高祥牙醫-牙周病專科

雷射在牙周治療之臨床應用

前言

回顧雷射發展史，可簡易區分從1960～1990年所使用的雷射屬於前三代雷射（例如CO2, Argon, Diode, Ho:YAG, Nd:YAP,Nd:YAG），直到1998年10月Er,Cr:YSGG雷射(附註1)通過美國FDA安全評估許可上市(附註2)，實為牙醫雷射科技的重大突破，更開創了牙醫界新紀元。Er,Cr:YSGG雷射屬於第四代雷射，與前三代雷射比較，主要差異在於Er,Cr:YSGG雷射在操作過程中同時釋放水分子，以冷卻組織，避免組織受到傷害，且利用Hydrophotonics(水光子)所產生的動能達到安全切割牙齒，齒槽骨及牙齦組織.至於前三代雷射在牙周及牙周病治療之相關研究報告與臨床應用，限於篇幅，在此不容再贅述，敬請讀者參閱Periodontology 2000 在2004年所發表的Lasers in nonsurgical periodontal therapy及 2002, 2006年,AAP(美國牙周病醫學會)在JP所發表的 Lasers in Periodontics之review literature. 本文筆者主要以連續兩年( 2005,元月及 2006, 3月)參加世界臨床雷射醫學會( WCLI)在美國 San Diego所舉行年度 Super Symposium 收集的資料及最新有關雷射在牙周治療之文獻回顧為主，探討Er,Cr:YSGG雷射在牙周治療之臨床應用，且以一臨床病例( 牙周膿腫，局部慢性牙周炎，角化牙齦寬度不足，頰側過度繫帶及齒質敏感 )與諸位讀者分享該雷射臨床牙周治療經驗。

 

病例報告

Name : 蔡 小姐
Age : 23 Y/O
Gendar : Female
Chief complaint : Pain & swelling over lower L’t cheek region for about 2 days.

 

 

Intraoral & Dental Examination :
a. Missing of #36 due to severe caries.
b. Ill-fitting bridge over #35 ,#36, # 37
c. Periodontal abscess formation over buccal region of #35.
d. Pulp test for #35 : “ + “ after removal of ill-fitting bridge

 

 

d. Gingival recession & inflammation over buccal surface of #35.
e. Probing depth : #35
f. High buccal frenum over buccal surface of #36
g. Inadequate width of keratinized gingiva over buccal surface of #35 & #36

 

Roentgenographic findings :

1. Ill-fitting bridge of #35, #36, # 37
2. Thin & narrow angular bony defect over buccal & distal surface of #35

 

Diagnosis :

1. Periodontal abscess of #35
2. Localized advanced chronic periodontitis of #35
3. High buccal frenum of #36
4. Inadequate width of keratinized gingiva of #35

 

Treatment plan :

1. Patient education, motivation .
2. Plaque control program.
3. Full mouth scaling, root planing & polish.
4. Removalof ill-fitting bridge & Provisional bridge : #35,#36,# 37
5. Incision & Drainage over buccal surface of #35, #36 with Waterlase.
6. Frenectomy with Waterlase.
7. Free gingival graft over buccal surface of #35, #36. with Waterlase.

 

Sequence of Management :

Removal of ill-fitting bridge
Subgingival scaling ( Thick & Thin tip )
Incision & Drainage
Decontamination

 
 

 

 

Preparation of Donor site

 
 
   

 

Before
  
After

 

Prosthesis Finish

 

 

Pre-treatment

 

 

Post-treatment

 

 

討論

此病例主要病因為牙菌斑，而促發因子為Ill-fitting bridge ( #35, #36, #37 ) 與High buccal frenum ，進而不能做好plaque control，造成大量牙菌斑堆積 ,導致 #35 發生Periodontal abscess & Localized advanced chronic periodontitis.處理順序：首先拆除Ill-fitting bridge及製作Temporary bridge,，接著做Conventional initial periodontal treatment,用一般型Scaling tip清除Supragingival heavy calculus,再用細的Scaling tip 清除Subgingival calculus.其次在periodontal abscess處塗抹表面麻醉,用T4 tip(附註3)做I&D,以大量生理食鹽水沖洗傷口，最後用Z4 tip對傷口內部及#35 periodontal pocket做Decontamination. 用 Z4 tip做I&D時，切線要夠長以利於Z4 tip做Decontamination,操作過程，應避免Z4 tip touch到bone.用Z4 tip對#35 periodontal pocket做Decontamination前，準備charting記錄表，且在Z4 tip上mark probing depth，Z4 tip貼著Soft tissue做Z字形回抽（從Apical往Coronal方向），操作過程，應避免Z4 tip touch到bone & root surface. 用Z4 tip做FGG，Preparation of Recipient site的速度並不會比傳統手術刀慢，只是在Preparation of Donor site時，一小部分仍須藉助手術刀。在Suture of Graft前，用G tip對#35 root surface及bony defect（深窄型）做Decontamination. 術後2個月，#35頰側probing depth已降至3mm，術後1年追蹤檢查，發現#35 bony defect有bone fill，而probing depth維持3mm，至於是否有Regeneration需要有Histologic Evidence才能證實. 治療前#35 periapical portion出現radiolucent shadow,經EPT檢測為〝＋〞，術後一年，再做EPT檢測仍是〝＋〞。在治療初期，#35頰側有gingival recession，出現root sensitivity，用 G4 tip以Turtle technique(附註4)做去敏感，處理後,至術後一年追蹤檢查，root sensitivity現象已不再發生。

