laser international No. 3, 2012

Cover / Editorial / Content / Effect of diode laser on enamel fissure system / Laser treatment of dentine hypersensitivity - An overview III / Diode lasers: The soft-tissue handpiece / Hygiene requirements for dental laser fibers / The use of the LiteTouch Er:YAG laser in peri-implantitis treatment / Up-to-date vestibuloplasty at the age of implant dentistry / Quantum Square Pulse Er:YAG lasers in clinical practice / Manufacturer News / 100th Annual FDI congress celebrated in Hong Kong / Study club honored for elevating educational standards in the New York City area / Barcelona meets laser specialists from more than 45 countries / German distributor files against dental laser manufacturer / News / Meetings / Imprint / Subscription

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issn 2193-4665

Vol. 4 • Issue 3/2012

laser
international magazine of

laser dentistry

3

2012

| research
Effect of diode laser on enamel fissure system:
Morphological and microhardness analysis

| case report
Up-to-date vestibuloplasty at the age of implant
dentistry

| industry report
Quantum Square Pulse Er:YAG lasers in clinical
practice

[2] =>

FOX
BREAKTHROUGH
in

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Implantology

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editorial

Dear colleagues,
dear friends,

I

Prof Dr Norbert Gutknecht

_Sometimes we wonder about the content of discussions about the use of lasers between
universities and private offices. For decades we have had to listen to arguments such as “if you
use a laser you will carbonize the enamel” or “you will overheat and necrotize the soft tissue
or pulpal tissue” or “you will destroy root canal structures” or “you will produce micro cracks on
root surfaces” and so on. All of these arguments have been investigated seriously and for many
years we have gained a lot of evidence on the beneficial effects of lasers used on different types
of tissues.
In-vitro studies, clinical studies and scientific case reports have been presented on various
conferences, seminars and congresses on all of the five continents. And still there is an insufficiently reflected resistance against this technology. I can understand that a certain kind of
pride is hard to overcome and admitting that, although one might be a good dentist, one has
no idea of an appropriate use of lasers in dentistry must be equally difficult. Another reason
could be the fear of not having enough background information on physics and biophysics to
understand how lasers are operated on the tissues found in the oral cavity.
It is actually a shame that we are ready to see an ophthalmologist who uses a laser to improve
our sight knowing that we have only two eyes, none of which can be replaced if this laser treatment fails—still we don’t believe that there should be a possibility to treat other kinds of tissues
in the same way or an equally eloquent way as we believe an ophthalmologist treats our eye.
I am proud of all colleagues around the world who have taken the challenge to submit themselves to an education and are now successfully using lasers in their various dental treatments.
You all can be proud to use this technology—and you should be proud by telling other, non-laser
users, about your knowledge and success.

Multiple wavelengths greetings,

Prof Dr Norbert Gutknecht

laser
3
I 03
_ 2012

[4] =>

I content _ laser

page 16

41

I editorial
03

page 22

Dear colleagues, dear friends

I meetings

I research
Effect of diode laser on enamel fissure system

42

| Ali M Saafan

16
20
22

Barcelona meets laser specialists from more than
45 countries
| Javier de Pison

I overview
12

Study club honored for elevating educational standards
in the New York City area
| Dental Tribune America

| Prof Dr Norbert Gutknecht

06

page 34

Laser treatment of dentine hypersensitivity

49

International events 2012

| Dr Ute Botzenhart et al.

I interview

Diode lasers: The soft-tissue handpiece

44

| Dr Fay Goldstep

German distributor files against dental laser
manufacturer

Hygiene requirements for dental laser fibers

| Georg Isbaner

| Hans-Joachim Koort

I news

The use of the LiteTouch Er:YAG laser
in peri-implantitis treatment

38

Manufacturer News

| Prof Tzi Kang Peng

46

News

I case report

I about the publisher

30

50

Up-to-date vestibuloplasty at the age of
implant dentistry

| imprint

| Dr Darius Moghtader

I industry report
34

Quantum Square Pulse Er:YAG lasers in
clinical practice
| Evgeniy Mironov
Cover image courtesy of A.R.C. Laser GmbH,
www.arclaser.de
Original Background: ©Kundra
Artwork by Sarah Fuhrmann, OEMUS MEDIA AG.

I education
40

100th Annual FDI congress celebrated in Hong Kong
| Dental Tribune International

page 42

04 I laser
3_ 2012

page 44

page 47

[5] =>

[6] =>

I research

Effect of diode laser on
enamel fissure system
Morphological and microhardness analysis
Authors_Ali M. Saafan, Samah S. Mehani & Nermin M. Yussif, Egypt

_Introduction

Wear and marginal loss are still the most prominent drawbacks of conventional sealing materials,
which lead to exposure of the previously sealed areas.5 Hence, failure to achieve a satisfactory bond
using fissure sealants may be due to the lack of tag
formation following poor etching of the prismless
structural lines of the fissure system.6

Owing to all of these drawbacks of pit and fissure
sealants, attention has been directed to laser and its
positive effect on the enamel surface. A wide range
of lasers (argon, CO2, Nd:YAG and Er:YAG) have been
used to increase the resistance of the tooth structure to caries. It has been demonstrated that laser
can alter the permeability and the crystalline structure significantly, promoting the enamel’s resistance to demineralisation.7 The phenomenon responsible for this effect is related to the chemical
and physical changes in the enamel induced by
laser. The irradiated enamel surface is subjected to
water loss between 80–120°C, to decomposition of
the small quantity of organic substance at 350°C, to
initial loss of carbonate hydroxyapatite between
400–600°C, and to enamel melting at more than
800–1,000°C. The high temperatures reached in the
superficial layers of the irradiated areas of the tooth
cause melting of the enamel, which then recrystallises, forming hydroxyapatite crystals larger than
the initial ones.8 Tagomori et al. found that the irradiated enamel surfaces show higher surface roughness in comparison with the untreated ones.9 Marquez et al. observed that the lased surface usually

Fig. 1

Fig. 2

Although a declining incidence of dental caries
has been observed worldwide, it is still the most
prevalent disease in childhood and adolescence.1
Several methods of prevention have sought to reduce caries prevalence,2 such as fluoride application, sealants, preventive resin restorations and antibacterial therapy, which can reverse the caries
process.3 Nowadays, sealing materials are gaining
acceptance in the scientific community, although
they still present some disadvantages: contamination of the operation field and contraction during
polymerisation. These issues have led researchers
to investigate alternative solutions in order to overcome these limits.4

Fig. 1_An ESEM image of group two
2 shows the rods (R) and interrod
regions (I) at X3,000x magnification.
Interrod regions (I) are deprived
deviate from the normal crystalline
arrangement.
Fig. 2_ An ESEM image of group four
4 shows melting and resolidification
of the lateral walls of the fissure and
enamel crystals (arrows) at 3,000 x
magnification.

06 I laser
3_ 2012

[7] =>

research

Table 1_Grouping.

Group

1
(control)

Treatment

None

Artificial caries

diode Laser

diode Laser and
artificial caries

exhibits three layers (from the deepest layer): unaltered enamel crystals,fused crystals and hexagonal
hydroxyapatite columns, voids and microcracks on
the external surface.10
Among the wide range of lasers now used in
dentistry, diode lasers offer many advantages that
make them quite popular among dentists. Their low
cost, small size and ease of use in the oral cavity owing to fibre delivery are important features that
favour their use in clinical practice and encourage
new studies.11 Previous studies using diode lasers
have demonstrated that the enamel surface of the
deciduous teeth underwent melting and resolidification. These changes suggest an increase in the resistance of the enamel to acids, thus possibly playing an important role in the prevention of dental
caries.12

The aim of this article thus is the evaluation of
the microhardness and morphological changes
that occur in the fissure system of human dental
enamel after diode laser treatment in order to examine its sealing and anti-cariogenic effect.

_Material and method
Sample preparation
Forty disease-free recently extracted permanent
molars and premolars were used in the experiment.
Extraction had been done for orthodontic treatment. Using a diamond low-speed disc, the teeth
were sectioned into two halves buccolingually,
which were then used in four different groups
(Table 1). Each group contained ten teeth. Group 1
(control group) consisted of teeth with normal
enamel. The teeth in group 2 were immersed in arAD

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[8] =>

I research
Fig. 3_ An ESEM image of group
three 3 shows fusion of the lateral
walls of the fissure, leaving retaining
the depth of the fissure preserved
(black arrow), as well as the rod (R)
and interrod regions (I) at 800 x
magnification.
Fig. 4_ An ESEM image of group
three 3 shows an accumulation of
large crystals with differentof various
shapes and sizes (arrows) at 3,000 x
magnification.

Fig. 3

Fig. 4

tificial caries media. Group 3 was subjected to diode
laser irradiation. Lastly, group 4 was exposed to
diode laser irradiation and artificial caries media.
The specimens were kept in distilled water prior to
and after examination.13

Environmental Scanning Electron Microscope
analysis
The specimens were examined occlusally and
proximally using an ESEM (Inspect S ESEM, FEI). In
group 3, ESEM was very useful in examining the
specimens before and after in order to confirm the
results.

Enamel-surface treatment
In groups 3 and 4, enamel occlusal depressions
were irradiated using diode laser irradiation of
980 nm, 2 W for 15 seconds, in contact mode
(Quanta System) and an optic fibre transmission
system. The fibre tip was positioned perpendicular
to the pit and fissure areas. The irradiation was performed by hand, scanning the enamel surface with
a uniform motion.14
Measurement of thermal changes
Surface and intra-pulpal temperature changes
were measured using a thermocouple tester (Fluke
52) in order to evaluate the changes during irradiation.
Artificial caries
The specimens of groups 2 and 4 were individually immersed in an artificial caries media (a media
of 50 mmol lactic acid in 6 % hydroxyethyl cellulose) with a pH of 4.5 for seven days.15 The specimens were then washed and kept in distilled water.
Fig. 5_ An ESEM image of group
three 3 shows an occlusal view of the
sealed enamel fissure (black arrow)
and with molten globules were
detected near the irradiated areas
(white arrow) at 800 x
magnification.

Fig. 5

08 I laser
3_ 2012

Microhardness measurement
Surface hardness was measured using Vickers
microhardness tester (HMV-2 Shimadzu). Measurement was done proximally at the depth of the
fissures and at their lateral sides to determine the
effect. Indentations were made with the long axis
of the Knoop diamond perpendicular to the inner
enamel surface laterally and at the depth of the fissures. Each group underwent a load of 19.61 N, applied for 20 seconds, in order to evaluate the variations in surface hardness eventually caused by laser
treatment in comparison with unlased enamel. The
hardness values were computed automatically.
Statistical analysis
The data was collected and analysed using the
ANOVA test. The statistical results were processed
by SPSS software (version 17.0, SPSS).

_Results
Environmental Scanning Electron Microscope
analysis
Total destruction and loss of surface topography, such as the disappearance of the normal elevations and depressions, were clinically observed in
the specimens of group 2. Structurally, the surface
showed a feather-like or scaly appearance. Few
enamel crystalline aggregations reprecipitated on
the decayed surface, indicating the demineralisation of enamel. Rod and inter-rod regions due to
loss of the surface rodless enamel were detected at
the wall of the fissures. The inter-rod regions appeared as voids that deviated from the normal crystalline arrangement as seen in Figure 1. Contrary to

[9] =>

research

those of group 2, the specimens of group 4 showed
a preserved surface structure and morphology of
the lased areas. The grooves appeared pitted and intact, while the nearby enamel showed a typical keyhole appearance (rod ends) owing to the loss of the
rodless enamel. The lateral walls of the pits exhibited an irregular surface owing to the presence of
areas of melted enamel intermingled with carious
enamel (Fig. 2). The boundaries between lased and
unlased areas were distinct, as the intact lased area
could easily be distinguished from the surrounding
damaged unlased area.
Morphologically, laser irradiation induced localised enamel fusion of the lateral walls of the fissures in group 3, resulting in a sealing-like effect
(Fig. 3). Surface pitting was detected occlusally, indicating the disappearance of the continuous fissures. The lateral walls of these pits revealed a
melted homogeneous enamel surface that was
masked by multiple enamel granules. Elimination
of the defects was accomplished by the accumulation of crystals, which varied in shape and size,
forming amorphous and heterogeneous tissue and
interrupting the prismatic regions (Fig. 4). Figure 5
shows molten droplets found near the irradiated
areas. Occasionally, minimal surface destruction
was detected.
Measurement of thermal changes
The measurements recorded only a 1°C elevation in the intra-pulpal temperature and a 67°C
elevation in the surface temperature during lasing.
A rapid decay of the gained degrees occurred once
lasing had been stopped and the temperature returned to normal in less than one minute.
Statistical results
Statistical analysis of the data was done using
the ANOVA test. The results were presented as
mean ± standard deviation, and a p-value of less
than 0.05 was considered statistically significant.
The analysis determined that both laser and artificial caries treatments had had statistically significant effects on the enamel microhardness. The degree of demineralisation and the ability of the
specimens in each group to resist caries were
translated into changes in the microhardness
measurements. Table 2 shows the mean Vickers
hardness values for the four groups. When comparing all groups to the control group, a highly significant difference was detected (p = 0.0001). A
post hoc test was done to evaluate the differences
among groups regarding the measured normal
enamel scores. Group 3 (laser) showed a highly significant difference (p = 0.0001). In most of the
cases, surface hardness significantly decreased after artificial caries immersion. The contrary was

Group

Mean ± standard deviation S.D.

566.3

79.250 ± 33.9894*

1577.40 ± 272.517*

191.890 ± 22.7996

± 197.265*

found for group 4 (p > 0.05), which means that the
positive effect was due to laser only (Table 2).

Table 2_Vickers microhardness
tests results.

_Discussion and conclusion

*Indicatesing a statistical significant
valuece.

