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CLINICALCLINICAL APPLICATIONAPPLICATIONOFOF LASERSLASERS USEUSEDD ININ
RREESTORATIVE STORATIVE DENTISTRYDENTISTRY
รศ. ปทมา ชัยเลิศวณิชกุลรศ. ปทมา ชัยเลิศวณิชกุล
LL IGHTIGHTAA MPLIFICATIONMPLIFICATION bybySS TIMULATEDTIMULATEDEE MISSIONMISSION ofofRR ADIATIONADIATION
LaserLaser characteristicscharacteristics
MonochromaticPhotons stimulate photons ofthe same frequency, One specific colorCoherentPhoton waves in phase-maximumintensity, Identical amplitudeNon-divergentPhotons at angles to cavity axis, notstimulate others
LaserLaser OutputOutput
ContinuousContinuous wavewaveChopChop beambeam toto produceproduce pulsespulses((mechanicalmechanical)),, PulsePulse cancan bebeshortershorter thanthan thethe thermalthermalrelaxationrelaxation timetime ofof thethe tissuetissue((nono heatheat transmissiontransmission))PulsedPulsed laserlaser ((higherhigher powerpower))
Electromagnetic Wave ScaleElectromagnetic Wave Scale
100 100 nmnm
400 nm400 nm 750 nm750 nmUltraviolet Ultraviolet VisibleVisible
InfraredInfrared
HeNeHeNe (632nm)(632nm)
KTP (532nm)KTP (532nm)
Argon (514 nm)Argon (514 nm)
Argon Argon (488nm)(488nm)
Diode 812nmDiode 812nm
Diode 980nmDiode 980nm
NdNd: YAG : YAG (1064 nm)(1064 nm)
ErCr:YSGErCr:YSGGG
Er:YAGEr:YAG ( 2.94( 2.94µµ))
CO (10,600 nm)CO (10,600 nm)22
10,000 nm10,000 nm
XeF(351 nm)XeF(351 nm)ExcimerExcimer
ExcimerExcimer XeClXeCl (308 nm)(308 nm)
KrFKrF (248nm)(248nm)
ArFArF (193nm)(193nm)
2.78 2.78 µµ
A A bsorbancebsorbance--usefuluseful energyenergyR R eflectanceeflectanceT T ransmittanceransmittanceS S catteringcattering
AblationAblation
RemovalRemoval ofof tissuetissue byby laserlaser energyenergyVisiblVisible & e & IRIR laserslasers -- thermalthermal processprocessEExcimerxcimer laserslasers –– photochemicalphotochemicalprocesprocess (bs (beakeak bondsbonds))
ExcimerExcimer laserlaser
NonthermalNonthermal laserslasers --interactinteract withwith tissuestissuesthroughthrough a a photochemicalphotochemicalprocessprocess,, ablationablation beingbeing thetheresultresult ofof breakingbreaking bondsbondswithinwithin tissuetissue
ExcimerExcimer laserlaser
MostMost prevalentprevalent excimerexcimer::ArArF (193 F (193 nmnm) ) producesproduces a a cleanercleanercutcut withwith lessless thermalthermal damagedamage ininbothboth hardhard && softsoft tissuestissuesXeCXeCl (308 l (308 nmnm) ) cancan bebe delivereddeliveredthroughthrough anan opticaloptical fiberfiber muchmuch moremorereliablereliable
AbsorptionAbsorption WindowsWindows
200200--350 350 nnm (Um (UV) V) proteinprotein &&DNADNA dominatedominate absorptionabsorption>>20002000nnm (Im (IR) R) waterwater isis mainmainabsorberabsorber600600--3000 3000 nmnm lowlow opticalopticalabsorptionabsorption,, highhigh penetrationpenetration
CallingCalling
NdYAGNdYAG NeodymiumNeodymium--yttriumyttrium--aluminumaluminum--garnetgarnetGaAlAsGaAlAs GalliumGallium--aluminumaluminum--arsenidearsenideNdYAPNdYAP NeodymiumNeodymium--yttriumyttrium--aluminumaluminum--perovskiteperovskite
LaserLaser mathmath
PowerPower -- laserlaser outputoutput expressedexpressedasas wattswattsEnergyEnergy-- laserlaser outputoutput expressedexpressedasas joulesjoulesFluenceFluence--laserlaser energyenergy densitydensityexpressedexpressed asas joulesjoules//cmcm22
1 1 wattwatt == 1 1 joulejoule//secondsecondwattswatts x x secondsseconds == joulesjoules
DyeDye enhancedenhanced laserlaser ablationablation
