LASERS IN OPERATIVE

DENTISTRY
ANISHA
The word LASER is an acronym for light amplification
by stimulated emission of radiation.

The theory was postulated by Albert Einstein in 1916.

The laser light is different from the ordinary light -- aim a high amount
of energy in a limited space in the form of light radiation.

Collimated --- one focused direction.

Coherent --- each wave/photon has the same phase with the other
emitted waves/photons
Monochromatic --- each photon has one wavelength and one color
Characteristics Laser light Ordinary light

Direction Collimated One very focused Noncollimated or

direction multidirectional
Temporal phase Coherent Each wave/photon has Noncoherent or
the same phase with the other disorganized
emitted waves/ photon that are
kept in time

Color Monochromatic One wavelength Multichromatic from

and just one color (if visible) 400 to 700 nm
Emission

Spontaneous Emission

Bohr found that an electron could jump to a higher (and unstable)

level by absorbing energy and then the electron would return

to a lower (more stable) level while releasing a photon

He termed this spontaneous emission.

Stimulated Emission

In 1916 Albert Einstein postulated the theory of lasers .

-- during the process of spontaneous emission, an additional photon,
if present in the field of the already excited atom with the same
excitation level, would stimulate a release of two quanta.

These would be identical in phase, direction, and wavelength.

Also monochromatic and coherent—thus a laser is born.
Amplification

Once stimulated emission occurs, the process continues as more

photons enter the field both to excite the atoms and to interact with
the excited photons returning to their ground state.

Requires - constant source of energy– pumping mechanism.

Radiation
The entire array of wave energy is described by the electromagnetic
spectrum (ES) . 7 general classes, with increasing order of wavelength

• gamma rays
• X-rays
• UV
• visible radiation
• infrared radiation
• Microwaves
• radiofrequency waves
The ES can be more broadly divided into two divisions

gamma rays, X-rays, and UV - ionizing radiation

all the other wavelengths - nonionizing

Ionizing - radiant wave has enough photon energy to remove an electron

from an atom -- can cause mutagenic changes in cellular DNA.
For dentistry,

there are two basic types of lasers:

(1) one that operates as a semiconductor and compact in size
(2) one that has distinct components that, when assembled, occupy a
larger footprint.

The first type is generally known as a diode laser;

the second type encompasses all other lasers.
Basic Components of Lasers

1. The optical cavity (or resonator) that includes the active medium
2. The active medium which characterizes different wavelengths of
specific lasers
3. The pumping source (or energy source) to supply the energy
necessary for the stimulation
4. A controller that is a software that controls the modality and
parameter of laser emission and a cooler
5. The delivery system that transports the laser energy to a terminal
handpiece and tips
All available dental laser devices have emission wavelengths
of approximately 450 nanometers to 10,600 nanometers.

That places them in either the visible or the invisible nonionizing

portion of the ES
Active Medium
Lasers are generically named for the material that is being stimulated
such material is called the active medium.

Common materials for dental lasers

can be broadly designated as one of three types:
a container of gas, a solid-state crystal, or a semiconductor.

The active medium is at the center or core of the laser, termed the
optical cavity.
Gas Lasers

The most common gas dental laser is carbon dioxide, which

contains a gas mixture of carbon dioxide, helium, and nitrogen.

Helium is not directly involved in the lasing process

Nitrogen interact with the excitation process
Argon
A tube of this noble gas when excited – radiation,
most common being a visible blue and blue-green beam of
collimated light.

The physical demands of power and cooling -- limited application in

dentistry.
Solid-State Crystal Lasers
Various solid-state crystals are used in dental lasers.
The host material is composed of yttrium aluminum garnet (YAG),
yttrium aluminum perovskite (YAP), or yttrium scandium gallium
garnet (YSGG.)

Any of these can then be doped with ions of neodymium, erbium, and
chromium.
Semiconductor Dental Lasers
A semiconductor laser utilizes the basic positive-negative
(p-n) junction —the diode:

negatively charged electrons flows into the positively charged area

across the junction. The lasing action takes place between the charged
layers, called the depletion region.

Ex. GaAs ,AlGaAs, InGaAsP

Pumping Mechanism

Surrounding this optical cavity with its active medium is an

excitation source, known as the pumping mechanism.