Er,Cr:YSGG雷射，利用水光子原理(Hydrophotonics)，以雷射能量激發水分子，瞬間產生微爆(Microexplosion)動能來達到切割軟硬組織效果.. Er,Cr,YSGG雷射屬於第四代雷射，於1998年通過美國FDA上市使用. 每種雷射有其不同的波長，臨床適應範圍亦不同，使用者在使用前必須先接受該雷射嚴格的專業操作訓練及取得認證，完全充分了解使用操作程序與適應範圍，才能避免對牙周組織造成傷害. 已有多篇相關文獻報告證實，臨床上使用Er,Cr;YSGG雷射對pulp, soft tissue, tooth, bone, root surface皆不會造成傷害.該雷射安全性甚高，臨床上適用於軟硬組織，是一全功能雷射，應用在牙周手術方面能有效滅菌，術中減少流血與不適 ,術後減少腫痛與用藥,受診者滿意度能有效增加. 除了牙周手術(附註5)，植牙手術，門診小手術對受診者術中與術後亦有相同助益。

有關Er,Cr;YSGG雷射應用於根管治療及牙體復形的研究文獻報告已超過千篇,然而目前有關該雷射應用於牙周治療方面的研究文獻報告卻有限，且並無足夠研究文獻報告證實該雷射能取代傳統牙周基本治療( SRP ). 該雷射用在牙周治療後就gingival recession, reduction in probing depth, gain in clinical attachment level之變化與在傳統牙周治療後兩者比較情形，仍需有更多animal studies及human clinical studies來做進一步確認. 任何牙周病患,皆需先施予傳統牙周基本治療(SRP)，而且病患必須高度配合做好plaque control，再配合該雷射做牙周輔助治療，進而病患配合定期維持保養,才能有牙周療效。

 

附註 1：

 

附註 2：美國 FDA 安全認可 Er, Cr :YSGG雷射(Waterlase)於各項治療時程

 

附註3：tips的分類及其用途 G-tip：通用型光纖端頭，軟硬組織可用。T-tip：尖型光纖端頭，I &D專用，細切軟組織。Z-tip：細長有彈性，適用於Perio與Endo療程。

 

附註4：Turtle technique ( 去敏感術 ) 之 Power, Air, Water, Time 的設定
Power Air Water Time
0.25W 15% 15% 40秒
0.25W 7% 7% 40秒
0.25W 0 0 30秒

 

附註5 : 牙周手術

參考資料 :

  1. AAP. Academy Report : Lasers in periodontics. J Periodontol , 73:1231-39, 2002.
  2. Aoki A,Sasaki KM,Watanabe H,Ishikawa I.Lasers in nonsurgical periodontal therapy. Periodontol 2000 36:59-97 , 2004.
  3. Charles M. Cobb. Lasers in Periodontics : A Review of the Literature J Periodontol 77:545-564, 2006.
  4. Midda M. Lasers in periodontics . Periodontal Clin Investig 1992 ; 14:14-20.
  5. Midda M. The use of lasers in periodontology. Curr Opin Dent 1992 ; 2:104-108.
  6. Bader H. Use of lasers in periodontics. Dent Clin North Am 2000; 44:779-792.
  7. Wigdor H, Walsh J, Featherstone LDB, et al. Lasers in dentistry. Lasers Surg Med 1995 ;16:103-133.
  8. Rizoiu I , et al. Pupal thermal response to an Er, Cr : YSGG laser hydrophotonic “ . Oral Surg Oral Med Pathol Oral Radiol Endod , 1998
  9. Walinski, CJ. Irritation fibroma removal : A comparison of two laser wavelengths J Gen Dent , 2004 May/June
  10. Kimura Y et al .Effects of Erbium, Chromium:YSGG Laser Irradiation on Canine Mandibular Bone. J Periodontology 2001;72:1178-1182
  11. XIAOGU WANT et al .Morphological Changes of Bovine Mandibular Bone Irradiated by Er,Cr:YSGG Laser: An in vitro Study.Journal of clinical laser Medicine & surgery 2002 ; 20: 245-250
  12. Kimura Y,et al.Effects of Er, Cr: YSGG laser irradiation on root surface: morphological and atomic analytical studies. J Clin Laser Med Surg ,2001 April
  13. Kimura Y, et al.Laser –aided periodontal therapy.Effects on Subgingival Plaque. J Clin Laser Med Surg 1998 ; 22:302-311
  14. Eversole LR, Rizoiu I, Kimmel AI. Pulpal response to cavity preparation by an Er,Cr:YSGG laser-powered Hydrophotonic system. JADA, Aug. 1997

