Peter Rechmann

Er:YAG lasers in dentistry: an overview

Aim of this presentation is to review the role of the Er:YAG laser in dentistry and to give a general overview on the work done with it up to date. A look at the development and evolution of this system is given as well as a brief introduction into the basic principles of ablation at the characteristic wavelength 2.94 micrometer. The more important research reports of the different groups all over the world are summarized and the large field of applications such as cavity preparation, caries ablation, periodontology and bacterial reduction is considered.

Selective ablation of sub- and supragingival calculus with a frequency-doubled Alexandrite laser

In a preceding trial the absorption characteristics of subgingival calculus were calculated using fluorescence emission spectroscopy (excitation laser: N2-laser, wavelength 337 nm, pulse duration 4 ns). Subgingival calculus seems to contain chromophores absorbing in the ultraviolet spectral region up to 420 nm. The aim of the actual study was the ablation of sub- and supragingival calculus using a frequency doubled Alexandrite-laser (wavelength 377 nm, pulse duration 100 ns, repetition rate 110 Hz). Extracted human teeth presenting sub- and supragingival calculus were irradiated perpendicular to their axis with a laser fluence of 1 Jcm-2. Using a standard application protocol calculus was irradiated at the enamel surface, at the junction between enamel and root, and at the root surface (located on dentin or on cementum). During the irradiation procedure an effective water cooling-system was engaged. For light microscopical investigations undecalcified histological sections were prepared after treatment. The histological sections revealed that a selective and total removal of calculus is possible at all locations without ablation of healthy enamel, dentin or cementum. Even low fluences provide us with a high effectiveness for the ablation of calculus. Thus, based on different absorption characteristics and ablation thresholds, engaging a frequency doubled Alexandrite-laser a fast and, even more, a selective ablation of sub- and supragingival calculus is possible without adverse side effects to the surrounding tissues. Even more, microbial dental plaque can be perfectly removed.

Caries selective ablation by pulsed lasers

The aim of the study was to find conditions for selective ablation of carious dentine. Absorption characteristics of healthy enamel, dentine, and carious lesions were studied by means of microspectrophotometry. It was found that in the spectral range of 330 to 520 nm optical density of carious dentine is higher by about a factor of 4 as in respect to healthy dentine. In the second part of the study, ablation thresholds were studied for different tissues at 355 nm (frequency tripled Q-switched Nd:YAG-Laser). By means of a piezoelectric detector, ultrasonic waves generated by ablation and subthreshold thermoelastic mechanisms were detected. Employing a fiber-optic delivery system, selective ablation of carious dentine occurred for pulse energies exceeding 0.4 Jcm-2 up to 1.2 Jcm-2.

Changes in surface morphology of enamel after Er:YAG laser irradiation

Aim of the study was to investigate the surface and subsurface structure of enamel after irradiation with an Er:YAG laser (wavelength 2.94 micrometer, pulse duration 250 - 500 microseconds, free running, beam profile close to tophead, focus diameter 600 micrometer, focus distance 13 mm, different power settings, air-water spray 2 ml/min; KAVO Key Laser 1242, Kavo Biberach, Germany). The surface of more than 40 freshly extracted wisdom teeth were irradiated using a standardized application protocol (pulse repetition rate 4 and 6 Hz, moving speed of the irradiation table 2 mm/sec and 3 mm/sec, respectively). On each surface between 3 and 5 tracks were irradiated at different laser energies (60 - 500 mJ/pulse) while each track was irradiated between one and ten times respectively. For the scanning electron microscope investigation teeth were dried in alcohol and sputtered with gold. For light microscopic examinations following laser impact, samples were fixed in formaldehyde, dried in alcohol and embedded in acrylic resin. Investigations revealed that at subsurface level cracks can not be observed even at application of highest energies. Borders of the irradiated tracks seem to be sharp while melted areas of different sizes are observed on the bottom of the tracks depending on applied energy. Small microcracks can be seen on the surface of these melted areas.

SEM investigations of the cementum surface after irradiation with a frequency-doubled alexandrite laser

During prior studies it could be demonstrated while engaging a frequency doubled Alexandrite-laser (wavelength 380 nm, pulse duration 100 ns, fluence 1 J/cm2, pulse repetition rate 110 Hz) a fast and strictly selective ablation of supra- and subgingival calculus is possible. Even the removal of unstained microbial plaque was observed. First conclusions were drawn after light microscopical investigations on undecalcified sections of irradiated teeth. In the present study the cementum surface after irradiation with a frequency doubled Alexandrite-laser was observed by means of a Scanning Electron Microscope. After irradiation sections of teeth were dried in alcohol and sputtered with gold. In comparison irradiated cementum surfaces of unerupted operatively removed wisdom teeth and tooth surfaces after the selective removal of calculus were investigated. A complete removal of calculus was observed as well as a remaining smooth surface of irradiated cementum.