IIncreasencrease absorptionabsorption bybyadditionaddition ofof anan exogenousexogenousdyedye onon thethe surfacesurface ofof tissuetissueEnergyEnergy thatthat wouldwould bebereflectedreflected oror scatteredscattered isisnownow coupledcoupled intointo dyedye--tissuetissueinterfaceinterface
ClinicalClinical applicationsapplications ofof laserlaser inin endodonticsendodontics
DiagnosisDiagnosis ofof pulpalpulpal bloodblood flowflowDentinalDentinal hypersensitivityhypersensitivityPulpPulp cappincapping & g & pulpotomypulpotomySterilizationSterilization ofof rootroot canalscanalsRootRoot canalcanal shapinshaping & g & obturationobturationApicectomyApicectomyOthersOthers
DiagnosisDiagnosis ofof bloodblood flowflow inin dentaldental pulppulp
LaserLaser DopplerDopplerFlowmetryFlowmetry ((LDFLDF))HeHe--NeNe,, GaAlAsGaAlAs,, IRIRLowLow--powerpower levellevel ofof11--22 mWmW
LLightight scatteredscattered byby movingmoving RBCRBC,, produceproduce a a signalsignalthatthat waswas a a functionfunction ofof thethe redred cellcell fluxflux ((volvol ofofcellscells illuminatedilluminated x x meanmean cellcell velocityvelocity))
DentalDental hypersensitivityhypersensitivity
22 grgr :: lowlow outputoutput powerpower((HeHe--NeNe,, GaAlAsGaAlAs))
: : middlemiddle outputoutput powerpower((NdNd--YAGYAG,, COCO22))
DentalDental hypersensitivityhypersensitivity
LowLow powerpower :: laserlaser’’ss energyenergy isistransmittedtransmitted throughthroughenamelenamel//dentinedentine toto reachreach thethe pulppulp
: : affectaffect actionactionpotentialpotential oror blockblockdepolarizationdepolarization ofof CC--fiberfiber,, nonodamagedamage toto pulppulp
DentalDental hypersensitivityhypersensitivity
MiddleMiddle powerpower :: laserlaser’’ss energyenergy isistransmittedtransmitted throughthrough dentinedentine,,thermallythermally effectseffects && pulpalpulpal analgesiaanalgesia
: : sealingsealing dentinaldentinaltubulestubules
: : hyperemiahyperemia: : focalfocal degenerationdegeneration ofof
odontoblastsodontoblasts
PulpPulp cappingcapping && pulpotomypulpotomy
VaporizeVaporize tissuestissues,, coagulatecoagulate &&sealseal smallsmall bloodblood vesselsvessels totoproduceproduce bloodlessbloodless fieldfieldSterileSterile woundwound surfacesurfaceTheThe firstfirst laserlaser pulpotomypulpotomy waswasCOCO22 laserlaserNdYAGNdYAG,, GaAlAsGaAlAs,, ArAr
SterilizationSterilization ofof rootroot canalscanals
NdYAGNdYAG isis popularpopular becausebecause of of a a thinthin fiberfiber--opticoptic forfor enteringentering canalscanalsNdYAGNdYAG significantlysignificantly reducedreducedEE..faecalisfaecalis whilewhile NaOClNaOCl effectivelyeffectivelydisinfecteddisinfected canalcanals s (M(Moshonovoshonov etet alal..,, 1995)1995)
XeClXeCl,, ErYAGErYAG,, NdYAPNdYAP
SterilizationSterilization ofof rootroot canalscanals
NdYAPNdYAP ++ SerialSerial prepprep ++ MMM 3000M 3000 showedshowed thethecleanestcleanest preprep (Yp (Yvesves BluBlum & m & AbadieAbadie,, 1997)1997)BactericidalBactericidal effecteffectPrecautionsPrecautions :: spreadingspreading bacterialbacterial contaminationcontaminationtoto patienpatient & t & dentaldental teamteam viavia smokesmoke byby laserlaser
: : thermalthermal injuryinjury toto periodontperiodontiumium
Bactericidal effectBactericidal effect
Chemical rinseChemical rinse 100 100 µµmmUltrasonic cleansingUltrasonic cleansing1000 1000 µµmmLaser Laser > > 10001000 µµmm
ExcimerExcimer inin EndodonticsEndodontics ((inin vitrovitro))
PiniPini,, LasersLasers inin SurSurgg & & MeMed d 9, 9, 352352--7, 19897, 1989
