Symptoms
Eye Damage - Cornea, retinal Choose proper eye wear for the
correct wavelength of laser.
cataract formation 164-165
Skin hazard - Dry skin blistering Fully covered, no skin exposure167
and burning164
Laser Plume - Emissions of High volume evacuation and masks
noxious plume containing toxic 164
checmicals and debris. Cause
coughing, nasal congestion
nausea and vomiting.166
Fire hazard - Heat generated No combustible or explosive material in
by laser irritation contact with the nominal hazardous zone; avoiding
combustible material will cause alcohol-based anesthetics and gauze;
2
and O2 can only be used in a close
circuit delivery sytem; perform the
operation near a water source.164-165
52
Pain relief produced by LLLT in orthodontic treatment
has been investigated by few researchers. Studies were carried
out to evaluate and compare the pain perception of patients
with or without laser irradiation at different times. Most of the
studies showed positive results and concluded that LLLT helped
reduce pain in orthodontic treatment within the first 5 or 7 days,
especially within the first 2 to 3 days.141-145,176 Only few studies
found insignificant differences of pain perception between
patients with and without laser irradiation.146 In the previous
studies, different treatment protocols and lasers were used which
might lead to differing results. Some investigated pain relief with
CO2 laser after the first wire was placed,141 while others studied
pain relief after separators placement with gallium-aluminum-
arsenium and CO2 lasers.142,145-146,175 Further investigations are
needed to study the analgesic effect of LLLT.
Tooth Movement
The “biostimulating effect” of LLLT has been studied since
1971. LLLT was reported to be able to stimulate fibroblast and
chondrocyte proliferation, collagen synthesis, nerve regeneration,
wound healing, and bone regeneration.147-153 It was suggested LLLT
can accelerate bone remodeling and cause changes in alveolar bone
during induced tooth movement. Changes were found in the
number and proliferation of osteoblasts and osteoclasts and collagen
deposition in both pressure and tension sites.154-155
Based on the previous basic science studies, LLLT has
been demonstrated to increase the rate of tooth movement
during orthodontic therapy. Animal and clinical studies were
conducted to investigate this effect. Tooth movement with
LLLT was found to be faster in some studies.156-158,177 Cruz et
al156 showed an increase of 34% of canine retraction within
60 days with fixed appliance. The group irradiated by laser
moved 4.39mm comparing to the control group which moved
3.30mm. Kawasaki157 showed a 1.3 fold more movement of rat
teeth irradiated by laser after 12 days. However some studies
found insignificant differences159-160 or even diminished tooth
movement.161 According to some authors, if a laser dose is too
low it will not cause a biostimulating effect, whilst a higher dose
can inhibit tooth movement.162
Bone Regeneration after Expansion
Rapid maxillary expansion is commonly used in orthodontic
therapy.177-179 The separation of mid-palatal suture with an
increased bone mass in the center can change the maxillary arch
shape dramatically. Usually following expansion a retention
period of 3 to 4 months is needed for bone regeneration and
remodeling.180 Low-level lasers can accelerate the opening of the
mid-palatal suture and improve bone regeneration during and
after rapid maxillary expansion according to several studies.181-185
It can be helpful in reducing the retention time and preventing
relapse. However, further study is required to closely investigate
this effect.
Dental Laser Safety
Safety issues are a major concerns of laser applications
in dentistry. Laser injuries are reported every year around the
world. Laser hazards vary, depending on the type and use of
laser. According to guidelines provided by American National
Standards Institute Z136.1-2007, there are four classifications
IJO VOL. 25 NO. 1 SPRING 2014
(ranging from 1 to 4) of lasers based on the potential of causing
biological damage to the eyes or skin by the primary or reflected
beam. Lasers used in dentistry mainly fall into classes 3B and
4. Class 3B represents a maximum output of 0.5W which can
cause eye damage. Class 4 includes all high-powered lasers that
are used in dentistry and oral maxillofacial surgery. There is no
upper output limit, so lasers in this class will cause different
injuries.163 All staff in clinics where lasers are used must receive
appropriate safety training. Summary in Table 4.