Caries is a dynamic process consisting of numerous episodes of the loss and gain of minerals
(demineralisation and remineralisation) that occur
on the enamel surface.16 Wavelengths in the red and
near infra-red regions are poorly absorbed by dental minerals, but are optimally transmitted and
scattered through sound enamel.17, 18 However, in
vivo and in vitro studies have described the beneficial effects of lasers in the former spectrum, such as
the Nd:YAG laser (1,064 nm) in caries prevention,
but they have not been able to describe the cause or
the mechanism.19 Owing to their low absorption coefficient in hard tissue, neodymium lasers are commonly used with a photosensitiser, which increases
the absorption of the laser beam at the enamel surface.20 Diode lasers were used according to the
same protocol, but with different parameters
(810 nm, 100 mW/cm2, 30 mW, 90 seconds, continuous wave).21
This study was carried out to investigate the
sealing ability of the diode laser (980 nm) by measuring changes in the surface microhardness and
detecting the morphological changes using ESEM
analysis. ESEM has been established as a useful
means of non-destructive microscopic examination of the surface areas of naturally moist oral hard
tissue, without the need for a complex preparation
and drying process. Another advantage is the
avoidance of preparation artefacts. The ESEM results revealed a significant difference between
lased and unlased tissue.
Among the four groups, the sealing-like effect of
the diode laser in the pit and fissure system and an
increased surface hardness were found to be the
highest in group 3. Laser treatment produced obvious changes in the orientation and shape of the
enamel prisms. The resulting homogenous and heterogeneous apatite crystals, different in shape and
larger in size when compared with the untreated
enamel, might have been due to enamel melting

laser
3
I 09
_ 2012

[10] =>

I research
and resolidification, as well as a loss of prismatic
structure, which corroborates the results of Mercer
et al.22 The granules observed in group 3, according
to Zuerlein et al.23 and Fried et al.,24 can be explained
by the release of the inter-rod and the intercrystalline substance (mainly water and carbonate)
near the areas directly exposed to the laser action.
Contrary to the results of Bedini, who used
Nd:YAG laser, minimal microcracks and surface
roughness were detected with comparable parameters but with a different application mode for the
laser, from pulsed to continuous wave.25 According
to Bedini, the use of the Nd:YAG laser with low parameters for caries prevention and high parameters for conservative dentistry is recommended.25
Simulating the clinical condition and using the
free-hand technique (continuous wave mode) assisted the reduction of heat accumulation.26
Romanos found that the optical penetration
depth of a diode laser at a wavelength of 980 nm
was smaller than the penetration depth at
1,064 nm and greater than that of the CO2 laser.27
For a better understanding of the penetration
depth, an absorption spectrum was taken of water.
The absorption in water was markedly higher with
a diode laser at 980 nm (0.68 cm-1) than at 810 nm
(0.12 cm-1), or even using an Nd:YAG laser at
1,064 nm (0.26 cm-1). The smaller penetration
depth results in an increased energy deposition in
the upper tissue layers.28
The low absorption coefficient of the diode laser
wavelength in enamel was of great benefit, as it
caused rapid elevation of the surface energy during exposure and rapid decay in temperature once
lasing had been stopped. There was no adverse effect on the dental pulp. According to Sulieman et
al., the increase in the pulp chamber temperature
with a diode laser used at 1 to 2 W is below the critical temperature increase of 5.5°C, which is regarded as the threshold value. In order to prevent
irreversible pulp damage, this value should not be
exceeded.29
In the present study, the maximum temperature
elevation on the enamel surface was 67°C, with an
intra-pulpal elevation of only 1°C. Previous reports
have demonstrated the bactericidal effects of
980 nm wavelength diode lasers. The surface temperature detected thus provides sterilisation of the
fissures, destroying Streptococcus bacteria, the
causative agent of dental caries, which die at
60°C.30 Regardless of the parameters that were
used, Souza et al.12 found smooth surface melting
and resolidification at 1 W power for six seconds.
These parameters are roughly half the size of the

10 I laser
3_ 2012

parameters used in this study. So far, no data has
been published that describes the effect of the
980 nm high-power diode laser on enamel microhardness.31
Massive destruction of the enamel surface and
the lowest surface hardness were found in group 2.
Contrary to group 2, the lased samples in group 4
appeared to retain the normal enamel architecture
in spite of the pH of the artificial caries media being below 4.5. The appearance of the keyholes in
group 4 indicated a loss of prismatic structure, corroborating the results of Mercer and Anderson.22
Group 4 also exhibited irregular lateral walls of the
pits, possibly owing to the presence of areas of
melted enamel intermingled with carious enamel.
In agreement with our results, Fox et al.32 found an
increase in the acid resistance of irradiated enamel,
proving the potential of laser in preventing caries.
We conclude that a diode laser can simulate the
sealing effect of conventional methods to a limited
extend by inducing enamel fusion with no harmful
effects on the dental pulp._
Editorial note: A list of references is available from the
publisher.

_contact

laser

Ali M. Saafan
Associate professor
Dental Laser Application Department
National Institute Oof Laser Enhanced Sciences
Cairo University, Giza, Egypt.
Tel.: +20 0100 516 2873
alisaafan@yahoo.com
Samah S. Mehani
Associate professor
Oral Biology Department
Faculty of Oral and Dental Medicine
Cairo University, Cairo, Egypt.
Tel.: +20 0100 114 3525
hemasls@hotmail.comhemasls@hotmail.com
Nermin M. Yussif
BDCs
Dental Laser Application Department
National Institute of Laser Enhanced Sciences
Cairo University, Giza, Egypt.
Tel.: +20 011 827 1929
nermin.yussif@yahoo.com

[11] =>

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[12] =>

I overview

Laser treatment of
dentine hypersensitivity
An overview III
Authors_Dr Ute Botzenhart, Dr Andreas Braun & Prof Matthias Frentzen, Germany

_Introduction
More than two decades ago, laser applications in
the treatment of dentine hypersensitivity were introduced to dentistry. Many clinical studies using different laser types have been published since. This
overview summarises the basic and clinical aspects,
including treatment protocols.

Fig. 1_Hypersensitive dentine with
SnF2 gel layer.

In the first issue of laser, conventional approaches
towards the treatment of dentine hypersensitivity
were discussed with regard to a set of criteria for a
successful treatment as proposed by L. I. Grossman
(1935). The authors came to the conclusion that, so
far, no conventional therapy has been able to meet all
the criteria. The authors then moved on to studies on
laser treatment. Studies on GaAIAs laser and He-Ne
lasers were introduced and analysed. Part I of this article was finished by a comparison between He-Ne
lasers and Nd:YAG lasers. Part II in this year’s second
issue of laser continued with studies on Nd:YAG-laser
treatment, Er:YAG lasers. The third and last part of this
extensive study gives insight into the workings of CO2
lasers and sums up important aspects of laser treat-

ment of dentine hypersensitivity in a final conclusion
on laser treatment of dentine hypersensitivity.

_Middle-output power lasers: CO2 laser
The CO2 laser with a wavelength of 10.6 µm also belongs to the group of the middle-output power lasers.
It is easily absorbed by tissues with a high water content, presenting superficial penetration (Romano et
al. 2011), none penetrating beyond 0.1 mm (Silberman
et al. 1994). Its effect is based upon the closure or narrowing of the dentinal tubules and a reduction in dentine permeability (Gholami et al. 2011; Romano et al.
2011; Moritz et al. 2006; Kimura et al. 2000b; Zhang et
al. 1998; Pashley et al. 1992; Bonin et al. 1991). Most
effects are explained by laser dehydration, protein destruction and carbonate evaporation (Lin et al.
2000a).
Moritz et al. (1995, 1996, 1998, 2006) described
two ways to apply the CO2 laser to the therapy of dentine hypersensitivity: the direct method, that is CO2
laser application alone (Moritz et al. 2006); and the indirect method, that is the combination of laser application and fluoridation (Moritz et al. 1995, 1996,
1998). The output power for both methods is approximately 0.5 to 1 W (cw). Irradiation time is approximately 0.5 to five seconds, with a repetition rate of
five to ten pulses (Moritz et al. 2006).
The direct method
With the direct method, the use of the CO2 laser at
moderate energy density, the sealing of the dentinal
tubules in terms of a narrowing or reduction in their
permeability can be achieved (Lan et al. 1999). Silberman et al. (1994) hypothesised that CO2 lasers enhance the retention of the smear layer, which is partly

Fig. 1

12 I laser
3_ 2012

[13] =>

overview

Fig. 2_CO2-Laser application
throught the SnF2 gel layer.

Fig. 2

responsible for the successful desensitisation of hypersensitive roots. Like other wavelengths, the CO2
laser light can also cause a desiccation of dentine and
a temporary clinical alleviation of symptoms (Bonin
et al. 1991). With an application of 0.3 W for 0.1 seconds, the sealing depth is about 2 to 8 µm (Fayad et al.
1996). As for the in vivo application of CO2 laser light
in dogs and monkeys, no thermal damage to pulpal
tissue could be detected at an output power of 3 W
and in cw mode for two seconds (Kimura et al. 1998),
but morphologically, parameters above 1 W (cw, noncontact mode, without cooling) led to carbonisation
and cracks in human dentine, making it unfeasible for
clinical procedures (Romano et al. 2011). González et
al. (1999) too observed that CO2 laser application to
human dentine at 2 W and 10 J for 0.2 seconds and 25
pulses led to varying effects in SEM examinations, for
instance charring, cratering, poring, fissuring, fracturing, cracking and localised melting processes or
complete disorganisation of the dentinal structure
without sealed dentinal tubules. In several studies,
melted areas, probably composed of melted hydroxyapatite were detected inside or around the crater
formation after CO2 laser application. This is due to the
high temperature gradient that occurs at the surface
(Romano et al. 2011; Lin et al. 2000a). PIXE resulted in
a decrease in calcium and an increase in the phosphorous content of the dentinal surface treated,
compared with controls, indicating changes in the
hydroxyapatite crystal structure (González et al.
1999).
Side-effects
In a study by Zhang et al. (1998), the efficiency of
CO2 lasers in the therapy of dentine hypersensitivity in
vivo and potentially damaging thermal effects at the
dental surface were evaluated over a period of three
months. Dentine hypersensitivity was determined by
thermal stimuli with cold air and VAS score. Immediately after laser application and after one week, two
weeks, one month and three months, hypersensitivity
was re-evaluated. Laser light was applied to the affected area with an output power of 1 W in cw mode
for five to ten seconds and non-contact mode at a
right angle with water-cooling. Each application of

0.5 seconds was followed by a break of five seconds.
The procedure was repeated as long as the patient was
free of pain. The application time for each tooth was
five to ten seconds overall. Patients who had not been
free of pain after one week were retreated under the
same parameters (Zhang et al. 1998). After three
months, 50 % of the treated tooth necks were no longer
hypersensitive. An interesting phenomenon is that all
teeth were free of pain directly after the laser application, but hypersensitivity returned already after one
week in nearly 50 % of the cases (Zhang et al. 1998). The
pain relief directly after laser application can be explained by the anaesthetic effect of laser or the obturation of tubules by denatured proteins from the dentinal fluid, but there are no reports of nerve analgesia as
a result of CO2 laser application (Zhang et al. 1998).
One possible explanation for the recurrence of
symptoms is that the CO2 laser application did not
close the dentinal tubules completely and/or durably
(Zhang et al. 1998) or that the melted dentinal surface
was abraded, for example by tooth brushing (Pashley
et al. 1992). In the study, as described above, the parameters chosen did not damage the pulp. All of the
teeth were sensitive to electrical stimuli. The study
demonstrates that the CO2 laser, if used with adequate
water-cooling, can be helpful for the therapy of dentine hypersensitivity without thermal damage to the
pulp. Coleton (1998) reported a success rate of more
than 60 % using the CO2 laser for the reduction of
post-operative sensitivity of root surfaces after periodontal surgery. He did not observe any side-effects.
The indirect method
The indirect method is based upon the idea of combining the advantages of laser and fluoride therapy,
thereby achieving as durable a result as possible. First,
fluoride is applied onto the cleaned tooth-neck area.
Then laser light is applied through this gel layer. By
combining these two methods, the integration of fluoride into the dentine surface should be enhanced
(Figs. 1–3).
Moritz et al. (1996) analysed the efficiency of this
combined therapy compared with fluoride applica-

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[14] =>

I overview
Fig. 3_Sealed surface after
CO2–Laser irradiation
(indirect methode).

Fig. 3

tion alone, over a period of twelve weeks. Before laser
application, a layer of SnF2 of 10 µm thickness was applied, and then the dentine was irrigated at an output
power of 0.5 W in cw mode for five seconds followed
by a break of 20 seconds and subsequently a repeated
laser application for five seconds (Moritz et al. 1996).
This procedure was repeated until each patient had
undergone laser application for 30 seconds. Patients
who were not free of pain after the first recall were retreated under the same parameters. The control
group was treated with SnF2 exclusively.
After one week, two weeks, four weeks, six weeks
and three months, dentine hypersensitivity was
measured again. In combination with VAS, the subjective patient response concerning pain response to
specific stimuli was used as an indicator, for example
to contact, cold, heat, sweetness and acid. One week
after the laser application, all of the patients in the
laser group reported an improvement in symptoms
and nearly 60 % were free of pain. After two weeks,
87.5 % of the laser group were free of pain, after four,
six and twelve weeks, 94.5 % were free of pain. The results of the control group differed from those of the
laser group. After one week, a mild improvement was
detected, and there was no further improvement in
the follow-up periods. Nearly all patients reported a
reappearance of the symptoms after fluoridation was
stopped. The results concerning fluoride application
corroborate the findings of Saxer et al. (1974).
Side-effects
Here, SnF2 was only able to achieve limited and
short-term success. In order to check possible thermal
effects of laser light immediately before and after
laser application and after one week, laser Doppler
measurements of the pulpal blood flow of irrigated
teeth were elevated. No laser-induced effect to the

14 I laser
3_ 2012

pulpal blood flow was detected (Moritz et al. 1996). Six
weeks after the combined application of laser light
and fluoridation, SnF2 was still detectable in the surface. Therefore, it can be assumed that the combined
application of the CO2 laser and fluoridation leads to
permanent integration of fluoride into the dentine
surface. With a few exceptions, patients had no pain
during the therapy. Laser application was accepted
without any problems (Moritz et al. 1996).
Although the combined therapy mentioned above
is noted to be more effective and durable compared
with the GaAlAs diode (Gerschman et al. 1994), He-Ne
or Nd:YAG laser (Gelsky et al. 1993), there was no evidence of statistical clinical superiority of the CO2 laser
in the comparisons by Ipci at al. (2009). They examined
how the CO2 (1 W, cw, ten seconds) and Er:YAG (30 Hz,
60 mJ, ten seconds) lasers were used with and without fluoride. A clinical improvement in dentine hypersensitivity was achieved in all of the cases (Ipci et
al. 2009).
Combination with bioactive glass
Another promising therapy method for dentine
hypersensitivity is the combined use of laser light and
bioactive glass (bioglass) paste. The application of hydroxyapatite, the principal inorganic constituent of
the tooth, also promises rapid relief from clinical pain
by complete obliteration of dentinal tubules in hypersensitive teeth (Shetty et al. 2010). Bioglass and glassceramics resemble human dentinal hard tissue to a
large extent and are characterised by high biocompatibility (Bakry et al. 2011a; Tirapelli et al. 2010; Kuo
et al. 2007). Melting the bioglass paste and its resolidification promise a homogeneous blockage of dentinal tubules and deep precipitates in the dentinal
tubules, offering a prolonged therapeutic duration
(Lee et al. 2005a).