 

雷射在牙周再生手術之臨床應用

前言

雷射的發展源於1917年，Albert Einstein（愛因斯坦）發現激發輻射原理。1958年，Shawlow和Townes兩位學者建立光線強度放大的原理。”LASER”全名為Light Amplification by Stimulated Emission of Radiation，指透過激發輻射以產生光線強度的放大。1960年梅曼（Mainman TH）成功的製造全世界第一台雷射－紅寶石雷射1。1961年被首度應用於眼疾治療。1964年Leo Goldman2始應用雷射作去除齲齒. 波長的不同，決定雷射的種類 ;每種雷射，有不同的臨床操作方式及注意事項，臨床應用範圍亦不同.目前有二氧化碳（CO2）雷射，釹雅克（ Nd：YAG）雷射，鉺雅克（Er：YAG）雷射及二極體（Diode）雷射等應用於牙科及其他醫療用途上。而應用雷射於牙周治療最早在1985年Pick等學者使用二氧化碳（CO2）雷射切除因藥物引起的牙齦腫大之病例報告.綜觀雷射發展，可簡易區分從1960～1990年所使用的雷射屬於前三代雷射（例如CO2, Argon, Diode, Ho:YAG, Nd:YAP,Nd:YAG）3-55，直到1998年10月Er,Cr:YSGG雷射(附註 1)通過美國FDA安全評估許可上市，實為牙醫雷射科技的重大突破，更開創了牙醫界新紀元。Er,Cr:YSGG雷射屬於第四代雷射，與前三代雷射比較，主要差異在於Er,Cr:YSGG雷射在操作過程中同時釋放水分子，以冷卻組織，避免組織受到傷害，且利用hydrophotonics(水光子)所產生的動能達到安全切割牙齒，齒槽骨及牙齦組織.至於前三代雷射在牙周及牙周病治療之相關研究報告與臨床應用56-62,限於篇幅,不容在此贅述, 本文筆者主要以一臨床病例( 牙周膿腫，局部嚴重慢性牙周炎)探討Er,Cr:YSGG雷射在牙周再生手術之臨床應用。

 

臨床病例

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

討論

此病例主要病因為牙菌斑, 而促發因子為Ill-fitting bridge ( #14, #15, #16,#17 )，進而不能做好plaque control，造成大量牙菌斑堆積 ,導致 #14發生Periodontal abscess & Localized advanced chronic periodontitis.處理順序：首先拆除Ill-fitting bridge及製作Temporary bridge,，接著做Conventional initial periodontal treatment,用一般型Scaling tip清除Supragingival heavy calculus,再用細的Scaling tip清除Subgingival calculus.其次在periodontal abscess處塗抹表面麻醉,用T4 tip(附註2)做I&D,以大量生理食鹽水沖洗傷口，最後用Z4 tip對傷口內部及#14 periodontal pocket做Decontamination. 用 Z4 tip做I&D時，切線要夠長以利於Z4 tip做Decontamination,操作過程，應避免Z4 tip touch到bone.用Z4 tip對#14 periodontal pocket做Decontamination前，準備charting記錄表，且在Z4 tip上mark probing depth,Z4 tip貼著Soft tissue做Z字形回抽（從Apical往Coronal方向），操作過程，應避免Z4 tip touch到bone & root surface. 用G tip對#14 root surface及bony defect（深窄型）做Decontamination. 術後6個月，#14頰側,腭側,近心側及遠心側之probing depth已降至3mm，且發現#14 bony defect之近心側,遠心側有bone fill，至於是否有Regeneration需要有Histologic evidence才能證實. 治療前#14 periapical region出現radiolucent shadow,經EPT檢測為〝＋〞，術後四個月，再做EPT檢測是 〝－〞，因此施予#14根管治療。

