Introduction
It is incredible to think how much dentistry has changed in the last 20 years. From a diagnostic standpoint, nothing can hide from us. Digital radiography, whether periapical or a 3D Cone Beam CT, gives us the ability to slice images, rotate images, colorize, increase the brightness or contrast, and see things in incredible detail. The way we take impressions is beginning to transition to a digital environment, and soon we will be utilizing virtual articulators if we choose.
As these areas of dentistry continue to evolve at a rapid rate, it is not surprising that some dentists are utilizing technology for routine dental procedures involving the teeth and surrounding tissues (gingiva and bone). The first procedure that utilized a laser intraorally was a CO2 laser used on soft tissue in 1977. It was not until 1987, however, that the CO2 laser received FDA clearance. Although this laser was specifically for soft tissue, the stage was set for research and further study to look at different wavelengths that could alter enamel, dentin, and bone. What has transpired is a revolution of interest that has some in dentistry utilizing this technology on virtually every procedure they do.
Understanding Laser Energy
Theodore H. Maimain was the first to develop a laser. He utilized a theory from Albert Einstein, where a crystal medium (Ruby) was stimulated with energy and radiant laser light was emitted from the crystal. Shortly after this discovery, the Neodymium laser was released (Nd:Yag laser). Early dental research focused on the Ruby laser, but it was soon found to be ineffective to cut the hard tissues inside the mouth. As a result, the Argon, Carbon Dioxide, and Nd:Yag lasers were utilized for soft-tissue procedures only in the early years.
In 1985, Dr. Terry Meyers and his brother William (an ophthalmologist) started using an ND:Yag laser to remove incipient caries. They founded American Dental Laser (acquired by Biolase in 2003) and created the first true dental laser system called the D-Lase 300. Many in the industry believe this was the beginning of the laser revolution, focusing the lens of interest on the topic of lasers. In 1997, Premier Laser received the first US FDA clearance for cutting enamel and dentin using the Eb:yag laser. Soon other companies utilized a similar crystal, furthering the R & D of the dental laser industry.
It is important to note that lasers have been used in virtually every other specialty in the medical field. It is also interesting that in medicine, specific wavelengths have been aligned with specific clinical applications. Although this thought process was carried over to dentistry for many years, we are fortunate that a single wavelength laser has emerged that can be used across the full range of oral tissues. Like other lasers they are named for the active medium that is charged with energy (the crystal) inside the laser. The YSGG laser receives its name from Yttrium, scandium, gallium, and garnet doped with erbium and chromium (Er, Cr:YSGG). The specific wavelength for this laser is 2780 nanometers, by comparison Erbium : Yag is 2940, Nd:Yag is 1064, many Diodes are at 980. Specific wavelengths will interact and be absorbed by the tissues in different ways. A diode is best absorbed by pigmented tissues, and is ideal for cutting and coagulating soft tissue. The YSGG laser, first called the Millenium laser, utilized a combination if the YSGG laser energy combined with water and air to effectively ablate enamel and dentin. It was soon found that with the water turned down or off, this same laser could be used for additional uses that involve the cutting and coagulating of soft tissue. By 2000 the FDA had cleared the use of this laser so that clinicians were able to work on oral tissues with one laser. In 2000 and 2004, Biolase released as second-and-third generations of the YSGG laser—the Waterlase and Waterlase MD, respectively. They provided a number of improvements never before seen in dentistry.
Clinical Procedures
Cutting Enamel & Dentin
Conserving the maximum amount of tooth structure during our restorative procedures is the goal of any standard of care. Magnification and quality radiography as well as improved materials and techniques all have made this a clinical reality. Utilizing a surgical microscope in conjunction with an appropriate dental laser is the ultimate in minimally invasive dental procedures.
When using a traditional high-speed handpiece at very high magnification, it is impossible to see to the depth of the cavity preparation as you prepare the tooth. This is because the water and debris have nowhere to go and thus cloud the operator’s field of vision. As clinicians, we learn to develop a tactile sense of enamel, dentin, restorative materials and even caries. Nothing, however, replaces the ability to see. Because the laser ablates the tissues, there is no debris. This allows the clinician to have an exquisite view of all areas of the cavity preparation, leading to more conservative results.
The laser has been cleared for Class I, II, III, IV, and IV cavity preparations since 1999. Additionally, the laser has been shown to reduce the smear layer (due to ablation), which can improve surface adhesion and ultimately the strength of our bonded restorations.
Osseous Surgery
The YSGG laser has been cleared for shaving and contouring bone since 2002. Shortly there after, in 2003, the device obtained its FDA clearance for osseous crown lengthening and the ultimate recreation of the biologic width. Some doctors are doing these procedures without laying a flap or suturing in certain indications. Combining certain restorative procedures in conjunction with laser-assisted surgery can add increased visualization, efficiency, and predictability with these procedures.
Soft-tissue surgery
Since the early soft-tissue work with lasers, the YSGG laser has been cleared for a multiple of uses for soft tissue. It is important to note that this is the only device cleared for use on both hard and soft tissues. Procedures such as the treatment of aphthous ulcers, herpetic lesions, frenectomy’s, gingivectomy, fibroma removal, and atraumatic troughing around crown preparations are some of the procedures that are routinely performed with this laser.
Cosmetic/esthetic dentistry has shined a light on the importance of the gingival frame as it relates to the backdrop of the esthetic restorations. Being able to properly manipulate the gingival tissues’ biologic width becomes an integral part of nearly every cosmetic case. Having the technology and skill to complete these procedures, increases the fun, efficiency, quality, and profitability of these cases.
Root Canal
The use of the dental laser has long been associated with the potential benefits of disinfection and sterilization. When the YSGG was cleared for use on hard tissues, this device was a natural for the shaping and cleaning of the root canal system. Similar benefits that are evident that exist when cutting enamel and dentin also exist inside a canal. Utilizing a laser decreases debris and eliminates the smear layer, which leads to dentinal tubules that are free and clear, ultimately improving obturation and sealing.
Efficiency & Productivity
Increasing the numbers of procedures that a dentist can offer his or her patients all goes to increasing the productivity of the practice. The expansion of periodontal procedures in the diseased-based realm as well as the increased esthetic possibilities adds to practice expansion. Restorative procedures also become more efficient, because the need for anesthetic is reduced and many times eliminated in operative care. As a result, the dentist can work in multiple quadrants at the same visit. This translates to fewer, well planned, longer visits. Not only is this great for the practice, but patients appreciate less time away from family and work, as well as leaving the office without being numb.
Conclusion
We are practicing in a very interesting time. Technology, materials, and new procedures are evolving at an unbelievable rate. At the same time, financial pressures exist that affect our own practices as well our patients. As clinicians, we have to make a decision about what we are going to get involved with and what specifically we want to master. We also have to be conscious of the message we are sending to our patient population and surrounding community. What do we want our practice to be known for? What are we doing to make our practice distinct in the community? How can we attract patients who value their oral health and want to continue to invest in better care.
Laser dentistry is not a panacea for everything in dentistry. It has evolved as a valuable tool to do numerous procedures within general and specialty practices with increased precision and efficiency. It is also a tool that will place your practice, in the eyes of your patients, right on the cutting edge.
