Journal of Clinical Laser Medicine & Surgery

Volume 19, Number 4, 2001

Mary Ann Liebert, Inc.
Pp. 193–198

The Use of Er:YAG, Nd:YAG and Ga-Al-As Lasers in

Periapical Surgery: A 3-Year Clinical Study

S. GOUW-SOARES, D.D.S., M.S.,1 E. TANJI, D.D.S., M.S.,1 P. HAYPEK, D.D.S.,1

W. CARDOSO, D.D.S., M.S.,2 and C.P. EDUARDO, D.D.S., M.S., Ph.D.1

ABSTRACT

Objectives: In an attempt to increase the successful rate of endodontic surgical procedures this study proposes
the use of an association of three lasers in apicectomy: Er:YAG laser, (wavelength 2.94 mm pulse mode),
Nd:YAG laser (wavelength 1.064 mm, pulse mode), and Ga-Al-As laser, (wavelength of 790 nm, continuous
wave). Background Data: Previous studies have shown the low success rate of apicectomy by conventional
methods due to the presence of remaining bacteria in the surgical site. Methods: The Er:YAG laser was used to
perform osteotomy and root resection without vibration, discomfort, less contamination of the surgical site,
and no smear-layer on the dentine surface. The Nd:YAG laser irradiation through a fiber performed sealing of
the dentinal tubules and bacterial reduction of the cavity bone. In addition, the improvement of healing and
better post-operative achieved with the Ga-Al-As laser encourages the use of those lasers in periapical surg-
eries. Results: Three years follow-up examination of the clinical case showed radiographically significant de-
crease of the radiolucent periapical area and no clinical signs and symptoms. Conclusion: The outcome of this
clinical case indicates that the use of those lasers could be considered an alternative, suitable, and useful
method to perform an apicectomy.

INTRODUCTION morphological structure of dentin cut surface, sealing the denti-

nal tubules.8–14 Gutknecht et al.11 investigated in vitro the bac-

T he insufficient removal of bacteria from an infected root

canal system is a common cause for failure in endodontic
treatment.1,2 However, when a conservative approach is im-
possible or inadvisable for retreatment, frequently a periapical
surgery should be performed as an alternative to dental
extraction.
Several authors have used laser systems in apicectomies.3–6
The Er:YAG laser is highly absorbed by water and hydroxiap-
atite and has been considered efficient for cutting hard dental
and bone tissues with extremely small thermal damage.7
Paghdiwala4 demonstrated in vitro a smooth, clean dentin sur-
face after root resection using the Er:YAG laser. Gouw-Soares
et al.,6 in an in vitro study of apicoectomy with Er:YAG laser
using safe lasers parameters, showed a clean dentine cut sur-
face, no cracks, no carbonization, no smear layer, and with ex-
posure of the dentinal tubules.
Several laser systems have shown a bactericidal effect within
contaminated dentine.8–10 Nd:YAG laser irradiation has
demonstrated a bactericidal effect and the ability to change the
tericidal effect of the pulsed Nd:YAG laser in root canals inoc-
ulated with Enterococcus faecalis and achieved an average of
99.91% bacterial reduction. Dederich et al.15 were the first to
report the melting and recrystallization of root canal wall den-
tine followed by Nd:YAG laser irradiation with a potential de-
crease of permeability to fluids on the basis of the nonporous
aspect of the dentine under scanning electron microscopic ex-
amination.
In addition, the photodynamic effect of the Ga-Al-As laser
has been related to improve the healing with less surgical post-
operative pain and discomfort.16–18
MATERIAL AND METHODS
Clinical case study
Clinical examination: A 56-year-old white male presented
with an intra-oral soft tissue swelling at the apical region of teeth

1Department of Restorative Dentistry, and 2Department of Oral Surgery School of Dentistry, Universidade de São Paulo, São Paulo, Brazil.

