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[1] =>
issn 1616-6345
Vol. 3 • Issue 4/2011
laser
international magazine of
laser dentistry
4
2011
| research
Treatment of gingival hyper-pigmentation
with the Er,Cr:YSGG laser
| case report
Smile enhancement with laser technology—
Predictable and esthetic
| education
Start of the new Master of Science course
Lasers in Dentistry at RWTH Aachen University
[2] =>
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Visit www.lightwalkerlaser.com today!
[3] =>
editorial _ laser
Under the laser
light tree!
I
Prof Dr Norbert Gutknecht
WFLD President
Editor-in-Chief
_The year 2011 was full with a numerous of highlights.
Depending on the regional cultures and customs, the christmas trees are differently adorned.
A big variation of different light sources are found all around it, generating varying pleasant impressions of all kinds.
Looking at our “Laser Light Tree”, the year 2011 generated a number of new laser light sources
and laser light combination in medical and dental devices generating varying pleasant treatment methods. Presents under the Christmas trees can be compared with the different conference meetings, exhibitions, and congresses such as IDS, WFLD-ED and a number of national
meetings.
All we can say—it was a rich and enlightening year.
Now, the year 2012 is just around the corner, triggering special expectations. For sure, the
WFLD congress in Barcelona will be the highlight in laser dentistry in the upcoming year 2012,
where participants from all around the world will share their experiences and knowledge in their
fields of expertise.
Looking forward to meet you in Barcelona I wish you all a Merry Christmas and a Happy New
Year.
Prof Dr Norbert Gutknecht
Editor-in-Chief
laser
4
I 03
_ 2011
[4] =>
I content _ laser
page 10
36
I editorial
03
I research
Treatment of gingival hyper-pigmentation
with the Er,Cr:YSGG laser
39
International events 2012
40
Laser’s rightful place in modern dentistry
| Jürgen Isbaner
Some aspects of the use of the Nd:YAG laser
in periodontal therapy
I education
| Dr Talat Qadri et al.
42
Fascination of Laser Dentistry
44
Graduation of the first Mastership Course
of AALZ Greece
I overview
16
Laser-assisted dentistry in the daily office routine:
A “multi-wave” concept
| Dr Kresimir Simunovic et al.
| Dr Dimitris Strakas
46
Smile enhancement with laser technology—
Predictable and esthetic
| Dr Hugh Flax
26
Start of the new Master of Science course in Aachen
| Dajana Klöckner
I case report
22
Laser in daily practice use
I meetings
| Dr Gizem Berk et al.
10
page 22
| Prof Dr Frank Liebaug et al.
Under the laser light tree!
| Prof Dr Norbert Gutknecht
06
page 16
I news
48
Manufacturer News
Papillon-Lefèvre syndrome
I about the publisher
| Dr Maziar Mir et al.
50
| imprint
I user report
30
Er,Cr:YSGG laser for cavity preparation
| Dr Ralf Borchers
I industry report
32
Cover image courtesy of Syneron Dental Lasers,
www.synerondental.com .
Artwork by Sarah Fuhrmann, Oemus Media AG.
The use of the Er:YAG in laser-assisted
periodontal surgery
| Dr Avi Reyhanian
page 30
04 I laser
4_ 2011
page 36
page 46
[5] =>
[6] =>
I research _ hyper-pigmentation
Treatment of gingival
hyper-pigmentation with
the Er,Cr:YSGG laser
Clinical observation and one-year follow-up
Authors_Drs Gizem Berk, Kubra Atici & Nuket Berk, Turkey
_Introduction
The colour of the gingiva is determined by several factors, including the number and size of
blood vessels, epithelial thickness, quantity of keratinisation and pigments within the epithelium.
Melanin, carotene, reduced haemoglobin and
oxyhaemoglobin are main pigments contributing
to the normal colour of the oral mucosa.1 Frequently, the gingival hyper-pigmentation is
caused by excessive melanin deposits mainly located in the basal and supra-basal cell layers of the
epithelium.2
06 I laser
4_ 2011
pecially those with gummy smiles.2 The degree of
pigmentation depends on a variety of factors, particularly the activity of melanocytes. Fair-skinned
individuals are very likely to have non-pigmented
gingival, but in darker-skinned persons, the
chance of having pigmented gingiva is extremely
high. The highest rate of gingival pigmentation
has been observed in the area of incisors. The rate
decreases considerably in the posterior regions.4
Melanin is produced by specific cells—
melanocytes residing in the basal layer—and is
transferred to the basal cells, where it is stored in
the form of melanosomes. It can also be found in
keratinocytes of gingival epithelium.3
Gingival depigmentation has been carried out
using surgical, chemical, electrosurgical and
cryosurgical procedures.2, 5 Recently, laser ablation has been recognised as one of the most effective, pleasant and reliable techniques.5 Many laser
systems such as Q-switched ruby laser, flash-lamp
pumped-dye laser, argon laser, CO2 laser, Nd:YAG
laser and Er:YAG laser have been used for skin pigmentation.1, 2, 5
Melanin hyper-pigmented gingiva is an aesthetic problem for many individuals, particularly if
the hyper-pigmentation is on the facial aspect of
gingiva and visible during smiling and speech, es-
In the late 1990s, the Er,Cr:YSGG laser with a
wavelength of 2,780 nm, frequency of 10 to 50 Hz,
and pulse energy between 0 and 300 mJ was introduced as a safe and efficient wavelength to be
Fig. 1
Fig. 2
[7] =>
research _ hyper-pigmentation
Fig. 3
Fig. 4
used on hard and soft periodontal tissues, supported by several published studies regarding its
beneficial effect in periodontal treatment.6, 7
the tissue and with a sweeping motion localised
only on the pigmented regions. The procedure was
performed in a cervico-apical direction on all pigmented areas. After slight removal of the connective tissue, the setting was changed to 1.75 W, 40 %
air and 5 % water in order to obtain more rapid ablation with less haemorrhaging but without thermal damage to the tissue.
Re-pigmentation after gingival depigmentation
is an important point of which clinicians should be
aware. Reports of re-pigmentation are quite limited and varied.1
The following case shows successful depigmentation using an Er,Cr:YSGG laser and results regarding re-pigmentation obtained after a one-year
follow-up period.
I
Every five minutes, the operation field was
wiped with sterile gauze soaked in 1 % normal
saline solution. The depigmentation procedure
continued until no visible pigments remained. The
complete treatment was performed in 30 min.
_Case report
A 29-year-old female, Turkish patient presented
to our clinic who was not happy with her smile and
aesthetic appearance owing to the pigmented regions, most pronounced in the anterior region. She
had extensive pigmentation on her maxillary gingiva and moderate pigmentation on her mandibular gingiva (Fig. 1). The colour of the gingiva was
dark to black. There was no contributory medical
problem. The patient was very fearful of dental injections.
Preoperative pictures were taken and topical
anaesthetic gel applied to the operatory field. In
compliance with FDA rules, patient and staff used
special eyeglasses for protection.
After wiping of the operative fields for the last
time, there was slight bleeding (Fig. 2).
No periodontal pack or additional material was
applied to support the healing procedure.
The patient was recalled 24 hours, four days and
seven days later and intra-oral pictures were taken
(Fig. 3).
The patient was instructed to avoid smoking, alcohol, acidic beverages, and hot and spicy foods. He
was advised to keep his wound area clean by brushing with a soft brush for the first week. No analgesic
was prescribed.
_Clinical results
Er,Cr:YSGG laser application started with 600
sapphire tips (MG6, 6 mm) with 20 Hz, 140 s pulse
duration (H mode) and 1.5 W, 20 % air and 15 % water in non-contact mode, about 1.5 mm away from
After 24 hours, the lased gingiva was partly covered with a thin layer of fibrin, which exfoliated
during the first week after treatment. The ablated
AD
Please contact Dajana Mischke
d.mischke@oemus-media.de
laser
4
I 07
_ 2011
[8] =>
I research _ hyper-pigmentation
wound was healed almost completely after four
days. The colour of ablated gingiva was pink and
healthy four days after ablation. The gingiva was visually similar to the normal untreated gingiva,
completely without melanin pigmentation.
On the fourth day post-operatively, the patient
was asked whether she had had any pain or discomfort within the past four days. She revealed
that she had had a slight sensitivity on her maxilla
about twelve hours post-operatively but did not
need any medications and this did not cause any
change in her usual routine. The patient was recalled six months and one year later, and intra-oral
pictures were taken again (Fig. 4).
_Discussion
Numerous authors have reported successful results for the use of the lasers in hard and soft tissue
applications. They include procedures common to
oral surgery, oral pathology, restorative dentistry
and periodontics.6–9 There is abundant evidence
that confirms markedly less bleeding, particularly
of highly vascular oral tissues with laser surgery.
Anecdotal reports that incising oral soft tissue with
a laser is less painful then using a scalpel and therefore requires less oral aesthetic have no scientific
confirmation to date.10 In our study, topical aesthetic gel was applied, but no infiltration anaesthetic was used and we observed less bleeding during laser therapy compared with conventional surgical techniques. Post-operative pain from oral and
otolaryngological surgical procedures has been
claimed to be reduced in laser surgery. It is theorised
that this may be due to protein coagulum that is
formed on the wound surface, thereby acting as a
biological wound dressing10, 11 and sealing the ends
of the sensory nerves.12 In the present study, patient
satisfaction was high. There was no complaint of
pain during treatment or post-operatively.
Some reports suggest that laser-created
wounds heal more quickly and produce less scar tissue than conventional scalpel surgery.13, 14 In contrast, some studies have shown the delay of re-epithelisation of the laser wound compared with conventional wounds.15, 16 In our report about depigmentation treatment with the Er,Cr:YSGG laser,
re-epithelisation was completed after seven days
and the gingiva was similar to the normal untreated
gingiva.
Re-pigmentation after depigmentation has
been reported following the use of different techniques. The mechanism of re-pigmentation is not
understood but according to the migration theory,
active melanocytes from the adjacent pigmented
08 I laser
4_ 2011
tissues migrate to treated areas, causing re-pigmentation.17 Dummett and Bolden18 observed partial recurrence of hyper-pigmentation in six out of
eight patients after gingivectomy at one to four
months, whereas Perlmutter and Tal17 described
partial recurrence after seven to eight years. Tal
et al.19 and Tal20 did not observe re-pigmentation
until 20 months after cryosurgical depigmentation.
No recurrence of hyper-pigmentation was found in
any of the four patients treated by Atsawasuwan
et al.2 at 11 to 13 months after gingival depigmentation using the Nd:YAG laser. Nakamura et al.21
reported depigmentation with the CO2 laser in ten
patients. No re-pigmentation was seen in the first
year, but four patients showed re-pigmentation at
24 months. Tal et al.1 observed no re-pigmentation
in any of the patients treated with the Er:YAG laser
after six months.
In the present study, re-pigmentation was not
observed during a one-year follow-up period.
However, long-term observations are required to
determine the efficiency of the Er,Cr:YSGG laser in
hyper-pigmentation treatment.
_Conclusion
Treatment of gingival hyper-pigmentation by
Er,Cr:YSGG laser radiation in a defocused mode was
found to be a safe and effective procedure. Postoperative patient satisfaction in terms of aesthetic
and pain was impressive. The gingiva healed uneventfully and completely regenerated with no infection, pain, swelling or scarring. No re-pigmentation had occurred after one year post-surgery.
Based on these observations, the Er,Cr:YSGG laser is
a good treatment choice for gingival hyper-pigmentation._
Editorial note: A list of references is available from the
publisher.
_contact
Dr Gizem Berk
Denta Form Health Center
Mahatma Gandi Cad. No. 34
06700 G.O.P.
Ankara, Turkey
Tel.: +90 312 4476090
Fax: +90 312 4462782
gizemberk@yahoo.com
www.dentaform.com.tr
laser
[9] =>
Lay the Foundations to your
successful Future now!
New course: 17-22 February 2012, Aachen Dental University College, Dubai
Mastership Curriculum Laser Therapy in Dentistry
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www.aalz.de · info@aalz.de
[10] =>
I research _ periodontal therapy
Some aspects of the use
of the Nd:YAG laser in
periodontal therapy
Authors_Drs Talat Qadri & Jan Tunér, Sweden
Fig. 1a
Fig. 1b
Fig. 1a_X-ray.
Fig. 1b_The situation before
treatment.
Fig. 1c_After creating the funnel.
Fig. 1d_The post-op situation.
Fig. 1c
_Introduction
Moderate forms of periodontitis are demonstrated in 50 to 90 % of adults with regional and agebased differences. Periodontitis destroys the integrity
of oral mucous membranes and is one of the main
reasons for tooth loss, especially amongst people
aged 40 and older. Aggressive forms of periodontitis
may result in advanced loss of periodontal attachment and alveolar bone, resulting in urgent need for
prosthetic treatment for those individuals within a
very short time. The presence of bacteria in the gingival sulcus and periodontal tissues is a determining
factor of the development of periodontal disease. The
Fig. 1d
10 I laser
4_ 2011
conventional periodontal therapy aims to suppress
inflammatory signs and pathogenic bacteria. This
therapy consists of root scaling and planing, whether
associated with antibiotic chemotherapy or not. In areas of different access such as the furcations, invaginations and concavities, the use of manual curettes or
ultrasound does not ensure the eradication of periopathogenic bacteria and the success of treatment.
Moreover, the increase of strains capable of resisting
antibiotic chemotherapy may also damage the efficacy of conventional periodontal treatment. Based on
these facts, alternative methods are being studied
with the aim of achieving a more efficient therapy
with more predictable prognosis. In this regard, lasers
have become an interesting adjuvant therapy with
promising results. The scientific base for this approach to treating periodontitis is still not entirely evidence based and more studies are needed to determine its effectiveness and optimal parameters. The
present article will provide a summary of our experiences and the outcome of four clinical studies.
_The dental Nd:YAG laser
Modern dental Nd:YAG lasers are free running and
pulsed as opposed to other continuous wave lasers
with gated pulse options. The ablation ability is set
either by increasing the output power or the pulse
repetition rate. The therapy is performed in tissue
contact and in constant motion.
For pulsed lasers, peak power has an order of magnitude higher than an average power. There are very
high spikes, with peak power being 1,000 times higher
than average power, and relatively long rest periods.
Pulse width (the amount of time for each pulse) varies
from 90 to 1,200 microseconds in different pulsed
Nd:YAG lasers and is an important component of this
[11] =>
research _ periodontal therapy
Fig. 2
technology. The short duration allows for a long resting time, which sometimes obviates the need for local anaesthesia. The number of pulses (frequency,
pulse repetition rate) per second is one of the crucial
factors in pulsed Nd:YAG lasers. With a high repetition
rate of 10 to 100 Hz in different devices, one can
achieve smoother cutting at a very low power setting
because the peak power in each pulse can be very high
(White et al. 1994).
The 1,064 nm wavelength is invisible, which makes
the evaluation of the actual effected area difficult.
Seen through an infra-red camera, it is obvious that
the light is spread like a small ball over a rather large
area and not just around the fibre tip.
Fig. 3a
fines the ablation threshold. Ablation thresholds for a
single pulse were determined for both P. gingivalis
and for blood agar alone. The large difference in ablation thresholds between the pigmented pathogen
and the host matrix for pulsed-Nd:YAG indicated a
significant therapeutic ratio and P. gingivalis was ablated without visible effect on the blood agar. Near
threshold, the 810 nm diode laser destroyed both the
pathogen and the gel. The pulsed Nd:YAG, however,
may selectively destroy pigmented pathogens, leaving the surrounding tissue intact. The 810 nm diode
laser may not demonstrate this selectivity owing to its
longer pulse length and greater absorption by
haemoglobin”(Harris 2004).
I
Fig. 3b
Fig. 2_Lateral distribution of
the light.
Figs. 3a–d_The fibre with water
cooling, easy to clean (3a–b) and
without water cooling (3c–d).
_Which microbes are eliminated?
The Nd:YAG laser energy is absorbed by tissue and
it is this absorbance that allows surgical excision and
coagulation of tissue. The absorption in different
dental tissues shows a low absorption and a moderate absorption for hydroxyapatite. The ablative effect
of this wavelength on hard dental tissue is obviously
rather low. Its wavelength has a particular affinity for
melanin or other dark pigments. Therefore, microbes
with dark pigment are more sensitive to this laser.