308 308 nmnm XeClXeCl laserlaserNecroticNecrotic dentinedentine inin canalcanal wallswallsisis removeremovedd atat lowerlower fluencesfluencesthanthan healthyhealthy tissuestissuesCanalCanal preparedprepared iin 10 n 10 minsmins
RootRoot canalcanal shapinshaping &g & obturationobturation
WeichmaWeichman & n & JohnsonJohnson (1971)(1971)firstfirst appliedapplied COCO22 laserlaser totosealseal apicalapical foramenforamen inin vitrovitro
RemovedRemoved debridebris & s & smearsmearlayerlayer:: ErYAGErYAG isis moremoreeffectiveeffective thanthan ArAr oror NdYANdYAG G (M(Matsuokaatsuoka etet alal..,, 1998:1998:Takeda Takeda etet alal..,, 1999) 1999)
ErYAG
MeltMelt dentindentine & e & sealseal exposedexposedtubulestubules :: XeClXeCl,, ArFArFArAr,, COCO22,, NdYAGNdYAG :: softensoften gpgpHardHard toto cleanclean allall wallswalls becausebecausethethe laserlaser isis emittedemitted straightstraight,,makingmaking itit impossibleimpossible toto irradiateirradiatethethe laterallateral wallswalls
InfectedInfected teethteeth,, postoppostop discomfortdiscomfortinin thethe laserlaser--treatedtreated grgr waswassignificantlysignificantly reducedreduced comparedcompared totononlasernonlaser--treatedtreated grgr(K(Kobaoba,, 19951995; ; KobaKoba etet alal..,, 19991999))
UsefulUseful asas anan adjunctadjunct duringduring RCTRCTbutbut notnot possiblepossible toto useuse alonealone forforRCTRCT
AAAEAE
Fiber tip Fiber tip cannot be curvedcannot be curved to to follow the natural curvatures follow the natural curvatures of the root (cof the root (canals are often anals are often curved curved ≥≥ 2 dimensions)2 dimensions)EElevationlevation in temp can in temp can damagedamagethe tooth, soft tissue the tooth, soft tissue surrounding the bonesurrounding the bone
ApicectomyApicectomy
AdvantageAdvantage forfor thethe surgerysurgery––BloodlessBloodless fieldfield––SterilizationSterilization ofof woundwound––LessLess opop && postpost--opop painpain––ShorterShorter hospitalhospital staysstays
ApicectomyApicectomy
AdvantageAdvantage forfor thethe cutcut surfacesurface––SurfaceSurface isis sterilizedsterilized––DentinalDentinal tubulestubules areare sealedsealed––NoNo needneed forfor mechanicalmechanical drilldrilleliminateeliminate thermalthermal &&structuralstructural damagedamage
ApicectomyApicectomy
COCO22 laserlaser waswas firstfirst useused (Md (Miserendinoiserendino,,19881988))BadeBader &r & LejeuneLejeune (1998) (1998) showedshowed thatthatCOCO22 diddid notnot improveimprove thethe healinghealing processprocessNdYANdYAG G (S(Sumitomumitomo & o & FuruyaFuruya,, 1988)1988)smoothsmooth,, cleanclean resectedresected rootroot surfacessurfaces,,improveimprove healinhealing &g & postoppostop discomfortdiscomfortLessLess workingworking timetime thanthan ultrasonicultrasonic
ApicectomyApicectomy
OthersOthers
SterilizeSterilize dentaldental instrumentsinstruments :: ArAr,, COCO22,,NdYAGNdYAGFusedFused fracturedfractured rootroot (A(Arakawarakawa etet alal..,,19961996) ) butbut waswas notnot achievedachievedRetreatmentRetreatment :: NdYAPNdYAP (F(Fargearge etet alal..,,19981998))
FDAFDA
ApprovalApproval forfor manymany softsofttissuetissue proceduresproceduresErYAGErYAG recentlyrecently approvedapprovedforfor cavitycavity preprep & p & cariescariesremovalremoval
Millennium Specifications
Wavelength 2780 nanometers (Er, Cr:YSGG)
Frequency 20 Hz
Power 0.0-6.0 W
Pulse Energy 0-300mJOperating Voltage 115~ ±10%
Cooling System Air & water
Erbium, chromium: yttrium scandium gallium garnet
Waterlase™ Technology
Revolutionary Er, Cr: YSGG Waterlase™ for Hard & Soft Tissue
•Half size & weight of original Millennium.