193
194
FIG. 1. Swelling of mucosa on the apex area of teeth 11 and 21.
11 and 21. The patient reported no significant pain. Sensitivity to
palpation of the periradicular tissues caused discomfort (Fig. 1).
Radiographic examination: A radiographic exam revealed a
large radiolucent area extending from teeth 12 to 23 according
to the patient, incisors and canines were endodontically treated
18 months before and retreated 6 months before using laser ir-
radiation (Fig. 2).
Diagnosis: By clinical and radiographic examination the a
presence of a periapical lesion was diagnosed. The later histo-
logical exam of the infected soft tissue revealed a cyst.
Treatment: The infected soft tissue was removed by curettage
and the infected root apex was resected with Er:YAG laser.
Informed consent: An outline of use of the Er:YAG laser
(KAVO Key 2, Germany); Nd:YAG laser (ADT, American
Dental Technology), and Ga-Al-As (J. Morita) laser in the sur-
gical procedure was given along with an explanation of the ad-
vantages of the nontactile, reduced sensation, the bactericidal
effect, and the decrease of postoperative pain using lasers in-
stead of the conventional treatment. The patient signed a con-
sent form following this explanation. Glasses with proper opti-
FIG. 2. Radiographic examination shows a large radiolucent
image.
Gouw-Soares et al.
FIG. 3. Osteotomy with Er:YAG laser.
cal density were used in all the laser procedures by patient, op-
erator, and staff.
Treatment sequence: Using a scalpel with a size 15 blade
mounted, a firm incision was made through the periosteum to the
bone, along the vertical line of lateral incisors followed by an
horizontal line in the gingival sulcus. A full-thickness flap was
elevated and the bone defect was exposed. To improve access for
instruments and visual access of the infected lesion and root
apex, the cortical bone was properly removed by osteotomy with
Er:YAG laser irradiation, at no-contact mode, with a setting of
350 mJ of energy, repetition rate of 4 Hz, and output of 1.4W,
with a constant water spray refrigeration (Fig. 3).
The periapical lesion exposed was removed using a curette
and the root resection was done with the Er:YAG laser irradia-
tion with 450 mJ of energy, 4 Hz of repetition rate, and 1.8W of
power (Fig. 4). This root resection procedure took approxi-
mately 10–15 sec.
The bactericidal effect was performed with the Nd:YAG
laser irradiation applied in the bone cavity surrounding all of
the infected area through a fiber in the no-contact mode, with a
FIG. 4. Root apex of tooth 11 cut perpendicular to the long axis.
Lasers in Periapical Surgery 195

FIG. 7. Low-power Ga-Al-As laser irradiation on the mucosa

FIG. 5. Bactericidal effect with the Nd:YAG laser, in the cav-
after suture of the flap in position.
ity bone, no-contact mode.

setting power of 100 mJ of energy, 15 Hz of repetition rate, with cally for at least 5 years, due to the possibility of very late failures
an output of 1.5W, for 30 sec (Fig. 5). With the same laser para- in conventional periapical surgeries reported by some authors.21
meters, for 30 sec with the fiber in a contact mode, the Nd:YAG
laser irradiated the dentine cut surface sealing the dentinal
tubules (Fig. 6). DISCUSSION
After the flap was repositioned and sutured in place, a low-
power Ga-Al-As laser (continuous wave, 30 mW of power), ir-
The use of the Er:YAG laser in periapical surgery performing
radiated the mucosa on the area corresponding to the apical le-
osteotomy and root resection has the advantage of less contami-
sion and to the sutures, for 6 min (energy density of 4 mJ/cm2),
nation of the surgical site by the decrease of aerosol when com-
to improve the healing (Fig. 7). The suture removal was done 1
pared with the turbine handpieces and absence of vibration dis-
week after the surgical procedure.
comfort because of the no-contact mode. In our previous in
A periapical control radiograph was recorded before dismiss-
vitro study, scanning electron microscopy showed that the root
ing the patient, and subsequent recall radiographs and clinical
resected by Er:YAG laser irradiation produced a clean surface,
examination were recorded 1, 3, 6, and 12 months, and there-
no smear layer, and evidence of open dentinal tubules6 (Fig.
after (Figs. 8–12).
13). Although the exposure of dentinal tubules might increase
Radiographs were taken with the same X-ray unit using the
the permeability of the dentine cut surface, the statistical analy-
long-cone technique and standardized exposure and processing to
obtain optimal diagnostic quality. Criteria and classification for
healing or failure are given according to previous studies.19,20
The present case will be checked clinically and radiographi-