These microbes can be eliminated at rather low
power settings at which there will be no collateral
damage to the adjacent tissue. The choice of wavelength is important when it comes to bactericidal effect.
Harris (2004) aimed to develop a method for quantifying the efficacy of ablation of Porphyromonas
gingivalis in vitro with two different lasers. The ablation thresholds for the two lasers were compared in
the following manner. “The energy density was measured as a function of distance from the output of the
fibre-optic delivery system. P. gingivalis cultures were
grown on blood agar plates under standard anaerobic conditions. Blood agar provides an approximation
of gingival tissue for the wavelengths tested in having haemoglobin as a primary absorber. Single pulses
of laser energy were delivered to P. gingivalis colonies
and the energy density was increased until the appearance of a small plume was observed coincident
with a laser pulse. The energy density at this point de-
It is postulated that the Nd:YAG laser eliminates
primarily the dark-pigmented microbes, such as
P. gingivalis, whereas Aggregatibacter actinomycetemcomitans, having no pigments, would not be
similarly reduced. However, in Andrade et al. (2008)
A. actinomycetemcomitans was eliminated directly
after irradiation, but regained approximately 50 % of
the baseline level after six weeks. Such recurrence is
reported in several studies and is attributed to crosscontamination from non-treated pockets and/or
saliva (Teughels et al. 2000). A. actinomycetemcomitans is found in 90 % of all cases of juvenile periodontitis but only in 50 % of adult chronic periodontitis (Slots et al. 1980). P. gingivalis is reported to be
aggregated with other periodontal pathogens, such
as Prevotella intermedia so light absorption into the
dark pigment of P. gingivalis is likely to cause consid-
Fig. 3c
Fig. 3d
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[12] =>
I research _ periodontal therapy
other hand, causes uncontrolled tissue necrosis and
non-selective effects on microbes. Adding watercooling to the electrocauter is not standard procedure, but by doing so, the cutting effect is slower but
carbonisation is reduced and post-operative healing
is improved.
Fig. 4_Varicosity formation
in the axons. (Courtesy of Ambrose
Chan, Australia)
_Dental calculus
Fig. 4
erable collateral damage to other microbes. Therefore, it appears that the Nd:YAG laser has a promising
potential in eliminating the majority of the microbes
in the pocket’s soft tissue.
_The use of water-cooling
Fig. 5a_Example of the use of
Nd:YAG tissue ablation using only
Xylocaine ointment immediately
before treatment.
Fig. 5b_The post-op situation.
Fig. 5c_One week post-op.
Fig. 5a
12 I laser
4_ 2011
Negative thermal effects of the Nd:YAG laser
have been reported in in vitro studies (Liu et al. 1999;
Israel et al. 1997). However, in vivo effects on the
root surface and the pulp are not well documented
(Gaspirc & Skaleric 2001; Schwarz et al. 2008). The
effect of laser irradiation on the surrounding tissues
is influenced by parameters such as power, pulse, fibre size, fibre angulations and cooling/no cooling.
White et al. (1994) suggest that powers between 0.3
and 3.0 W should not cause a damaging rise in intrapulpal temperature. Likewise, Gold and Vilardi
(1994) and Spencer et al. (1996) also report that the
use of laser at 4 W is safe and does not damage the
root surface. The use of water-cooling is not standard in dentistry. In our experience, the cooling further reduces the risk of local carbonisation with the
following increased absorption and unwanted tissue destruction. In spite of the use of 3 W in our studies, the speed of operation was still satisfactory and
no carbonisation was observed. The advantage of
using water is also relevant as described above for
the accumulation of carbonised tissue on the probe,
as described below.
It is essential to understand that the effect of the
Nd:YAG is not based upon heating, but upon selective absorption in the tissue. Electrocautery, on the
Fig. 5b
It has been postulated that the use of Nd:YAG
laser prior to SRP softens the calculus deposits and
makes conventional SRP easier. However, the marginal benefit of this procedure probably does not
compensate for the potential damage to the root
surface. On the other hand, the use of the Nd:YAG
laser can be compared to open flap surgery. By removing the epithelial lining and widening the access
to the root surface, calculus deposits are made visible and can therefore be removed conventionally
with greater accuracy. The photographs above illustrate this possibility (Figs. 1a & d). The advantage of
this technique is obvious, since there is no need for
anaesthesia other than topical anaesthesia occasionally, there is no bleeding, and no need for sutures
or re-appointment to remove the sutures. In addition, there is less post-operative pain and oedema.
The laser irradiation itself creates an anaesthetic period of up to 24 hours, after which the patient experiences some tenderness in the area. In short, this is
a cost-effective procedure with benefits for the operator and the patient.
_The technique
Several techniques have been proposed. In our
own studies (Qadri et al. 2008, 2010), a 600 µm fibre
was used in contact with the soft tissue only, in constant motion and with water-cooling. To be able to
compare the effect with SRP, both sides of the
mouth were treated by SRP before the Nd:YAG was
used as an adjunct treatment. Clinically, we prefer a
different approach. The pocket epithelial lining is
first removed with the fibre at an angle of approximately 30°, avoiding contact with the root. This approach creates a funnel-like shape of the pocket
with a reduction of the pocket depth by a few mil-
Fig. 5c
[13] =>
research _ periodontal therapy
Fig. 6a
limetres. Once this has been done, the pocket is open
for inspection, with no or little bleeding, and SRP can
be performed with excellent visual control.
_The characteristics of different
Nd:YAG fibres
Most bare fibres consist of a glass rod core made
of silica quartz with an outer surface cladding that
has a different refractive index from that of the silica-quartz fibre, and an outer protective vinyl jacket.
The standard options are diameters ranging from
200 to 600 µm. As the fibre diameter decreases, the
energy densities increase and fibre flexibility increases. Thin fibres are popular for non-contact irradiation because of the high power density but less
than ideal for closed curettage, because they are too
prone to fracture and the energy density is too high.
The energy density of a 300 µm fibre is four times as
high as that of a 600 µm fibre. Thus, the use of a thin
fibre in a closed area has disadvantages. The high
power densities will easily cause charred areas in the
pocket and sticking of carbonised tissue to the tip. In
the dark carbonised areas, absorption of the light increases, and so does heat. The aim of the laser treatment is not to use the instrument as a thermocauter but to take advantage of the interaction between the light and the specific tissue targeted. Further to that, a thicker diameter makes the fibre
stronger and difficult-to-reach areas can more
comfortably be accessed.
Figure 2 shows the distribution of the light at the
fibre tip. As can be seen, the light is not only distributed along the axis of the fibre, but also to a considerable degree to the lateral sides. This is illustrated
by the plume of smoke caused by the lateral spread
of the beam and only occurring in pigmented (dark)
structures.
During treatment, the fibre has to be cleaned and
cut frequently. The output at the tip can be reduced
by more than 50 % after being used around a single
tooth. By using water-cooling, there will be less carbonised tissue in the pocket epithelium and less on
the fibre as well. The debris sticking to the fibre will
Fig. 6b
also be easier to remove (Figs. 3a & b). Further to that,
the fibre should be kept in constant motion during
therapy. The cutting capacity of the fibre is greater
when in motion than in a stationary position.
Nd:YAG, which has little absorption in water, may
be effectively cooled with simultaneous air and water spray. Several studies have confirmed that application of an air and water spray provides adequate
heat protection of the pulp, comparable with cooling of the conventional rotary bur (Miserendino et
al. 1994).
I
Fig. 6c
Fig. 6a–c_Nd:YAG treatment without
anaesthesia (day of treatment, at
seven weeks and at three months).
Note the good condition of the
gingiva at three months in spite of
poor oral hygiene.
_Nd:YAG laser and pain perception
A major advantage of Nd:YAG laser periodontal
therapy is that the procedure is more or less pain
free. From the patient’s point of view, this is certainly
the major aspect. The degree of pain is largely related
to the skill of the operator. Still, an anaesthetic gel is
required in some cases during the initial phase of the
surgery. After a while, it seems that the laser in itself
provides an anaesthetic effect. The prolonged
anaesthetic effect and the reduced trauma make
compliance with post-operative home care easier.
When performing sulcular debridement with the
laser around hypersensitive teeth, there is sometimes a pain reaction. In these cases, the tooth crown
can be irradiated from a short distance without water until the pulp has been anaesthetised. For the
same obvious reason, no water should be used when
conventional hypersensitive tooth necks are treated
with Nd:YAG laser. In combination with water, the
area will be cleaned and the tubules will be even
more open. Without water, they may be sealed.
The anaesthetic effect of the Nd:YAG laser is not
fully understood, but in vitro studies have shown
that Nd:YAG and 808 nm therapeutic lasers give rise
to transient nodules along the axons, possibly slowing down nerve conduction. Figure 4 shows these
varicosities after Nd:YAG irradiation of axons in vitro.
In general, it can be stated that the lasers themselves are not dangerous or damaging. It is the lack
laser
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[14] =>
I research _ periodontal therapy
_The therapeutic laser connection—
Low-level laser therapy
Fig. 7a
Fig. 7b
Fig. 8a
Fig. 8b
Fig. 7a_Furcation one day
of treatment.
Fig. 7b_Furcation at two years.
Fig. 8a_Mesial pocket before
therapy.
Fig. 8b_Mesial pocket at one year.
of knowledge that results in damage. The undesirable side effects can vary firstly with power and energy density and secondly with the type of laser used.
In summary, the advantages of the Nd:YAG laser in
periodontal therapy are:
1. reduced need for local anaesthesia;
2. reduced bleeding and better visual control of the
pocket;
3. local reduction of microbes in the pocket;
4. reduction of post-operative discomfort; and
5. reduction of the need for pharmaceuticals.
_Nd:YAG and bone regeneration
In our long-term study (Qadri 2010), some new
bone was gained. In many clinical cases, much more
bone regeneration has been seen, but typically in
these cases the condition has been worse than the
4+ mm pockets treated in our study. Another difference in the more successful cases is that there were
several therapy sessions, while the two Nd:YAG studies that are the subject of the present article only used
one single irradiation. One single session may therefore not be optimal, even though it may be quite useful. Figures 7 & 8 show some examples of bone regeneration using the Nd:YAG laser.
Fig. 9_The Arndt-Schultz law
(Tunér & Hode 2004).
Fig. 10_Schematic illustration of the
different light intensity zones.
LPT is other term for LLLT.
(Courtesy of Edson Nagib, Brazil)
14 I laser
4_ 2011
Fig. 9
While dental lasers such as the Nd:YAG and the
Er:YAG are used for removal of tissue, the therapeutic lasers (also called low-level lasers and the
therapy itself low-level laser therapy—LLLT) are
non-thermal and cause cellular modifications
through absorption in specific cellular photoreceptors, such as the cytochrome c oxidase, the terminal
enzyme in the mitochondrial respiratory system.
Such absorption causes a cascade of primary and
secondary effects on conditions such as wound
healing, oedema, inflammation, cellular proliferation and pain.
The first commercially available therapeutic laser
was a helium-neon (HeNe) laser of 1 mW. The wavelength is 632.8 nm. This is a gas laser and it is rather
large and fragile, and the light is distributed through
a fragile optical fibre. The narrow bandwidth of this
laser is believed to be an advantage, since the length
of coherence increases with the narrowness of the
wavelength. HeNe lasers are today not very common
on the market. In the late 1990s, they were being replaced by diode lasers. This technology allowed for
smaller machines and gradually also higher power.
The gallium-arsenide laser has a wavelength of
904 nm and is a pulsed laser with a high peak power
but an average power between 10 and 100 mW. The
gallium-aluminium-arsenide laser has a wavelength
of between 780 and 980 nm. Since the electrical driving system is less complicated, these lasers can be
small and still offer high outputs, typically between 5
and 500 mW. Recently, HeNe lasers have begun to be
replaced by semiconductor lasers containing indium
gallium aluminium phosphate. Wavelengths are typically between 630 and 680 nm in the red part of the
spectrum. Unlike the HeNe laser, these lasers can be
small and handy and are typically in the 10 to 300 mW
range.
LLLT follows the Arndt–Schultz law, which stipulates that for every substance, small doses stimulate,
moderate doses inhibit, large doses kill. Here, the
“killers” are the surgical lasers. There are specific dose
Fig. 10
[15] =>
research _ periodontal therapy
intervals in LLLT: wound healing requires a low dose,
anti-inflammatory effects 50 to 100 % higher and
pain-relieving effects much higher, because here an
inhibition is needed. But it should be born in mind
that a medium dosage aimed at the inflammatory
process is also pain relieving but not immediate. A
high dose will inhibit pain but will also prolong the
inflammatory phase, which in itself is painful (Tunér
& Hode 1998; Huang et al. 2009). LLLT is probably
most efficient during the first week following surgery (Gerbi et al. 2005; Fig. 9).
I
_Summary
The different parameters and techniques used in
Nd:YAG periodontal work contribute to the lack of a
firm evidence-based conclusion regarding the usefulness of this therapeutic modality. This article summarises our own experiences. The use of water-cooling can, in our opinion, offer several advantages. The
size and colour of the fibre also affect the outcome.
Further clinical studies are needed to determine the
optimal parameters for each indication._
_Additional bio-stimulatory effect
Bio-stimulatory effects have been confirmed using the Nd:YAG and the Er:YAG at low fluences. Thus,
the Nd:YAG laser has a certain bio-stimulatory effect
and this contributes to enhanced post-operative
healing (Abergel et al. 1984; Herman & Khosla 1989;
Fortuna et al. 2002; Vescovi et al. 2008). The energy
densities in the most peripheral zone fall within the
bio-stimulatory range, as illustrated in Figure 10. The
clinical effects in periodontal therapy are described
by Qadri et al. (2005, 2007). The current literature on
the use of LLLT in periodontal therapy has been reviewed by Eduardo et al. (2010).
_contact
laser
Dr Talat Qadri
Department of Periodontology
Karolinska Institutet
171 77 Huddinge
Sweden
Dr Jan Tunér
Spjutvägen 11
772 32 Grängesberg
Sweden
AD
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[16] =>
I overview _ concept
Laser-assisted dentistry
in the daily office routine:
A “multi-wave” concept
Authors_Dr Kresimir Simunovic, André Scholtz, Switzerland
What nature gives and
man forms can achieve
essential harmony and
benefit in the right hands,
like laser in dentistry.
_Since Einstein pictured the nature of light and
therefore postulated the basics of the concept of laser
over almost a century ago, a long and sometimes rebellious time of experimentation elapsed before we
finally witnessed a rapide and wide expansion of this
instrument of light across all fields of dentistry in the
new century.
At the beginning of the 1960s, Maiman developed
the first laser, a ruby laser. Thus, a “solution looking for
a problem“ was born, then with no concrete indica-
16 I laser
4_ 2011
tions. Only at the dawn of our millennium a vast range
of wavelengths, pulse durations and power settings
was achieved, to support safe and efficient clinical
applications of lasers in dentistry today. Thus we have
the privilege to be able to use the laser as an assistive
or completely independent evidence-based tool in almost every field of dentistry, in terms of a multi-wave
concept. In our office we classify laser-assisted dentistry into three categories, based on the focused main
effect:
1. Ablation: mostly in aesthetic and operative dentistry and surgery;
2. Decontamination: mainly in endodontics, periodontology and surgery;
3. Photobiomodulation PBM as additional effect for
the applications mentioned above, or as a therapy
on its own, like essential bio-modulation or photodynamic therapy.
In this multi-wave concept, all three function
together, unifying their basic features. We use following wavelengths in our office: 810 nm, 980 nm,
1,064 nm and 2,940 nm.This choice resulted gradually
from increasing knowledge and need to expand the
laser-assisted indications in our practice, based on
the chart of laser-assisted dentistry by Prof Dr N.
Gutknecht from the RWTH Aachen University. In dependency of the target tissue and the corresponding
coefficient of absorption, we evaluate and select
along the horizontal line the wavelength with the
most efficient tissue interaction.