 

Er,Cr:YSGG雷射，利用水光子原理(hydrophotonics)，以雷射能量激發水分子，瞬間產生微爆(microexplosion)動能來達到切割軟硬組織效果.. Er,Cr,YSGG雷射屬於第四代雷射，於1998年通過美國FDA上市使用(附註 3). 每種雷射有其不同的波長，臨床適應範圍亦不同，使用者在使用前必須先接受該雷射嚴格的專業操作訓練及取得認證，完全充分了解使用操作程序,設定值與適應範圍，才能避免對牙周組織造成傷害。已有多篇相關研究文獻報告證實，臨床上使用Er,Cr;YSGG雷射對pulp，soft tissue，tooth，bone，root surface皆不會造成傷害63-68.該雷射安全性甚高，臨床上適用於軟硬組織，是一全功能雷射，應用在牙周手術方面能有效滅菌，術中減少流血與不適 ,術後減少腫痛與用藥,受診者滿意度能有效增加. 除了牙周手術(附註4)，植牙手術，門診小手術對受診者術中與術後亦有相同助益。

 

使用有關Er,Cr;YSGG雷射應用於根管治療及牙體復形的研究文獻報告已超過千篇,然而使用目前有關該雷射應用於牙周治療方面的研究文獻報告卻有限，且並無足夠研究文獻報告證實該雷射能取代傳統牙周基本治療( SRP ). 該雷射用在牙周治療後就gingival recession，reduction in probing depth，gain in clinical attachment level之變化與在傳統牙周治療後兩者比較情形，仍需有更多animal studies及human clinical studies來做進一步確認. 任何牙周病患,皆需先施予傳統牙周基本治療(SRP)，而且病患必須高度配合做好牙菌斑控制(plaque control)，再配合該雷射做牙周輔助治療，進而病患配合定期維持保養,才會有牙周療效。

 