FIG. 6. Nd:YAG laser in contact mode on the dentine cut sur-

face to promote melting and recrystallization.
FIG. 8. Postoperative radiograph after 3 months.
196
FIG. 9. Postoperative radiograph after 6 months.
sis showed no significant difference of dye penetration between
the group of samples resected with Er:YAG laser irradiation
and the control group resected with a conventional high-speed
drill. On the other hand, other in vitro work demonstrated less
dye penetration through the dentinal cut surface resected by
Er:YAG laser following Nd:YAG laser irradiation, when com-
pared with the group of apex resected with Er:YAG laser only,
or even with the group resected by conventional handpiece22
(Fig. 14), due the sealing ability of the dentinal tubules attrib-
uted to the Nd:YAG laser irradiation.
FIG. 10. Postoperative radiograph after 12 months, with sig-
nificant bone regeneration.
Gouw-Soares et al.
FIG. 11. Two years follow-up radiograph. Significant de-
crease of periapical lesion.
In our clinical case, root resection with Er:YAG laser and
Nd:YAG laser irradiating the dentine surface enhance the suc-
cess of periapical surgery by reducing leakage from the root
canal system to periodontal tissues, as well as by the bacterial
reduction of the infected bone cavity. In addition, the use of a
low-power laser has been reported to improve the healing
process. It is well known that during a wound repair the adhe-
sion between cell–cell and cell–matrix changes. Karu et al.,16,17
irradiating HeLa cells with a low-power laser, observed that the
increase of adhesion between those cells was stimulated.
It is known that periapical lesion refractory to conventional
endodontic treatment is heavily dominated by anaerobes, and
that a large periapical lesion can be associated with a larger
number of bacterial species and a higher bacterial density when
FIG. 12. Radiograph aspect after 3 years follow-up care,
bone healing, decrease of the translucent periapical image, and
presence of scar tissue.
Lasers in Periapical Surgery
FIG. 13. SEM view of resected root surface with Er:YAG
laser. Exposure of the open dentinal tubules.
compared with small lesions.23 This is in agreement with the
study of Sjögren et al.1,2 and Allen et al.,24 who demonstrated
that the size of preoperative lesion has influence on the out-
come of treatment. Those authors demonstrated that cases with
apical radiolucencies greater than 5 mm in diameter that were
endodontically retreated had a failure rate of 50%, and those
with less than 5 mm failed 24.9% of the time, requiring some
type of surgical treatment.
The high frequency of periapical surgeries done to reach an
endodontic treatment success as well as the high percentage of
failure in those surgical procedures due to presence of bacteria,
related in the literature, encourage the use of lasers.
CONCLUSION
The outcome of this clinical case indicates that the use of
lasers could be considered an alternative method, suitable and
useful to perform apicectomies.
ACKNOWLEDGMENTS
This investigation was supported by L.E.LO-FOUSP-Labo-
ratório Experimental de Laser em Odontologia da Faculdade de
Odontologia da Universidade de São Paulo; Clinica SOL (So-
ciedade de Odontologia a Laser), and CAPES (Coordenação de
Aperfeiçoamento de Pessoal de Ensino Superior), São Paulo,
Brazil.
REFERENCES
1. Sjögren, U., Hägglund, B., Sundqvist, G., and Wing, K. (1990).
Factors affecting the long-term results of endodontic treatment.
J. Endodon. 16, 498–504.
2. Sjögren, U., Figdor, D., Persson, S., and Sundqvist, G. (1997). In-
fluence at the time of root filling on the outcome of endodontic
treatment of teeth with apical periodontitis. Int. Endodon. J. 30,
297–306.
197
FIG. 14. SEM view. Root resected with Er:YAG laser fol-
lowed Nd:YAG laser irradiation with melting and recrystalliza-
tion of the dentine cut surface.
3. Miserandino, L., and Waukegan, I. (1988). The laser apicoectomy:
Endodontic application of the CO2 laser for periapical surgery.
Oral Surg. Oral Med. Oral Pathol. 66, 615–619.
4. Paghdiwala, A.F. (1993). Root resection of endodontically treated
teeth by Erbium:YAG laser radiation. J. Endodon. 19, 91–94.
5. Moritz, A., Gutknecht, N., Goharkhay, K., Schoop, U., Wernisch,
J., Pöhn, C., and Sperr, W. (1997). The dioxide laser as an aid in
apicoectomy: An in vitro Study. J. Clin. Laser Med. Surg. 15,
185–188.
6. Gouw-Soares, S., Lage Marques, J.L., and Eduardo, C.P. (1996).
Apicoectomy by Er:YAG laser: permeability and morphological
study of dentine cut surface, in: International Laser Congress,
25–28 Sept. 1996, Athens, Greece. Proceedings. Bologna: Mon-
duzzi Editore, pp. 365–370.
7. Keller, U., and Hibst, R. (1989). Experimental studies of the appli-
cation of the Er:YAG laser on dental hard substances: II. Light mi-
croscopic and SEM investigations. Lasers Surg. Med. 9, 345–351.
8. Klinke, T., Klimm, W., and Gutknecht, N. (1997). Antibacterial ef-
fects of Nd:YAG laser irradiation within root canal dentin. J. Clin.
Laser Med. Surg. 15, 29–31.
9. Gouw-Soares, S., Gutknecht, N., Conrads, G., Lampert, F., Mat-
son, E., and Eduardo, C.P. (2000). The bactericidal effect of
Ho:YAG laser irradiation within contaminated root dentinal sam-
ples. J. Clin. Laser Med. Surg. 18, 81–87.
10. Gutknecht, N., Gogswaardt, D. van, Conrads, G., Apel, C., Schu-
bert, C., and Lampert, F. (2000). Bactericidal effect of Diode lasers
in Endodontics. DGL—Deutsche Gesellschaft für laser
Zahnnheilkunde e. v. 2000, abstract, p. 34.
11. Gutknecht, N., Moritz, A., Conrads, G., Sievert, T., and Lampert,
F. (1996). Bactericidal effect of the Nd:YAG laser in in vitro root
canals. J. Clin. Laser Med. Surg. 14, 77–80.
12. Gutknecht, N., Kaiser, F., Hassan, A., and Lampert, F. (1996).
Long-term evaluation of endodontically treated teeth by Nd:YAG
lasers. J. Clin. Laser Med. Surg. 14, 7–11.
13. Tanji, E.Y., and Matsumoto, K. (1994). The comparative study of
the morphological changes of dentin surface after Nd:YAG, CO2
and Argon lasers irradiation. J. Japan Endodon. Assoc. 15, 14–20.
14. Lage-Marques, J.L., Eduardo, C.P., and Matsumoto, K. (1995). A
study on morphological changes of the root canal walls laserd by
pulsed Nd:YAG laser. J. Japan Endodon. Assoc. 16, 64–69.
15. Dederich, D.N., Zakariansen, K.L., and Tulip, J. (1984). Scanning
electron microscopic analysis of canal wall dentin following
Neodymium-Yitrium-Aluminum-Garnet laser irradiation. J. En-
dodon. 10, 428–431
198 Gouw-Soares et al.