•Elegant. Slender. Fits into any operatory.
•Incorporates state-of-the-art technological advances-laser design, optics, electronics, computerization & delivery system.
•Optimize costs, service & decrease shipping expenses.
•Macrospheres, generated by atomization chamber, are impinged at the laser beam delivery tip, & become superkinetically energized.
•This causes the macrospheres to disperse whereby the energy is released in an interactive zone within 1.5 mm from the laser delivery tip.
•The energized macrosphereacts as cutting agent to remove the target tissue.
Macrospheres1.5 mmInteractive Zone
Atomization Chamber
Hydrokinetic Energy
YSGG
WaterlaseWaterlase™™
Waterlase™ vs Laser Comparative Clinical Evidence
Cut produced by Waterlase™with atomized water spray
Optical Photomicrograph of a Human Tooth
Cut produced by same laser with NO water spray
*Both cuts were done at the same power setting with a micro-positioner, controlling the rate of speed & distance to tissue.
Hard Tissue Procedures(Adult & pediatric patients)Cavity Prep - Cl I-V
Caries Removal
Roughening & Etching
Enameloplasty
Excavation of pits & fissures for sealants
Root canal treatment
Soft Tissue ProceduresGingival Recontouring
Gingivectomy
Frenectomy
Fibroma Removal
Biopsy
Hemostasis
Aphthous Ulcer Treatment
WaterlaseWaterlase™™ Clinical ApplicationsClinical Applications
EffectEffect onon periodontalperiodontal tissuestissuesThresholdThreshold levellevel forfor bonebone survivalsurvival waswas4747o o CC ((ErikssonEriksson && AlbrektssonAlbrektsson,, 1983)1983)AnkylosisAnkylosis,, CementalCemental lysislysis,, MajorMajor boneboneremodelingremodeling
EffectEffect onon periodontalperiodontal tissuestissues
NdYAGNdYAG producedproduced thermalthermaleffectseffects whichwhich couldcould causecausepulpalpulpal traumatrauma..WWaterater coolantcoolant waswaseffectiveeffective inin reducingreducingthermalthermal effectseffects (G(Gowow etetalal..,, 19991999))
EffectEffect onon periodontalperiodontal tissuestissues
NdYAGNdYAG lasinglasing cyclescycles ofof 33 JJ//S S forfor 1515S S followedfollowed byby a a 1515 S S recoveryrecoveryintervalinterval cancan bebe continuedcontinued withoutwithoutriskrisk ofof thermalthermal damagedamage (R(Ramskoldamskold etetalal..,, 19971997))QQ--switchedswitched nanosecondnanosecond pulsepulse modemode(K(Kimuraimura etet alal..,, 1997, 1998)1997, 1998)
TemperatureTemperature requirementsrequirements
COCO22 laserlaser cooledcooled withwithairair--waterwater spraysprayproducedproduced similarsimilar pulpalpulpaltemperaturetemperature changeschangestoto thosethose causedcaused byby ananairair--waterwater cooledcooled highhighspeedspeed drilldrill
FactorsFactors relatedrelated toto heatheat generationgeneration
WavelengthWavelength ofof laserlaser:: excimerexcimerproduceproduce lessless heatheatAbsorptionAbsorption characteristicscharacteristics ofofexposedexposed tissuestissuesPowerPower densitydensity ofof laserlaserExposureExposure timetimeModeMode -- pulsedpulsed vsvs continuouscontinuous
Clinical CasesClinical Cases
Xenon Bulb & Xenon Bulb & Liquid Light Guide Liquid Light Guide technologytechnology
DIAGNOdentDIAGNOdent™™
Sweden, 1980 KavoDiode red light 655 nmReduce signals in deminarea0-14: No caries15-20: Enamel caries21-99: Dentine caries
Pre-op
Intra-op Preparation Completed
Post-op Restoration Completed
Photos courtesy of William A. Greider, D.M.D., M.A.G.D.
Cl V With Gingival Recontouring
ClCl V With Gingival V With Gingival RecontouringRecontouring
Two Cl V lesions located on the labial surface of teeth No. 6 & 7.