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  32. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Ultrastructural analysis of bone tissue irradated by Er:YAG laser. Lasers Surg Med 2002;31:322-332.
  33. Sasaki KM, Aoki A, Ichinose S, Yoshino T, Yamada S, Ishikawa I. Scanning electron microscopy and Fourier transformed infrared spectroscopy analysis of bone removal using Er:YAG and CO2 lasers. J Periodontol 2002;73:643-652.
  34. Zaffe D, Vitale MC, Martignone A, Scarpelli F,Botticelli AR. Morphological, histochemical, and immunocytochemical study of CO2 and Er:YAG laser effect on oral soft tissues. Photomed Laser Surg 2004;22:185-189.
  35. Israel M,Cobb CM, Rossmann JA, Spencer P. The effects of CO2,Nd:YAG and Er:YAG lasers with and without surface coolant on tooth root surfaces. An in vitro study.J Clin Periodontol 1997;24:595-602.
  36. Frentzen M, Braun A, Aniol D. Er:YAG laser scaling of diseased root surfaces.
    J Periodontol 2002;73:524-530
  37. Crespi R, Barone A, Covani U. Effect of Er:YAG laser on diseased root surfaces: An in vivo study. J Periodontol 2005;76:1386-1390.
  38. Schoop U, Moritz A, Maleschitz P, et al. The impact of Er:YAG laser irradiation on toot surfaces: An in vitro evaluation. J Oral Laser Appl 2001;1:35-41.
  39. Schwarz F, Putz N, Georg T, Reich E. Effect of an Er:YAG laser on periodontally involved root surfaces: An in vivo and in vitro SEM comparison. Lasers Surg Med 001;29:328-335
  40. Yamaguchi H, Kobayashi K, Osada R, et al. Effects of irradiation of an Erbium:YAG laser on root surfaces. J Periodontol 1997;68:1151-1155.
  41. Theodoro LH, Haypek P, Bachmann L, et al. Effect of Er:YAG and diode laser irradiation on the root surface: Morphological and thermal analysis. J Periodontol 2003;74:838-843.
  42. Schoop υ, Moritz A, Kluger W, et al. Changes in root surface morphology and fibroblast adherence after Er:YAG laser irradiation. J Oral Laser Appl 2002;2:83-93.
  43. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Morphological analysis of cementum and root dentin after Er:YAG laser irradiation. Lasers Surg Med 2002;31:79-85.
  44. Folwaczny M, Benner KU, Plasskamp B, Mehl A ,Hickel R. Effects of 2.94 micron Er: YAG laser radiation on root surfaces treated in situ: A histological study.
    J Periodontol2003;74:360-365.
  45. Crespi R, Romanos GE, Barone A, Sculean A, Covani υ. Er:YAG laser in defocused mode for scaling of periodontally involved root surfaces: An in vitro pilot study .
    J Periodontol2005;76:686-690.
  46. Ando Y, Watanabe H, Ishikawa I. Bactericidal effect of erbium YAG laser on periodontopathic bacteria. Lasers Surg Med 1996;19:190-200.
  47. Aoki A , Ando Y, Watanabe H, Ishikawa I. In vitro studies on laser scaling of subgingival calculus with an erbium:YAG laser. J Periodontol 1994;65:1097-1106.
  48. Folwaczny M, Mehl A, Haffner C, Benz C, Hickel R. Root substance removal with Er:YAG laser radiation at different paramenters using a new delivery system.
    J Periodontol 2000;71:147-155.
  49. Aoki A, Miura M, Akiyama F, et al.In vitro evaluation of Er:YAG laser scaling of Subgingival calculus in comparison with ultrasonic scaling. J Periodontal Res 2000;35:266-277.
  50. Schwarz F, Sculean A,Georg T,Reich E. Periodontal treatment with an Er:YAG
    laser compared to scaling and root planing. A controlled clinical study. J Periodontol 2001;72:361-367.
  51. Schwarz F, Sculean A Berakdar M, Georg T, Reich E Becker J. Clinical evaluation of an Er:YAG laser combined with scaling and root planing for nonsurgical periodontal treatment. A controlled, prospective clincal study . J Clin Periodontol 2003;30-26-34.
  52. Schwarz F, Sculean A, Berakdar M, Georg T , Reich E, Becker J. Periodontal treatment whit an Er:YAG laser or scaling and root planing. A 2-year follow-up split-mouth study. J Periodontol 2003;74:590-596.
  53. Sculean A, Schwarz F, Berakdar M, Romanos GE, Arweiler NB, Becker J.
    Periodontal treatment with an Er:YAG laser compared to ultrasonic instrumentation: A pilot study. J Periodontol 2004;75:966-973.
  54. Schwarz F, Sculean A, Georg T Becker J. Clinical evaluation of the Er:YAG
    laser in combination with an enamel matrix protein derivative for the treatment of intrabony periodontal defects:A pilot study. J Clin Periodontol 2003;30:975-981.
  55. Sculean A, Schwarz F, Bearkdar M, Windisch P,Arweiler NB, Romanos GE.
    Healing of intrabony defects following surgical treatment with or without an Er:YAG laser. J Clin Periodontol 2004;31:604-608.
  56. AAP. Academy Report : Lasers in periodontics.
    J Periodontol , 73:1231-39, 2002.
  57. Aoki A,Sasaki KM,Watanabe H,Ishikawa I.Lasers in nonsurgical periodontal therapy. Periodontol 2000 36:59-97 , 2004.
  58. Charles M. Cobb. Lasers in Periodontics : A Review of the Literature
    J Periodontol 77:545-564, 2006.
  59. Midda M. Lasers in periodontics . Periodontal Clin Investig 1992 ; 14:14-20.
  60. Bader H. Use of lasers in periodontics. Dent Clin North Am 2000; 44:779-792.
  61. Wigdor H, Walsh J, Featherstone LDB, et al. Lasers in dentistry.
    Lasers Surg Med 1995 ;16:103-133.
  62. Kimura Y, et al.Laser –aided periodontal therapy.Effects on Subgingival Plaque.
    J Clin Laser Med Surg 1998 ; 22:302-311
  63. Eversole LR, Rizoiu I, Kimmel AI. Pulpal response to cavity preparation by an Er,Cr:YSGG laser-powered Hydrophotonic system. JADA, Aug. 1997
  64. Rizoiu I , et al. Pupal thermal response to an Er, Cr : YSGG laser hydrophotonic “. Oral Surg Oral Med Pathol Oral Radiol Endod , 1998
  65. Walinski, CJ. Irritation fibroma removal : A comparison of two laser wavelengths
    J Gen Dent , 2004 May/June
  66. Kimura Y et al .Effects of Erbium, Chromium:YSGG Laser Irradiation on Canine Mandibular Bone. J Periodontology 2001;72:1178-1182
  67. XIAOGU WANT et al .Morphological Changes of Bovine Mandibular Bone Irradiated by Er,Cr:YSGG Laser: An in vitro Study.Journal of clinical laser Medicine & surgery 2002 ; 20: 245-250
  68. Kimura Y,et al.Effects of Er, Cr: YSGG laser irradiation on root surface:
    morphological and atomic analytical studies. J Clin Laser Med Surg ,2001 April