Our patients involved are given a folder of fact
sheets, with a short description of any laser-assisted
therapy and its benefits, which is accompanied by an
individual consultation with our team on any scheduled laser therapy.
[17] =>
overview _ concept
I
_About searching and finding
Any therapy is based on diagnostics and laserassisted diagnostics is often a patient‘s first exposure to
laser light at a first visit, a recall check-up or during an
emergency consultation.
Laser-assisted detection tools for plaque, decay,
calculus and concrements are based on the direct analysis of different qualities of fluorescence on the target
(DIAGNOdent pen, KaVo; VisaProof, Dürr Dental; Figs. 1
& 2). Additional laser-based diagnostic tools for objective vitality tests are based on Laser Doppler Flowmetry
or the intra-oral fluorescence visualisation for detection and prevention of early mucosal alteration through
reduced fluorescence from the target tissue.
The DIAGNOdent pen, VistaProof and similar detection tools are based on the spectral analysis between the
quality of light emission in the green/blue wavelength
area of sound enamel/dentine and the red wavelength
area infected by bacterial metabolic products. The numerical and/or visual result distinguishes between the
necessity of therapy or just long therm monitoring of
the detected spot.
_Ablation
Applications in conservative/operative dentistry
Since the new generation of Er:YAG lasers allows
very subtle settings for pulse duration, frequency and
energy, the array of indications covers almost every possible treatment of dental hard tissue from simple fissure
sealing trough extended onlays, overlays, veneers to
complex cases using CAD/CAM and CEREC. It is important to point out the positive and preventive side-effect
Fig. 2
Fig. 1
of the resulting micropores after lasing, as being collecting tanks for fluoride, calcium and phosphate ions.
This phenomenon optimises the enamel crystal structure, modifying carbon apatite versus hydroxyapatite
and finally the stronger and essentially more resistent
fluor-apatite. The removal of metal and porcelain fillings is still not an application of laser.
New pulse qualities, like the QSP (Fotona, Slovenija)
allows us trough an additional sophisticated tuning of
each single pulse, a very precise and even more efficient
ablation with very specific structural changes in the tissue and on its surfaces and borders.
Laser-assisted aesthetic dentistry
This field includes tooth bleaching, management of
hard and soft tissue and lasing dental hard tissue for
CAD/CAM, different ceramic crowns and any kind of
resins and porcelain veneers.
Our in-office power bleaching entails laser activation of a wavelength-specific activator, developed at
the University of Vienna. The powder is mixed with 25%
H2O2 and applied to each buccal tooth surface. The ir-
Fig. 1_Detection of caries and
concrements through spectral
analysis and numerical differentiation between sound dental tissue,
concrements and bacterial metabolic
products with the DIAGNOdent pen.
Fig. 2_Imaging of plaque and caries
through laser- and computerassisted differentiation between
sound enamel and contaminated
dental hard tissue by bacterial
by-products. In the photograph
shown with the LED intra-oral
camera is VistaProof.
Figs. 3–8_Partial ablation with the
Er:YAG laser after earlier biopsy,
removal of the second part after one
week, subsequent monitoring after
two to three weeks and at every
recall. In the meantime, instructed
self-monitoring by the patient.
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
laser
4
I 17
_ 2011
[18] =>
I overview _ concept
The Er:YAG laser is the laser of choice for a selective biological bone ablation and does not result in any
classical thermal or mechanical trauma. The laser
treatment results in a native, original and stress-free
bone structure, allowing immediate revascularisation
and initiating biological processes almost during surgery already and excellent tissue healing.
_Decontamination
Fig. 9
Fig. 10
Figs. 9 & 10_Buccal opening, root
resection and surface modification of
the peri-apical lesion on the lower left
first molar with the Er:YAG laser,
decontamination with the Nd:YAG
laser and LLLT immediately post-op
with the diode laser.
radiation time is 30 seconds, with up to three cycles
per session. The redox reaction is primarily related to
the specific activator and not to heat, and the presence of TiO2 keeps the temperature rising in a medium
range of 1 to 1.5 °C. No enamel surface alteration was
shown on the SEM before or directly after the treatments with different wavelengths.
Modelling of soft gingival and hard bone tissue is
often necessary to ensure the biological width and in
aesthetic surgery as a first step to the right smile harmony.
Owing to the new settings, mostly of shorter or
longer pulse durations, the erbium wavelength allows
us to manage soft, hard and dental tissues with only
one laser type and one handpiece.
Laser-assisted surgery
Oral surgery offers the widest range of indications
for treatment by laser. The Er:YAG laser is the gold
standard in our office for excellent handling of soft
and hard tissue (Figs. 3–10), thanks to an efficient
modulation of pulse duration, frequency, energy and
water/air ratio.
Figs. 11–13_Step-by-step removal
of the vascular lesion on the upper lip
with the Nd:YAG laser using the ice
cube technique: no invasive opening,
but slow inner lasing of the lesion,
initiated by non-contact Nd:YAG
surface scanning through ice
(five-minute weekly sessions).
Fig. 11
The wavelengths of the 810 nm and 980 nm diode
lasers extend the range to bio-modulation and a different laser approach to soft tissue modelling, decontamination and photodynamic therapy. The Nd:YAG
laser completes the team as the wavelength for vascular lesions (Figs. 11–13), for deep decontamination,
soft tissue surgery and as an alternative for the treatment of herpes and aphthae.
Fig. 12
18 I laser
4_ 2011
Laser-assisted endodontics
Endodontics is certainly one of the most rewarding and best-investigated areas of laser-assisted evidence-based dentistry. The classic and highly efficient
wavelengths of 810 nm and even stronger 1,064 nm
enable a deep decontamination of the main rootcanal system and the very important mosaic of lateral
tubules and other anatomical variations, seen as obstacles to a successful traditional root-canal treatment or retreatment. The Nd:YAG laser decontaminates the complex anatomical root system also over
the main canals, spreading its effect approximately
1.1 mm into the system, the distance of bacterial migration, allowing around 95 % of effectiveness. No
other wavelength and no other rinsing of any nature
can attain this phenomenon of decontamination.
Owing to the pigmentation of the involved bacteria (Enterococcus faecalis detected as the problem
germ), the bactericidal effect focuses exactly on its
target, with no collateral damage to the surrounding
tissue, if settings are correct. The only resulting sideeffect during lasing is the scattering to lower energy
levels by means of bio-modulation of the neighbourhood tissue for faster cell regeneration and good
wound healing.
Our in- office protocol includes usually two to three
sessions of a combined Er:YAG/Nd:YAG laser use,
known actually as Twinlight Endodontic Treatment.
Thanks to new erbium quartz fibres (Preciso tip,
Fotona), which allow side-firing in any area of the root
walls at different depths, we are able to remove smear
layer and debris selectively in combination with saline
solution, to perform an initial decontamination of
Fig. 13
[19] =>
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Office Stamp
laser 4/11
[20] =>
I overview _ concept
about 0.4 mm from the main canal into the lateral root
system, to bio-stimulate (fibroblasts) and to leave an
ideal microstructure on the walls for a 3-D filling.
close debridement or open flap surgery, with a surface
reactivation and bio-modulation of the remaining
wound, are the pillars of modern periodontal therapy.
The alternative erbium quartz fibre Pips (Photon Induced Photoacoustic Streaming by M.Colonna, E. DiVito
and G. Olivi) System replaces even a part of the mechanical root canal treatment, in adjunct to all the effects already mentioned above. The Pips fibre (Fotona) is
placed in the pulp chamber filled alternatively with 15
to17 % EDTA and saline solution. It entails by laser activation the production of shockwaves in direction to
each root canal separately, along the anatomy from cervical to apical at very low energy settings, converting
thermal energy into an athermal mechanical precise
and complete debridement (Fig.14). Both protocols are
completed in our office by a final deep decontamination
laterally up to 1.1 mm with the Nd:YAG laser, perform-
The corresponding laser assistance is highly efficient, as demonstrated with success during the last
decade by various methods, such as LANAP. There are
still some questions regarding the major benefits compared with the classic protocol, even if the combined use
of laser-assisted and classic methods has been demonstrated as more advantageous and efficient by various
studies. We set the perio chart in our office with the
Florida probe, as an objective and hand-independent
system, allowing direct comparisons of results in time
and place.
Fig. 15
Fig. 14
Fig. 17
Fig. 16
Figs. 14 & 15_PIPS protocol, with
the additional final dry and deep
decontamination using the Nd:YAG
laser.
Figs. 16 & 17_Laser-assisted
treatment of the fistula to manage the
symptoms and preserve the first
upper left molar until the scheduled
surgery, depending on patient’s work
schedule: rinsing, decontamination,
de-epithelialisation and sloughing of
the tunnel, followed by a bio-modulation with the 810 nm diode laser or
Nd:YAG laser.
ing three to five cycles of constant circuiting movement
at 2 mm/sec from apical to coronal, allowing an interval
of 30 seconds of down-cooling between the actions
(Fig.15). An equivalent office protocol is followed to
manage the prepared root canal before pin cementation, after a provisional time elapse. Besides the decontamination, it allows a stronger adhesive cementation,
changing the root-canal anatomy by a precise 3-D superficial modification.
Fistulas are often a side-effect in active peri-apical
or periodontal lesions. The decontamination of the bone
lesion, the de-epithelialisation of the tunnel and the
sloughing of the entrance are performed efficiently
with a diode or Nd:YAG laser (Figs. 16 & 17). A scattered
bio-modulation is always included.
Laser-assisted periodontology
The bactericidal effect and the systematic removal of
granulomatous soft and infected hard tissue during
20 I laser
4_ 2011
During a closed periodontal treatment into pockets
to a depth of 6 mm (or even more) the protocol suggests
the assisting applications of Er:YAG, diode and/or
Nd:YAG wavelengths. Periodontal open flap surgery is
the primary action area of the Er:YAG laser, combined
with a diode or an Nd:YAG laser for supplementary decontamination, bio-modulation and de-epithelialisation. The de-epithelialisation of the cervical tissue border and the upper buccal soft tissue area allows a discrete reattachment at the bottom of the pocket, before
the faster re-epithelialisation of lesser quality from cervical starts growing down to the bottom. The laser-assisted perio protocol includes also peri-mucositis
and/or peri-implantitis, often first with a closed debridement, as an emergency treatment to manage
mainly the symptoms, and subsequently as open flap
surgery to eliminate the cause.
Even if longer pulse durations are available, the
closed decontamination of peri-implant areas with the
Nd:YAG laser is still not included in our office protocol,
because of its affinity to titanium and therefore more
risky handling. In cases of closed decontamination, we
switch to the 810 nm diode laser.
The regular office protocol is based on three steps
(Figs. 18–23). Independent of the pocket anatomy, we
start with an initial sterilisation with the diode, Nd:YAG
or Er:YAG laser, to minimize the bacteria spreading into
the body system. It is a medical sensible measure for all
patients, but mandatory for the immune-compromised
risk patients of any type. The second step entails classical closed debridement with ultrasound or piezo, supported by an Er:YAG-assisted concrement ablation on
the hard root surface, and the elimination of granulomatous tissue on the soft gingival side, followed by a
root surface modification and decontamination, to improve a local regeneration. The mandatory third step involves the final deep decontamination with the Nd:YAG
laser in three to five cycles with a constant 2 mm/sec
movement from apical to cervical along the soft tissue
side of the pocket. The last cycle of more superficial
[21] =>
overview _ concept
I
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
movements at wider pulse durations entails the formation of a stable fibrin clot (Fig. 23), to close the cervical
entrance by means of a biological wound dressing and
in the de-epithelialisation versus buccal.
Photobiomodulation PBM or Laser Photo Therapy LPT
Photobiomodulation is one essential biological
quality of laser-assisted therapy. Photobiomodulative
radiations as a result of scattering are the positive side
effect of a laser-assisted therapy. But they are also stand
alone indications for LPT: the photodynamic therapy
PDT (often part of the recall) and the specific photobiomodulation on cellular level. This one to optimise a high
level wound healing in all kind of oral surgery, in cases
of myoarthropathies, in laser acupuncture, local or systemic pain control, neuralgies, ghost pain, damage of
specific neural areas and more. The new EmunDo PDT
protocol (by Prof N. Gutknecht, University of Aachen,
Germany), is the only one permitting the most efficient
and complete decontamination of gram+ and grambacterias, allowing an immediate initialisation and activation trough a very low energetic level output of the
diode 810 nm (by ARC).
Photobiomodulation enjoys finally its long deserved renaissance, rising up from the shade of uncertain anedoctical evidence to the sunny side of scientific evidence. The range of indications and the protocols are quite complex and mostly based on chemical effects in the cell or between cells, interactions,
which need more space of discussion than the basic
aim of this publication is. The motto is “similis simlibus
curantur” or in another words “using the body natural resources to provide”. Those phenomenons explain
PBM acting as the third pillar of our multi-wave inoffice concept.
_Conclusion
We have purposely not mentioned any concrete settings for the therapies and their protocols reviewed in
this article. The aim was not to be instructive, but to give
some inspiration for the daily office using laser-assisted
dentistry. The parameters and settings, scientifically
verified, are given by the manufacturers, to ensure safe
use of the laser-assisted therapy. The essential requirements are basic knowledge about physics, physiology,
wavelengths, their tissue interactions and their applications and the evidence-based background, and self confidence. The study of a range of evidence-based literature, including medical websites, and the participation
at theoretical and practical CE courses and workshops
are mandatory for a safe, conscious and productive laser
use._
Figs. 18–23_Protocol for a laserassisted closed perio debridement:
initial superficial decontamination
and ablation of granulomatous tissue
with the Er:YAG laser and Varian
600 µm fibre (Fotona), supported by
one cycle of the 810 nm diode laser
or Nd:YAG laser. Chlorhexidine
rinsing and debridement with
concrement-detecting piezo
(PerioScan, Sirona). Final deep
decontamination and bio-modulation
with the Nd:YAG and 810 nm diode
lasers. A stable fibrin clot as biological wound dressing was achieved by
longer Nd:YAG pulse durations.
I would like to thank particularly my father Zlatko as one
of the early pionieers of LLLT/PBM. He gave me the
strength, a profound credo and the fundamental knowledge to understand the spirit of healing light and its
unique biological benefits.
_contact
laser
Dr Kresimir Simunovic, MSc
André Scholtz, DDS
Praxis für laserunterstützte Zahnmedizin
Seefeldstr. 128
8008 Zurich, Switzerland
ksimunovic@smile.ch
www.simident.ch
laser
4
I 21
_ 2011
[22] =>
I case report _ smile esthetic
Smile enhancement with
laser technology—
Predictable and esthetic
A case report
Author_Dr Hugh Flax, USA
supracrestal fibers also become interrupted, causing
the tissues to become further inflamed and esthetically
unmanageable. Kois’ landmark study defined the total
dentogingival complex (DGC) as clinically predictable at
3.0 mm on the direct facial aspect, and at 3.0–5.0 mm
interproximally when measured from the free gingival
margin to the osseous crest. It is critical anteriorally that
the gingival margin mimics the osseous scallop while
maintaining the DGC.1 Further complicating these
complex situations is the degree of inflammation in the
soft tissue, affecting the clinical development of health
and esthetic symmetry.
Fig. 1_Visualizing the entire oralfacial composition helps to diagnose
less harmonious features of the
smile.
Fig. 1
_Introduction
Fig. 2_Close-up photography is
essential to planning periorestorative care.
22 I laser
4_ 2011
With the esthetic zone
being absolutely critical to
Fig. 2
a patient’s external appearance and inner emotions, orchestrating a bioesthetic result is mandatory.