Pumping transfers energy into the optical cavity,

so that the occupation of a higher energy level exceeds that of

a lower level. This condition is called population inversion
and it allows amplification to occur.
Diode lasers are electronically pumped

solid-state crystal lasers use high-powered strobes (flash lamps)

carbon dioxide lasers can be operated with AC or DC current or RF

Resonator

Aka optical cavity or optical resonator, is the laser component

surrounding the active medium.

In most lasers, there are 2 mirrors one at each end of the optical cavity,
placed parallel to each other in the case of a semiconductor
In all cases, these mirrored surfaces then produce constructive
interference of the waves:

the incident wave and the reflected wave can superimpose on each
other producing an increase in their amplitude.

This continued effect will help to collimate the developing beam.

Other Mechanical Components

cooling system

Focusing lenses - employed for each beam, and in the case of diode
lasers, for collimation.

laser control panel - allows the user to adjust the parameters of

energy emission
Laser energy is produced because the active medium is energized by
the pumping mechanism.

This energy in the form of photons is absorbed into the active medium,
raising its atomic electrons to higher orbital levels.

As the electrons return to their stable ground state, photons are

emitted while other entering photons can produce stimulated emission.

The resonator allows more numbers of these photonic interactions and

will continue the amplification process.
Laser Delivery Systems
Laser energy can be delivered to the surgical site by various
means that should be ergonomic and precise.

An optical fiber

A hollow waveguide

An articulated arm
Optical Fiber

An optical glass fiber usually made of quartz-silica.

This glass core conducts the laser beam along its length.

A thin polyamide coating surrounds the core to contain the light

Hollow Waveguide

A hollow waveguide is a jacketed flexible tube.

The internal surface has a reflective coating like silver iodide to
allow the beam’s transmission.

The waveguide is connected to the emission port on the laser.

Articulated Arm

An articulated arm consists of a series of

reflective hollow tubes with pivoting
internally mirrored joints along its length.
Contact and Noncontact Procedures

Clinically, a laser used in contact can provide easy access to

otherwise difficult-to-reach areas of tissue.

The fiber tip can easily be inserted into a periodontal pocket to

remove granulation tissue
In noncontact,

the beam is aimed at distance from the target

useful for following various tissue contours

but the loss of tactile sensation -- close attention to the tissue

interaction with the laser energy.
The active beam is focused by lenses

there will be a precise spot at the focal point where the

energy is the greatest

that spot should be used for incisional and excisional surgery.

Aiming Beam

dental lasers are equipped with a separate aiming beam,

which can either be laser or conventional light.

The aiming beam is delivered coaxially along the fiber or

waveguide and shows the operator the exact spot where the
laser energy will be focused.
Emission Modes

There are two natural modes of wavelength emission for dental

lasers, based on the excitation source:

continuous wave

free-running pulse
Continuous Wave

Continuous wave emission means that laser energy is emitted

continuously when the laser is switched on and produces constant
tissue interaction.

KTP, diode, and older model CO2 lasers

Free-Running Pulse

short bursts of laser energy due to a very rapid on-off pumping

mechanism.

Ex: high-powered strobing lamp or RF electronic field.

The power produced has a high peak and low average level

Nd:YAG, Nd:YAP, Er:YAG, and Er,Cr:YSGG and few carbon dioxide

Gated Pulsed Mode

equipped with a mechanical shutter with a time circuit to produce

pulsed energy.

Pulse durations can range from tenths of a sec to microsec.

Another method to produce very short pulses is called Q
switching

An attenuating mechanism modulates the rate of stimulated

emission, while the pumping mechanism continues to provide energy
into the resonator.

When the Q switch is turned off (opened), the result is a very short
pulse of light, on the order of tens of nanoseconds.
Alternatively, an acousto optic modulator can be placed
in the laser cavity to ensure that the phases of emission can
interfere with each other.

This is called mode-locking and can produce pico or femtosecond pulse

durations with resulting extremely high peak powers.

Current dental lasers do not utilize Q switching or mode-locking

emission modes
Photonic Energy and Target Molecular Structures

laser photonic energy is capable of ablative interaction

with target tissue elements (chromophores).