 

附註1：

 

附註2：tips的分類及其用途 G-tip：通用型光纖端頭，軟硬組織可用。T-tip：尖型光纖端頭，I &D專用，細切軟組織。Z-tip：細長有彈性，適用於Perio與Endo療程。

 

附註3：美國 FDA 安全認可 Er, Cr :YSGG雷射(Waterlase)於各項治療時程使用

 

附註4:牙周手術

 

Clinical Applications Of Er,Cr:YSGG Laser In Implant Therapy

Introduction

 

Laser theory was originally developed in 1916 by the great scientist, Albert Einstein, as the theory of " Stimulated Emission of Radiation ". Shawlow and Townes then established the theory of " Light Amplification " in 1958. "LASER" was abbreviated by “Light Amplification by Stimulated Emission of Radiation”, which means “light amplification is produced by stimulated emission of radiation”. The first laser, ruby laser, was developed by Maiman in 1960.1 Ophthalmologists began using the ruby laser for eye lesion therapy in 1961. The laser was first applied for caries removal by Leo Goldman in 1964.2 The characteristics of a laser depend on its wavelength. Wavelength affects not only the clinical applications but also the functional design of a laser. There are several different dental applications and precautions for different types of lasers. In general, there were three generations of lasers(CO2; Nd:YAG; Ho:YAG; Argon and Nd:YAP; Diode)3-31 available for dental and medical surgical specialties in the period of 1960-1990. The fouth generation lasers, namely Er:YAG32-55 and Er,Cr:YSGG56-62 (Erbium, Chromium, Yttrium, Scandium , Gallium and Garnet), were developed in 1990. A few years later, FDA awarded safety clearance for Er,Cr:YSGG laser in Oct. 1998. The major difference between Er,Cr:YSGG laser and the first three generation laser is that Er,Cr:YSGG laser does release water for cooling tissue as protection function in the operation process and cut tooth, alveolar bone, gingival tissue safely by “ Hydrophotonics63 mechanism.

The main purpose of this article was to present the soft tissue management with Er,Cr:YSGG laser in implant therapy by case reports . The clinical cases include incision , uncovering, minor gingivoplasty around dental Implant, mucogingival surgery-keratinized gingiva .

 

Case Presentation

Case 1- Incision


The settings of Er,Cr:YSGG laser for incision are power- 1~2 W, air- 11 %, water – 7 %.
Bleeding of the operation site is reduced and patient’s discomfort is minimal when using Er,Cr:YSGG laser during implant surgery.

 

Case 2- uncovering


The settings of Er,Cr:YSGG laser for uncovering are power- 1~2 W, air- 11 %, water – 7 %.
The uncovering procedure :
First- find out the central hole of healing screw.
Second- “ Cross” shape incision along with the central hole of healing screw with T4 tip.
Third- Exposure the head of fixture with minor gingivoplasty.
Fourth- Connection of prosthetic abutment.
Recommendation : The tip of Er,Cr:YSGG laser only can touch soft tissue lightly; it can not
touch metal surface, or tip and optic fiber will break

 

Case 3- Minor gingivoplasty


The minor gingivoplasty procedure :
First – Remove the gingival tissue surrounding the head of fixture with T4 tip
Second – Connection of prosthetic abutment

 

Case 4 –Mucogingival surgery

 

Inadequate width of keratinized gingival over # 46 is noted in implant therapy’s
pre-surgical evaluation. Autogenous gingival graft over # 46 is decided before
implant surgery.

 


Preparation of the recipient site :
First – Mark the distinction between K.G and Non-K.G. zone with local anesthesia.
Second – Touch lightly or no touch soft tissue with T4 tip for creating partial-thickness flap.

 

 

Preparation of donor site :
Mark the range of graft ( length & width & depth ) , incision with T4 tip.
Recommendation : Do not manage the inner surface of graft with T4 tip.

 


Suture of graft with 5-O chromic. Removal of stitches P-OP one week.
Soft tissue management over graft surface with G4 tip .

 


The healing wound is uneventful P-OP 2 weeks & 1 month.

 

Case 5 –Mucogingival surgery

 
 

Sinus lifting over #26, #27 with open window technique simultaneously with first stage
of implant surgery is noted. Second stage (uncovering) was proceeded after 5 months healing and combined with frenectomy for correcting high buccal frenum & rotated palatal flap for increasing width of keratinized width.

 


Incision over mesial , distal, palatal for creating full-thickness flap and vertical releasing Incision over mesiobuccal surface.