[15] =>

overview

From various in vitro investigations (SEM and FTIR
analysis), it was found that DP-bioglass paste could
produce a new carbonate-apatite formation at the
dentinal surface as a thin protective layer and that it
was also able to induce a hydroxyl-carbonate apatite
deposition in open tubules (Mitchell et al. 2011;
Tirapelli et al. 2010) with a sealing depth of up to
60 µm (Kuo et al. 2007). In a study by Mitchell et al.
(2011), a bioglass paste with a particle size range of
less than 1 µm to approximately 20 µm mixed with
glycerol as a carrier was more effective in the immediate reduction in fluid conductance with resistance
to acidic solutions and tooth brushing, compared
with non-bioactive particles (Mitchell et al. 2011).
The combined use of the CO2 laser and bioglass actually melted DP-bioglass paste and reached a sealing
depth of 10 µm (Lee et al. 2005a). A mixture of bioglass
paste with 50 % phosphoric acid and CO2 laser irradiation (0.5 W, 0.12 ms, 100 Hz, non-contact mode, one
minute, energy density 136 J/cm2) can modify the surficial layer, creating a more compact layer, rich in calcium phosphate, with a thickness of 5 µm, higher mechanical properties and a penetration depth of 3 µm
in the dentinal tubules (Bakry et al. 2011b).
No clinical investigations thus far
Compared with bioglass application alone, it is assumed that CO2 laser irradiation could improve the
mechanical organisation of the surficial precipitates
(Bakry et al. 2011b).
Clinical investigations into the therapeutic effect
of such a combined treatment are not available. One
of the principal problems still is the very high temperature rise that accompanies the production of glazes
with this procedure, and makes clinical application
currently impossible. The temperature must be over
900 °C to form a melting glass and an even higher rise
in temperature is needed to melt apatite to fuse these
two components together (Lin et al. 2000b). If the
glaze point could be reduced, this procedure would be
conceivable as a possible treatment (Lee et al. 2005b).
Maybe in the future, it will be possible to fuse a bioglass with a low melting point to enamel and/or dentine (Lin et al. 2000a).
Recently, Romano et al. (2011) analysed the morphological and temperature changes after CO2 laser
irradiation with different energy parameters (0.5 W,
1 W, 1.5 W, cw, six times for five seconds with intervals of ten seconds between for cooling, non-contact
mode, sweeping movement) with and without calcium-hydroxide paste applied prior to laser treatment. Statistically significant differences were detected between laser irradiation and combined treatment, with more satisfactory closure of tubules and
mineral deposition on the dentinal surface after com-

bined treatment. It is known that calcium-hydroxide
paste can promote the tissue-repair process (Olsson
et al. 2006) and it promises an interaction between
calcium-hydroxide paste and dentine associated with
the morphological changes resulting from the thermal effect of the CO2 laser on dentine, possibly also resulting in the reduction of clinical symptoms of pain
(Romano et al. 2011). With the protocols used in this
study, a change of temperature in the dental pulp of 1
to 5 °C was noted, but parameters above 1 W led to
carbonisation and cracks, a characteristic result of
high temperature, making it unfeasible for clinical
procedures (Romano et al. 2011). However, in this
study, with parameters of 0.5 W in cw mode for five
seconds, the temperature rise was less than 5 °C,
which is assumed to be safe for clinical use (Romano
et al. 2011). Nevertheless, further studies should be
undertaken before clinical application. Table 1* gives
an overview of the clinical studies conducted on the
application of laser for the therapy of dentine hypersensitivity thus far.

_Conclusion
There are many studies on the application of laser
for the clinical therapy of hypersensitive tooth necks.
Current evidence is based upon a slight superiority of
laser application compared with conventional topical
applications (He et al. 2011). In vitro experiments have
not yet been able to clarify the mechanisms of the different application modes sufficiently. Besides analgesic effects, the modification of the dentinal surface
in terms of a reduction in dentine permeability is in
the foreground (Fig. 1). The latter mechanism could be
enhanced by the combination of other techniques, for
example the additional application of fluoride. In order to achieve optimal monitoring of the patients, the
user should be familiar with the different mechanisms that the specific laser and the chosen parameters produce._
Editorial note: *Table 1 and the list of references are
available from the publisher.

_contact

laser

Dr Ute Botzenhart
Department of Orthodontics
Centre of Dentistry and Oral Health
Ernst Moritz Arndt University of Greifswald
Germany
Dr Andreas Braun/Prof Matthias Frentzen
Department of Periodontology, Operative and
Preventive Dentistry
University of Bonn
Germany

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[16] =>

I overview

Diode lasers:
The soft-tissue handpiece
Authors_Dr Fay Goldstep & Dr George Freedman, Canada

_Introduction
While dental lasers have been commercially
available for several decades, and their popularity among patients is unparalleled, the dental profession has taken to this treatment
modality rather slowly. Lasers have been thoroughly documented in the dental literature.
They are an exciting technology, widely used in
medicine, kind to tissue, and excellent for
healing.
So why have they not been more widely
embraced by the practising dentist? There
was a perception in the profession that
somehow the dental laser was not useful,
too complicated, or too expensive. These concerns have changed with the arrival of the diode
laser on the dental scene.
Fig. 1_ Picasso diode laser.

There is now a convergence of documented scientific evidence, ease of use and greater affordability that makes the diode laser a necessity for every
dental practice.

_The science in brief
LASER is an acronym for “light amplification by
stimulated emission of radiation”. Lasers are com-

monly named for the substance that is stimulated to
produce the coherent light beam. In the diode laser,
this substance is a semiconductor (a class of materials that is the foundation of modern electronics,
including computers, telephones and radios).
This innovative technology has produced a laser
that is compact and far lower in cost than earlier
versions. Much of the research has focused on the
810 nm diode laser. This wavelength is ideally suited
for soft-tissue procedures since it is highly absorbed by haemoglobin and melanin. This gives the
diode laser the ability to cut precisely, coagulate,
ablate or vaporise the target soft tissue.1
Treatment with the 810 nm diode laser (Picasso,
AMD Lasers; Fig. 1) has been shown to have a significant long-term bactericidal effect in periodontal pockets. Aggregatibacter actinomycetemcomitans, an invasive pathogen associated with the development of periodontal disease and generally
quite difficult to eliminate, responds well to laser
treatment.2, 3
Scaling and root planing outcomes are enhanced when diode laser therapy is added to the
dental armamentarium. The patient is typically
more comfortable during and after treatment, and
gingival healing is faster and more stable.4, 5

_Ease of use

Fig. 2

Figs. 2–6_Removal of gingival tissue
covering the tooth. (Photographs
courtesy of Dr Phil Hudson)

16 I laser
3_ 2012

Fig. 4

Fig. 3

Early adopter dentists thrive on new technologies. They enjoy the challenges that come with being the first to use a product. Most dentists, however, are not early adopters.

Fig. 5

Over the past two decades, lasers have intimidated mainstream dentists with their large footprint, lack of portability, high maintenance profile,
confusion of operating tips and complex procedural settings.

[17] =>

overview

Figs. 7 & 8_Management of excess
gingival tissue (ezlase).

Fig. 6

Enter the diode laser. It is compact. It can easily
be moved from one treatment room to another. It is
self-contained, and does not have to be hooked up
to water or air lines. It has one simple fibre optic cable that can be utilised as a reusable operating tip.
The units come with several presets, although
after a short time the operator becomes so comfortable that they are rarely needed. The power and
pulse settings are quickly adjusted to suit the particular patient and procedure.
One of the authors is a dentist who does not
thrive on the challenge of brand new high-tech,
“high-stress” technology. In fact, having tried many
lasers in the past that promised to be user-friendly,
they were found to be anything but. The 810 nm
diode laser was a different experience: after a brief
in-office demonstration, the laser handpiece felt
comfortable enough to perform some simple clinical procedures. Further online training and lecture
courses enhanced both clinical comfort level and
competency.

_Affordability
Laser technology has always come with a high
price tag. Manufacturing costs are high and cutting-edge technology commands steep prices, but
diode lasers are less expensive to produce. Pricing
for this technology has now reached under
US$5,000. At this level, the diode laser becomes eminently affordable for the average practising dentist.

Fig. 8

Fig. 7

_Soft-tissue laser
The 810 nm diode laser is a soft-tissue laser. This
wavelength is suited for soft-tissue procedures,
since haemoglobin and melanin, both prevalent in
dental soft tissue, are excellent absorbers. This provides the diode laser with broad clinical utility: it
cuts precisely, coagulates, ablates or vaporises the
target tissue with less trauma, improved post-operative healing, and faster recovery times.6–8 Given
its incredible ease of use and versatility in treating
soft tissue, the diode laser has become the soft-tissue handpiece in the dentist’s armamentarium. The
dentist can use the diode laser soft-tissue handpiece to remove, refine and adjust soft tissue in the
same way in which the traditional dental handpiece
is used on enamel and dentine. This extends the
scope of practice of the general dentist to many
soft-tissue procedures.
The following procedures are easy entry points
for the new laser user:
1.Gingivectomy, haemostasis and gingival troughing for impressions
The diode laser makes restorative dentistry a
breeze (Picasso). Any gingival tissue that covers a
tooth during preparation can easily be removed, as
haemostasis is simultaneously achieved (Figs. 2–6).
The restoration is no longer compromised due to
poor gingival conditions and there is no more battling with unruly soft tissue and blood. Excess gingival tissue can readily be managed (Figs. 7 & 8) for
improved restorative access for Class V preparation

Figs. 9–11_Removal of hyperplastic
tissue (Ivoclar Vivadent).

Fig. 9

Fig. 10

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[18] =>

I overview
Fig. 12_Frenectomy (ezlase).

Fig. 11

Fig. 12

(ezlase, BIOLASE Technology). Gingival troughing
prior to impression taking (Picasso; Figs. 6 & 7) ensures an accurate impression, particularly at the
margins, and an improved restorative outcome.
Packing cord is no longer necessary.

directly improving the patient’s cardiovascular
health.

2. Operculectomy, excision and/or recontouring of
gingival hyperplasia, and frenectomy
These procedures are not commonly offered or
performed by the general dentist. They are examples
of the expanded range of services readily added to
the general practice. The dentist becomes more
proactive in dealing with hyperplastic tissue that
can increase the risk of caries and periodontal disease (Figs. 9–11). In addition, a frenectomy has now
become a simple and straightforward procedure
(ezlase; Fig. 12).
3.Laser-assisted periodontal treatment
The use of the diode laser in conjunction with
routine scaling and root planing is more effective
than scaling and root planing alone. It enhances the
speed and extent of the patient’s gingival healing
and post-operative comfort.4, 5 This is accomplished
through laser bacterial reduction (Picasso), debridement and biostimulation (Figs. 13 & 14).

_Conclusion
The soft-tissue diode laser has become an essential mainstream technology for every general practice. Its science, ease of use and affordability make it
simple to incorporate. The laser is now the essential
soft-tissue handpiece for the practice. In fact, there
is a case for having a diode laser in each restorative
and each hygiene treatment room. Restorative dentistry becomes easier, more predictable and less
stressful. Laser therapy expands the clinical scope of
practice to include new soft-tissue procedures that
keep patients in the office. The patient’s gingival
health is improved in a minimally invasive, gentle
manner._

_contact

laser

Dr Fay Goldstep
DDS, fellow of the American College of Dentists and
the International Academy for Dental Facial Esthetics
goldstep@epdot.com

A. actinomycetemcomitans, which has been implicated in aggressive periodontitis, may also be implicated in systemic disease. It has been found in
atherosclerotic plaque9 and there has been recent
data suggesting that it may be related to coronary
heart disease.10 The diode laser is effective at decreasing A. actinomycetemcomitans,2, 4 thereby in-

Figs. 13 & 14_Laser bacterial reduction, debridement and biostimulation.
(Photographs courtesy of
Dr William Chen)

18 I laser
3_ 2012

Fig. 13

Dr George Freedman
DDS, fellow of the American Academy of Cosmetic
Dentistry and the American College of Dentists
epdot@rogers.com

Fig. 14

[19] =>

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[20] =>

I overview

Hygiene requirements
for dental laser fibers
Author_Hans-Joachim Koort, Germany

Fig. 1

Fig. 2

Fig. 1_Laser application in periodontology: The fiber is inserted into the
gingiva pocket, parallelly to the long
axis of the tooth to kill pathogen
germs with the laser radiation by
means of heat.
Fig. 2_Laser use in endodontics: The
laser fiber is inserted into the root
canal for disinfection.
Fig. 3a & b_Different situations with
laser treatments.

Fig. 4_Preparation does not equal
sterilization alone.

20 I laser
3_ 2012

Fig. 3a

Fig. 3b

_Introduction
Methods including laser application have been successfully established in the clinical work, especially in
soft tissue surgery, periodontics and endodontics as
well as in therapeutic applications (e.g. in photodynamic therapy) and in bleaching. Lasers can be used successfully for the decontamination of periodontal pockets (Fig. 1) and for the disinfection of root canals (Fig. 2).
Although laser devices have been widely adapted to the
dental needs in terms of performance parameters, design, size and mobility, only a few enhancements have
been made with respect to the fibre-based systems. A
situation frequently encountered is that laser fibres, although designed as single-use products, are not verified
and validated to be reprocessed and reused. This situation must be regarded as very risky and, therefore, critical. A solution to this problem is the use of special single-use fibre tips. Still, a considerable amount of fibre
lasers on the market neither corresponds with the re-

quirements of the relevant standards nor do they agree
with recommendations such as EN ISO 60601-2-22, EN
ISO 13485 and national government guidelines. They
are often neither subjected to biocompatibility (e.g.
NAMSA) tests nor do they possess a proof of sterilization according to EN ISO 17664. Sometimes there is not
even a certification. In cases such as these, these products must be scrutinized very carefully for their usability according to the Medical Devices Act, and their capability of being prepared for reuse. The reuse of unauthorised and undocumented products after refurbishing and reprocessing can be deemed at least negligent
and at most very risky. Primarily for cost reasons, fibre
systems are often used again and again after cleaning
and disinfection. However, only rarely are they used with
proper sterilization, independently from their suitability for recycling and reuse. To quote an expert: "What's
happening during the preparation process is a largescale experiment on people" and to quote a judge, "It is
usually medical malpractice when choosing the riskier
method among several alternatives. Neither economics,
nor negative bid lists or budgeting can put this normative system out of power..."