Too often, this is complicated when esthetic desires infringe on the health of the periodontal complex. This is
often true when biologic width violations have occurred
iatrogenically. Many factors may contribute to these
failures, the two main culprits being intracrevicular
margin location and overcontoured restorations. Not
only is plaque accumulation problematic, but the
Dental lasers have evolved considerably as an adjunctive and alternative treatment to safely, conservatively, and reliably decrease bacterial levels and improve
the hard and soft tissue contours. Often the patient is
frustrated with his or her previous poor cosmetic results. However, to improve the periodontal
framework in order to
create an ideal result, they
must be referred to yet
another doctor. Even
more challenging is the
extended healing time
created by reflective mucoperiosteal surgery. This
not only affects the
chronology of final restorative care, but also delays the
patient’s ultimate satisfaction and happiness for a minimum of two to three months. Fortunately, dental lasers
have evolved considerably as an adjunctive and alternative treatment to safely, conservatively, and reliably
decrease bacterial levels and improve the hard and soft
tissue contours. Studies of Er: YSGG lasers by Rizoiu and
others have shown that thermal coagulative results, as
[23] =>
Bella Center
Copenhagen
+
Welcome to the 45th Scandinavian Dental Fair
The leading annual dental fair in Scandinavia
The 45th SCANDEFA invites you to exquisitely meet the Scandinavian dental market and
sales partners from all over the world in springtime in wonderful Copenhagen
SCANDEFA 2012
Exhibit at Scandefa
Is organized by Bella Center
and is being held in conjunction
with the Annual Scientific
Meeting, organized by the
Danish Dental Association
(www.tandlaegeforeningen.dk).
Book online at www.scandefa.dk
Sales and Project Manager, Christian Olrik
col@bellacenter.dk, T +45 32 47 21 25
175 exhibitors and 11.422
visitors participated at
SCANDEFA 2011 on 14,220 m2
of exhibition space.
Travel information
Bella Center is located just a 10 minute taxi drive from Copenhagen
Airport. A regional train runs from the airport to Orestad Station,
only 15 minutes drive.
Check in at Bella Center’s newly built hotel
Bella Sky Comwell is Scandinavia’s largest design hotel.
The hotel is an integral part of Bella Center and has direct
access to Scandefa. Book your stay on www.bellasky.dk
Fotos from Bella Center, Wonderful Copenhagen
2012
[24] =>
I case report _ smile esthetic
Fig. 4
Fig. 3
The patient shared her frustration about previous dental consultations that had focused solely on orthodontic or surgical solutions without considering a more
practical approach that would fit her busy life. Her smile
analysis established a collapse of the bicuspids in the
buccal corridor. Furthermore, the axial inclinations, irregular gingival margins, and incisal edges created a
downward tilt to the patient’s right due to tooth positioning. Close-up imaging showed ealthy gingival tissues as well as a weakened right central incisor from a
large composite (Fig. 2).
_Findings
Fig. 6
Fig. 5
Fig. 3_A mounted diagnostic wax-up
is a critical roadmap to planning a
realistic result.
Fig. 4_Outlining the desired gingival
margins, prior to anesthesia,
communicates a blueprint to the
patient and restorative team.
Fig. 5_A stick-bite helps to verify that
incisal and gingival planes will
be parallel.
Fig. 6_The tissues are treated in a
very nontraumatic manner with the
Waterlase.
Fig. 7_To modify the bone, a very
tight up-anddown movement is
performed, using the black mark as a
reference following the gingival
scallop.
Fig. 8_A curette helps clean and
smooth the sulcus of any debris.
well as bony ablation characteristics are similar to a dental bur.2 From a patient-friendly standpoint, less need
for suturing and shorter healing times improves case
acceptance for doing ideal dentistry. In selected cases,
such as the one presented in this article, minimally invasive laser procedures, with precise restorative planning and technique, can satisfy esthetic and functional
parameters. Furthermore, patients can enjoy optimal
results more comfortably and efficiently.
A conservative strategy was devised that would allow us to correct the problems and causes in a “multitasking” manner.
_Case Presentation
A 38-year-old female patient presented for correction of what she termed her “tilted smile” (Fig. 1). Given
that she was starting a new sales career, she also wanted
to make her teeth brighter and her smile much broader.
Fig. 8
Fig. 7
A full clinical examination with radiographs and
mounted models revealed the following:
– Biomechanically, the majority of her teeth remained
strong despite previous dental care.
– Periodontally, soft and hard tissues were healthy.
– Occlusally, load testing was normal (after muscle relaxation) and there was obvious CR-CO anterior-vertical slide due to a premature contact at tooth #30.
– Esthetically, the width-to-length ratio of the upper
centrals was 1:2, far from the ideal range of 0.75:1.0.
Tooth shade was a VITA A2.
_Treatment plan
Given the patient’s previous history and her desire
for minimally invasive dental care, a conservative strategy was devised that would allow us to correct the problems and causes in a “multi-tasking” manner:
– muscle and bite therapy with a Tanner appliance, followed by careful equilibration aided by the T-scan
(Tekscan System; South Boston, MA)
– three-dimensional wax-up on a Stratos articulator
(Ivoclar Vivadent; Amherst, NY) (Fig. 3)
– home bleaching of the lower teeth with Opalescence
15% (Ultradent; South Jordan, UT)
– “closed flap” periodontal modification with the
Waterlase ErCr:YSGG (Biolase Technology; San
Clemente, CA) while the first three items were being
accomplished (the combination of these four steps
was a tremendous time saver and also allowed us to
carefully monitor progress on a weekly basis)
– definitive restorative care with porcelain veneers and
a crown on tooth #8.
No tissue necrosis or significant bleeding occurred
as a result of using the laser’s relatively lower settings.
_Treatment
Fig. 10
Fig. 9
24 I laser
4_ 2011
At the initial closed periodontal lift, the ErCr:YSGG
laser was used in three modes (gingival sculpting, osseous recontouring, and bio-stimulation). Prior to
anesthesia, the desired framework was planned and
outlined using a fine marker (Fig. 4). Furthermore, a
[25] =>
case report _ smile esthetic
stick-bite was used, not only to establish an ideal incisal
plane, but also to properly align the gingival margins
(Fig. 5).
With the settings at 2.0 Watts (W), 20 pulses per second, 20 % air, and 20 % water, a G-6 tip (600 µ in diameter) was used to shape the labial gingival region. No tissue necrosis or significant bleeding occurred as a result
of using the laser’s relatively lower settings. All areas
were “sounded” using a periodontal probe (Fig. 6). At the
facial margins, osseous sculpting required great precision in order to maintain a 3-mm DGC. A specially tapered T4 tip (400 µ in diameter) was used at a 25 %
higher wattage of 2.5 W. Prior to usage, the tip was
measured and marked to 3 mm in order to maintain
controlled adjustments within the gingival sulcus during perio probing movement of the tip (Fig. 7). The
resection was smoothed
with a 7/8 curette (Fig. 8).
Using low-level laser therapy at a setting of 0.25 W,
a decrease in the release of
inflammatory histamine
and increased fibroblasts
for junctional epithelial
growth was achieved by
“frosting” the outer epithelium and injection sites
(Fig. 9). The patient was placed on a vigorous home-care
regimen (Oxygel, Oxyfresh; Coeur d’Alene, ID) and
closely monitored for a month while occlusal therapy
and bleaching procedures were performed.
Four weeks after surgery, the tissues had healed and
restorative care could be initiated. The patient’s teeth
were prepared for veneers and a crown with mild soft
tissue reshaping, to fine-tune our previous treatment.
After taking impressions and bite registrations, prototype provisionals (Luxatemp Plus, Zenith DMG; Englewood, NJ) were fabricated using the “shrink-wrap”
technique. The patient was sent home with the same
home-care regimen as mentioned previously, and instructed to “test-drive” her new smile for esthetics and
function. She returned in a week to perfect the prototype’s occlusion, color, and morphology. Photographs
and models were sent to the laboratory, providing a final blueprint for the porcelain restorations (Fig. 10).
Four weeks later, the provisionals and cement were
carefully removed from the teeth. All restorations were
tried in individually and as a group to verify fit and esthetics. After the patient’s enthusiastic approval, the
porcelain was bonded using the two-by-two technique
and isolation. Margins were smoothed and polished and
occlusion balanced with the T-scan. A protective nighttime appliance was created to add longevity to the rehabilitation. Our very satisfied patient said that we had
exceeded her expectations.
I
Fig. 9_A “laser bandage” is placed
along the treated area to improve the
healing time and decrease the
patient’s discomfort. Note the
immediate improvement of the
geometric progression of gingival
embrasures.
Fig.10_Detailed information helps
the laboratory to translate clinical
results to the porcelain restorations.
Fig. 11
_Conclusions
Fig. 11_The great improvement in
esthetics boosted the patient’s selfconfidence and pride in her dental
care.
Fig. 12_Ideal proportions and emergence profiles will create long-term
healthy tissues and bioesthetics.
Fig. 12
The use of a hard/soft
tissue laser is a wonderful
adjunctive tool for cosmetic and restorative dentistry. The case discussed here
demonstrates that this type of laser technology gives
dentists the ability to make significant soft and hard tissue changes while being minimally invasive. These
changes not only improve the final esthetic outcome of
the case but also provide the physiologic functional parameters required for successful dentistry.
_Acknowledgments
The author thanks his office team and laboratory
technician, Mr. Wayne Payne (Payne Dental Lab, San
Clemente, CA), for continually enhancing the lives of
many patients like the one presented here. He also is
thankful to his family, who allow him to contribute to
the education of other dentists and their teams._
_contact
Hugh Flax DDS
1100 Lake Hearn Dr. NE
Suite 440
Atlanta, Georgia 30342
Tel.: +1-404-255-9080
Fax: +1-404-255-2936
smile@flaxdental.com
www.flaxdental.com
laser
Editorial note: A list of references
is available from the publisher.
Editor’s Note: This article was
reprinted with permission of Journal of Cosmetic Dentistry©, 2011
American Academy of Cosmetic
Dentistry, All Rights Reserved.
608.222.8583; www.aacd.com
laser
4
I 25
_ 2011
[26] =>
I case report _ Pappilon-Lefèvre syndrome
Papillon-Lefèvre
syndrome
New laser-assisted treatment method
Authors_Dr Maziar Mir, Dr Surena Vahabi, Dr Shahrzad Jalali, Dr Bahram Kazemi, Dr Susanne F. de Haar,
Dr Gholam Hossein Ramezani, Prof Dr Friedrich Lampert and Prof Dr Norbert Gutknecht
spp.5 In a PCR study, Bacteroides, in particular, Bacteroides forsythus, were associated with different
types of periodontitis.7 It was mentioned by
Kabashima et al.8 that IL-8, IL-1 alpha and IL-1 beta
cytokines may be responsible for modulating the
process of rapidly progressive periodontitis in a patient with PLS.8
Fig. 1
Fig. 1_Maxillary and mandibular
occlusal view radiographs taken on
April 1998: Bone loss around the
primary teeth shows a very poor
diagnosis for saving the teeth.
Therefore, all primary teeth were
extracted.
26 I laser
4_ 2011
_Introduction
Papillon-Lefèvre syndrome (PLS) is a rare autosomal recessive disorder. Its reported incidence is one
to four per million and both the sexes are equally affected.1 PLS is characterised by palmo-plantar hyperkeratosis, periodontopathy and premature loss
of deciduous, as well as permanent dentition.2
Plaque and calculus deposits may be present, along
with significant halitosis.3 It manifests between one
to five years of age and the patient becomes edentulous in the early teens. Another component of PLS
is asymptomatic ectopic calcification in the
choroids plexus and tentorium,2 hearing loss, follicular hyperkeratosis and nail abnormalities.4 About
20 % of these patients also show an increased susceptibility to infection, probably due to dysfunction
of lymphocytes and leukocytes.2 PLS is diagnosed
mainly clinically.5 It needs to be differentiated from
other conditions that show similar oral and cutaneous clinical features, such as acrodynia, hypophosphatasia, histocytosis X, leukaemia, cyclic
neutropenia and Takahara syndrome, which are also
associated with periodontitis and premature loss of
teeth.6 The risk of developing periodontal disease
decreases with age because of the immune response
to antigenic challenge.3 PLS patients usually have
very complex subgingival flora, which includes the
presence of Actinobacillus actinomycetemcomitans, capnophilic bacteria and Capnocytophaga
PLS is caused by mutations in the gene that encodes cathepsin C (CTSC),9 as well as the related condition Haim–Munk syndrome and some cases of
prepubertal periodontitis.10 This gene encodes a
lysosomal cystein protease or dipeptidyl aminopeptidase I (DPPI) necessary for the activation of serine
proteinases in polymorphonuclear leukocytes
(PMNs). It has also been suggested that DPPI is involved in a wide variety of immune responses, such
as the activation of phagocytes and T lymphocytes.
If the protein is truncated, it may not be transported
to the organelle and may be not able to activate protein kinases. In addition, it will not be able to activate
phagocytes and T lymphocytes, thereby leading to
disease phenotype. Therefore, any typical mutation
may result in either truncation or alteration in the
conformation of CTSC-encoded enzyme DPPI.4 This
gene is located on chromosome 11. Codon seven of
this chromosome shows the exact mutation. This
mutation has been registered as Hm040133 and directly affects one of the amino-acid residues at the
active site of the enzyme.9 Up to now, 50 different
mutations have been described in PLS patients.11 The
most common class of point mutation is a transition
involving substitution of a G-C (guanine-cytosine)
pair with an A-T (adenine-thymine) pair or vice
versa. Variations at the site harbouring such
changes have recently been termed “single nucleotide polymorphisms”.6 In patients with PLS, lossof-function mutations in CTSC do not affect lym-
[27] =>
case report _ Pappilon-Lefèvre syndrome
phokine-activated killer cell function. Natural killer
(NK) cells from affected patients contain inactive
granzyme B, indicating that CTSC is required for
granzyme B activation in unstimulated human NK
cells.12 However, according to the existing data,
CTSC gene mutations are only responsible for 70 to
80 % of PLS cases.13 De Haar et al. demonstrated that
PLS patients lack the activity of the PMN-derived
serine proteinases elastase, cathepsin G and proteinase 3. They found that the PMNs of PLS patients
released lower levels of IL-37. Furthermore, because
of their deficiency in serine proteases, the PMNs of
PLS patients were incapable of neutralising the
leukotoxin produced by this pathogen, which resulted in increased cell damage.14
The goal of periodontal therapy is to eliminate
bacteria in the pockets, to remove hard- and soft-tissue deposits, to remove the granulation tissue and
pocket epithelium in the periodontal lesions, to do
root planing and, later, to enhance the attachment
gain.15 The conventional mechanical treatment of
periodontitis in a patient with PLS has a poor prognosis. Almost no treatment that saved the permanent dentition in PLS patients has been described so
far. The most optimistic papers have described an extraction of all the deciduous teeth six months before
eruption of permanent molars #16 and 17 followed
by a period of edentulism. The edentulous period may
explain there being no recurrent attachment loss in
the permanent teeth up to age 17.16 After this age,
treatment shifts to the use of dental implants and
complete dentures as the best solutions to this problem.18 Also, regular bacteriological tests may help to
prevent or control the risk of infection.3 Several studies have demonstrated that additional irradiation
with low-level and diode lasers is better than scaling
and root planing alone.19–22
Relatively recently, Cobb concluded some clinical
evidence from the literature that demonstrates that
certain laser wavelengths could be helpful for the decontamination of periodontal sockets.23 Qadri et al.
demonstrated that additional treatment with lowlevel laser reduced gingival inflammation after nonsurgical treatment. Plaque index, gingival index and
probing depth declined more on the side given such
treatment. Another marker of inflammation, gingival crevicular fluid volume, has been also reported to
be greater on the treated side.19 Ishikawa and
Sculean published a review article in 2007 that
demonstrated the successful results of diode laser
assistance in de-epithelialising and sulcus decontamination therapies.24
In this study, additional to complete clinical, radiological, pathological and genetic diagnosis, a laserassisted periodontal therapy was performed on a PLS
Fig. 2
I
Fig. 2_Panoramic view taken on
December 2008: The bone-level and
soft-tissue lines are all normal. There
is no pathological finding reportable.
patient. Following the accurate evaluations of the
studies noted earlier, a 980 nm diode laser was selected to treat this particular patient, who lived in a
village with no access to well-equipped laser clinics.
Diode lasers are semiconductors that use solid-state
elements to change electrical energy into light energy, and are smaller and more easily transported to
areas far from medical centres. These lasers with
wavelengths of 810 to 980 nm approximate the absorption coefficient of soft-tissue pigmentation.