 


Reflecting the full-thickness flap ,unscrewed the healing screw, connected the healing abutment , sutured the buccal plap with 4-O chromic suture.

 


Creating the pedicle flap for filling the gap over the palatal surface of healing abutment.

 


The healing is uneventful P-OP two weeks & P-OP one month.
Removal of stitches P-OP two weeks.

 

Discussion

Er, Cr:YSGG laser is a hydrophotonic system, referring to the removal of tissues with highly energized water particles. Strong absorption of laser energy by atomized water droplets results in an intensed yet controlled water particle excitation and microexplosion. The resulting forces induce mechanical separation of surface material. It produces little heat and vibration and does minimal invasion on adjacent tissue in the process For soft tissue procedures, the Er,Cr:YSGG laser performs tissue removal, incision, excision, ablation and coagulation. At present, there are many articles clarify that Er,Cr:YSGG laser does not damage pulp, gingiva, tooth, alveolar bone, root surface in the process.64-68 Er,Cr:YSGG laser did not damage soft tissue and adjacent tissue in implant surgery. Er,Cr:YSGG laser can seal blood vessels and lymphatic vessels. It also can elevate the threshold level of pain. Less bleeding ,less edema and less pain in the process is predictable when using Er,Cr:YSGG laser in soft tissue management . Prognosis is so good that increases patient's comfort rate . In most cases, pre-operative anesthesia is not necessary. Topical anesthesia was applied just in case of sensitivity.

 

Conclusion

Soft tissue management with Er,Cr:YSGG laser in implant therapy provides less bleeding, less edema , less pain, less infection and less medication. Prognosis is so good that increases patient's comfort rate.

 

Reference :