_The legal situation
The Medical Devices Directive (MDD) does not explicitly distinguish between disposable products and
those that can be used multiple times. However, when it
comes to reprocessing, at least the statutory requirements for a validated method must be fulfilled. This is almost impossible to accomplish for most dentists in their
private practice. All preparations of medical devices are
based on the requirements of the MDD and other national directives, in particular the "hygiene requirements when processing medical devices". For the reprocessing of medical devices (e.g. laser fibres), therefore,
only persons with specialized knowledge, appropriate
training and practical work should be appointed. The
marketability of reusable medical devices according to
EN ISO 17664 also includes that the original manufacturer provides data on the validated preparation. A conformity declaration by the manufacturer of the respective disposable instruments consequently concerns sin-

[21] =>

overview

Fig. 5

gle-use only. Risk assessment and classification of the
medical device must be made before the treatment,
stating whether, how often and by what measures the
device, e.g. a laser fibre, can be reprocessed. Procedures
which were validated accordingly to the manufacturer’s
information must therefore be applied for the reprocessing of semi-sterile or sterile medical devices. This
validation should be appropriate with regard to the
medical device, its risk assessment and classification. It
should furthermore be established in agreement with
generally accepted engineering standards, as well as the
current state of science and technology. This means that
processes applied in the preparation of laser fibres must
be documented. They also have to be repeatable in order
to ensure that the objectives to be achieved by each
preparation process can be reached before re-application. Manual cleaning and disinfection procedures must
be performed with proven efficacy and documented according to standard operating procedures. The disinfection procedures must demonstrate bactericidal, fungicidal and virucidal effects.

_Problem and solution
The used laser fibre can be assumed to become microbiologically contaminated in the oral cavity. Direct
contact with the tissue can result in soiled fibres, changing the optical properties of the fibre tip by cracks and
erosion, thus diminishing their quality. Typical problems
which may occur in laser fibres are shown in figure 3a:
The tip of a laser fibre is covered by combustion products, with the fibre acting upon further use like a hot soldering iron. As a result, the surrounding tissue will be affected by the heat much stronger than planned by the
dentist. Figure 3b shows coagulum and tissue residuals
at the laser fibre, which, if not immediately removed and
without cleansing of the fibre tip, may quickly burn
down to the glass fibre. Proper use and care in terms of
a strict hygiene therefore must play an important role
when using laser fibres. The patient’s safety and benefit
must always and above any economic considerations be
regarded as imperatives. More stringent hygiene directives with the respective laws and regulations, increased
control practices, high costs and the commitment to run
a quality management system in the dental practice are
requirements which must be met. Moreover, they make
single-use items, such as disposable fiber tips for laser
applications in dentistry, worth considering. Each

Fig. 6

Fig. 7

preparation of fibres, including those fibres which are
explicitly declared for reuse, must be critically assessed
in terms of patient safety. Due to the high requirements
for validation and verification measures, necessary
qualifications of the dentist and his or her assistant as
well as the time of preparation, the alleged costs of disposable products are relativized (Fig. 4). International
regulations often allow the preparation of single-use
products, but this permission is usually tied to high standards, which are usually hard to meet by any dentist
owning a private practice. In addition, special tools are
required for the preparation of laser fibres. In this regard,
the fact that preparation tools such as fibre stripping
devices or ceramic/diamond knifes cannot be sterilized
in most cases should be considered. Thus, the preparation can take place only in a non-sterile area.

Fig. 5 _Hygienic compliant hand
piece.
Fig. 6_Schematic drawing of a fiber
tip as a single-use product.
Fig. 7_The tips available on the
market are not quite perfect yet,
however, they lead the right way.
Tips made by Biolase (USA), elexxion,
Hager & Werken, Sirona (Germany).

A solution to these problems can be found in the use
of single-use fibre tips. Combinations of hygienic compliant hand pieces with matching disposable fiber tips
are required, as shown in figures 5 and 6. A hand piece
such as this consists of two parts: The "cold" part is
permanently fixed to the laser device and can be disinfected. The "hot" part should be cleaned by machine
and can ideally be autoclaved. Finally, to transmit the
laser radiation to the tissue, short fiber tips are added.
These tips should be designed as single-use products,
sterile and individually packaged and documented by
the manufacturer. Some producers have recognized
these problems and have already developed hand pieces
and fiber tips (Fig. 7). A final solution – in terms of patient safety, hygiene, as well as a reasonable price-performance ratio – will probably be achieved within the
next few years. In the future, the acceptance of laser applications in dentistry can be assumed to increase
greatly._

_contact

laser

Hans J. Koort
MedLas Consult
Auf der Schleide 18
53225 Bonn, Germany
ceo@medlas.com
www.medlas.com

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[22] =>

I industry report

The use of the LiteTouch
Er:YAG laser in
peri-implantitis treatment
Authors_Prof Tzi Kang Peng, Taiwan & Prof Georgi Tomov, Bulgaria

_Introduction
With oral implantology experience its Renaissance,
the growing incidence of peri-implantitis worldwide
today is point of interest for both scientists and clinicians. Peri-implantitis is a disease of inflammatory nature which leads to the loss of the implant when left
untreated.11,24 The aetiological factors of peri-implantitis are very similar to periodontitis.2,24 Different treatment modalities for the inflammatory soft tissue and
bone lesions in peri-implants have been proposed—
antibiotics, antiseptics, mechanical debridement, and
surgical procedures have been suggested, depending
on the grade of the clinical and radiographic manifestations.6,7,10,16,17
Treatment modalities such as scaling and root
planing, used to treat roots with periodontitis, cannot
be used in the same way on the threaded and retentive
implant surfaces. The rough implant surface provides
bacteria with shelter, unapproachable to conventional
mechanical removal.23 Conventional treatment procedures like closed peri-implant pocket debridement
have shown limited success7,10 whereas the treatment
of peri-implantitis using open-flap procedures has
shown more promising results.17 Although the improved access to the implant surface with open proce-

Fig. 1_Periapical radiograph of a
dental implant with bone loss
of > 3 mm.
Fig. 2_Implant site prior to
measurement (implant suprastructure still in place).
Pus discharge is evident.

22 I laser
3_ 2012

Fig. 1

dures can be seen as a fact, clinicians meet the same
problems as encountered with open periodontal therapy. The decontamination of the retentive implant
surface is much more complicated than the decontamination of a plane root surface.23 The instruments
used in periodontal treatment are too large to clean an
implant surface from bacteria and any metal to metal
contact during mechanical debridement has the potential to damage the implant surface.12,13 The common antiseptic therapy seems to be effective against
bacterial biofilm in in vitro conditions.5 In addition, the
local antibiotics used as an adjunct therapy to mechanical debridement has been advocated and shown
to reduce bleeding on probing and probing pocket
depth in patients with peri-implantitis,16 but there are
no data supporting the effect of antibiotics on the decontamination of implant surfaces and more specifically the endotoxin elimination.10,16,18
Currently, there are no clinical studies or case series
documenting successful regenerative procedures in
periimplant bony lesions after conventional treatment.
Some case series demonstrated limited bone fill after
GBR procedures.6 Another treatment modality that
may offer an advantage over traditional mechanical
treatment is the use of lasers.25,26 Studies have demonstrated that the treatment with an Er:YAG laser has a

Fig. 2

[23] =>

industry report

bactericidal effect.8 Er:YAG laser treatment can debride
the implant surface effectively and safely without
damaging.31,35 Much better clinical results have been
reported for Er:YAG laser treatment compared with
non-surgical mechanical debridement.15,27,31,35

_Aim
The aim of the (present study) intercontinental research led by Syneron was to assess the clinical outcomes of an open-flap procedure performed with
conventional mechanical therapy (CMT) or laser-assisted surgical treatment (LAS) with the novel LiteTouch Er:YAG laser (Syneron Dental Lasers) in patients
with implants and a diagnosis of peri-implantitis.

_Materials and methods
The design was a single-masked, randomized sixmonth clinical intervention trial with two groups of
patients diagnosed with peri-implantitis. The ethics
committees of Cheng Hsin General Hospital, Taipei,
Taiwan, and the Faculty of Dental Medicine, Plovdiv
Medical University, Bulgaria, approved the study. Written consent was obtained from all enlisted patients.
Patients were enrolled if they presented with at least
one dental implant with bone loss of > 3mm around
the implant identified on intra-oral radiographs (Fig. 1),
and with a PPD of > 5mm with bleeding and/or pus
discharge (Fig. 2) on probing. The study was conducted
between September 2010 and August 2011 at the
Cheng Hsin General Hospital and Plovdiv Medical University‘s Faculty of Dental Medicine. The following
general criteria were used to exclude subjects from the
study:
_subjects having taken medications likely to cause
gingival hyperplasia within one month prior to baseline examination;
_subjects receiving regular periodontal maintenance
treatment or having undergone any sub-gingival
cleaning less than twelve months prior to baseline
examination;
_subjects received peri-implantitis surgery of any type
prior to baseline examination;
_subjects with clinically significant chronic illness
(diabetes mellitus, compromised heart condition,
rheumatism, joint replacement) requiring antibiotic
prophylaxis;
_subjects having undergone systemic cancer therapy
and/or radiation therapy at any time;
_subjects taking or having taken bisphosphonates;
_subjects having taken antimicrobials, steroids or
non-steroidal anti-inflammatory drugs within one
month prior to baseline examination;
_pregnant or lactating women;
_subjects engaged in excessive tobacco or alcohol intake or drug abuse.

Fig. 3

Sixty-eight patients with a total number of 128 implants were included consecutively over a period of one
year.

Fig. 3_Removal of plaque biofilm
and granulation tissue using
the LiteTouch Er:YAG laser with its
1.3 x 1.4 mm sapphire tip.

_Clinical measurements
The measurement scale used in this study was constructed in order to obtain quantitative measurement
data:
_PPD at four sites per implant (mm);
_presence/absence of BOP at the implant (four sites/implant), graded as follows:
_no bleeding, (1) point of bleeding, (2) line of blood and
(3) drop of blood;
_bone loss (in mm on segment radiographs).
The PPD and BoP measurements were taken using
a color-coded plastic periodontal probe (Kerr). All
clinical measurements were obtained after removing
the suprastructures. Intraoral standardized radiographs of sites of interest were obtained at baseline
and at six months. Holders were used for standardization purposes. Radiographs were analyzed by two
of the study investigators after previous calibration.

_Hygiene phase (non-surgical phase)
Before treatment, the suprastructures were removed and the baseline measurements were taken.
The goal of the initial phase was the reduction of as
much tissue inflammation as possible. The patient
moved on to the support phase once signs of improvement and reduction of inflammation had been
observed. In case of persisting bleeding and pus discharge, a surgical procedure was planned. For this
surgical phase, fifty-one of all sixty-eight patients
with a total number of 100 implants were randomized
with a lottery assignment.

laser
3
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_ 2012

[24] =>

I industry report

Fig. 4a
Fig. 4_The periapical radiograph
revealed peri-implantitis with bone
loss of > 5 mm (a). The abutment
was removed and surgical treatment
using the LiteTouch laser was
performed. Bone grafting with a
biomembrane followed the laser
treatment (b). The periapical
radiograph revealed bone
regeneration after six months (c).

Fig. 4b

Fig. 4c

_Surgical phase
_Postoperative Instructions
If there was no significant improvement after the
non-surgical phase (in the second week), a surgical intervention was planned (surgical phase). Surgical intervention was indicated in cases in which the conditions
around the implant had failed to improve after the initial phase, but plaque control was adequate, and there
was a need to retain the contaminated implant. The
supraconstruction of the implants was removed in order to gain access and to preserve as much soft tissue as
possible to cover the area after surgery. Patients were
randomly assigned to one of the two treatment regimens.

_Conventional mechanical therapy
(Group I)
Infiltration local anesthesia was used during treatment. The first incision was an internal gingivectomy, directed towards the bony ridge, which separates the periimplant tissue from the mucosal flap. The flap was then
raised to the level of the bony ridge, gaining access to
the entire implant surface. The granulation tissue
around the implant was carefully removed with sharp
curettes and the implant surface was inspected for calculus deposits. The implant surface was then carefully
cleaned using an ultrasonic device at low settings (PI tip,
Piezon® ultrasonic unit, EMS). The PI tip was placed and
used for approximately 60 seconds around the implant,
ensuring coverage of the full circumference of the implant. Chemical debridement with a tetracycline solution was performed after ultrasound cleaning. In addition, bone augmentation was performed when required
(21 patients; Bio-Oss, Geistlich Pharma; Dembone).
During the study, all subjects received individualized
oral hygiene instructions.

_Laser-assisted surgical treatment
(Group II)
Under local anesthesia, gingivectomy and the separation of the peri-implant tissue from the mucosa were
performed. The flap was raised to the level of the bony
ridge, gaining access to the entire implant surface. The
granulation tissue around the implant was removed
with the LiteTouch Er:YAG laser (Fig. 3). Tip of choice was
1,300 micron, noncontact mode (distance between end
of the tip and target tissue = 1.5mm). If calculus de-

24 I laser
3_ 2012

posits were found, the implant surface was then carefully cleaned with laser. Decontamination with a noncontact, defocused Er:YAG laser was performed by systematically moving the laser tip along the surface. The
area was rinsed with a sterile saline solution. Bone augmentation was performed when necessary (19 patients;
Bio-Oss and Dembone with or without an absorbable
biomembrane). The tips and settings used during treatment are given in Table 1.

The patients were prescribed clindamycin 150mg x
50 tabs to avoid infection. They were also given ibuprofen 800mg x 15 tabs for pain. Patients were instructed
to rinse with chlorhexidine 0.2%, starting the next day,
for two weeks three times a day, and were advised to
maintain good oral hygiene.

_Support phase
The goal of the support phase was to maintain longterm treatment results. Regular examination of the soft
tissue, plaque control, radiographs and minor local
treatments were performed, based upon the recall interval. If there was a recurrence of minor inflammation
around an implant, the antibacterial periodontal treatment was repeated.

_Statistical methods
A statistical software package (SPSS) was used for
the statistical analysis. Statistical significance was defined by a p-value of < 0.05. A change in PPD was defined as the primary outcome measure. The secondary
outcome measure was a change in bone height. The data
was also analyzed using independent t-tests for continuous variables with a normal distribution (equal variance not assumed; PPD, changes in bone height) and using the Mann-Whitney U-test for non- parametric data
(BoP, suppuration) and a chi-squared test.