Light and scanning electron microscope investigations comparing calculus removal using an Er:YAG laser and a frequency-doubled alexandrite laser

With respect to lasers emitting within the mid-IR spectral domain fiber applicators are being developed. Intended is the use of these lasers in periodontal therapy and their application inside the gingival pocket. Aim of the study presented here is to compare the effect of an Er:YAG laser on dental calculus with the results following irradiation with a frequency doubled Alexandrite laser. The surface of freshly extracted wisdom teeth and of extracted teeth suffering from severe periodontitis were irradiated with both laser wavelengths using a standardized application protocol. Calculus on the enamel surface, at the enamel cementum junction and on the root surface was irradiated. For light microscope investigations undecalcified histological sections were prepared after treatment. For the scanning electron microscope teeth were dried in alcohol and sputtered with gold. Investigations revealed that with both laser systems calculus can be removed. Using the frequency doubled Alexandrite laser selective removal of calculus is possible while engaging the Er:YAG laser even at lowest energies necessary for calculus removal healthy cementum is ablated without control.

Selective ablation of dental calculus with a frequency-doubled Alexandrite laser

The aim of the study was the selective removal of dental calculus by means of pulsed lasers. In a first approach the optical characteristics of subgingival calculus were calculated using fluorescence emission spectroscopy (excitation laser: N2-laser, wavelength 337 nm, pulse duration 4 ns). Subgingival calculus seems to absorb highly in the ultraviolet spectral region up to 420 nm. According to these measurements a frequency doubled Alexandrite-laser (wavelength 377 nm, pulse duration 100 ns, repetition rate 110 Hz) was used to irradiate calculus located on enamel, at the cementum enamel junction and on the root surface (located on dentin or on cementum). Irradiation was performed perpendicular to the root surface with a laser fluence of 1 Jcm-2. During the irradiation procedure an effective water cooling-system was engaged. Histological investigations were done on undecalcified sections. As a result, engaging low fluences allows a fast and strictly selective removal of subgingival calculus. Even more the investigations revealed that supragingival calculus can be removed in a strictly selective manner engaging a frequency doubled Alexandrite-laser. No adverse side effects to the surrounding tissues could be found.

Caries-selective ablation: the second threshold

The aim of the study was to describe the appropriate fluence necessary for the effective removal of dental decay by ablation processes without or with at least minimal removal of healthy dentin. The experiments were conducted at two wavelengths [355 nm (frequency tripled, Q-switched Nd:YAG-laser) and 377 nm (frequency doubled, gain-switched Alexandrite-laser)] found to be close to the maximum of preferential absorption of carious dentin over healthy dentin. Optoacoustic techniques were applied to determine the ablation thresholds of healthy and carious dentin. The ablation efficiencies at characteristic fluences were determined using non-tactile microtopography. During all experiments a fiber optic delivery system was engaged.

Caries-selective ablation: wavelength 377 μm versus 2.9 um

The aim of this study was to compare the conditions for selective removal of carious lesions by pulsed lasers emitting wavelengths in the near UV in contrast to lasers emitting in the IR spectral region at 2.9 micrometers . Absorption measurements of carious lesions and healthy dentin revealed highest absorption differences at wavelengths between 320 and 520 nm. The effects of a frequency doubled, gain-switched Alexandrite-laser (wavelength 377 nm) and a q- switched Er:YAG-laser (wavelength 2.9 micrometers ) on carious and healthy dentin were studied in comparison. Both lasers emitted pulses of 200 ns duration. The ablation thresholds for the different tooth structures were determined. The ablation threshold of carious lesions is about the same for the Er:YAG as for the second harmonic Alexandrite-laser. For the Er:YAG-laser the ablation threshold of healthy dentin is about 2 times higher than the ablation threshold of carious lesions. In the case of the second harmonic Alexandrite-laser the difference between ablation is 4 times higher. Thus, regarding the window of fluences sufficient for truly caries selective ablation, the conditions for selective removal of carious dentin are better in the near UV than in the IR spectral region at 2.9 micrometers .

Periodontal treatment with the frequency-doubled Alexandrite laser in dogs

While earlier periodontal investigations have proved the frequency doubled Alexandrite laser to eliminate efficiently and selectively dental calculus as well as bacteria the aim of this study was to demonstrate the safety of this laser for removal of dental calculus with respect to the dental pulp. Four adult Labrador dogs were treated with a frequency doubled Alexandrite laser (laboratory prototype, q-switched, fiber guided, wavelength 377 nm, pulse duration 1 microsecond, pulse repetition rate 70 Hz, water cooling) to remove dental calculus. After performing a modified Widman flap procedure the buccal surface of nine teeth in the lower and upper right jaw were irradiated for four minutes per tooth. Three different laser fluences up to four times higher than the fluence required for calculus removal were used (1.5, 3 and 6 J/cm2). At three other sites of the right jaw deep cavities were prepared with a dental drill and filled with compomere material (DyractR, Dentsply, Germany) to serve as a positive control with regard to possible pulpal reactions. The corresponding teeth of the lower and upper left jaw served as controls. Animals were sacrificed one day, one week, four weeks and six weeks after treatment. Teeth were separated, fixed in formalin and decalcified. After embedding and sectioning the histological sections were stained and investigated by a totally blinded investigator (P.A.R). Histological investigations revealed that irradiation with the frequency doubled Alexandrite laser for periodontal treatment with fluences of 1.5 J/cm2 -- those fluences necessary for the selective removal of dental calculus and microbial plaque -- had no adverse side effects to the pulpal tissues. Moreover this pulpal safety study demonstrated that even applying fluences two or four times higher than those suggested for calculus removal do not lead to observable changes or alterations in the odontoblast cell layer or the pulpal tissues. No inflammatory reactions and no differences between irradiated and control teeth occurred, while the positive controls showed reactions in the odontoblast cell layer and the connective pulpal tissue.