Therefore, light energy from diode lasers is well absorbed by the soft tissue and poorly absorbed by
teeth and bone.25
_Review of a case with a new
laser-assisted treatment plan
A three-and-a half-year-old female patient was
referred to the clinic with ten missing and six mobile
primary teeth in April 1998. Physical examination
revealed palmar and plantar hyperkeratosis. No
other physical, mental or laboratory disorders were
found. Dental examinations showed severe generalised gingival loss of attachment in both dental
arches. There was a root exposure all around the existing teeth. Periodontitis as a manifestation of systemic disease is concluded as diagnosis.
Radiographic findings
Severe bone loss was evident in occlusal view radiographs (Fig. 1). The permanent teeth were found
healthy inside the bone.
Microbiological and histopathological findings
The early antibiogram detection showed
cephalexin as the antibiotic of choice for the disease.
The result of the cultures revealed the predominant
presence of Bacteroides. Hypercementosis and inflammatory reactive hyperplasia (fibrosis) were observed in the slides of the teeth involved and surrounding tissues, respectively.
Genetic analysis
By use of polymerase chain reaction (PCR), we
amplified the seven exons of cathepsin C using the
laser
4
I 27
_ 2011
[28] =>
I case report _ Pappilon-Lefèvre syndrome
nated the need for antibiotic therapy before eruption of the permanent teeth, which was recommended by some earlier studies.
Follow-ups and laser-assisted therapy
The infection was successfully controlled. The
patient was re-evaluated clinically and para-clinically and no future antibiotic therapy was needed.
The permanent incisors and first molars erupted under good oral hygiene care. A recall on November
2003 showed no significant finding on the
panoramic X-ray either.
In July 2007, gingivitis and the start of new contamination were reported. Therefore, laser treatment using a diode laser (970+/-10 nm wavelength,
K-laser, Eltech S.R.L.) was selected in addition to routine hand instrumentation and curettage. This laser
irradiated a beam with a diameter of 300 µm and 2.5
to 3 W output power around free gingival margins
and inside the pockets after removing the necrotised parts of tissue. The full mouth procedure took
approximately 15 minutes and the entire operation
was documented using a professional video camera.
The exact output power was 2 W during treatment
and a reputation rate of 20 was selected.
Fig. 3a
Fig. 3b
Fig. 3a & b_Final clinical and
radiograph condition of patient is
shown as was registered in February
2011. This is the first time that a
12-year follow-up of a case of PLS
has reported success in complete
teeth eruption without any tooth
mobility until the age of 16.
primers described in other studies. After the PCR
process, we confirmed the presence of the PCR
product by 2 % agarose gel electrophoresis. The PCR
products were purified using columns and the concentration of the DNA was determined spectrophotometrically. For the sequence reaction, we used the
same primers as for the PCR reaction and the reaction was carried out using the BigDye Terminator
mix (Applied Biosciences). The data was automatically collected and analysed by the software of the
Sequencer. The sequences were compared with the
published cathepsin C sequence. A nucleotide 1212
A>G mutation in the cathepsin C gene was found,
which was predicted to result in an amino acid 405
His>Arg mutation. The mutation was confirmed by
the use of restriction enzyme analysis performed on
exon seven. The nucleotide mutation has not been
reported previously.
Treatment
The patient was treated with a daily chlorhexidine mouth rinse. To eliminate the source of infection, all the primary teeth were extracted in June
1998. An early anti-biogram test has reported
cephalexin to be recommended after extraction of
the teeth. This selective antibiotic therapy elimi-
28 I laser
4_ 2011
The patient was re-evaluated after 1.5 years due
to the relocation of her parents and difficult access
to them. Although no treatment was done in this
time, gingival tissue colour was normal in December
2008, and there were no evidences of deep periodontal pockets or loss of attachments, except
slight inflammation around the gingival margins.
No significant pathological finding was reported
from the panoramic radiograph either (Fig. 2). Orthodontic treatment was proposed by a related department, but as the orthodontic wire and brackets
are a source of plaque accumulation, diode laser
therapy is done at the same time as each orthodontic visit to maintain the good condition of teeth until the age of 18. On February 2011, all teeth were still
healthy and the patient was still undergoing periodical laser therapy additional to scaling and root
planing. The final radiograph and clinical condition
are presented in Figure 3.
_Discussion
The aetiology of the periodontal component is
not entirely clear. The gene abnormality that causes
PLS is found on chromosome 11q14, which involves
mutations of cathepsin C.26 This mutation was
shown as in this case. The enzyme cathepsin C is active in skin, gingival tissue and immunologically active cells;27 it is possible that the absence of functional cathepsin C affects the immune response to
microbial infection. Thus, periodontal pathogens
[29] =>
case report _ Pappilon-Lefèvre syndrome
are enabled, secondary to the impaired local immune response. Periodontal treatment included extraction of all the deciduous teeth and mechanical
therapy with the concomitant use of systemic antibiotics.
In case reports, both mechanical debridement
alone and mechanical therapy plus a single antibiotic have failed to eradicate A. actinomycetemcomitans and improve the periodontal condition in
PLS.16, 28 In this case, microbiological studies showed
Bacteroides as the predominant bacterial species
and cephalexin as the antibiotic of choice which has
been resulted.
Numerous studies have demonstrated that the
period of edentulism following the extraction of all
deciduous teeth prevented involvement in later
erupting permanent teeth. In these studies, extraction was followed by other treatment, such as mechanical therapy, systemic antibiotics and surgical
treatment.16, 29–33 So, early diagnosis to extract the
deciduous teeth before eruption of permanent
teeth is very important, which was done in this case.
Success in retaining the permanent teeth seems to
depend on the timing of these therapies. If any teeth
erupt after the period (edentulism) into a mouth
that is free of periodontal disease, patients have a
good chance of remaining periodontally healthy,
even if oral hygiene and maintenance are not optimal, as happened in this case.
Several lasers have been used to decontaminate
periodontal pockets.19 Some authors have reported
proliferation of gingival fibroblasts after using lowlevel laser and have shown that the stimulated fibroblasts are better organised in parallel bundles.19
Low-level laser therapy may play an important role
in periodontal wound-healing and regeneration by
enhancing the production of the growth factors.34
Application of the diode laser can reduce bacteria20
in gingival crevices, which may reduce bacteraemia
following ultrasonic scaling.22 Thermal and photodisruptive laser effects result in the elimination of
periodonto-pathogenic bacteria, regardless of laser
wavelength.21, 35 Some studies have demonstrated
that instrumentation of soft periodontal tissues
with a diode laser (980 nm) leads to complete epithelial removal as compared with conventional
treatment methods with hand instruments.15
Periodontitis in PLS is a multifactorial process believed to have genetic, bacterial and immunological
aetiologies, making it difficult to diagnose and treat.
Early diagnosis and administering appropriate systemic antibiotic therapy in patients with PLS might
preserve all permanent teeth that otherwise would
exfoliate spontaneously or be extracted. We con-
I
clude that microbiological tests may be a powerful
tool to select the proper antibiotic for the successful treatment of a PLS patient. Decontamination of
sockets after de-epithelialisation of gingival soft
tissue in inflamed margins with a diode laser is a
successful aid to the previous hand instrumentation
and medicament therapies. This fact has been clinically proven by a ten-year follow-up of a case that
has a healthy periodontal condition. Similar cases
reported in the literature mostly resulted in loosened permanent teeth. This success, while partly due
to the correct antibiotic selection, is mostly the result of sufficient laser therapy. More studies are
needed to establish this finding. As PLS is a very rare
syndrome, no randomised clinical trial could be
done. Therefore, collaboration between several
medical universities could be the key to conducting
a long-term cohort study entailing laser treatment._
_References
1. W.A.D. Griffiths, M.R. Judge and I.M. Leigh, “Disorders of Keratinisation”, in R.H. Champion, J.L. Burton, D.A. Burns and S.M.
Breathnach (eds.), Textbook of Dermatology, 6th edn. (Oxford:
Blackwell Scientific Publications, 1998), 1569–71.
2. R. Bergman and R. Friedman-Burnham, Papillon–Lefèvre syndrome: A study of the long-term clinical course of recurrent pyogenic infections and the effects of etretinate treatment, British
Journal of Dermatology, 119/6 (1998): 731–6.
3. H.U. Toygar, C. Kircelli, E. Firat, et al., Combined therapy in a patient with Papillon–Lefèvre syndrome: A 13-year follow-up,
Journal of Periodontology, 78/9 (2007): 1819–24.
4. A.A. Wani, N. Devkar, M.S. Patole, et al., Description of two new
cathepsin C gene mutations in patients with Papillon–Lefèvre
syndrome, Journal of Periodontology, 77/2 (2006): 233–7.
Editorial note: The whole list of references is available from
the publisher.
_contact
laser
Dr Maziar Mir
British Lasik and Cosmetic Surgery Center,
Dubai, UAE
Department of Preventive and Conservative
Dentistry
University Hospital Aachen and
Aachen Dental Laser Center
RWTH Aachen University
Pauwelsstr. 19
52074 Aachen
Germany
mmir@ukaachen.de
laser
4
I 29
_ 2011
[30] =>
I user report _ cavity preparation
Er,Cr:YSGG laser for
cavity preparation
A case presentation
Author_Dr Ralf Borchers, Germany
ment of the tooth. Laser treatment of cavities can be
done minimally invasively with maximum preservation
of sound tissue and even selective removal of caries is
possible if the dentist is well versed. Subsequently, a cavity and caries treatment will be explained to demonstrate the procedure.
_Case presentation
Fig. 2
_Introduction
Fig. 1
Fig. 1_BIOLASE Waterlase
MD Turbo.
Fig. 2_Upper right lateral incisor
with caries.
Fig. 3_Turbo handpiece with
MX7 tip.
Fig. 4_Preparation of enamel.
Fig. 3
In the early 1990s, cavity preparation by Er:YAG laser
was an exercise in patience. Owing to the low peak
power of the pulse and a slow frequency the cavity was
finished in what felt like hours after starting the laser
treatment. Today, short pulse length, high power and increased frequency lead to short treatment times, comparable with conventional mechanical treatment by
burs. Nearly all kinds of preparation and caries excavation can be done without any anaesthesia if the dentist
is familiar with his laser and the correct treatment options. The procedure itself is more comfortable for the
patient because there is no pressure or vibration on the
tooth owing to the non-contact mode of the treatment.
Additionally, the bactericidal effect of the laser results in
a nearly sterile cavity without any smear layer, which in
the case of direct or indirect pulp capping speeds up
healing and helps to avoid eventual endodontic treat-
Fig. 4
30 I laser
4_ 2011
The patient was a 28-year-old man with a carious lesion at the upper lateral incisor on the right side (Fig. 2).
Laser treatment was done with a Waterlase MD Turbo
(BIOLASE), an Er,Cr:YSGG laser with a wavelength of
2,780 nm (Fig. 1) and a turbo handpiece with a MX7 fibre tip (Fig. 3). The treatment was done without any
anaesthesia and began with the preparation of the cavity. In case of interdental cavities the use of the „gold
handpiece“ with longer tips would be preferable. Using
the longer tips increases the ability to reach deeper
zones in the mesial or distal part of the cavity and prevents from harming the adjacent tooth. Because of the
different form of the tip and handpiece the speed of ablation will drop down slightly in this case.
Enamel treatment was done with the following parameters: 6.25 W, 30 Hz, 140 µs pulse, 75 % water, 90%
air (Fig. 4). Treatment of caries and dentine was done
with the following parameters: 3 W, 30 Hz, 140 µs pulse,
35% water, 45 % air (Fig. 5). During the procedure, the
treated area was marked by the ablated enamel, a white
surface looking nearly already etched (Fig. 6). The complete procedure was done in non-contact mode; therefore, the cavity had to be probed occasionally to ensure
caries removal because the usual tactile feeling is absent
during hard-tissue laser treatment. After cavity preparation and caries removal, the lased surface was treated
with an excavator to remove the loosened enamel particles and thereby avoid a white area shining through
the filling surface. The tooth was subsequently etched
[31] =>
user report _ cavity preparation
Fig. 5
and bonded as with conventional treatment. The finished filling after polishing is shown in Figure 7.
_Summary
The entire procedure was done in ten minutes. No
change of instruments was necessary, so as in classical
treatment and therefore only a minimum of instruments have to be cleaned and sterilised. Due to laser
preparation and additional etching the long term prognosis for such fillings is very high, which could be proved
already by clinical studies and dye penetration tests. Patients compliance is very high for laser treatment because the entire procedure is more comfortable and
mostly painfree. There is no vibration or pressure on the
tooth, no injection for anesthesia is needed and treatment is accomplished in a short time. Sometimes its
Fig. 6
Fig. 7
possible to finish the complete procedure in the time another conventional treated patient is still waiting for
anesthesia success. Last but not least it has to be mentioned that more than 90 % of the already laser treated
patients are asking for laser treatment the next time although they know about the additional charging of the
laser treatment._
_contact
laser
Dr Ralf Borchers, MSc
Bahnhofstraße 14, 32257 Bünde, Germany
Tel: +49 5223 10222
Dr.Borchers@praxis-borchers.de
www.laserdentistry-germany.de
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I
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[32] =>
I industry report _ open flap
The use of the Er:YAG
in laser-assisted
periodontal surgery
Author_Dr Avi Reyhanian, Israel
_Introduction
Periodontal diseases are some of the most
widespread of oral pathologies. Chronic periodontitis, characterised by local inflammation
owing to infection with pathogenic bacteria, destroys the supporting structures of the teeth including periodontal ligaments, cementum and
alveolar bone. Untreated periodontal disease then
leads to tooth loss because the attachment apparatus and tooth-supporting structures are destroyed. The goals of periodontal therapy are to arrest the progression of periodontal disease and regenerate those structures lost to disease. Since
periodontal diseases are considered both chronic
and destructive, the sooner diagnosis and treatment begin, the better the prognosis is for the patient.
Fig. 1_X-ray image at presentation.
Fig. 2_Periodontal probe indicate
pockets around 8 to 7 mm.
Fig. 3_Er:YAG laser incision with
600 µ sapphire tip, contact mode,
power 200 mJ, 35 Hz.
Fig. 1
Periodontal inflammation is reversible when
limited to soft tissue areas (gingivitis), but when
supportive bone tissue becomes involved (periodontitis), the situation does not reverse if left untreated. To accomplish these goals, it is essential to
eliminate etiological factors such as adherent
plaque, dental calculus, and diseased cementum
Fig. 2
32 I laser
4_ 2011
from the root surface and infected connective tissue within intra-bony defects around the teeth.
Recently, various regenerative therapies in conjunction with flap surgery have come into use for
the treatment of advanced periodontitis. Basically, however, the success of these therapies still
depends on thorough debridement of the contaminated root surface and removal of infected
granulation tissue. The aim is to preserve the natural teeth. Many variables are considered to determine whether surgically reducing the depths of
the pockets will benefit the patient’s oral hygiene.
_Periodontal surgery with the
Er:YAG laser
Usually, the removal of calculus and diseased
soft tissue is performed with mechanical instruments. However, conventional mechanical instrumentation using curettes is still technique dependent, time consuming and occasionally ineffective, and power scalers are a source of uncomfortable stress such as noise and vibration for the
patient. Laser-assisted periodontal therapy has
attracted attention recently as a potential alternative to conventional mechanical treatment.