_Results
At baseline, a point of bleeding was found at 4.2% of
all implant surfaces, a line of blood at 47.6% and a drop
of blood at 56.9% of the sites. Statistical analysis failed
to demonstrate baseline differences in BoP between different implant surfaces (p = 0.85). At six months, no evidence of bleeding was found in 81% of the implants in
the LAS group and in 59% of the implants in the CMT
group. The decrease in BoP was significant in both study
groups (p < 0.001). Statistical analysis demonstrated
differences in changes in BoP between the study groups
(p < 0.001). The mean PPD reduction in the CMT and LAS
groups was 0.8mm (SD ± 0.5) and 1.7mm (SD ± 1.3), respectively, with mean changes in bone height (loss) of
-0.5mm (SD ± 0.6) and -0.1mm (SD ± 0.2), respectively

[25] =>

October 5-6, 2012//Hamburg, Germany//Elysee Hotel
Congress President//Prof. Dr. Dr. Frank Palm/DE
Scientific Director//Dr. Roland Hille/DE

International annual

congress of the dgzi
Quality driven implantology –
On the way to long term success

Speakers
Prof. Dr. Dr. Kai-Olaf Henke/DE
Prof. Dr. Dr. George Khoury/DE
Prof. Dr. Dr. Albert Mehl/CH
Prof. Dr. Herbert Deppe/DE
Prof. Dr. Werner Götz/DE
Prof. Dr. Shoji Hayashi/JP
Prof. Dr. Andrea Mombelli/CH
Prof. Dr. Dr. Frank Palm/DE
Prof. Dr. Suheil Boutros/US
Prof. Dr. Peter Rammelsberg/DE
Prof. Dr. Anton Sculean/CH
Prof. Dr. Dr. Jörg R. Strub/DE

Gold Sponsor:

Silver Sponsor:

Prof. Dr. Hans-Peter Weber/US
Prof. Dr. Thomas Weischer/DE
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Dr. Sami Jade/LB
Dr. Ramy Fahmy Rezkallah/EG
Dr. Osamu Yamashita/JP
ZTM Andreas Kunz/DE
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Mohamed Moataz M. Khamis
B.D.S., M.S., Ph.D./EG

Bronze Sponsor:

FAX REPLY
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Please send me further information on the
42nd International annual congress
of the DGZI October 5–6, 2012, in Hamburg, Germany.

Office Stamp

laser 3/12

[26] =>

I industry report
Procedure

Hard tissue/
soft tissue

Contact/
non-contact

Laser
energy
(mJ)

Pulse
frequency
(Hz)

Tip diameter x
length
(mm)

Waterspray
level

Releasing
incision of the
flap

Soft tissue

Contact

200

35

0.4 x 17

5–6

Granulation
tissue ablation

Soft tissue

Non-contact

400

17

1.3 x 14

6

Bone
remodelling

Hard tissue

Non-contact

300

25

1.3 x 19

8

Implant
decontamination

Hard tissue

Non-contact

150

45

1.3 x 17

6

Decortication
for GBR
technique

Hard tissue

Non-contact

300

25

1.3 x 19

8

Table 1_Tips and settings used
during laser treatment.

(S) (Table 2). The proportional changes in bone height
between baseline and six months, assessed from radiographs and defined at the implant level, are presented
in Table 3. A positive treatment outcome, PPD reduction
of >4mm and gain or no loss of bone were found in 59%
of the CMT and 81% of the LAS groups, respectively (S).
All subjects completed the study, and no implants were
lost.

_Discussion
In modern oral implantology, lasers have a considerable spectrum of clinical application. The literature data
revealed that different laser wavelengths are used on
Table 2_Proportional changes in PPD
between baseline and six months,
defined at the implant level based on
the mean value of changes at four
sites/implant.

PPD changes

CMT (%)

LAS (%)

>4

1.2

37.4

3.1–4.0

7.9

35.0

2.1–3.0

14.0

7.9

1.1–2.0

35.4

12.1

0.1–1.0

1.7

4.2

29.2

1.4

0.1–1.0

7.9

0.0

1.1–2.0

1.2

0.0

2.1–3.0

1.0

0.0

3.1–4.0

0.0

0.0

Decrease (mm)

Unchanged (mm)
0.0
Increase (mm)

26 I laser
3_ 2012

peri-implant tissues: treatment of peri-implant mucositis, treatment of infrabony defects, removal of periimplant hyperplastic overgrowth tissue, preparation of
bone defects for GBR.3,4,22,28,29 Unlike mechanical decontamination methods, which cannot fully adapt to
the irregularities on the surface of an implant, lasers can
irradiate the whole surface, reaching areas that are too
small to receive mechanical instrumentation. Recent in
vivo studies have analyzed the outcome of peri-implantitis treatment using Er:YAG lasers1,21,27,31 and CO2
laser.3,28,29 Many of these studies showed promising
short-term results (less than six months), but report no
long-term follow up. In the present study, differences in
the reduction of BoP six months after treatment were
found between LAS and CMT groups. While oral hygiene
had improved greatly and no plaque was found at the
treated implants, a large proportion of the implants in
the CMT group continued to exhibit BoP at the sixmonth post-treatment assessments. In the present
study, BoP was graded to distinguish the severity of inflammation and approximately 14% of the implants in
the LAS and 41% in the CMT groups presented with
bleeding, which was consistent with other data.30 The
reasonable explanation for these results is the quality of
decontamination of the implant surface provided by the
treatment approaches evaluated.
Contaminants such as bacteria and their by-products, calculus, and granulations should be removed
without modifying the implant surface and with respect
to surrounding soft tissues. Numerous methods for the
decontamination of implant surfaces have been suggested, either alone or in various combinations, as part
of the surgical treatment of peri-implantitis. The literature data revealed that methods as cleaning with metal
curettes and impropriate ultrasonic tips or irradiation

[27] =>

[28] =>

I industry report
Table 3_Proportional changes in
bone height between baseline and
six months, defined at the implant
level based on the mean value of
changes in mesial and distal bone
height.

Radiographic changes
in bone
height

LAS (%)

CMT (%)

Decrease (loss in mm)
1.1–2.0

12.2

35.4

0.1–1.0

37.1

39.5

29.3

4.2

Unchanged (mm)
0.0

Increase (gain in mm)
0.1–1.0

17.4

12.5

1.1–2.0

4.9

2.1

2.1–3.0

7.1

6.3

with Nd:YAG laser can damage the implant surface and
could compromise the residual implant stability.9,20 Airpowder abrasive units are often recommended for the
surgical treatment of peri-implantitis. A recent study
aimed at evaluating the influence of different air-abrasive powders on cell viability at biologically contaminated titanium dental implant surfaces revealed that no
surface treatments led to mitochondrial cell activity values comparable to the sterile control group.33 Citric acid
application and sandblasting have also been recommended.18 However, implant decontamination using
sandblasting units have been associated with risks such
as soft tissues damage and emphysema.34
Er:YAG lasers are seen as the most promising new
technical modalities of treating failing dental implants,
since their performance of tissue ablation is accompanied by a high bactericidal and detoxification effect.26,32
When considering the use of Er:YAG lasers in the treatment of peri-implantitis, there are some crucial points
with clinical importance. Power settings are variable,
and the clinician must also choose a setting that will effectively disinfect the implant while not damaging the
surface. A narrow range of power settings (100mJ/ per
pulse) was described in the literature.21,27,30,31,32 Only one
study used a higher power setting of 120mJ per pulse.1
The frequency was set at 10Hz for each of the mentioned studies, however, neither the distance from
which the laser was applied, nor the time of application
to each implant was stated. In the present study, the settings used for implant surface decontamination are
150mJ/45Hz, at non-contact mode and constant
movement. Another important point is the interaction
between laser light and metal surfaces. This interaction
is mainly determined by the degree of absorption and
reflection. With a reflectance capacity of about 71%,19
titanium implant surfaces do not absorb irradiation.
Consequently, there is no increase in temperature which
could damage the implant surface. Several investiga-

28 I laser
3_ 2012

tions have reported on the promising ability of the
Er:YAG lasers in implant surface debridement without
producing thermal side-effects on implant surface and
adjacent tissues.14,35 Treatment of peri-implantitis using
Er:YAG laser therapy has been investigated before and
appears to result in a more effective reduction in bleeding around implants than surgical debridement with
hand instruments and sub-gingival application of
chlorhexidine.1,27,30,31 Irradiation with this specific
wavelength seems to have a bactericidal effect on periodontopathic bacteria and remove bacterial biofilm.
However, in order to treat the implants with the laser device in the present study, the suprastructures were removed, allowing the access to the implant surfaces to
improve. Thus, the results of the present study are limited to implants where the suprastructures can be removed during treatment.

_Conclusion
Among lasers used in the field of dentistry, the Er:YAG
laser seems to possess the characteristics most suitable
for peri-implantitis treatment because of its ability to
ablate both soft and hard tissue, as well as bacterial
biofilm and calculus, without causing thermal damage
to the adjacent tissues and implant surfaces. The decontamination effects of Er:YAG laser are also beneficial regarding peri-implantitis pathogenesis. In the present
study, the use of the LiteTouch Er:YAG laser has been proposed for the treatment of peri-implantitis and the results indicate that the laser-assisted surgical therapy
may lead to significant clinical improvements such as
BoP and PPD reduction as well as a gain in clinical attachment. From a clinical point of view, these results advocate the Er:YAG laser as an alternative treatment
modality to conventional mechanical therapy._
With the collaboration of Dr Ke, Dr Yu, Dr Lu , Taiwan;
Dr Kenny Chiu, Hong Kong; Drs Kanbayashi, Takahashi,
Ikeda & Kamiya, Japan.
Editorial note: A list of references is available from the
publisher.

_contact

laser

Prof Tzi Kang Peng
DDS, MS, PhD, FICD
Professor and Chair of the Department of Dentistry
Cheng Hsin General Hospital
Taipei, Taiwan
Assoc Prof Georgi Tomov
DDS, MS, PhD
Associate Professor and Chair of the Department of
Oral Pathology, Faculty of Dental Medicine
Medical University of Plovdiv, Bulgaria

[29] =>

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[30] =>

I case report

Up-to-date vestibuloplasty
at the age of implant
dentistry
Author_Dr Darius Moghtader, Germany

_Introduction
Whether nowadays, in the age of implant dentistry, one can still perform vestibuloplasty in good
conscience, is a question constantly being raised. In
the pre-implant era, vestibuloplasty was applied to
deepen the vestibule with the aim of lining the
vestibular trough with functional mucosa in order
to form a valve-type margin.1 Vestibuloplasty today
continues to be used for this purpose if the patient’s
financial resources preclude implantation.

_Classical surgical procedures

Fig. 1_Initial situation.
Fig. 2_Laser cutting. Anterior view.
Fig. 3_Laser cutting. Lateral view.
Fig. 4_Check-up and soft laser one
day post-op.

Fig. 1

There are three possible approaches to the classical surgical procedure1:
1. Incision of the mucosal, leaving the periosteal
wound surface to secondary healing;
2. Covering the periosteal wound area with skin or
mucosal graft;
3. Submucosal incision without opening of the mucosal cover, using Obwegeser’s technique.

Fig. 2

30 I laser
3_ 2012

Fig. 3

Procedure one is the technique most commonly
used in practice, although it has the drawback of being associated with a loss of the gained alveolar
ridge height of 50 % as a result of scar contraction.
The patient has to endure pain due to the open
wound surfaces and is limited in terms of food intake. In addition, patients often have to re-attend
the dental practice because they develop pressure
sores owing to scar contraction. In the worst-case
scenario, the relined denture is not worn by the patient, resulting in conditions similar to the pretreatment situation. The elexxion diode laser and its
patented high-pulse technology enable practitioners to achieve a more sustainable result, causing
minimal pain to the patient, without the disadvantages of the conventional surgery.

_Pre-implantation surgery
Apart from the social indications, the implant era
bears the following medical indications prior to
planned implantation:

Fig. 4

[31] =>

case report

1. Removal of the mobile mucosa and fraenal attachments extending into the area of the implants;
2. Creating valve-type margins for coverimplant
dentures;
3. Reduction of the impaction of food remnants, especially if performing immediate loading of implants.
These pre-implantation surgical measures provide the implants with lasting protection against
mobile mucosa. Even in the event of implant loss or
if only a few implants are placed, additional retention can be achieved by the valve-type margin. If immediate loading is performed, the implants can heal
unaffected by external influences.

_Case presentation
A patient with a long history of pain presented at
our dental practice and reported that she can no
longer eat even semi-solid foods and that she is using analgesics constantly without being able to
wear her lower denture. After general and specific
history-taking, treatment with at least six minimally
invasive implants and a preceding vestibuloplasty in
the mandible were proposed. A new denture in the

lower jaw was to be fabricated, with immediate
loading of the implants. After detailed advice and a
thorough explanation, the patient consented to the
proposed treatment. As a complicating factor, the
patient’s heavy consumption of analgesics resulted
in a highly reduced anaesthesia time.
Anaesthesia was performed first (Fig. 1). Superpulsed laser cutting was then performed with the
elexxion diode laser 810 nm (Fig. 2). It is important to
make sure that the laser is guided parallelly to the
bone in order to avoid unwanted side effects (Fig. 3).
This procedure is accompanied by the instant
haemostasis known to be typical of laser treatment,
as well as reduced postoperative pain resulting from
the deactivation of the nerve fibre endings. Fast,
high-performance cutting with low carbonization
is made possible by the patented high-pulse technology.
Immediately afterwards and on the following
day, the glass rod of the elexxion diode laser was
used for soft laser application in order to reduce pain
and accelerate wound healing. A reline impression
was taken immediately after surgery and inserted at
the evening of the surgery after indirect relining in
the laboratory.

[PICTURE: ©SUKIYAKI]

Please contact Claudia Jahn
c.jahn@oemus-media.de

laser
3
I 31
_ 2012

[32] =>

I case report
Fig. 5_Wound healing after five days.
Anterior view.
Fig. 6_Wound healing after five days.
Lateral view.
Fig. 7_Wound healing after ten days.
Anterior view.

Fig. 5

Fig. 8

Fig. 6

Fig. 7

Fig. 9

Fig. 8_Immediately after
implantation.
Fig. 9_Exit of the mental nerve close
to the alveolar ridge.
Fig. 10_One week after implantation.

Fig. 10

On the following day, the patient presented for
check-ups with the expected fibrin deposit (Fig. 4).
She was delighted to report that this was the first
time she managed to do without pain killers after
any dental surgery. At the subsequent check-ups after five (Fig. 5 and 6) and ten (Fig. 7) days, wound
healing appeared to proceed successfully and painfree.

pains which were resistant to analgesics when the
patient wore the previous full denture. In cases such
as this, it is important to ensure a sufficient number
of at least six implants or, if there are only four implants, a bar restoration should be planned in order
to relieve the mental nerve from pressure. Only four
weeks after implantation, almost complete contouring of the vestibule was achieved (Fig. 11).

_Complete preservation of the
alveolar ridge

_Is vestibuloplasty still up-to-date?