Class V where decay is located subgingivally is one of the best uses for the Millennium
ClCl V With Gingival V With Gingival RecontouringRecontouring
The decay is extended subgingivally so soft tissue recontouring was necessary before preparation. No anesthesia was utilized.
Tissue was removed using preset no.1. The soft tissue recontouring took < 1 min & the hemostasis was completed. Preset no.4 was used to access the carious lesions. The left shows the result immediately following surgery.
ClCl V With Gingival V With Gingival RecontouringRecontouring
The entire restoration & recontouring was performed with the BIOLASE Millennium®, in < 10 min - no shots, no pain.
Pre-op
Intra-opPreparation Completed
Post-opRestoration Completed
ClCl I RestorationI Restoration
Photos courtesy of William A. Greider, D.M.D., M.A.G.D.
Cl I carious lesions on the occlusalsurface of teeth No. 28 & 29.
Cl I Restoration
Class I Restoration
The “Enamel” Preset was used, carious lesions were eradicated. Anesthesia was not utilized - no shot, no pain!
Class I Restoration
Hydrokinetic usage totaling 1 min for completed restoration.
SEMSEMScanning Electron MicrographsScanning Electron Micrographs
Waterlase™ Millennium®
vs Air Abrasion
Air abrasion causes smear layer & debris on enamel. SEM of enamel cut surface shows smear layer & debris. (x1000)
100 µm
Millennium® Er, Cr: YSGG cuts enamel with NO smear layer, no micro fractures. SEM of enamel cut structure is compact with no column displacement & no modification of the intercolumnar distances. No smear layer or denaturatedtissue structure. (x1000)
100 µm
Bonding surface quality for enamel
Air abrasion causes smear layeron dentin. SEM shows smear layer covers the dentinal tubules. (x1000)
100 µm
Millennium® Er, Cr: YSGG creates cuts on dentin with no smear layer. SEM shows longitudinally cut dentinal tubules which are open & free of smear layer.(x1000)
100 µm
Bonding surface quality for dentin
Waterlase™ Millennium®
vs. Air Abrasion
*All of the above slides were performed at a magnificationof x2000 on a Jeol SEM model JSM-840.
SEM of enamel cut with high speed drill & etched. Notice typical etched enamel surface structure. (x2000)
10 µm
Waterlase™ Millennium®
vs Drill, Air Abrasion & Acid Etch
10 µm
SEM of enamel cut with Waterlase is similar to that of the acid etched surface. Notice the microroughness & absence of smear layer. This structure provides strong micromechanical bonding of the resin composite material to the cut surface. (x2000)
*All of the above slides were performed at a magnificationof x2000 on a Jeol SEM model JSM-840.
Waterlase™ Millennium®
vs. Drill, Air Abrasion & Acid Etch
Enamel Bonding Surface Quality
Cutting Hard Tissue with HighCutting Hard Tissue with High--speed Drill speed Drill vsvs MillenniumMillennium
Drill creates smear layer & microfracture of approximately 10 μ in width (x200)
Millennium creates clean cuts on dentin. No smear layer, tubules open & free of debris (x3500)
SafetySafety
AppropriateAppropriate eyewearseyewearsWavelengthWavelength dependentdependentOperatoOperator &r & patientpatient mustmustbebe protectedprotected
RecommendedRecommended readingreading
LasersLasers inin Dentistry (2003) Dentistry (2003) Ishikawa I, Ishikawa I, Frame JW, Aoki A editors.Frame JW, Aoki A editors. International International Congress Series 1248Congress Series 1248..ChailertvanitkulChailertvanitkul PP,, JitpakdeebodinJitpakdeebodin KK,,SattayutSattayut S (S (20020011) ) AnAn apicalapical microleakagemicroleakageofof SuperSuper EBAEBA,, NdNd::YAGYAG laselaser &r & coldcoldburnishedburnished gpgp inin apicoectomyapicoectomy.. KDJKDJ 4 (1), 4 (1), 5454--61.61.
RecommendedRecommended readingreading
ปทมาปทมา ชัยเลิศวณิชกลุชัยเลิศวณิชกลุ (2547) (2547) การประยุกตใชเลเซอรการประยุกตใชเลเซอรในงานวทิยาเอนโดในงานวทิยาเอนโดดอนตดอนต.. เอ็นโดสารเอ็นโดสาร 9 (2), 179 (2), 17--2323..www.laserdentistry.orgwww.laserdentistry.org