Fig. 3
[33] =>
industry report _ open flap
Fig. 4
Fig. 5
Various types of lasers have been investigated as
an adjunct to periodontal therapy. The Er:YAG
laser, which emits at a wavelength of 2.94 µ, has
been demonstrated to be useful for both hard and
soft tissue. The Er:YAG laser has produced the
most promising results32 and has come to be one
of the most promising lasers used in periodontics
with a wide range of applications such as:
tient. This case study demonstrates the use of the
LiteTouch Er:YAG laser system (Syneron Dental)
for the entire procedure, both hard and soft tissue.4, 8, 9 This article will demonstrate that the
Er:YAG laser may be used as a treatment alternative when working with bone.8, 14
– incision for flap lifting;2, 4, 26
– calculus removal;18
– high bactericidal capacity;9
– granulation tissue ablation;1, 27
– detoxification effect on lipopolysaccharides of
the diseased root surface;7, 30, 31
– bone ablation: remodelling and shaping, without major thermal side-effects; and
– favourable root conditioning for the adherence
of fibroblasts.20, 2, 26, 1, 28, 29
A 55-year-old healthy male patient presented
with complaints of halitosis and recurrent bleeding. Clinical examination showed bleeding on
probing with pocket probing depths of 5 to 6 mm
(Fig. 1), stable teeth with no mobility, and exudation. An X-ray revealed vertical and horizontal
bone loss (Fig. 2). Therefore, this case was classified as severe periodontitis. The dental hygienist
initiated treatment through plaque removal and
scaling and root planing, and then instructed the
patient in more aggressive oral hygiene. Six weeks
later, the situation was re-evaluated: there was no
significant clinical improvement in pocket depth
and bleeding on probing. A surgical procedure was
decided that involved lifting a flap.
A controlled clinical trial was performed by
Schwarz et al.23 They demonstrated that periodontal pocket therapy with an Er:YAG laser obtained equivalent or better results compared with
conventional mechanical therapy with Gracey
type curettes. Also, Sculean et al.24 have reported
that Er:YAG laser debridement of granulation tissue within intra-bony defects during periodontal
flap surgery was as effective as with conventional
mechanical instruments. Therefore, the clinical
safety and effectiveness of the Er:YAG laser have
been demonstrated for both non-surgical and
surgical periodontal therapy, and this laser has become one of the most promising lasers used in periodontics.2, 24
The purpose of this case study is to demonstrate the effectiveness of using an Er:YAG laser
for periodontal surgery. The conventional approach is to make an incision with a scalpel and
then use a periosteal elevator to lift a flap, then to
remove the granulation tissue with mechanical
tools. Bone reshaping and remodelling are then
performed with rotary instruments and assorted
chisels. The use of an Er:YAG laser for periodontal
surgery is faster and more comfortable for the pa-
I
Fig. 6
Fig. 4_Immediately after raising
the flap.
Fig. 5_Granulation tissue ablation
with 1,300 µ sapphire tip,
non-contact, 400 mJ, 20 Hz.
Fig. 6_Immediately after ablation.
_Surgical case study
_Laser apparatus
The laser apparatus used was the LiteTouch
Er:YAG laser system. The features of this system
are a wavelength of 2.94 µ, an output energy range
of 50 to 700 mJ/pulse, a pulse frequency range of
11 to 50 pulse/second (Hz) and pulse duration of
200 microseconds. The system does not employ a
fibre delivery system; the laser medium is in the
applicator. The system also uses a special water
spray system to cool the irradiated area. Air-mixed
water is released coaxially to the contact tip, covering the target area during irradiation, providing
precise and adequate water delivery. An optional
feed bottle system is integrated into the system
for sterile saline water supply during surgery. Intrasulcular palatal and buccal incisions were performed with a 600 µ tip 4 under local anaesthesia
(Fig. 3). Water spray was used for tissue cooling
throughout the entire laser procedure. The 600 µ
sapphire tip was used at settings of 200 mJ/35 Hz
laser
4
I 33
_ 2011
[34] =>
I industry report _ open flap
(= 7 W) in contact mode at intrasulcular depth. After the flap had been lifted (Fig. 4), the granulated
tissue was removed by ablation and vaporisation
using a 1,300 µ tip, in non-contact mode, at a distance of 1 to 1.5 mm from the target tissue (Fig. 5).
The energy used for this procedure was 400 mJ/20
Hz (= 8 W). In narrow embrasures where the tip
was too wide, the 1,300 µ tip was replaced with a
narrower conical tip (800 µ) and the energy was
decreased. Since the laser fires from the end of the
tip and not from its sides, even when the side of the
tip is touching another tooth while firing, no damage occurs to the adjacent tooth. After ablating
the soft tissue,2 the hard tissue was treated: for
bone remodelling the power set was 300 mJ/20
Hz1, 2, 8 (= 7 W). The tip of choice is a 1,300 µ sapphire tip applied in non-contact mode.8, 14 For bone
smoothing, the energy applied is 150 mJ/50 Hz (=
7.5 W), 1,300 µ sapphire tip in non-contact mode.
Before closing the flap, laser energy should be applied to the exposed roots in non-contact mode on
the buccal, palatal and interproximal sites at a very
low energy of 100 mJ/35 Hz (= 3.5 W), using a
1,300 µ sapphire tip in non-contact mode (Fig. 6).
This step is important because it improved the
attachment of the soft tissue to the root and
greatly reduced bacterial endotoxin from the
root’s surface.5, 7, 9, 10, 12, 13, 15, 18, 19 A vertical release
incision was not necessary because flap reflection
was adequate. This particular procedure was performed without the assistance of curettes, rotary
equipment or chisels. Were sub-gingival calculus
present, however, I would have removed it with a
chisel tip sapphire (Fig. 11).
ceeded 3 mm. The photographs and X-rays presented in Figures 1 to 11 show the various stages
of this case study.
_Several observed advantages of using
lasers in periodontal surgery
The following are observed advantages of using lasers in periodontal surgery:
– less bleeding during the procedure;
– surgical site decontamination—the laser is bactericidal18 (no antibiotics necessary after surgery);
– comfortable post-operative outcome—less
swelling and less pain (studies show this may be
partly due to the closure of smaller blood vessels,
lymphatic vessels, and exposed nerve endings);3
– more effective bone cleaning;1, 2, 14
– faster completion of the surgical procedure3 and
easy handling;2
– no rotary tool vibrations—patient comfort;3
– the Er:YAG laser produces no smear layer, leaving a bone surface that is absolutely clean, thus
reducing the possibility of secondary infection.
Many studies have shown that when Er:YAG
and other lasers are applied to bone, growth factors are released that enhance bone regeneration:1 faster bone repair after irradiation than
conventional bur drilling. Implants inserted into
Er:YAG laser-placed holes can exhibit greater bone
contact than those prepared by conventional
methods.14
_Particular points of attention
Fig. 7_Immediately post-op.
Fig. 8_Six months post-op.
Fig. 9_Fifteen months post-op.
Fig. 7
Studies show that sub-gingival calculus can be
removed with an Er:YAG laser.15–19 The patient returned the following day and reported that he was
no longer in pain. No swelling was observed.3, 9 The
patient was scheduled for maintenance therapy at
three-month intervals for a period of three years.
Fifteen months after the interventions, clinical attachment levels, pocket probing depths, recession,
full-mouth plaque scores and full-mouth bleeding scores were assessed. No pocket depths ex-
Fig. 8
34 I laser
4_ 2011
There are particular points that require attention when using lasers for bone tissue:
– constant hand motion during laser emission—
avoid applying the laser beam on any one spot
longer than necessary (dental lasers are thermal
devices by nature; therefore, long interaction
between the laser and target tissue raises the
temperature of the tissue—studies show, how-
Fig. 9
[35] =>
industry report _ open flap
ever, that when properly used the temperature
generated by a laser beam is no higher than that
generated by rotary tools);6, 8
– the use of saline solution as opposed to distilled
water as a cooling liquid; this is to provide the
bone tissue with an isotonic environment;
– the Er:YAG laser energy setting should stay below 400 mJ (8 W), keeping the applicator in constant motion;
– laser application to bone tissue should be in
non-contact mode at a distance of 1 to 2 mm between the applicator tip and the target tissue—
when the overlying tissue incisions are performed, operating in contact mode until you feel
contact with the bone it is recommended;
– tissue-cooling water spray should be used
throughout the entire Er:YAG laser procedure.
_Discussion
Surgery with the Er:YAG laser takes less chair
time, and invariably delivers better results than
conventional approaches, making for an allaround happier patient. The definition of a wellrounded dental laser surgeon is the one who
knows how to match the wavelength to the procedure, but that is not enough! The energy of the
wavelength and the motion and position of the
beam must be suited to the procedure as well
(power energy, energy density and duration of irradiation). The surgeon should be well trained and
skilled. A higher quality level of granulation tissue
removal was achieved with the laser,2, 4, 8 the bone
was free of a smear layer, the tissue healed faster,
and the patient felt better after laser-assisted periodontal surgery.3
_Conclusion
In conclusion, the LiteTouch Er:YAG laser can be
safely and effectively utilised for degranulation
and root debridement in periodontal flap surgery,
without causing major thermal side-effects on
the root and bone surfaces, and pulpal damage.
The LiteTouch laser possesses characteristics particularly suitable for periodontal treatment, owing to its dual ability to ablate soft and hard tissue
with minimal damage. The LiteTouch Er:YAG laser
has proven itself to be an effective and promising
tool for periodontal therapy and surgery, and has
a sterilising effect upon dental structures._
_References
1. K.M. Sasaki, A. Aoki, S. Ichinose, et al., Scanning electron microscopy and Fourier transformed infrared spectroscopy analysis
of bone removal using Er:YAG and CO2 lasers, Journal of Periodontology, 73/6 (2002): 643–52.
Fig. 10
2. I. Ishikawa, A. Aoki & A.A. Takasaki, Potential applications of
Er:YAG laser in periodontics, Journal of Periodontal Research,
39/4 (2004): 275–85.
3. N. Lioubavina-Hack, Lasers in dentistry. The use of lasers in periodontology, Ned Tijdschr Tandheelkd, 109/8 (2002): 286–92.
Errata in: Ned Tijdschr Tandheelkd, 109/10 (2002): 415.
4. H. Watanabe, I. Ishikawa, M. Suzuki, et al., Clinical assessments
of the Er:YAG laser for soft tissue surgery and scaling, Journal of
Clinical Laser Medicine and Surgery, 14/2 (1996): 67–75.
5. M. Folwaczny, H. Aggstaller, A. Mehl, et al., Removal of bacterial
endotoxin from root surface with Er:YAG laser, American Journal
of Dentistry, 16/1 (2003): 3–5.
6. V. Armengol, A. Jean & D. Marion, Temperature rise during
Er:YAG and Nd:YAG laser ablation of dentin, Journal of Endodontics, 26/3 (2000): 138–41.
7. H. Yamaguchi, K. Kobayashi, R. Osada, et al., Effects of irradiation of an Er:YAG laser on root surfaces, Journal of Periodontology,
68/12 (1997): 1151–5.
8. Institute for Laser Dentistry, “Use of the dental Er:YAG laser
(2940nm) for contouring and resection of osseous tissue (bone)
and the preparation of endodontic canals” , accessed 30 Oct. 2006.
9. Y. Ando, A. Aoki, H. Watanabe, et al., Bactericidal effect of Er:YAG
laser on periodontopathic bacteria, Lasers in Surgery and Medicine, 19/2 (1996): 190–200.
10. A. Pourzarandian, H. Watanabe, A. Aoki, et al., Histological and
TEM examination of early stages of bone healing after Er:YAG laser
irradiation, Photomedicine and Laser Surgery, 22/4 (2004):
342–50.
I
Fig. 11
Fig. 10_X-Ray image 15 months
post-op.
Fig. 11_The chisel tip for calculus
removal.
Editorial note: The whole list of references is available from
the publisher.
_contact
laser
Avi Reyhanian, DDS
Shaar Haemek Street
Netanya 42292, Israel
avi5000rey@gmail.com
http://www.avidentallaser.com/
dental@syneron.com
http://www.synerondental.com
laser
4
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[36] =>
I industry report _ treatment possibilities
Laser in daily
practice use
The key to therapeutic and economic success
Authors_Prof Dr Frank Liebaug & Dr Ning Wu, Germany
_Laser dentistry went through a rapid development within the last years. Today, the use of laser
devices enhances the whole dental treatment
range valuably and supports conventional as well
as conservative therapies. So the practioner
achieves more safety and a better clinical result can
be obtained for the patient in a gentle way. In the
following, the authors show different alternatives
based on clincial case studies.
Especially for the colleagues with their own
practice it is important to study the possibilities, but
also the limitations of modern laser dentistry and
to get an idea about the possible introduction in
their practice.
_Practical indication for lasers
in dentistry
Fig. 1_Antimicrobial, photodynamic
therapy in marginal periodontitis.
Fig. 2_Laser for periimplantitis therapy, 17 years post implantationem
and dental bar provision.
Fig. 1
Today, application fields of laser devices in oral
therapy are to be found in diagnostics, caries and
hard tissue removal, periodontology, antimicrobial,
photodynamic therapy of mucosa diseases, en-
Fig. 2
36 I laser
4_ 2011
dodontics, implantology and preparation of
suprastructures, periimplantitis therapy (Fig. 2),
high-quality prosthetics, laser-supported pediatric
dentistry, prophylaxis, bleaching and—last but not
least—in esthetic dentistry.
_Wavelenghts determine indication
of use
However, there is not just one device for all applications and indications, in fact the indication is
determined by the respective wavelength of the
laser. Caries and hard tissue removal are treated
with the Er:YAG device. As these devices are highend developments, they are connected with high
investment costs for the dental practice. If appropriately used by the dentist and integrated into the
daily treatment concept, the use of such devices is
reasonable midterm, therapeutically as well as economically.
Within the last years, various dental laser systems have gained importance in the therapy of pe-
[37] =>
industry report _ treatment possibilities
Fig. 3
riodontitis. In principle, the use of laser can only be
seen as completion of the conventional, systematic
therapy even though the field of non-surgical periodontal therapies could have been expanded by
laser application meanwhile.
Before using laser devices, the patient must be
prepared in terms of a completed initial therapy.
Due to the latest developments in the field of laser
technology, it seems to be conceivable that even the
removal of concrements can be done by means of a
laser.
Fig. 4
_Usage of laser creates a bactericidal
environment and supports healing
Primarily, however, the dentist takes advantage
of the bactericidal effect of a certain wavelength.
Numerous studies and publications in various
fields of dentistry have proved that laser shows an
excellent antibacterial effect in the infrared area
and that it is able to deactivate bacterial toxins. This
effect starts developing at an output power clearly
underneath the limit for a thermic damage of soft
and hard tissue. Thin and flexible light conductor
Fig. 3_Pocket decontamination at
telescopic tooth with a laser.
Fig. 4_Laser decontamination of root
canals at a molar under Rubberdam.
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[38] =>
I industry report _ treatment possibilities
Fig. 5
Fig. 6
Fig. 5_Laser incision at acute,
submucous abscess in primary
dentition.
Fig. 6_Laser application for
desensitization o hypersensitive
tooth surfaces.
systems bring the laser radiation to nearly any desired place and can be well used even in the bifurcation area of molars. So it seems to be obvious to
profit from these advantages in connection with a
systematic periodontal therapy. If the output
power is increased, also pocket epitheliums in
terms of a closed curettage can be removed with an
Nd:YAG or diode laser. Therefore, pocket decontamination with the laser is very effective, even in
case of an acute local periodontitis.
_Advantages of laser-supported
periodontal therapy
Most dentists as well as patients will quickly realize the advantages especially in the fields of periodontology and laser-supported endondontics. For
the field of laser-supported* periodontal therapy
this means:
– no bleeding after treatment, even in patients suffering from a bloodclotting disorder or taking anticoagulants*
– significantly less anesthesia demand
– agreeable and easier treatment
– better healing process without complications
– considerably less postoperative pain
– drinking and eating possible after subsiding of
anesthesia
– less postoperative hypersensitivities of tooth
necks by sealing of dentin tubuli
– germ reduction in periodontal pockets (Fig. 3).
_Advantages of laser-supported
endodontic treatment
The success rate in endodontic therapy can be
significantly increased by a consequent use of the
laser device, too, thus avoiding surgical interventions to the point of necessary tooth extraction in
case of clinical failures (Fig. 4). A major advantage
is the 99 % germ reduction* in the root canal immediately after exposure to laser light resulting in:
38 I laser
4_ 2011
– possibly no medicamentous insert
– time saving, often whole treatment in just one appointment
– sealing of the apical dentin tubuli
– avoiding of apicectomy.