After complete healing, minimally invasive implantation was performed with six Champions
tulip-head implants (Fig. 8), followed by immediate
loading with the overdenture (Fig. 10). Masticatory
function was immediately restored, and complete
osseointegration of the implants was successfully
achieved after six and twelve weeks. The exit point
of the mental nerve can clearly be identified on the
control X-ray (Fig. 9). This also explains the severe

With laser it definitely is. This is because a very
good outcome can be achieved with minimal discomfort for the patient and the surrounding area
can be prepared for implantation to ensure problem-free, undisrupted healing even with immediate
loading, provided there are sufficient implants._

_information
1

Band 2 Spezielle Chirurgie, Norbert Schwenzer und Gerhard
Grimm, Thieme Verlag 1990, p.439 ff.

_contact
Dr Darius Moghtader
In den Weingärten 47
55276 Oppenheim, Germany

Fig. 11_Four weeks after
implantation.

32 I laser
3_ 2012

Fig. 11

laser

dr-moghtader@hotmail.de
www.oppenheim-zahnarzt.de

laser

[33] =>

[34] =>

I industry report

Quantum Square Pulse
Er:YAG lasers
in clinical practice
Authors_Evgeniy Mironov, Zhasmina Mironova, Bulgaria

optimally fast rate, resulting in both higher efficiency and precision at the same time. Cavities
made with QSP mode are sharp and well defined,
with high surface quality as required for high bond
strength.7,8

_Materials and methods
Fig. 1_ a) LightWalker AT settings for
QSP mode; b) H02-C handpiece;
c) H14-C handpiece.

Fig. 1a

_Introduction
Er:YAG lasers are becoming increasingly popular in every day dental practice due to a higher level
of patient acceptance and greater precision and
procedure quality. There are many advantages over
conventional mechanical preparations, such as
lower increases in pulp temperature, less pain for the patient,
less risk of secondary caries,1,2,3
and improved strength of adhesion of the composite resin to
dentin prepared by low-energy
SSP Er:YAG laser pulses.4
The ability tosetdifferent laser
pulse durations represents a significant development that expands the versatility of Er:YAG
dental lasers.5,6 One of the recent advances in Er:YAG laser
technology is the introduction
of Quantum Square Pulse
(QSP) technology. In QSP
mode, low-energy, short
pulses follow each other at an

34 I laser
3_ 2012

A LightWalker AT laser (Fotona, Slovenia) was
used with a H02 non-contact handpiece (beam
spot size in focus: 0.6 mm) for enamel and composite preparation, and with a H14 contact handpiece with a cylindrical fiber tip of 0.8 mm diameter for surface modification and dentine (Fig. 1b,
1c). For all clinical cases QSP mode was used: pulse
energy varied from 120 mJ to 500 mJ, with repetition rates ranging from 10 to 15 Hz (Fig. 1a).

The composites used for fillings and bonding
were supplied by Voco (Cuxhaven, Germany).
Prior to the beginning of the treatment, the effects of the Er:YAG laser
treatment, benefits and possible risks
and complications were explained in
understandable terms to every patient. Laser safety rules were strictly
observed by the LSO (laser safety officer, Dr. Evgeniy Mironov) during the
treatments.

_Patient cases

Fig. 1b & c

All patient cases with chronic
and acute conditions (described
below) were taken from everyday
practice. Patients signed informed

[35] =>

industry report

I

Fig. 2_ a) Tooth 16 after preparation with QSP;
b) Tooth 16 after complete restoration (Case I).
Fig. 3_a) Tooth 26 before treatment;
b) Tooth 26 after preparation with QSP;
c) Tooth 26 after complete restoration (Case I).
Fig. 4_a) Removal of old composite veneer with QSP
mode; b) After complete surface preparation;
c) Clinical situation after complete direct restoration
(Case II).
Fig. 2a

Fig. 2b

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 5_a) Clinical situation on both premolars before
the treatment; b) Clinical situation after surface
modification with QSP mode and filling with flow
composite (Case III).
Fig. 6_a) Clinical situation before the treatment;
b) The situation just after treatment with QSP mode
showing completely untouched gingiva, even though
high energy was used for the treatment;
c) Clinical situation after treatment.
Fig. 5a

Fig. 5b

Fig. 6a

Fig. 6b

Fig. 6c

laser
3
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_ 2012

[36] =>

I industry report

Fig. 7a

Fig. 7b

Fig. 7_ a) Clinical situation before the
treatment; b) The situation just after
treatment with QSP mode showing
an ideal surface for bonding;
c) Clinical situation after the final
filling (Case V).

consent forms after reading the explanation of the
procedures to be performed with the LightWalker
AT laser, and they permitted photos to be taken.

The preparation took 1.5 to 2 minutes for each
central incisor and one minute each for the laterals (Fig. 4b).

Case I
The filling on tooth 16 of a 26-year old female
patient was to be changed due to discoloration and
reported transitive hypersensitivity. For removal of
the existing composite filling, the parameters were
set to QSP, 500 mJ, 12 Hz, and for the dentine
preparation, to QSP, 160 mJ, 15 Hz. The preparation
with QSP mode was fast and precise: QSP mode is
very suitable for the removal of secondary and
chronic caries, which are not as rich in internal substrate water as acute caries. It is also beneficial to
use QSP mode in deeper zones to reduce the risk of
thermal damage due to insufficient water inflow.
No anesthesia was used during the treatment, and
the patient did not show any signs of discomfort or
pain (Fig. 2).

After placing the rubber dam, direct adhesive
restorations were made with a layer of Grandioso
Heavy flow (VOCO, Germany) to establish a strong
and uniform connection between the two kinds
of composites. The patient was satisfied with her
new look and felt relaxed after the painless procedure (Fig. 4c).

A deeper abrasion on the filling of tooth 26 was
made in the same patient. A fresh and sterile surface for changing its occlusal part was performed
with QSP mode, with pulse energy of 300 mJ, 15 Hz,
water and air spray (Fig. 3). The patient reported the
disappearance of hypersensitivity at the fifth day
post-op check-up, and after six months the stability and functionality of the restorations were confirmed.
Case II
A female patient required an aesthetic treatment on her front teeth. One week after undergoing a successful TouchWhiteTM Er:YAG teeth
whitening procedure, the replacement of her existing direct-made composite veneers was necessary to adjust the color to the new color of the
bleached teeth. Because of the high precision of
QSP mode, it was possible to keep the enamel untouched and to work in the previous composite
layer only. The ablation was started with QSP
mode, 150 mJ, 12 Hz (Fig. 4a). According to the material's response, the energy was raised to 180 mJ,
and in areas with a thicker layer of the existing
composite, the frequency was increased to 15 Hz.

36 I laser
3_ 2012

Fig. 7c

Case III
A 30-year-old patient reported hypersensitivity to mechanical irritation and cold liquids in the
region of the lower premolars. The gums were
healthy and no isolation cord was necessary. Using the laser’s especially precise QSP mode assured
keeping the gingival tissues untouched. The surface modification parameters were QSP, 120 mJ,
10 Hz. Easy accessibility with the non-contact
handpiece and a clearly visible pilot laser beam allowed the preparation to be finished in less than
20 seconds for both teeth (Fig. 5). The restorations
were made by flow composite. Some light gingival
bleeding around tooth 44, which is seen in Fig. 5,
was caused by polishing. This case demonstrates
how fast and accurate treatments can be made using QSP mode.
Case IV
A deep cervical carious lesion on tooth 45 was
treated in a 23-year-old male patient. Since the
carious lesion was deep and the patient was very
afraid of dental procedures, anesthesia was used
and the fastest possible treatment parameters
were set: QSP mode, 500 mJ, 12 Hz. The first step
of the preparation was performed in 5 seconds,
and then the energy was changed to 300 mJ because deep carious dentine was reached. To operate still faster, the frequency was increased to
15 Hz and the second step was also completed in
5 seconds. After placing the haemostatic cord,
Calcimol LC (VOCO) was used as a liner, covered
with Grandioso Heavy Flow and finally filled with
Grandioso.

[37] =>

Case V
This is a case of localised single-tooth Amelogenesis Imperfecta due to excessive fluoride intake.
The patient is an 18 year-old male and his only
complaint is due to aesthetic reasons. After explanation of the laser treatment procedure, a decision
was taken to make a filling, following Er:YAG ablation without anesthesia. The patient was afraid of
dentists and denied injections in previous visits for
dental treatment. The parameters on the Fotona
Lightwalker AT were set in QSP mode, which is exceptionally fast and quiet. In cases such as this,
enamel is much stronger and richer in mineral content, so a high energy setting of 500 mJ was used
with a 12 Hz repetition rate. After preparation, the
energy was lowered to 120 mJ at 10 Hz, still in QSP
mode, for a marginal laser-etching procedure.
The preparation was done in less than 30 seconds
and the patient remained still and calm. The filling
was done with GrandioSo and Futurabond M
(VOCO).

NOVEMBER 15–16,
2013// BERLIN,
GERMANY//MARITIM HOTEL

LASER
START UP
2013
22st
ANNUAL
CONGRESS
OF THE
DGL e.V.

_Conclusion
In the above-described clinical cases, QSP mode
was used because fast, precise, and minimally invasive treatments were required. This is of great
importance in pediatric dentistry and with highly
anxious patients. The treatment provided good
aesthetic results, and patients did not report any
subsequent sensitivity.
All patients appreciated the lower noise generated by QSP pulses in comparison to other pulse
modes as well as the speed of the treatments. A very
important clinical benefit of the QSP mode are the
resulting clear and sharp margins of preparations
for fillings or for surface modification. This is of primary importance when working close to the pulp
or near the gingiva. The quality of surfaces prepared by QSP mode seems to be excellent for the
composites that were used._

Bilder
20. Jahrestagung
DGL / / LASER
START UP 2011
QR-Code einfach
mit dem Smartphone
scannen (z. B. mithilfe
des Readers Quick Scan)

PLEASE FAX THIS FORM
+49 341 48474-390
Further information about:
LASER START UP 2013

22st ANNUAL CONGRESS OF THE DGL e.V

November 15–16, 2013, Berlin, Germany

_contact
Evgeniy Mironov DDS
Assist. Prof Zhasmina Mironova DDS
Dental Studio Mironovi
Sofia 1000
Preki Pat 16–18 str.

laser

NAME/E-MAIL

OFFICE STAMP

Mobile: +359 888205105
dr_em@abv.bg

laser 3/12

[38] =>

I manufacturer _ news

Manufacturer News
Miyachi

Fotona

Miyachi Europe displays laser precision

Fotona expands clinical & academic ties

Miyachi Europe, supplier of laser and resistance
welding systems and laser marking products, will
be showcasing its laser system solutions at LASYS
2012, the international trade fair for laser material
processing system solutions, which will take place
in Stuttgart, Germany, from June 12–14, 2012,
at the Stuttgart Trade Fair and Convention Centre,
Booth #4E10.

A team from the dental laser manufacturer Fotona
recently visited the newly-opened Faculty of Dentistry at Bezmialem Vakif University in Istanbul,
Turkey, which is offering postgraduate courses in
dentistry in cooperation with AALZ Aachen University in Germany.

On display will be the highly flexible NOVA-6 CNC
Class-1 laser welding workstation, designed for a
wide range of applications ranging from production
of spot and seamwelded medical implants to automotive sensors, pacemaker leads and research &
development environments. The NOVA-6 can be upgraded to a glovebox system for welding in a controlled atmosphere. Also featured is the ML-8150C

green (SHG) laser welder, ideal for
welding high reflectance materials like copper, gold
and their alloys. The new ML-7350C Yb:fibre laser
marker is designed for high speed laser marking,
laser engraving and laser ablation. The high power
level of 50 W results in high contrast marks on both
plastics and metals at high speed.
MIYACHI EUROPE GmbH
Lindberghstraße 1
82178 Puchheim, Germany

The new Faculty's lecture room and clinical rooms
are equipped with the latest technologies of modern dentistry and state-of-the-art research equipment, including dental laser systems and SEM and
AFM microscopes.

contact@mec.miyachi.com
www.miyachieurope.com

elexxion

delos 3.0 combines diode and Er:YAG
The delos 3.0 laser from elexxion AG enables gentle yet effective treatment of both hard and soft
tissue. By combining the 810 and 2,940 nm wavelengths, the device represents a perfect symbiosis of one of the fastest Er:YAG lasers and a powerful diode laser, and thus covers nearly all dental
indications for laser treatment.
delos 3.0 is therefore not only one of the most
universal devices on the market but it is
also one of the most operator-friendly
high power lasers thanks to the new
floating arm technology and
the 10.5 inch touchscreen.
With up to 50 W and a variable
impulse frequency of up to
20,000 Hz, the diode laser in
the delos 3.0 conservatively treats soft tissue at
low penetration depths –
whether in surgery,
prosthetics, implantology or periodontics. Atraumatic to the

38 I laser
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distal end: the Er:YAG laser wins over the practitioner with a power bonus of 50 per cent. Thus instead of conventional glass fibre cables, the system is equipped with
high quality mirror optics, which are
integrated in the floating arm and
which guide the laser beam without
scattering losses into the handpiece –
for effective hard tissue ablation with
a maximum output of 12 W.
Depending on the clinical requirement, the
power can be individually adjusted, which also
has presettings for more than 20 indications. Other features: Cooling system, pedal switch and an integrated
fee calculator.

The Faculty will conduct education, research and
clinical work using Fotona's LightWalker® AT dental laser system, which has received several highly
distinguished international design and technology
awards for its combination of innovation, technological excellence and superior design. The Faculty’s research team has already begun performing
intensive clinical studies using new dental-laser
technologies developed by Fotona, such as the
company’s patented QSP (Quantum Square Pulse)
mode and TwinLight® dual-wavelength treatment
method.

Elexxion AG
Schützenstraße 84
78315 Radolfzell, Germany

Fotona d.d.
Stegne 7
1000 Ljubljana, Slovenia

info@elexxion.com

info@fotona.com

www.elexxion.de

www.fotona.com

[39] =>

manufacturer _ news

Henry Schein/Planmeca

Omnia

Henry Schein becomes new US distributor for
Planmeca

Customized
procedure kits

Finnish dental company Planmeca has named Henry
Schein the US distributor of its full range of dental
equipment, software and other products, including
digital imaging products. Henry Schein is already familiar with Planmeca products, as it has served as its
exclusive distributor in Australia and New Zealand for
nearly two decades.