A chromophore is defined as a chemical group capable of selective

light absorption resulting in the coloration of certain organic
compounds
It must be stressed that laser–tissue interaction may occur
within one of 2 basic scenarios,

an interaction powerful to cause direct and irreversible change in the

target (usually achieved through thermal rise) - photothermolysis

second, less-powerful interaction that results in non damaging,

predominately stimulatory and biochemically mediated change
- photobiomodulation (PBM)
Laser–Hard Tissue Interaction

Hard dental tissues (enamel, dentin, and carious tissues) are composed
of different percentages of HA, water, and collagen matrix.

chromophores --have specific affinity with medium-infrared

wavelengths,
(Er, Cr:YSGG at 2,780 nm)
(Er:YAG at 2,940 nm),
The interaction of laser light with a target
tissue : a laser beam can be

reflected,
absorbed,
diffused (or scattered),
transmitted
The Wavelength
The first the hard tissue laser -
ruby laser (visible red at 694.3
nm)

The lack of cooling effect and the

low affinity for hard tissues

led to discouraging results

(charring, melting, and cracking)
CO 2 laser (in the far-infrared spectrum 10,600 nm)

XeCl laser (in the UV spectrum 308 nm)

Nd:YAG laser (in the near-infrared spectrum at 1,064 nm)

poor clinical outcomes

poor absorption in the enamel and dentin
excessive damage caused by heat
The lasers in the near-infrared light spectrum (from 810 to 1,340 nm) --
hb and melanin , less affinity for hard dental tissues.

The deep thermal effect of these wavelengths -- decontamination of a

deep cavity and melting of the superficial dentin --

Rx of dentinal hypersensitivity
In the visible light spectrum (from 532 to 675 nm)--
lasers with high affinity for hemoglobin and melanin.

KTP laser (532 nm) – surgery --to cut and for coagulation

in esthetic dentistry -- dental bleaching

The lasers in the red spectrum of visible light (630–675 nm) are used
for

pain therapy,
biostimulation,
anti-inflammatory therapy (lowlevel laser therapy, LLLT);
photodynamic therapy (PDT)
photoactivated disinfection (PAD)
CO 2 laser at 9,300 nm --- revived this wavelength for the ablation
of enamel and dentin
Medium-Infrared Lasers

specific affinity of water

specifically
(Er, Cr:YSGG at 2,780 nm) (Er:YAG at 2,940 nm)
-- erbium family laser
Er:YAG laser wavelength operates into
the peak of absorption of water, at 2,940 nm

Er, Cr:YSGG laser wavelength is absorbed slightly less by water

(300 % less) at 2,780 nm
The difference in the absorption
coefficients leads to a difference in the
penetration

Er:YAG laser approx –

7 μm in enamel
5 μm in the dentin

Er, Cr:YSGG laser -3 x deeper,

21 μm in the enamel
15 μm in the dentin
The Target Tissue
the main target tissues are enamel, dentin, and decayed tissue

composed of different percentages of HA, water, and collagen

and have selective affinity for the wavelengths 2,780 nm and 2,940
nm
Water and Hydroxyapatite Content of Dental Tissues

A healthy enamel is a highly mineralized tissue

93–96 % HA
3–5 % water
1 % organic tissue by weight

85 % HA
12 % water
3 % organic
tissue by volume
The water content of carious tissue is higher
than in healthy tissues (from 27 to 54 %)
depending on the stage of the caries lesion

highly and selectively absorbs the medium

Infrared wavelengths-- faster ablation
Mechanism of Interaction of the Erbium Family Lasers
on Hard Tissues

primarily -- photothermal effect

secondarily-- photomechanical and photoacoustic effects

Thermal Effect

The rapid temp. increase up to the bp of water (100 °C), trapped within
the dental interstitial str. -- increase pressure, when it exceeds the
structural tension of the surrounding tissue, --

microexplosion within the tissue

Photomechanical
and Photoacoustic Effects

photomechanical effect -- a rapid shock

wave that causes an expansion of the volume
of the disrupted tissue --
destruction of the surrounding mineral matrix
that explodes --- thus removing the tooth str.
Scattering of the laser beam after
the interaction with a cloud of debris, which
is formed following the ablation of dental
tissues.
Role of the Water in Hard Tissue Ablation

target chromophore

cleansing and cooling action -- for rehydration, which affects the

quality of the ablation of hard tissue
Meister J, Franzen R, Forner K, Grebe H, Stanzel S, Lampert F, Apel C.
Influence of the water content
in dental enamel and dentin on ablation with erbium YAG and erbium YSGG
lasers. J Biomed Opt.
2006;11