_Clinical examples
The following case studies show just a small selection of treatment possibilities, without claim to
be complete, to encourage interested colleagues to
integrate innovative methods into the daily practice
in the interest of their patients. It is not to be underestimated that especially children and anxious, sensitive patients are very open to this treatment
method. One example should be the incision of an
acute submucous abscess in the primary dentition
(Fig. 5). But also the relatively many patients with
herpes labialis or sore stomatitis aphthosa respond
positively to the oral laser therapy. Hypersensitive
tooth surfaces can be treated effectively with the
non-contact procedure (Fig. 6).
The newcomer might have difficulties to find the
appropriate device on the current dental market.
Aside from devices with just one laser of a certain
wavelength, the combination unit LaserHF, which
we use in our practice, has been available for more
than a year now. Apart from a diode laser with a
wavelength of 975 nm, this device includes a lowlevel-laser with 660 nm and an additional high frequency surgery unit for cutting and coagulation._
_contact
laser
Prof Dr med Frank Liebaug
Professor Hangzhou Normal University, China
Guestprofessor Shandong University, China
Praxis für Laserzahnheilkunde und Implantologie
Arzbergstraße 30
98587 Steinbach-Hallenberg
Tel.: +49 36847 31788
[39] =>
meetings _ events
I
International events
2012
13th WFLD World Congress
Barcelona, Spain
26–28 April 2012
Midwinter Meeting
www.wfld-barcelona2012.com
23–25 February 2012
Chicago, USA
90th General Session & Exhibition
www.cds.org
of the IADR
Rio de Janeiro, Brazil
Expodental 2012
20–23 June 2012
Madrid, Spain
www.iadr.org
23–25 February 2012
www.expodental.ifema.es
Laser Optics Berlin
Berlin, Germany
19–21 March 2012
www.laser-optics-berlin.de
IDEX Istanbul
Istanbul, Turkey
5–8 April 2012
www.cnridex.com
IDEM International Dental Exhibition
Singapore
20–22 April 2012
www.idem-singapore.com
Dental Salon
Moscow, Russia
23–26 April 2012
www.dental-expo.com
SCANDEFA
Copenhagen, Denmark
26–28 April 2012
www.scandefa.dk
laser
4
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_ 2011
[40] =>
I meetings _ DGL
Laser’s rightful place
in modern dentistry
Author_Jürgen Isbaner, Germany
_The LASER START UP 2011 and 20th annual
congress of the German Society for Laser Dentistry
(DGL) took place in Düsseldorf, Germany, from 28
until 29 October 2011. The attending 250 laser beginners and proficient users were fully rewarded by
the scientific and experience driven program.
In many respects the laser market developed extremely well in the past. Not least, this is reflected in
a wide range of modern and very effective lasers.
Due to the effort to integrate the laser dentistry
more and more into individual areas such as implantology, periodontics and endodontics, it becomes increasingly easy to fight for the laser’s rightful place in modern dentistry. Significant contributions for achieving this goal are the two laserrelated conventions in Germany, the annual
conference of the German Society for Laser Dentistry (DGL) and the LASER START UP congress.
The annual congress of the DGL builds on existing skills and provides a versatile program for continuing education regarding new applications of
lasers in the dental office. The LASER START UP offers the ideal opportunity to make beginners familiar with the basics of laser dentistry and the latest
laser technology.
40 I laser
4_ 2011
_Undisputed advantages of laser
treatment
For more than 30 years the laser is used as a tool
for therapy and diagnosis in medicine and dentistry. Its advantages over conventional methods,
such as touch-free and sterile working or the reduced tissue trauma, are mostly undisputed. In addition, the specificity of laser light allows the development of completely new treatment and surgical techniques.
_Laser is worth it
In the past there were mainly two reasons why the
almost unlimited spectrum of indications of lasers in
dental practices has not kept the unbroken triumph:
First, there were not any universal lasers in the past and
secondly, using the laser compared to conventional
[41] =>
meetings _ DGL
instruments was relatively expensive. However, things
have changed. The latest generation of lasers is flexible, powerful and ultimately economic. Still, the laser
is not superior to conventional therapies. But, and this
is crucial, the laser can be much simpler, faster, and in
the relationship between effort and result more efficient. In times of cost pressure there is a significant opportunity for the laser: In regard of the technical level
and the diversity of applications, dental lasers have
never been as good as today. It has been proved, for example, that the laser reaches excellent results in dental surgery or endodontic and periodontal therapy, especially in the treatment of peri-implantitis.
I
Deppe (Munich, Germany) and Dr George Bach
(Freiburg/Breisgau, Germany) both, the DGL-annual
conference and the LASER START UP offered firstclass speakers that covered all aspects of laser use in
daily practice in a comprehensive scientific program, hands-on courses and workshops of the leading laser manufacturers.
Thus, the joined conference in Düsseldorf was a
valuable training event for both, experienced laser
users and beginners.
_Education and training for beginners
and users
In the upcoming year, both the LASER START UP
2012 and the annual congress of the DGL will be held
in the city of Leipzig, Germany, on the 7 and 8 September 2012._
Under the scientific leadership of Prof Dr Norbert Gutknecht (Aachen, Germany) Prof Dr Herbert
For booking information please contact OEMUS
MEDIA AG via e-mail: events@oemus-media.de
laser
4
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_ 2011
[42] =>
Fascination of Laser Dentistry
From 28 October until 29 October 2011 both the 20th annual congress of the German Association of Laser
Dentistry (DGL) as well as the congress for laser beginners, LASER START UP, were held in Düsseldorf, Germany. Over the two congress days we welcomed up to 200 participants from all over Germany, Europe and
Middle East. Here you can read the abstracts of some lectures given during the congresses.
Laser-supported reduction of specific microorganisms in the
periodontal pocket with the aid of an Er,Cr:YSGG laser: A pilot study
Author_Dr Constanze van Betteray, Msc/Germany
Aim of the study: This study evaluates the capability of the
Er,Cr:YSGG laser with a wavelength of 2,780 nm and the new 360°
firing elastic Radial Firing Perio Tip (RFPT; 14 mm length, 500 m diameter; BIOLASE) to reduce pathogenic microorganisms in the periodontal pocket and to eliminate the biofilm and the diseased gingiva as a non-surgical conservative periodontal treatment that offers effectiveness for the dentist and comfort for the patient.
Material and method: Twelve patients with chronic or aggressive periodontitis were examined and treated. In the second dental
hygienist session, a microbial smear as a pool probe from the deepest pocket in each quadrant was taken and the pocket depth of all
teeth were measured. Following, a conservative periodontal treatment with ultrasonic devices and hand instruments followed in all
quadrants within 24 hours. Afterwards, two randomly chosen
quadrants were lased three times in a seven-day period using the
Waterlase (BIOLASE) and the RFPT (output power of 1.5 W, 30 Hz,
11 % air, 20 % water and a pulse duration of 140 µs). After the last
lasing session, another microbial smear was taken from the lased
sites. This was repeated after three and six months. After six months,
the pocket depths were also measured again.
Results: The number of all bacteria in the pockets was reduced
to -88.72 % after six months. All bacteria, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, T.f., Treponema denticola and Fusobacterium nucleatum, were
reduced continuously throughout the whole examination period.
The pocket depth showed a slightly higher reduction in the lased
quadrants than in the non-lased ones. These results were found to
be consistent and in some cases improved after six months posttreatment.
Conclusion: The results demonstrate that the use of the
Er,Cr:YSGG laser with the new 360° RFPT in periodontal treatment
is able to reduce pathogenic microorganisms in periodontal pockets significantly.
Basics of laser-assisted diagnostic procedures
Authors_Priv.-Doz. Dr J. Meister, Dipl.-Phys. F. Schelle, Dr O. Brede, Priv.-Doz. Dr A. Braun, Prof Dr M. Frentzen/Germany
Diagnosis, in the broadest sense, describes the assignment of
findings to a term of illness, in which the discovery methods are
grouped under the term “diagnosis”. In dentistry and in oral and
maxillo-facial surgery, numerous optical methods of assessment
are used. These primarily include visual examination and imaging
techniques such as X-rays or MRI scans. With the help of more modern LED and laser technologies, the field of optical diagnosis has
been expanded. The selective excitation of fluorophores through
monochromatic light and the consequent detection of carious lesions, for example, have made these technologies an integral part
of the dental practice. A brief functional description is given and the
current state of fluorescence technology is discussed.
42 I laser
4_ 2011
The development of ultrashort-pulse laser (USPL) systems has
opened another diagnostic window. For a variety of detection procedures, very specific properties of the USPL are exploited, e.g. its
short coherence length or its very high intensities. The resulting
technologies, for example, are optical coherence tomography and
terahertz imaging. They allow not only superficial, but also deeper
tissue layers to be analysed. Their function and practicality are discussed in this article.
In the future, the combination of therapy and diagnosis (theragnostics) could be of particular importance. This is explained using USPL and OCT as examples.
[43] =>
Possibility of calculus removal with an ultrashort-pulse laser system
Authors_Prof Dr M. Frentzen, ZÄ P. Pourfarid, Dipl.-Phys. F. Schelle/Germany
The selective and careful removal of biofilm and mineral deposits in periodontal therapy is a clinical challenge. As an alternative to conventional techniques, laser technologies hold
significant potential regarding the selective removal of calculus and disinfection of the root surface. In the present study,
the potential of ultrashort-pulse laser technology was investigated in this therapeutic field.
The aim was to determine the ablation thresholds of calculus and cementum. The ability to remove calculus selectively
and the side-effects of this were assessed. The root surface of
freshly extracted teeth with and without calculus deposits
were treated with an Nd:YVO4 laser (1,064 nm, pulse energy of
6–8 µJ, pulse duration of 8 ps, repetition rate of 500 kHz, focus
Ø: 30 µm, scan parameter: line spacing 12.5 µm with a scanning speed of 2 m/s).
The study’s results demonstrate that biofilm and calculus
can be safely removed at 4 W average output power without
damaging the dental hard tissue. The result is a smooth surface
area. The results are the basis for further development of a clinical application system.
Material processing with ultrashort-pulse laser technology
Authors_Dipl.-Phys. F. Schelle, Dr B. Oehme, Dr O. Brede, Priv.-Doz. Dr A. Braun, Priv.-Doz. Dr J. Meister,
Prof Dr M. Frentzen/Germany
Ultrashort-pulse lasers (USPL) are a well-known and proven
radiation source for industrial material processing. The benefits
of this technology include its high precision, versatility and efficiency of processing. The aim of this study was to determine how
these properties can be transferred to application in dentistry. In
particular, ablation thresholds and ablation rates for oral hard
and soft tissue, and restorative materials were determined.
an optical profilometer. All materials investigated could be ablated. Ablation rates and thresholds were determined for all materials. Selectivity of material removal could be assessed from
the data obtained. Promising results regarding selectivity of removal were obtained with composite materials, which have the
highest ablation rate, as well as a remarkably low ablation
threshold.
A 1,064 nm Nd:YVO4 laser (with a pulse duration of 8 ps,
emitting at a repetition rate of 500 kHz) served as beam source.
The experiments were performed on dentine, enamel, cortical
bone, bone marrow, trabecular bone, titanium, amalgam, composites and ceramics. The resulting cavities were measured with
Regarding material processing properties, the use of USPL in
dentistry appears promising. However, no realistic treatment
situations could be simulated with the laboratory system
utilised. Further studies are needed to examine and assess possible side-effects and risks for patients.
Evaluation of the efficiency of the diode laser for the treatment of
pyogenic granuloma
Author_Dr Merita Bardhoshi/Albania
I report my experience in the treatment of two clinical cases of
pyogenic granuloma with a 980 nm diode laser in the University
Hospital, Department of Oral Surgery, Tirane, Albania. You will be
treated as an outpatient under infiltration anesthesia lidocaine
2% 1cc, laser parameters: 6 W, continuous wave, optical fiber 300
micrometer after surgery no sutures were required.
Patients are following up after one week, four weeks, six
months and one year after surgery to evaluate the early and longterm results. No analgesics and antibiotics were prescribed. The
diagnosis was confirmed by biopsy. The laser surgery is well accepted by patients.
Patient reported no pain, swelling or bleeding a week after the operation. Four weeks after surgery, the wound was completely healed
without complications. No scarring occurred and lips were normal in
consistency. Aesthetic result was perfect. One year after surgery no
recurrence occurred. The patients were satisfied with the result.
Laser surgery is a good modality for treatment of Granuloma pyogene. It is easy to perform, well accepted by the patients and the
wounds were healed without complication. The big advantage is the
lack of scars and a perfect aesthetic result. The application of 980 nm
diode laser for the treatment of pyogenic granuloma seems to be with
good benefice.
laser
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_ 2011
[44] =>
I education _ AALZ Greece
Graduation of the first
Mastership Course of
AALZ Greece
Author_Dr Dimitris Strakas, Greece
_Participants of the first Mastership/Fellowship
Course offered by AALZ Greece have graduated. AALZ’s
course is a one-year clinical specialisation course for
laser treatment at selected wavelengths. This offering is
geared towards dentists who would like to specialise in
certain wavelengths. Over the course of ten days spread
over one year, participants are taught fundamental
physical and technical knowledge and how to recognise
primary, secondary, and tertiary indications.
The course, which is split into four modules, started
on 14 November 2010. AALZ’s Director and Mastership
Course Director Prof Norbert Gutknecht and General
Manager Mr Leon Vanweersch initiated and welcomed
the participants by giving them the first guidelines to
support them in their studies.
The first day of the course was dedicated to the Laser
Safety Officer Course. This is a one-day course that offers official certification as a Laser Safety Officer (LSO;
this course is a prerequisite for laser use). The innovative
treatment methods of laser therapy pose risks for both
practitioners and their teams, as well as for patients, if
fundamental technical, biological and physical infor-
44 I laser
4_ 2011
mation about the application and laser safety measures
is not or insufficiently known. Dr René Franzen gave the
participants an in-depth understanding of laser physics
and laser-tissue interaction, preparing them for using
lasers safely. This was followed by an examination for
the LSO certificate. Our laser safety courses meet trade
association requirements for obtaining expertise as an
LSO. They are officially recognised according to the
guidelines of BGV B2 (follows EN 60825-1 and ANSI
Z136.1) and the State Radiation Protection Office.
On the second day, laser structure, function and handling of laser systems and laser-tissue interaction were
taught. In addition, participants were introduced to
AALZ’s exclusive e-learning platform (ILIAS). Each participant was required to use the system, interacting with
the lecturers and with the other participants and participating in the ILIAS forum, where questions and answers on lasers were posted and discussed.
The second module was presented from 28 February
to 1 March 2011. Nd:YAG, diode low and high power, and
CO2 lasers were covered in this module and Prof
Gutknecht explained the theoretical and biophysical
[45] =>
education _ AALZ Greece
background, clinical indications and clinical importance
in various fields of dentistry (e.g. periodontics, implantology, endodontics and soft-tissue surgery) to the participants.
The third module was presented from 8 to 10 May
2011. The erbium laser family (Er:YAG and Er,Cr:YSGG)
was the subject of Prof Gutknecht’s lectures over these
three days. Every aspect of erbium lasers was analysed
in detail and the participants had the opportunity to answer the vast number of questions they had.
We were then finally at the point at which our participants were preparing for the examinations at RWTH
Aachen University. Apart from the written exam, the
presentation of five clinical cases is essential. Guidelines
and protocols were given to the dentists so they could
prepare and demonstrate the laser treatments that they
offer to their patients. The two months until the exams
in Aachen were precious in order for them to prepare adequately.
On 13 July 2011, we flew to RWTH University in the
beautiful city of Aachen. The written examination was
held on the next day and the clinical presentations were
delivered to the committee by the dentists the day after.
Prof Gutknecht headed the four-member evaluation
committee, which included Drs Franzen, Antonis Kallis
and Dimitris Strakas.
In the afternoon, a reception and gala dinner hosted
by AALZ was held in the exceptional Hotel Kasteel Bloemendal. The graduation ceremony for awarding diplomas to successful participants was well planned and afterwards everyone enjoyed dinner in a friendly and
pleasant environment.