Eye Damage
The cornea mainly consists of water, and absorbs the
wavelength of CO2, erbium and holmium lasers. Thus these
lasers can burn the cornea. They can also affect aqueous, vitreous
humor and lens of the eye, resulting in aqueous flare and
cataract formation. Lasers such as Nd:YAG, diode and argon
are highly absorbed by pigment, and have greater penetration
into tissue. Retinal damage caused by these lasers can lead to
blindness.164-165
Eye protection is crucial for both the clinical staff and the
patient. There is specific eye wear for different wavelengths
available in the market. No goggle can provide protection
against all wavelengths ranging from 400nm to 10600nm.
When choosing eye goggles, be aware of the optical density and
wavelengths printed on the goggles. It is important that eye wear
is chosen for the correct wavelength of laser.165
Skin Hazard
Skin can be penetrated at wavelengths from 300nm to
3000nm. Laser-induced skin damaged includes excessively dry
skin, blistering and burning.164 Clinical staff and patient should
be fully covered during the laser therapy.167
Laser Plume
The emission of noxious plume by the laser vaporization of
tissue can obscure the surgical field and contains toxic chemicals
and debris including bacterial spores, cancer cells and viruses
(Human Papillomavirus HPV, Human Immunodeficiency Virus
HIV and herpes). Inhalation of the plume can cause symptoms
such as coughing, nasal congestion, nausea and vomiting.
Apart from the regular dental protective equipment, high
volume evacuation and masks that can filter up to 0.1u should
be added as extra protection during laser therapy.164,166
Fire Hazard
Heat generated by the laser beam may cause a fire if in
contact with combustible materials or gas. Some precautions
must be taken during laser therapy. Any combustible or
explosive materials should not be placed in the nominal
hazardous zone. Avoiding using any alcohol-based anesthetics
and gauze. Use wet or fire retardant material only. Gas such as
nitrogen dioxide and oxygen can only be used by dentist in a
close circuit delivery system with high-speed evacuation system
(ANSI Z136.3, 2005). Perform the operation near a water
source.164-165
Laser Safety Officer
A laser safety officer, LSO, is needed by every dental
practice with laser. According to the ANSI Z136.1 standard,
IJO VOL. 25 NO. 1 SPRING 2014
1993, “a LSO is defined as a person who is trained and certified
to take responsibility and have authority to monitor and enforce
the control of laser hazards and to effect the knowledgeable
evaluation and control of laser hazards.” A LSO must be present
when using class 3B and class 4 lasers.165
Conclusion
Laser therapy has influenced the orthodontic treatment
in many aspects. The advantages of laser over conventional
instruments were reported, which include improved hemostasis,
reduced swelling and pain, faster wound healing and precise
incision control. Other functions of laser have potential benefits
for orthodontic treatment such as enamel etching, bracket
debonding, pain control and accelerating tooth movement.
Today, laser begins to attract the attention of more
clinicians. However, an evidence-based approach of using
laser in orthodontic treatment must be developed. More
solid evidence must be provided to support the advantages of
laser. Also, the potential hazards of laser should be taken into
consideration and strict safety procedures must be carried out
during the application of laser therapy.
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Dr. Yunlong Kang is a lecturer in Orthodontics
Discipline of Orthodontics, School of Dentistry, James
Cook University, Cairns, Queensland, Australia. He
obtained his Advanced Diploma in Orthodontics
from the University of Hong Kong and his Master of
Stomatology in Orthodontics from the West China
College of Stomatology, China.
Dr. Bakr Rabie is a Professor of Orthodontics in
the Faculty of Dentistry at The University of Hong
Kong. He obtained his Certificate of Proficiency
in Orthodontics, Master of Science, and PhD from
Northwestern University, USA.
Dr. Ricky Wong is a honorary associate professor in
Orthodontics at the University of Hong Kong. He
obtained his Master of Orthodontics and PhD from
the University of Hong Kong.
IJO VOL. 25 NO. 1 SPRING 2014