Only the water content of dentin significantly influences the volume of

ablation ( p < 0.0001) of the Er:YAG laser.
The ablation volume of the Er, Cr:YSGG laser also would not be influenced
by the water content of enamel
This result can be explained by the low water content of the enamel
and the ablative mechanism of the Er, Cr:YSGG laser (2,780 nm)

that could involve the interaction with the HA rather than with the
water
Mechanism of Interaction of Different Lasers on Soft
Tissues

The different composition of the tissue in melanin,

hemoglobin, water, and protein matrix (non-operator-dependent

factors) determines the different interaction with the selected
wavelength
The lasers in the visible and the
near-infrared spectrum -- melanin
and Hb.

The medium-infrared (Er, Cr:YSGG

and Er:YAG) and far-infrared lasers
(CO 2 )
-- water

the CO 2 laser has a moderate surface

absorption in tissue.
Laser Parameters

The parameters of laser used that influence the

effects on the tissue are:

• The energy emitted and its density ( fluence )

• The frequency of pulses in the time unit
• The average power emitted and its density ( power density )
• The pulse duration and peak power
As the distance btwn the laser tip and

the target tissue fluence

At 2-mm tip-to-tissue distance,

fluence -- 68 %
3 mm , decreases --- 78 %
Threshold of ablation

enamel
9–11 J/cm 2 -- Er:YAG laser
10–14 J/cm 2 -- Er, Cr:YSGG laser Apel et al. (2002)

dentin
2.97–3.56 J/cm 2 Er:YAG
2.69–3.66 J/cm 2 Er, Cr:YSGG Lin et al. (2010)
Laser Effects on Hard Tissues

Macroscopically,
(overlapped) craters-- rough, white opaque aspect

Whitish color -- disruption of the prismatic str.

of enamel and Organic matrix of the dentin

--- low reflection of light

Microscopically,

the enamel has an etched- like pattern,

dentin -- typical chimney- like appearance,

an effect of ablation prevalent in the

intertubular level -- more rich in water

smear layer absent

Influence of Laser Technique on Hard Tissue Irradiation

Speed: enables better control over the release of energy on the

tissue.

slow movement of the hand -- greater energy release per unit of

surface area

fast movement -- ineffective ablation

Working distance and focus

the distance from the target affects the density of energy and
power.

focusing or defocusing the laser beam increases or decreases the

energy density and power
Angulation

ideal angulation for enamel ablation -- perpendicular

to the orientation of the prisms

The percentage of ablation is nearly constant with radiation angle of

45° on the dental surface;

Variations of up to 90° do not seem to be a critical

Laser Etching

Er:YAG and Er, Cr:YSGG are rarely able to

produce enamel modification with Silverstone
type 1 pattern –

laser interaction works more on the peripheral

interprismatic structure -- rich in water, than
in the central zone of the prism – Silverstone
type 2 pattern

– flatter surface with fewer peripheral

prismatic bumps
Dentin Ablation and Conditioning

The photothermal and photomechanical

effects -- dentin ablation with
debris and smear layer removal –
typical cuff-like appearance/chimney like
appearance

Vaporization and denaturing of the

collagen fibers
Laser Effects on Bacteria

creates a substrate that is almost bacteria-free

Franzen et al. (2009) - Er, Cr:YSGG radiation at a low pulse energy

of 3.13 mJ, delivered at an incidence angle of 5° to the dentin slice
surface, resulted in significant bacterial reduction up to a dentin
thickness of 500 μm

At 75 mJ -- damage the cell walls of the bacteria, alteration of the

osmotic gradient -- cell death
Enamel

acid etching with phosphoric acid - mandatory on laser-irradiated

enamel with respect to bond strength and marginal seal.

There was no value-added benefit of laser etching of the enamel

after laser preparation

--De Moor and Delmé 2009

Dentin

The hybrid layer -- thinner

compared to acid-etched bur-cut dentin

Reasons for the less profound hybridization:

• Increase of the Ca and P because organic components are selectively

removed.