Invaluable are the remarks by participants that characterised their experience of AALZ’s course. This is what
participants said about our programme:
“Starting the Mastership Course on November, I did
not expect to meet such a serious and simultaneously
I
pleasant experience with exceptional organisation
and high level of scientific-based lectures. Practically,
the help of the Greek ‘pioneer’ colleagues Antonis and
Dimitris and the German professors, especially Prof
Gutknecht, which I thank, made me change the philosophy of my dental clinic in terms of modern technological innovations. The comprehension and usage
of different wavelengths made it easier for me to implement lasers in my everyday dental treatments.”
Dr Evangelos Dimitriou, Athens
“Before the Mastership Course Lasers in Dentistry,
I felt like a blind man, using a laser. Now I feel stronger,
owing to the high level of education of AALZ, of the
great team working in this programme in Greece and
Germany and of course to Prof Gutknecht, a real
teacher and leader.”
Dr Pantelis Mavridis, Drama
“Great experience: A must-do programme for anyone who wants to work with dental lasers. It has
helped me to use 100 % of the capabilities of my laser
and not just by following given guidelines. It helps you
understand how lasers work so that you can work with
them effectively. Also for those who do not have any
laser equipment but want to start working with laser,
it will help them choose what is right for them and
choose the right machine with the correct capabilities.”
Dr Cristos Tzimogiannis, Ioannina
The second Mastership Course will start on 3 December 2011 in Athens:
Module I: 3–4 December 2011 (two days);
Module II: 5–8 February 2012 (four days);
Module III: 6–9 May 2012 (four days);
Module IV: 10–11 September 2012 (two days).
The programme is presented in English and the exams are held at RWTH Aachen University in Germany.
For more information, you can visit our website at
www.aalz.gr or e-mail us at aalzgreece@gmail.com._
laser
4
I 45
_ 2011
[46] =>
I education _ laser in dentistry
Start of the new Master
of Science course
in Aachen
Author_Dajana Klöckner, Germany
_On 26 September 2011 the 14th master course
“Lasers in Dentistry“ started in Aachen, Germany. This
postgraduate Master of Science programme has been
offered since 2004 at the RWTH Aachen University.
The Rector of RWTH Aachen University, Prof Dr
Schmachtenberg, welcomed the 24 curious dentists
who will get a taste of student’s life again. He introduced the University of Excellence where they will
study extra-occupational for the next two years.
The participants come from 12 Nations: Germany,
the European countries, Turkey, Iran and Saudi Arabia
but also from Hong Kong. Some of them have already
46 I laser
4_ 2011
been working for decades as successful dentists in
their countries. They have come to Aachen because
they are persuaded that laser dentistry is the future in
dental medicine. After the official enrolment at the
RWTH Aachen University the students got to know
their new study place by a bus tour. Already in the afternoon, the serious students life started with the first
lecture.
During the last seven years more than 120 dentists
could take their Master of Science degrees.
Dr Peter Fahlstedt, M.Sc., graduate from 2008, reports: “I will start the first Institute for Laser-sup-
[47] =>
education _ laser in dentistry
ported Dentistry in the Nordic Countries with the
aim to offer the highest achievable level of education in this field to dentists in Sweden and other
neighbour countries. This is only possible with the
extraordinary support and professionalism.“
The conclusion from Dr Dimitris Strakas, M.Sc.,
who started his studies in 2004: “The quality of the
program and its elaborate structure will certainly
give you the boost that you need while using and
successfully treating with lasers. I am grateful for all
the things I gained and for the security I feel having
a great team of colleagues beside me, as we all walk
with confident steps towards the new era of dentistry.“
All important theories and application options
pertaining to laser use in dentistry are taught. Participants obtain sound theoretical knowledge in lectures and seminars led by renowned, competent and
experienced international scientists and practitioners. Skill training sessions, exercises, practical applications, live operations and workshops with intensive assistance from scientific associates with doctorates guide participants towards using lasers successfully and professionally in their own surgeries.
During the ten modules, students remain in steady
contact with the RWTH Aachen University and the
I
lecturers between attendance days via the e-learning system. This kind of segmentation allows established dentists to remain active in their clinics while
getting their Master degree.
The Master course “Lasers in Dentistry” is the first
accredited dentistry laser Master program in Germany and indeed the world, recognized in the EU
and all countries of the Washington Accord (USA
and Anglo-American nations) and of the Bologna
Reform as an internationally valid academic degree.
The next course in English starts on 24 Septeber
2012 and the upcoming course in German Language
begins on 1 October 2012._
_contact
laser
AALZ – Aachen Dental Laser Center
Dajana Klöckner
Pauwelsstr. 17
52074 Aachen
Tel.: 0241/47571311
kloeckner@aalz.de
laser
4
I 47
_ 2011
[48] =>
I manufacturer _ news
Manufacturer News
FOTONA
be heated to higher temperatures without compromising the safety of the
tooth or pulp because laser light is fully
absorbed in the gel.
Fotona Gets Patent
for its TouchWhite
Tooth Bleaching Tx
Fotona, a leading developer and manufacturer of
dental laser systems, has received a patent for its
TouchWhiteTM minimally-invasive laser tooth
bleaching procedure.
TM
TouchWhite utilizes the Er:YAG laser to activate
the bleaching gel on the tooth’s surface using Fotona’s VLP pulse mode. The benefits of using the
Er:YAG wavelength’s high absorption in water
means that, unlike with Nd:YAG or diode lasers, any
Fig. 1_With TouchWhite™ only the gel is heated (a),
while with standard laser whitening the entire tooth is heated (b).
bleaching gel color can be used because bleaching
gels primarily consist of water. With TouchWhiteTM
patient safety and comfort are not a concern.
Fotona d.d.
Stegne 7
1210 Ljubljana, Slovenia
The Er:YAG laser power in the TouchWhiteTM technique, is utilized more effectively, and the gel can
www.lightwalkerlaser.com
info@lightwalkerlaser.com
KAVO
Greater performance for more
efficiency
The KaVo KEY 3 plus LASER with its gentle, effective and low-pain
application in periodontics, conservative dentistry, endodontics
and surgery has been well established in dental practices since
2009.
Through greater ablation speed in hard dental tissue and bone, treatment length is significantly reduced compared to conventional
LASERs. Fine ablation with variable pulse length also permits finishing the cavity margins. As a result, better aesthetics can be achieved
than with conventional technologies. In periodontics, the unique feedback system of the KEY 3 plus LASER allows the selective, complete and low-pain removal of calculus, with excellent protection of the root support structures. Bacteria
are killed and any biofilm on the tooth surface is dehy-
HAGER & WERKEN
Radio frequency and laser
combined for the first time
LaserHF® from Hager & Werken is a combined unit which for the
first time offers two technologies in one device: laser and radio frequency. While tissue can be perfectly cut, resected and
coagulated with radio frequency, the laser offers additional,
fascinating applications in endodontics, periodontics as
well as in implant surgery. On top of that, new approaches, such as the tissue treatment in therapeutic terms (Low Level Laser Therapy) and antimicrobial
48 I laser
4_ 2011
As a consequence, the TouchWhiteTM
procedure is extremely gentle and the
tooth whitening speed can be safely increased by 5–10 times.
drated and deactivated. The periodontic handpiece 2261 is small and features
an impressively easy exchange of application tips.
In conservative therapy, the Er:YAG LASER is suitable for caries preparation,
enamel/dentine conditioning and fissure sealing. With the aid of the special,
caries contact handpiece, the diseased tissue may be removed with
direct intimate contact of the tooth surface, while using the feedback system.
Furthermore, the KEY 3 plus LASER is suitable for numerous other
indications in endodontics and surgery, such as drying and sterilising the root canal, implant exposure and root tip resection.
KaVo Dental GmbH
Bismarckring 39
88400 Biberach/Riß, Germany
info@kavo.com
www.kavo.com
photodynamic therapy (aPDT) can be carried out. LaserHF includes two types of
laser: A diode laser with 975 nm/6 W and a diode soft laser with 650 nm/100 mW
for LLLT and aPDT. An easy to use touch-screen offers 15 pre-set programs in
the laser unit (10 x diode laser, 5 x diode soft laser). The radio frequency-unit offers various pre-set programs. Additionally the user can save individual programs. Further information is available at www.hagerwerken.de.
Hager & Werken GmbH & Co. KG
PF 10 06 54
47006 Duisburg, Germany
info@hagerwerken.de
www.hagerwerken.de
[49] =>
manufacturer _ news
SIRONA
SIROLaser Advance & Xtend:
intuitive, intelligent, universal
Laser therapy combines modern dentistry and up to date patient treatment. By
using a diode laser, dentists fulfill the wishes of their patients: having an alternative or an addition to a conventional treatment. Sirona, the dental technology
leader, offers two options for less experienced users and experts: SIROLaser
Xtend with the up-grade-ready option and SIROLaser Advance. Both dental
lasers offer a universal treatment spectrum: effective germ reduction, minimal
invasive surgery, support during CEREC restaurations, herpes treatment and
bleaching.
they need quickly via touchscreen—and they will also find their way quickly
back to the main menu.
The use of SIROLaser Advance and SIROLaser Xtend will result in happier patients. The stress-free treatment is efficient, causes hardly any pain and
achieves stable good clinical results. Countless users and patients around the
world agree. With these diode lasers Sirona offers dentist state-of-the-art devices and product quality that stands the tests of the time; along with a complete
range of accessories, easy-to-use consumables and the expertise of the company located in Bensheim.All this means treatment with SIROLaser Advance and
SIROLaser Xtend is treatment without stress. Further information about lasers
can be found under: www.sirona.com.
Dentists are able to handle the large spectrum of applications right from the
start—even without operating instructions. Thanks to
the intelligent software and intuitive
user navigation, they can get
the application programme
SYNERON DENTAL LASERS
Amongst top ten
fastest growing
companies in Israel
Syneron Dental Lasers, inventor of the LiteTouch
and Laser-in-Handpiece technology has been
ranked 9th in the prestigious 2011 Deloitte Technology Fast 50 competition in Israel. Deloitte’s Technology Fast 50 is a global program that recognizes
the 50 fastest growing public or private technology
companies in each region. To determine the fastest
growing companies, Deloitte reviewed fiscal year
revenues over five years (2006–2010), calculated
the revenue growth percentage over five years, and
compared the growth of technology companies.
“It is an honor to be recognized as one of the top ten
fastest growing technology companies in Israel by
a respected organization such as Deloitte,” said Ira
Prigat, President and General Manager at Syneron
Dental Lasers. “Our company’s Laser-in-Handpiece innovation has played a pivotal role in transforming the way practitioners perform dental treatments today. Just as the mobile phone freed our
world from wires, so has the LiteTouch freed dentists from the use of traditional tools and bulky optic fibers, making laser dentistry completely
portable.”
A.R.C. Laser
For the first time in dental history, PDT is considered
to achieve consistently effective and predictable
outcomes in combination with a normal FOX diode
laser.
Sirona Dental Systems GmbH
Fabrikstraße 31
64625 Bensheim, Germany
contact@sirona.de
www.sirona.de
According to the manufacturer, LiteTouch is the
world’s smallest versatile Er:YAG dental laser for both
hard and soft tissue dental treatments. The unique
Laser-in-Handpiece technology incorporated in the
LiteTouch offers a fiber-free laser delivery mechanism
that mimics the feel of the turbine drill but with all the
benefits of laser. The laser energy is swiftly delivered
to the tissue, providing supreme cutting power and
precise incision for soft tissue and bone. On November
24th, Syneron Dental Lasers ranked 119th in the Deloitte Technology Fast 500 EMEA program, and 8th
among the 32 companies in the Biotech/Pharmaceuticals/Medical Device Equipment sector in Europe.
Syneron Dental Lasers
POB 223
Yokneam 20692, Isreal
dental@syneron.com
www.syneron.com
edged therapy concept based on wide-range studies and the direct cooperation with AALZ Aachen,
Germany.
A.R.C. Laser convinces with EmunDo®
An increasing number of users speak on their enthusiasm concerning the positive impact of the entirely new Photodynamic Therapy. They are reporting of the simple and gentle laser-method to treat
periodontitis.
I
The colorant EmunDo®—stimulated through the
laser—generates aggressive singulett oxygen. As
a consequence EmunDo® kills effectively all grampositive and all gram-negative bacteria particularly in the periodontal therapy. Patients which
have had problems with antibiotics and its side effects in the past, can be relieved now. EmunDo® is
not only any kind of PDT agent—it is a acknowl-
Unique selling point for your office:
– 100 % anti-bacterial impact
– even germs in tissue are accessible
– Reliable therapy concept.
A.R.C. Laser
Bessemerstraße 14
90411 Nuremberg, Germany
info@arclaser.de
www.arclaser.de
laser
4
I 49
_ 2011
[50] =>
I about the publisher _ imprint
laser
international magazine of
laser dentistry
Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de
Chief Editorial Manager
Norbert Gutknecht
ngutknecht@ukaachen.de
Co-Editors-in-Chief
Samir Nammour
Jean Paul Rocca
Managing Editors
Georg Bach
Leon Vanweersch
Division Editors
Matthias Frenzen
European Division
George Romanos
North America Division
Carlos de Paula Eduardo
South America Division
Senior Editors
Aldo Brugneira Junior
Yoshimitsu Abiko
Lynn Powell
John Featherstone
Adam Stabholz
Jan Tuner
Anton Sculean
Editorial Board
Marcia Martins Marques, Leonardo Silberman,
Emina Ibrahimi, Igor Cernavin, Daniel Heysselaer,
Roeland de Moor, Julia Kamenova, T. Dostalova,
Christliebe Pasini, Peter Steen Hansen, Aisha Sultan, Ahmed A Hassan, Marita Luomanen, Patrick
Maher, Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk, Mukul Jain, Reza Fekrazad, Sharonit Sahar-Helft, Lajos Gaspar, Paolo Vescovi, Marina Vitale, Carlo
Fornaini, Kenji Yoshida, Hideaki Suda, Ki-Suk Kim,
Liang Ling Seow, Shaymant Singh Makhan, Enrique Trevino, Ahmed Kabir, Blanca de Grande, José
Correia de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep Arnabat,
Ahmed Abdullah, Boris Gaspirc, Peter Fahlstedt,
Claes Larsson, Michel Vock, Hsin-Cheng Liu, Sajee
Sattayut, Ferda Tasar, Sevil Gurgan, Cem Sener,
Christopher Mercer, Valentin Preve, Ali Obeidi,
Anna-Maria Yannikou, Suchetan Pradhan, Ryan
Seto, Joyce Fong, Ingmar Ingenegeren, Peter Kleemann, Iris Brader, Masoud Mojahedi, Gerd Volland, Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz, Herbert
Deppe, Friedrich Lampert, Jörg Meister, Rene
Franzen, Andreas Braun, Sabine Sennhenn-Kirchner, Siegfried Jänicke, Olaf Oberhofer, Thorsten
Kleinert
Toni Zeinoun
Middle East & Africa Division
Loh Hong Sai
Asia & Pacific Division
Executive Producer
Gernot Meyer
meyer@oemus-media.de
Designer
Sarah Fuhrmann
s.fuhrmann@oemus-media.de
Customer Service
Marius Mezger
m.mezger@oemus-media.de
Editorial Office
Dajana Mischke
d.mischke@oemus-media.de
Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com
Printed by
Messedruck Leipzig GmbH
An der Hebemärchte 6
04316 Leipzig, Germany
laser
international magazine of laser dentistry
is published in cooperation with the World Federation for Laser Dentistry (WFLD).
WFLD President
University of Aachen Medical Faculty
Clinic of Conservative Dentistry
Pauwelsstr. 30
52074 Aachen, Germany
Tel.: +49 241 808964
Fax: +49 241 803389644
ngutknecht@ukaachen.de
www.wfld-org.info
Copyright Regulations
_laser international magazine of laser dentistry is published by Oemus Media AG and will appear in 2011 with one issue every quarter. The
magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.
50 I laser
4_ 2011
[51] =>
laser
international magazine of
"
laser dentistry
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Signature
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Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de
[52] =>
The Dual Wavelength Waterlase iPlus
Advancing Laser Technology to Its Ultimate
NCOMPARABLe
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• No Pain, Therefore No Shot Necessary
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NTUiTiVe
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• Cutting Speed that Surpasses the High
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& Short Pulse for 600 mJ of Laser Energy
• Patented Laser Technology
LAse 940nm
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)
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