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    An evaluation of the Nd:YAG laser in periodontal pocket therapy..Br Dent J 1996;180:57-62.
  31. Liu C-M, Hou L-T, Wong M-Y, Lan W-H.Comparison of Nd:YAG laser versus scaling and root planing in periodontal therapy. J Periodontol 1999;70:1276-1282.
  32. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Ultrastructural analysis of bone tissue irradated by Er:YAG laser. Lasers Surg Med 2002;31:322-332.
  33. Sasaki KM, Aoki A, Ichinose S, Yoshino T, Yamada S, Ishikawa I. Scanning electron microscopy and Fourier transformed infrared spectroscopy analysis of bone removal using Er:YAG and CO2 lasers. J Periodontol 2002;73:643-652.
  34. Zaffe D, Vitale MC, Martignone A, Scarpelli F,Botticelli AR. Morphological, histochemical, and immunocytochemical study of CO2 and Er:YAG laser effect on oral soft tissues. Photomed Laser Surg 2004;22:185-189.
  35. Israel M,Cobb CM, Rossmann JA, Spencer P. The effects of CO2,Nd:YAG and Er:YAG lasers with and without surface coolant on tooth root surfaces. An in vitro study.J Clin Periodontol 1997;24:595-602.
  36. Frentzen M, Braun A, Aniol D. Er:YAG laser scaling of diseased root surfaces.
    J Periodontol 2002;73:524-530
  37. Crespi R, Barone A, Covani U. Effect of Er:YAG laser on diseased root surfaces: An in vivo study. J Periodontol 2005;76:1386-1390.
  38. Schoop U, Moritz A, Maleschitz P, et al. The impact of Er:YAG laser irradiation on toot surfaces: An in vitro evaluation. J Oral Laser Appl 2001;1:35-41.
  39. Schwarz F, Putz N, Georg T, Reich E. Effect of an Er:YAG laser on periodontally involved root surfaces: An in vivo and in vitro SEM comparison. Lasers Surg Med 001;29:328-335
  40. Yamaguchi H, Kobayashi K, Osada R, et al. Effects of irradiation of an Erbium:YAG laser on root surfaces. J Periodontol 1997;68:1151-1155.
  41. Theodoro LH, Haypek P, Bachmann L, et al. Effect of Er:YAG and diode laser irradiation on the root surface: Morphological and thermal analysis. J Periodontol 2003;74:838-843.
  42. Schoop υ, Moritz A, Kluger W, et al. Changes in root surface morphology and fibroblast adherence after Er:YAG laser irradiation. J Oral Laser Appl 2002;2:83-93.
  43. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Morphological analysis of cementum and root dentin after Er:YAG laser irradiation. Lasers Surg Med 2002;31:79-85.
  44. Folwaczny M, Benner KU, Plasskamp B, Mehl A ,Hickel R. Effects of 2.94 micron Er: YAG laser radiation on root surfaces treated in situ: A histological study.
    J Periodontol2003;74:360-365.
  45. Crespi R, Romanos GE, Barone A, Sculean A, Covani υ. Er:YAG laser in defocused mode for scaling of periodontally involved root surfaces: An in vitro pilot study .
    J Periodontol2005;76:686-690.
  46. Ando Y, Watanabe H, Ishikawa I. Bactericidal effect of erbium YAG laser on periodontopathic bacteria. Lasers Surg Med 1996;19:190-200.
  47. Aoki A , Ando Y, Watanabe H, Ishikawa I. In vitro studies on laser scaling of subgingival calculus with an erbium:YAG laser. J Periodontol 1994;65:1097-1106.
  48. Folwaczny M, Mehl A, Haffner C, Benz C, Hickel R. Root substance removal with Er:YAG laser radiation at different paramenters using a new delivery system.
    J Periodontol 2000;71:147-155.
  49. Aoki A, Miura M, Akiyama F, et al.In vitro evaluation of Er:YAG laser scaling of Subgingival calculus in comparison with ultrasonic scaling. J Periodontal Res 2000;35:266-277.
  50. Schwarz F, Sculean A,Georg T,Reich E. Periodontal treatment with an Er:YAG laser compared to scaling and root planing. A controlled clinical study. J Periodontol 2001;72:361-367.
  51. Schwarz F, Sculean A Berakdar M, Georg T, Reich E Becker J. Clinical evaluation of an Er:YAG laser combined with scaling and root planing for nonsurgical periodontal treatment. A controlled, prospective clincal study . J Clin Periodontol 2003;30-26-34.
  52. Schwarz F, Sculean A, Berakdar M, Georg T , Reich E, Becker J. Periodontal treatment whit an Er:YAG laser or scaling and root planing. A 2-year follow-up split-mouth study. J Periodontol 2003;74:590-596.
  53. Sculean A, Schwarz F, Berakdar M, Romanos GE, Arweiler NB, Becker J.
    Periodontal treatment with an Er:YAG laser compared to ultrasonic instrumentation: A pilot study. J Periodontol 2004;75:966-973.
  54. Schwarz F, Sculean A, Georg T Becker J. Clinical evaluation of the Er:YAG laser in combination with an enamel matrix protein derivative for the treatment of intrabony periodontal defects:A pilot study. J Clin Periodontol 2003;30:975-981.
  55. Sculean A, Schwarz F, Bearkdar M, Windisch P,Arweiler NB, Romanos GE.
    Healing of intrabony defects following surgical treatment with or without an Er:YAG laser. J Clin Periodontol 2004;31:604-608.
  56. AAP. Academy Report : Lasers in periodontics.
    J Periodontol , 73:1231-39, 2002.
  57. Aoki A,Sasaki KM,Watanabe H,Ishikawa I.Lasers in nonsurgical periodontal therapy. Periodontol 2000 36:59-97 , 2004.
  58. Charles M. Cobb. Lasers in Periodontics : A Review of the Literature
    J Periodontol 77:545-564, 2006.
  59. Midda M. Lasers in periodontics . Periodontal Clin Investig 1992 ; 14:14-20.
  60. Bader H. Use of lasers in periodontics. Dent Clin North Am 2000; 44:779-792.
  61. Wigdor H, Walsh J, Featherstone LDB, et al. Lasers in dentistry.
    Lasers Surg Med 1995 ;16:103-133.
  62. Kimura Y, et al.Laser –aided periodontal therapy.Effects on Subgingival Plaque.
    J Clin Laser Med Surg 1998 ; 22:302-311
  63. Eversole LR, Rizoiu I, Kimmel AI. Pulpal response to cavity preparation by an Er,Cr:YSGG laser-powered Hydrophotonic system. JADA, Aug. 1997
  64. Rizoiu I , et al. Pupal thermal response to an Er, Cr : YSGG laser hydrophotonic “. Oral Surg Oral Med Pathol Oral Radiol Endod , 1998
  65. Walinski, CJ. Irritation fibroma removal : A comparison of two laser wavelengths
    J Gen Dent , 2004 May/June
  66. Kimura Y et al .Effects of Erbium, Chromium:YSGG Laser Irradiation on Canine Mandibular Bone. J Periodontology 2001;72:1178-1182
  67. XIAOGU WANT et al .Morphological Changes of Bovine Mandibular Bone Irradiated by Er,Cr:YSGG Laser: An in vitro Study.Journal of clinical laser Medicine & surgery 2002 ; 20: 245-250
  68. Kimura Y,et al.Effects of Er, Cr: YSGG laser irradiation on root surface:
    morphological and atomic analytical studies. J Clin Laser Med Surg ,2001 April