Henry Schein, headquartered in Melville, New Jersey,
is a provider of health-care products and services to office-based dental, medical and animal-health practitioners. “Planmeca and Henry Schein have a shared
commitment to quality and customer service, and we

are pleased to be embarking on a new relationship with
this industry leader in the important US market,” said
Bob Pienkowski, President of Planmeca USA. “Henry
Schein’s customers rely on the company for a comprehensive offering of dental equipment and for the latest in advanced-technology solutions.We look forward
to helping Henry Schein continue to meet its customers’ needs and to our future mutual success.”
“Planmeca has a very good
reputation among dental
practitioners worldwide,
and we are delighted to be
selling the company’s leading dental equipment in the
US,” said Tim Sullivan, President of Henry Schein
Dental.

Source: DTI

Biolase

Biolase to distribute 3Shape Trios
intraoral scanner
Last week, dental laser enterprise Biolase announced that it had signed an agreement with dental scanner and software developer 3Shape. Biolase
will be distributing the Danish company’s Trios intraoral scanning technologies for digital impressiontaking solutions to dental professionals in the US
and Canada.
Biolase entered a five-year agreement
with 3Shape, making the dental laser
manufacturer a non-exclusive distributor
of the Trios system, which includes a
handheld scanner, operator’s control
cart and software. Under the agreement,
Biolase will distribute the Trios system to
dentists, dental specialists and dental
schools in North America.
“The Trios digital system is quickly becoming an important and integral part
of the modern high-tech dental suite
and our agreement with Biolase provides us with significant new access
to the important North American
market,” said Henrik Vestermark, vice

president of operations at 3Shape America. Federico
Pignatelli, Biolase chairperson and CEO, said that the
agreement not only allows the company to better
serve the periodontists, orthodontists, endodontists
and oral surgeons doing complex dentistry, but also
opens a new market for Biolase to partner with dental labs.
“By putting the Trios digital solution
together with our advanced laser
products and our full line of digital
imaging products under our Biolase
umbrella, we can offer dental professionals a ‘one-stop shop’ for a totally integrated group of devices and
dental engineering services while
driving new revenue growth in all aspects of the dental market,” he added.

I

OMNIA S.p.A. introduces the new brochure about
its customized procedure kits for oral surgery and
implantology.
The brochure clearly explains what a customized
procedure kit is, its benefits and how to set up a kit
in order to better fulfill the needs and requirements
of the surgical staff.
Simple, functional and
efficient, Omnia procedure kits assist
each dental surgeon
from basic to advanced surgery. Realized on the specific needs and requirements of the
surgical staff, the
customized procedure kits help
to improve the
quality and simplify the management of the surgical theatre, optimizing the long set
up phase and streamlining working times and
costs, for a general reduction of hidden costs.
The customization of the procedure kits also foreseen that the name of the surgical staff is printed
on the label of each kit. The label used by Omnia for
sterile kits contains all the information you need to
identify the device (code, lot, expiration date); there
are two more cut-outs for the end user that allow
easy data storage and traceability also by end customer. Traceability is a procedure that allows us to
reconstruct with ease and precision all the phases
of the production process (from the entrance of raw
materials/components, to sterilization) through
registration on paper and/or computer for proper
data storage and preservation.
Omnia procedure kits create an optimal working
environment in dental offices and in the best clinics all over the world.

Biolase Europe GmbH
Paintweg 10
92685 Floss, Germany

Omnia spa
Via F. Delnevo 190sx
43036 Fidenza (PR), Italy

info@biolase-europe.com

info@omniaspa.eu

www.biolase.de

www.omniaspa.eu

laser
3
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[40] =>

I education _ FDI World Congress

100 Annual FDI congress
celebrated in Hong Kong
th

Author_Dental Tribune International

The ceremony was attended by high-ranking
officials from the Hong Kong Dental Association, the
University of Hong Kong, among other institutions,
as well as the Chinese and Hong Kong SAR governments, including China’s Minister of Health Zhu Chen,
who also received the FDI World Oral Health Recognition Award, which was handed over by FDI President
Dr Orlando Monteiro da Silva.
Chen, who has served in this position since 2007,
is the first person ever to have received this award.
According to the FDI, he was selected for his contributions to the development of dentistry in China, as
well as his leadership in the education of new dentists
and the establishment of new dental schools.
In his welcome speech, da Silva congratulated
Chen, saying that the challenges the minister has had
to overcome in the People’s Republic of China are
a good example of the challenges his own organisation is confronted with in its goal to improve oral
health globally. With its “Vision 2020” document (see
also page 6 of this edition), introduced at a special
forum during the World Dental Parliament on Tuesday,
da Silva said that the FDI is able to provide not only
a roadmap for the future of dental medicine, but also
inspiration to the profession, preparing it for new and
exciting partnerships in leading the world to optimal
oral health.

40 I laser
3_ 2012

“Vision 2020 demonstrates the FDI’s agility and
determination to address issues such as the huge
disparities in access to oral care between countries
and within countries between urban and rural areas,”
he commented.
Available for download from the FDI’s website, the
document focuses on significantly improving access
to oral health care worldwide by 2020 by expanding
the role of oral health professionals and developing
a responsive model for future dental education, among
other things. In addition, the federation has launched
two new websites in Hong Kong, both for its Global
Caries Initiative, developed jointly with Dental Tribune
International, and for its noncommunicable diseases
campaign with the World Health Professions Alliance.
The latter aims to help professionals, including dentists,
to respond to the epidemic of noncommunicable diseases, such as cancer and respiratory disease.
This year marks the 100th time that the FDI has invited dental professionals to its Annual World Dental
Congress and it is the second time that it is being held
in Hong Kong. Thousands of dental professionals from
the region and around the globe are expected to attend
the event from Wednesday to Saturday, which has
been organised in collaboration with the Hong Kong
Dental Association.
Besides a comprehensive scientific programme,
including a presentation on oral health in China by
Dr Lingzhi Kong, Deputy Director-General of the PRC’s
Center for Disease Control and Prevention, in a special
session, the latest dental materials and equipment
were on display at the World Dental Exhibition in the
Hong Kong Convention and Exhibition Centre._

[PICTURE: ©LEUNGCHOPAN]

_The Grand Hall of the Hong Kong Convention
and Exhibition Centre saw its latest highlight on
29th August, when the FDI World Dental Federation officially opened its centennial congress with an eyecatching traditional performance featuring a 100-foot
long dragon dancing among a sea of lions and flags.

[41] =>

education _ DT Study Club

Study club honored for
elevating educational standards
in the New York City area
Author_Dental Tribune America

_The Office of Queens Council Member Daniel
J. Halloran submitted awards to Dr Alexander Ross
Kerr of New York University and Dr Robert Trager, to
acknowledge their work in raising educational standards and awareness on Oral Cancer at a recent meeting of the Fialkoff Dental Study Club.
Dr Bernard Fialkoff, a Queens periodontist and
dental implant specialist, founded the club in the mid
’90s and invited two of the most prominent dentists
in New York to present the New York state-mandated
oral cancer screening course. More than 160 dentists
from Long Island, the boroughs, New Jersey and even
Connecticut participated in the course.
The Oral Cancer Foundation and LED Dental’s
Velscope and Zila’s ViziLite Plus, both oral cancer
screening devices, sponsored the seminar, providing
additional information on ways to detect oral cancer
in dental offices.
Fialkoff said, “Many dental publications today are
publishing articles on the preventative methods we
can take on oral cancer. It is my job to ensure our study
club members are kept abreast of the latest dental
technology. We invited Dr Kerr and Dr Trager, as they
fit the bill to impart this vital information to our attending dentists, who can in turn, bring this information to their offices and further help their patients.
The driving purpose of our study club is to raise dental standards throughout the Greater New York area
through our monthly educational presentations and
meetings.”
Council Member Halloran’s City Council Citation
award reads, “Such service, which is truly the lifeblood
of the community and the city, so often goes unrecognized and unrewarded.”
Kerr is a clinical associate professor of the Department of Oral & Maxillofacial Pathology, Radiology &

Medicine at New York University College of Dentistry,
a member of the steering committee for the World
Workshop on Oral Medicine a and member of the Scientific Advisory Board of the Oral Cancer Foundation.
Trager has dental practices at LaGuardia and JFK
airports and is the chairman of the Oral Cancer Committee for the Nassau County Dental Society, past
president of the Queens County Dental Society, and
is known throughout New York for volunteering at
Belmont Raceway Track, Saratoga’s horse races and
numerous other occasions providing free oral cancer
screenings.
Attending dentists learned methods on preventing oral cancer, effective communication methods to
help their patients avoid the dangers of the disease
and practiced using the oral cancer screening device
at the meeting. Kerr’s NYU Oral Cancer Clinic also gave
out informational materials on the research and work
it is doing.
The study club has an audience of 60 to 100 dentists each month. It focuses on raising dental excellence, standards and camaraderie in the New York
boroughs. The club will continue its monthly meetings into 2012 with a presentation in September by
Dr Mark Montgomery, in October by Dr Bernard Fialkoff
and with a special appearance by Dr Harold Edelman
in December, instructing on the mandatory infection
control course.
Fialkoff has had a periodontal, dental implant and
cosmetic laser surgery office for more than 31 years
on 56-03 214th St. in Bayside, N.Y. The office web site
and blog, which shows study club photos and bulletins, and other community activities of the office,
is www.baysidedentist.com. Study Club newsletters
and past photos are also available for viewing at
www.facebook.com/DrBernardFialkoffDDS.
(Source: Fialkoff Dental Study Club)

laser
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[42] =>

I meetings

Barcelona meets laser
specialists from more than
45 countries
Author_Javier de Pison

_From 26 to 28 of May, the 13th World Federation for Laser Dentistry (WFLD) World Congress
and the 12th annual meeting of the Sociedad Española de Láser Odontoestomatológico (SELO) were
held in Barcelona. This meeting gathered more than
500 specialists from all around the world.
The high scientific standard of the invited lecturers, as well as the high quality of both oral presentations (150) and posters (140), tagged the event as
highly prestigious. The congress was developed in
four simultaneous rooms: two for the lecturers and
the other two for the oral presentations. There was
also a big space reserved for the poster presentations.
In one of the conferences rooms, in which general aspects of laser application in dentistry were treated,
simultaneous translations from English to Spanish
took place during all the congress. In the other main
room, more specific and advanced aspects of laser in
dentistry were discussed. The scientific programme
of the congress was meticulously organized, avoid-

42 I laser
3_ 2012

ing that a lecture of a certain field overlapped with
another lecture on a similar subject.
There was also a big space for the trade fair, in
which recent technologies and devices in the field of
dentistry were presented. The congress held the main
manufacturers of lasers in dentistry from around the
world at its disposal.
The different social events that took place during
the congress days also played a major role in its
success. On the first day, the opening ceremony was
celebrated, with the presence of the delegate of the
rector of the University of Barcelona, honorable
Dr Miquel Viñas, the dean of the dentistry faculty of
the International University of Catalonia. honorable
Dr Lluis Giner, the President of the Dentists Association
in Catalonia, honorable Dr Josep Lluis Navarro, the
president of the World Federation for Laser Dentistry,
Dr Jean-Paul Rocca, the president of the Sociedad Española de Láser Odontoestomatológico, Dr Josep

[43] =>

meetings

Arnabat, and the president of the congress, Dr Antoni
España. At the inaugural ceremony of the congress
and after the speeches, a representation of the Spanish folklore took place. In addition, snacks and Catalan cava were served.

Barcelona. During the dinner, there was a prize draw
for a diode laser, offered by Syneron Dental, the
Congress’ Gold Sponsor. The President of the SELO,
Dr Josep Arnabat, presented Dr Isao Ishikawa with
a commemorative plaque of acknowledgement for
his career and support, and Dr Antoni España with
another gratitude plaque for his work as previous
President of SELO.

The scientific committee rewarded the best oral
presentations of “young researchers”. The ten best
oral presentations were selected and repeated in one
of the main rooms, with a jury awarding the best
ones.
During the closing ceremony, president Dr JeanPaul Rocca thanked the organizing committee for all
the effort carried out during the congress preparation and emphasized that “the Barcelona congress
has been the best among all the WFLD Congresses
held so far, and exceeding this would be difficult”.
On the last day of the congress, a closing dinner
was prepared in a restaurant located in the Montjuic
mountain, with wonderful views of all the city of

In the meeting, the new President of the WFLD,
Dr Aldo Brugnera Jr., was introduced and dedicated
a few words to all the people at the dinner._

_contact

laser

Javier de Pison
Dental Tribune Latin America
7762 Tatum Waterway Dr.
Apt. 5
Miami 33141-1800, FL
United States

laser
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[44] =>

I interview

German distributor
files against dental
laser manufacturer
Interview by Georg Isbaner, Germany

“Lasers in dentistry are on a good way with a great with trailblazing technology, which you distributed
market potential. Even such an incident by an indi- with tremendous success from scratch.
vidual manufacturer will not change this.”
Trailblazing laser technology is complemented
NMT Senior Consultant Joachim Koop comments
on the current legal dispute between NMT and
Syneron Dental Laser. Interview by Georg Isbaner.
Leipzig, 17 August 2012.

Joachim Koop, Senior Consultant NMT Munich GmbH

_laser: Dear Mr Koop, in the year 2009 your
company started to market dental laser systems
made by Syneron. These are meant to be systems

44 I laser
3_ 2012

in this case with the consulting, sales and training
competence in your company. It also meant a great
opportunity to enter into a new promising partnership with new impulses that had long been awaited
by many in the dental laser market.
Since the end of last year the situation has
turned when a legal dispute between the manufacturer, you as the distributor of Litetouch products and the dentists harmed ensued. What happened?
If an accredited certification body, that furthermore has its seat in Germany, issues a CE certificate
for a medical device, all market players should have
the right to trust the certificate that the product
really meets the certification requirements.
The ordering of a suspension of a certificate
issued in 2007 raises many questions that the
responsible manufacturer Syneron has not yet
adequately responded to.
I would never have thought this is possible for
such a big and up to now very renowned laser manufacturer like Syneron that operates worldwide
and is listed on the Stock Exchange.

[45] =>

interview

_How did you find out about the increased EMC
radiation that led to the suspension of the CE certificate?
The corresponding indications came from a former sales partner of Syneron in Italy. The company,
Creation, represented by Prof Resch, during an attempt to get a CE admission for an OEM product on
the basis of Litetouch, did not get permission due
to increased EMC values which are practically
identical with the currently measured values of the
original product.

official decree confirming their non-applicability
without a CE certification.

This happened—as we know only today—in the
year 2009. Prof Resch correspondingly also informed the German officials and, among others,
the trade supervisory board in Munich. Despite all
placatory letters by Syneron, the company went on
to deny facts even in December 2011, which led to
an official order end of January 2012 to suspend
the CE license.

To me, this conduct is incomprehensible with
regard to a formerly highly respected manufacturer of high-calibre laser technology.