• Reduction of carbon-to-phosphorus ratio leading to more stable

and less acid-soluble compounds.

• Creation of a more acid-resistant enamel and peritubular dentin.

• More intensive loss of carbonates

• The chemical composition is altered.

• Heat during laser irradiation -- denaturation of the collagen
network and decreases dentin permeability

• Formation of a modified superficial layer -- collagen fibres are

poorly attached to the underlying dentin.

• Thermal effects impair inter diffusion zone formation

• Melting and recrystallisation leave the surface hypermineralised

and less permeable, which can affect the acid resistance .
Glass Ionomer Adhesion and Laser Dentistry

Higher bond strengths are registered for RMGIC adhering

to bur-cut dentin surfaces as compared lasers.
Lasers have many uses in preventive dentistry for the following
purposes
Caries detection: laser fluorescence (LF) has been used for
diagnosis of caries (DIAGNOdent, KaVo)

Caries prevention: lasers provide increased enamel surface resistance

to acid attack as experimental methods of caries prevention.

Sealants: erbium lasers irradiation are used to provide enamel surface

modifications that are suitable for the application of pit and fissure
sealants.
Laser Fluorescence:

non-ablative laser device that emits a visible, red light at 655 nm.
When the light is directed towards the occlusal fissures of post.
teeth, it is transmitted through the enamel and is absorbed by a
specific target.

bacteria by-products and porphyrins within the carious lesion absorb

and simultaneously reflect a red fluorescent light that is detected and
rated at a digital display and as an acoustic signal
Erbium lasers can be used as:

– Noninvasive technique for conditioning of

healthy pits and fissures

– Minimally invasive technique for

decontamination and conditioning
pretreatment of deep fissures / initial
demineralization

– Minimally invasive technique for white spot

or caries removal
Laser for Caries Prevention

Stern et al. first demonstrated the possibility of using laser

irradiation to improve the resistance of dental enamel to acid
attack.

A carbon dioxide (CO 2 ) laser irradiation (10,600 nm) was used to

melt the external enamel structure through heating
Near-Infrared Laser Irradiation

The enamel is essentially transparent to the Nd:YAG laser at 1064 nm

and researches were aimed to the use of a chromophore that could
absorb the near-infrared energy superficially ---- 39% caries redn.
--- Zezell et al

in vitro the effect of a 810 nm diode laser radiation with fluoride gel
application ---

fluoride uptake on enamel surfaces.

--- Vitale et al. (2011)
Visible Argon Laser Irradiation

Enamel is almost transparent

Powell et al --- positive remineralization and acid resistance effect

and increased enamel microhardness, following
the irradiation by Ar laser light alone or in combination with APF /ZnF

almost abandoned.
Medium Infrared Laser Irradiation

several studies showed the potential of erbium lasers irradiation

alone or in combination with fluoride application to provide

caries resistance to enamel or remineralization potential,

no definitive proof if they are suitable for clinical application

Laser Advantages in
Restorative Dentistry
No Pain Dentistry

Laser irradiation initiates the disruption of the NA+/K+ pump of the

cell membrane of the nerve fibre -- membrane hyperpolarisation
-- in loss/decrease of impulse conduction --- analgesic effect

and in order to initiate a potential action, a stimulus of greater

intensity is needed thus
--- raising the threshold of pain
Margolis Technique

Erbium laser Tip defocused at 4 mm from the tooth surface and

then run slowly across the facial surface of the ant. teeth /
occlusal surface of the post. teeth at 1.5 W, 20 Hz, for 30 s.
Olivi-Genovese Technique
laser tip is positioned defocused 10 mm
farther from the gum-tooth and run slowly
around the neck of the tooth at the gingival
margin for 40–60 s at very-low energy and
low pulse repetition rate and low air-water
ratio.
Laser-Assisted In-Office Bleaching

During an in-office bleaching

procedure, it is possible to activate
the bleaching material by a laser
Conclusion

Research continues to both improve existing instruments

and to discover new technologies, wavelengths, and clinical
applications. The possibilities are certainly numerous within
any area of study.
THANK YOU