16. Karu, T., Pyatibrat, L.V., Kalendo, G.S., and Esenaliev, R.O. 22. Gouw-Soares, S., Tanji, E., Matson, E., Lage-Marques, J., and Ed-
(1996). Effect of monochromatic low-intensity light and laser irra- uardo, C.P. (1999). Apicoectomy with Er:YAG and Nd:YAG
diation on adhesion of Hela cells in vitro. Lasers Surg. Med. 18, lasers. SEM and permeability study of dentine cut surface, in: In-
171–177. ternational Association for Dental Research—Division [#.B-116].
17. Karu, T. (1989). Photobiology of low power laser effects. Health J. Dent. Res. 78, 1008.
Phys. 56, 691–704. 23. Sundqvist, G. (1992). Ecology of the root canal flora. J. Endodon.
18. Utsunomiya, T. (1998). A histopathological study of the effects of 18, 427–430.
low-power laser irradiation on wound healing of exposed dental 24. Allen, R.K., Newton, C.W., Brown, C.E. Jr. (1989). A statistical
pulp tissues in dogs, with special reference to lectins and collagens. analysis of surgical and nonsurgical endodontic retreatment cases.
J. Endodon. 24, 187–193. J. Endodon. 15, 261–266.
19. Molven, O., Halse, A., and Grung, B. (1987). Observer strategy
and the radiographic classification of healing after endodontic
surgery. Int. J. Oral Maxillofac. Surg. 16, 432–439.
Address reprint requests to:
20. Molven, O., Halse, A., and Grung, B. (1986). Incomplete healing
Dr. Sheila Gouw-Soares
(scar tissue) after pariapical surgery—radiographic findings 8 to 12
years after treatment. J. Endodon. 22, 264–267. Avenue Prof. Lineu Prestes 2227
21. Frank, A.L., Glick, D.H., Patterson, S.S., and Weine F.S. (1992). Cidade Universitária,
Long-term evaluation of surgically placed amalgam fillings. J. En- São Paulo, Brazil
dodon. 18, 391–399. CEP: 05508-900