This was definitely not a voluntary attempt on
behalf of Syneron. An incredible case—unique in
its way.
_Are the examination and certification procedures insufficient?
In Germany and the EU there are no general
pointers to underline this hypothesis. In my view,
there is no such case.
_May the dentists continue treating their patients with their Litetouch?
With the current product on the market, we expressly recommend not to do that—however, very
much so with the new product which is now, after
almost seven months, used in exchange for the device with our customers—one after the other and
in a sequence that is not comprehensible.
_What does it mean for your company?
Thank God only very few users have tried to file
any claims against us because it is clear to everybody who is solely responsible for this situation. Our
customers supported us in our endeavour to find
out and make progress with the manufacturer for
the benefit of the customer. What is more, we filed
suit with the public prosecutor against Syneron
and the responsible representatives, because it is
important that all wronged parties find out about
the true circumstances. The result of the public
prosecutor investigations is of great importance
also for NMT. This is why the six doctors affected
filed their own demands for prosecution.
_May the laser devices still be sold?
The former device may no longer be sold within
the European Economic Area of the EU—due to the

_What does the manufacturer do?
The conduct of Syneron Dental after the loss of
the CE certificate seems almost worse than the loss
itself. Many months went by without any attempt
to limit the damage, without any appropriate compensation offer for the long non-operation of the
laser therapy during daily therapy—a completely
insufficient information policy.

_Does this new technology still have a market?
The basic idea of this new technology was and
has been irresistible. The device put on the market
by Syneron obviously was not ready for the market;
this is shown by the new heavy hand pieces of the
products to be exchanged. In my view, the development will be driven forward and lead to success
in the future.
_Which solutions do you offer to the customers
concerned?
We recommend to all to accept the exchange of
the instruments by Syneron, without waiving any
claims for damages at this very time. Damages may
also be claimed at a later time, depending on the
outcome of the public prosecutor investigations.
A future better alternative is already available
with the laser systems of Biolase, the world market
leader of dental laser systems. Only with the help
of this experienced manufacturer was it possible
for NMT to overcome the dispute and finally
emerge stronger from this ongoing legal dispute
with Syneron.
Lasers in dentistry are on a good way with great
application and market potential. Even such an
unbelievable and irresponsible incident by an individual manufacturer will not change this.
Mr Koop, thank you for this interview!

_contact

laser

NMT Neue Medizintechnik München GmbH
Flurstraße 5
82166 Gräfelfing, Germany
info@nmt-muc.de
www.nmt-muc.de

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[46] =>

NEWS
Russian healthcare system
Ultraviolet radiation offers

New hope
for cancer
patients
Scientists from Japan have announced that they will
soon have a new method of treating cancer that uses
ultraviolet C (UV-C) light to destroy abnormal cells while
leaving normal cells unharmed. Their findings, to be
presented at the International Congress of Histochemistry and Cytochemistry in Kyoto next week, indicate
that short bursts of UV-C radiation have the potential to
harm neoplastic cells, the biological units that form tumours.

Improving but in need of investments
According to a new Espicom market research report,
Understanding Russia’s Regional Health Markets, the
progress in improvement in Russia’s health system is
slow. Urban areas, particularly Moscow are of a high
quality, but provision in rural areas remains poor.
[PICTURE: ©STEPAN KAPL]

By irradiating these cells with high-intensity UV-C
pulsed flash rays through a modified UV sterilisation
system in the lab, researchers at the Tokai University
School of Medicine were able to effect changes in the
cells that led to their dysfunction and death within seconds. Non-neoplastic cells, however, were affected
much less and survived the treatment, the scientists
report. They now intend to develop their discovery into
a cancer treatment method using a range of light irradiation equipment, including endoscopy and laser microscopy.

Russia is the largest country in the world, with a land
area of over 17 million square kilometres, encompassing eleven time zones. It has an estimated population
of 142.9 million. Delivering universal high quality
health services is a challenge.

“This method offers a simple means of reducing the
burden on patients undergoing cancer therapy,” they
commented.

Tomorrow’s dentures

Sensitivity of neoplastic cells to UV-C radiation has
been also observed by other researchers. In a study,
published in the Biochemical and Biophysical Research Communications journal in 2009, for example,
scientists from the Gifu University Graduate School of
Medicine in Japan reported the potential of low-dose
UV-C combined with standard medication to inhibit the
growth of pancreatic cancer cells. Similar effects were
reported by the same research team regarding colon
cancer cells.
Short-wavelength UV-C light does not occur naturally
owing to the fact that it is completely reflected by the
earth’s ozone layer, but its germicidal effects have been
proven and applied in medicine for sterilising equipment. In dentistry, among other things, UV-C is used in
the sterilisation of toothbrushes and purification of air
in dental offices. In contrast to the latest method investigated in Japan, however, these applications use lowintensity UV-C light emitted over a longer period.

46 I laser
3_ 2012

Funding is at the heart of Russia’s health improvement
plans, and at the beginning of 2011 obligatory medical

insurance contributions increased from 3.1 % to 5.1 %,
deducible from salaries. This will raise an additional
R460 billion (US$15.1 billion) over two years and will
help cover the costs of overhauling, and equipping hospitals and polyclinics. The extra funds will also help to
provide a wider range of free-of-charge medical services. With measures to increase income, however, has
come the challenge of distribution and the recognition
that, in common with countries such as India and
China, there is a yawning gap between well provided
for cities and the more remote regions.
In 2010, the government introduced the idea of a regional healthcare services modernisation scheme that
aims to improve quality and availability of medical
services and raise the profile of the medical profession.
The decision to implement the required changes was
difficult, particularly during a period of economic pressure. Healthcare modernisation is well overdue. To put
this into context, over 30 % of hospitals lack a hot water supply, 8 % do not have a drinking water pipeline
and 9 % lack drainage.

For further information on the report please visit
www.espicom.com/rrmpr.

Resemble Shark teeth
Researchers at the German University of Duisburg-Essen and the Max Planck Institute for Iron Research in
Düsseldorf examined the teeth of two different sharks,
the shortfin mako and the tiger shark, in terms of their
structure, composition and mechanical properties.The
teeth of both sharks were found to have a similar crystalline composition. According to the researchers, the
interior of shark teeth contains dentine, a softer material also found in human teeth, while the enamel exterior is highly mineralised. Shark teeth contain fluorapatite, a very hard mineral, which could lead to the conclusion that they are harder than human teeth, which
contain hydroxylapatite, a softer mineral, according to
Dr Matthias Epple, Professor of Inorganic Chemistry at
the university.
However, comparative analyses revealed that the
hardness of shark teeth and human teeth was comparable, both for dentine and enamel. “This is mainly due

to the micro- and nano-structures of our teeth, in which
crystals are highly ordered in a special topological orientation,” said Epple. The scientists are now continuing their research on other shark species.They are hoping to recreate their dental structures for the production of dentures in the future. The study was published
in the June issue of the Journal of Structural Biology.

[47] =>

Strategic Partner

Supported by

[48] =>

NEWS
Student wins US$2,000

For toothbrush sterilizer

Through a one-year project, she found four disease-causing pathogens on household toothbrushes, especially on those from houses in rural
areas, and developed a promising method that destroys these bacteria and prevents cross-contamination.
Once when Chené Mostert from Ladysmith,
KwaZulu-Natal, South Africa, was brushing her
teeth she realized that bathroom layouts are hygiene disasters, as toilets are often situated in close

proximity to the basin, where
toothbrushes are generally
stored. In collaboration with microbiologists at a commercial laboratory in Pretoria, South Africa,
the 17-year-old tested 104 toothbrushes from urban and rural areas in South Africa and neighboring countries and established the
presence of pathogens such as
Staphylococcus, Streptococcus,
Candida and E. coli on a number
of brushes.

A South African high school student has won first
prize in the world's largest international pre-college science competition for a new toothbrushsterilizing device.

By turning a handle, the user activates a rotating mechanism that rinses the bristles with
hydrogen peroxide, which destroys any microorganisms present on the toothbrushes.
"It's basic but effective," she said.
As the device is still in the process of being
patented, Mostert was not allowed to provide
any images of her sterilizing unit.

The student's aim was to develop a
device to store toothbrushes that is

Surgeons perform

European Commission study

First in utero removal of oral tumor

Ban of dental
amalgam

For the first time in the history of fetal medicine,
doctors have successfully removed a large oral tumor from the mouth of a four-month-old fetus in a
pioneering in utero surgery. Last week, media representatives were invited to meet the child, who is
now 20 months old, at a press conference.

After serious consideration,
the procedure was carried
out in May 2010 by Ruben
Quintero, professor of obstetrics and gynecology, and Eftichia
Konopoulus, assistant professor
of obstetrics and gynecology, at
the Jackson Memorial Hospital
in Miami, Fla. Using an endoscope, guided by ultrasound,
and a laser, the tumor was
resected in utero without

48 I laser
3_ 2012

A new study, conducted on behalf of the European
Commission, recommends phasing out dental amalgam use over the next few years owing to mercury’s
negative impact on the environment.

any maternal or fetal complications in a 68-minute
operation under local anesthetic.
Five months after surgery, the patient went into
spontaneous labor and delivered a healthy female
infant without complication. The only sign of the
surgery was a tiny scar on the baby’s mouth, the
doctors said.
According to the surgeons, nasopharyngeal teratomas are associated with an exceptionally high
risk of neonatal mortality, particularly from airway
obstruction. If done early enough, as in the present
case, fetoscopic removal of the teratoma can avoid
growth of the tumor mass, distortion of the facial
structure, excess amniotic fluid, edema and the
risk of a stillbirth, they said.

According to the recently published study results, the
ban should be combined
with improved enforcement of the EU waste legislation regarding dental
amalgam.

As reported at the Jackson Memorial Hospital's
press conference on June 21, a 37-year-old
woman was diagnosed as having a fetus with a
mass protruding from the fetal mouth, during a routine ultrasound in the twentieth week of her second
pregnancy. According to the doctors, the findings
were suggestive of an oral teratoma, a rare tumor
that arises from all three embryonic germ layers.

simple in design and suitable for people in rural areas who do not necessarily have electricity. According to Mostert, the device consists of a box with four separate, perforated
plastic tubes, into which the brushes can be
placed to prevent cross-contamination.

The report explains that
mercury-free alternatives
are still not used widely in many EU
member states. The reasons are that alternative fillings are often believed to be more expensive
than amalgam fillings, that many dentists are simply
not trained to apply new methods and that many dentists think that composite materials have a lower durability than amalgam fillings.
Some dentists are also “reluctant to change their current practice and invest in new equipment to handle
mercury-free fillings,” according to the report. Additionally, many patients are not even aware that amalgam fillings contain mercury.

[49] =>

meetings _ events

I

International events
2012
AAID 61st Annual Meeting
Washington, DC, USA
3–6 October 2012
www.aaid-implant.org
42nd International Congress of DGZI
Hamburg, Germany
5–6 October 2012
www.dgzi-jahreskongress.de
ADF 2012 Conference and Trade Exhibition
Paris, France
27 November-1 December 2012
www.adf.asso.fr

Expodental Milan 2012
Milan, Italy
18–20 October 2012
www.expodental.it
NorDental – Dental Exhibition
and Congress
Lillestrom, Norway
11–13 October 2012
www.npg.no
Dental-Expo St. Petersburg 2012
International Dental Forum
St Petersburg, Russia
30 October–1 November 2012
www.dental-expo.com

7th CAD/CAM & Computerized Dentistry
International Conference
Singapore, Singapore
6–7 Oktober 2012
www.capp-asia.com
BDTA Dental Showcase 2012
London, United Kingdom
4–6 October 2012
www.dentalshowcase.com
3rd Congress of the European Society
of Microscope Dentistry
Berlin, Germany
4-6 October
www.esmd.info
World Dental Show 2012
Mumbai, India
5–7 October 2012
www.wds.org.in
Dental World 2012
Budapest, Hungary
11–13 October 2012
www.dentalworld.hu

laser
2
I 49
_ 2012

[50] =>

I about the publisher _ imprint

laser
international magazine of

laser dentistry

Publisher
Torsten R. Oemus
oemus@oemus-media.de

Loh Hong Sai
Asia & Pacific Division

Editorial Office
Georg Isbaner
g.isbaner@oemus-media.de

Senior Editors
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
Toni Zeinoun
Middle East & Africa Division

Aldo Brugneira Junior
Yoshimitsu Abiko
Lynn Powell
John Featherstone
Adam Stabholz
Jan Tuner
Anton Sculean

Claudia Jahn
c.jahn@oemus-media.de

Editorial Board

Sarah Fuhrmann
s.fuhrmann@oemus-media.de

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 SennhennKirchner, Siegfried Jänicke, Olaf Oberhofer,
Thorsten Kleinert

Executive Producer
Gernot Meyer
meyer@oemus-media.de
Designer

Customer Service
Marius Mezger
m.mezger@oemus-media.de

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laser
international magazine of laser dentistry
is published in cooperation with the World Federation for Laser Dentistry (WFLD).

Copyright Regulations
_laser international magazine of laser dentistry is published by Oemus Media AG and will appear in 2012 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
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50 I laser
3_ 2012

[51] =>

laser
international magazine of



laser dentistry

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[52] =>

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[cover] => laser international No. 3, 2012

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => Effect of diode laser on enamel fissure system [page] => 06 ) [4] => Array ( [title] => Laser treatment of dentine hypersensitivity - An overview III [page] => 12 ) [5] => Array ( [title] => Diode lasers: The soft-tissue handpiece [page] => 16 ) [6] => Array ( [title] => Hygiene requirements for dental laser fibers [page] => 20 ) [7] => Array ( [title] => The use of the LiteTouch Er:YAG laser in peri-implantitis treatment [page] => 22 ) [8] => Array ( [title] => Up-to-date vestibuloplasty at the age of implant dentistry [page] => 30 ) [9] => Array ( [title] => Quantum Square Pulse Er:YAG lasers in clinical practice [page] => 34 ) [10] => Array ( [title] => Manufacturer News [page] => 38 ) [11] => Array ( [title] => 100th Annual FDI congress celebrated in Hong Kong [page] => 40 ) [12] => Array ( [title] => Study club honored for elevating educational standards in the New York City area [page] => 41 ) [13] => Array ( [title] => Barcelona meets laser specialists from more than 45 countries [page] => 42 ) [14] => Array ( [title] => German distributor files against dental laser manufacturer [page] => 44 ) [15] => Array ( [title] => News [page] => 46 ) [16] => Array ( [title] => Meetings [page] => 49 ) [17] => Array ( [title] => Imprint [page] => 50 ) [18] => Array ( [title] => Subscription [page] => 51 ) ) [toc_html] =>

Table of contents

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