INTRODUCTION OF LASERS IN ORAL AND MAXILLOFACIAL SURGERY INITIAL USE IN ORAL AND MAXILLOFACIAL SURGERY CHARACTERISTICS OF LASER LIGHT CLASSIFICATION OF LASERS TISSUE INTERACTION TYPES OF LASERS ADVANTAGES AND DISADVANTAGES LASER SAFETY IN SURGERY AND ANESTHESIA PATIENT SELECTION APPLICATIONS SURGICAL LASER TECHNIQUE APPLIED ASPECTS RECENT ADVANCES COMPLICATIONS

1. LASERS IN ORAL AND MAXILLOFACIAL SURGERY
PRESENTED BY – MAHIMA SHANKER
DEPT. OF ORAL AND MAXILLOFACIAL
SURGERY

2. CONTENTS
• INTRODUCTION OF LASERS IN ORAL AND MAXILLOFACIAL SURGERY
• INITIAL USE IN ORAL AND MAXILLOFACIAL SURGERY
• CHARACTERISTICS OF LASER LIGHT
• CLASSIFICATION OF LASERS
• TISSUE INTERACTION
• TYPES OF LASERS
• ADVANTAGES AND DISADVANTAGES
• LASER SAFETY IN SURGERY AND ANESTHESIA
• PATIENT SELECTION
• APPLICATIONS
• SURGICAL LASERTECHNIQUE
• APPLIED ASPECTS
• RECENTADVANCES
• COMPLICATIONS

3. INTRODUCTION OF LASERS IN ORAL AND MAXILLOFACIAL SURGERY
• Light Amplification by Stimulated Emission of Radiation
• Efficacy of lasers as soft tissue incising agents first studied byYamamoto et al. in 1972 using ruby lasers
• Development of CO2 laser and its tissue ablating properties - increased interest in application of lasers to surgery
• Use of lasers led to reduced local hemorrhage, provided a clean surgical field to operate
• Designed specifically for use in dentistry - dLase 300 Nd:YAG laser, introduced in United States - Dr.Terry D. Myers and
Dr.William D. Myers on May 3, 1990
• Introduction of the laser in dentistry - credited to Goldman L - extensively studied effects on soft, hard tissues, staunch
advocate of use in routine dental practice
Kale LN, Garde JB, Garde SS, Gupta P. Evolution and applications of lasers in oral and maxillofacial surgery. J Dent Allied Sci 2017;6:28-31.

4. INITIAL USE IN ORAL AND MAXILLOFACIAL SURGERY
• First reported use of lasers specific to Oral and Maxillofacial surgery - Strong et al. - CO2 lasers - excision of
premalignant and malignant lesions, other surgical procedures
• Kaplan et al. - removal of oral cancers - 1974
• Ackermann - Nd:YAG lasers - hemophiliacs - various oral surgical conditions - 1984
• Apfelberg - Argon laser - vascular lesions - 1987
• Alternative to scalpel, development of treatment modalities like laser skin resurfacing - could not be performed by
existing means

5. CHARACTERISTICS OF LASER LIGHT

6. CLASSIFICATION OF LASERS
SOFT LASERSAND HARD LASERS
• Current soft lasers in clinical use - Helium-neon (He-N) at 632.8 nm (red, visible),Gallium- arsenide (Ga-As) at 830 nm
(infrared, invisible)
• Hard lasers - Argon lasers (Ar) at 488 to 514 nm, Carbon-dioxide lasers (CO2) at 10.6 micrometer, Neodymium-doped
yttrium aluminum garnet, (Nd:YAG) at 1.064 micrometer, Holmium yttrium-aluminum-garnet (Ho:YAG) at 2:1.micro-
meter, Erbium, chromium yttrium-slenium-gallium-garnet ( Er,Cr:YSGG) at 2.78 micro-meter, Neodymiumm yttrium -
aluminum - perovskite(Nd:YAP) at 1,340 nm
MODE OF APPLICATION
Parthiban J, Sargunar B, Prakash CA, Anandh B. Usefullness of Laser in Oral and Maxillofacial Surgery. Biomedical & Pharmacology Journal. 2015 Oct 1;8(SpecialOct):271.

7. ON BASIS OF STATE OF GAIN MEDIUM
• Solid state (Eg - Nd:YAG, Er:YAG, Er,Cr:YAG)
• Gas (Eg - HeNe, Argon,CO2)
• Excimer (Eg.ArF, KrCl)
• Diode (Eg - GaAIAs)
ONTHE BASIS OF OSCILLATION MODE
• Continuous wave (Eg - CO2, Diodes)
• Pulsed wave (Eg - Nd:YAG, Er:YAG)
ONTHE BASIS OF OUTPUT ENERGY
• Low output, soft or therapeutic (Eg - Low output diodes)
• High output, hard or surgical (Eg - CO2,Nd:YAG,Er:YAG)
Parthiban J, Sargunar B, Prakash CA, Anandh B. Usefullness of Laser in Oral and Maxillofacial Surgery. Biomedical & Pharmacology Journal. 2015 Oct 1;8(SpecialOct):271.

8. TISSUE INTERACTION
• Absorption - Specific molecules in the tissue
(chromophores) absorb photons - light energy converted
into other forms of energy, perform work
• Reflection - Laser beam bounces off surface, no
penetration/ interaction - usually undesired effect, useful
example - Erbium lasers reflect off titanium allowing for
safe trimming of gingiva around implant abutments
• Transmission - Laser energy passes through superficial
tissues - interact with deeper areas - Eg : Retinal surgery,
laser passes through lens to treat retina - deeper
penetration seen Nd:YAG, diode lasers
• Scattering - Once laser energy enters target tissue -
scatter in various directions - usually not helpful, help with
certain wavelengths biostimulative properties
Guttenberg SA, Emery 3rd RW. Laser physics and tissue interaction. Oral and maxillofacial surgery clinics of North America. 2004 May;16(2):143-7.

9. Chromophores in the skin
Are selectively laser energy absorbing target molecules in skin
Endogenous chromophores
• Melanin - UV -1200nm
• Haemoglobin - UV, blue (400 nm), green (541 nm),Yellow (577nm)
• Collagen -Visible and near infra-red spectra
• Water - in the mid and far infrared regions
Exogenous chromophores - such as tattoo ink

10. FIVE INTERACTION MECHANISMS ASSOCIATEDWITHTHE USE OF LASERS IN BIOMEDICINE
Optical effect - fluorescence spectroscopy for cancer screening, optical coherence tomography (OCT) for high-resolution
imaging
Photomechanical effect (photoacustic) - laser lithotripsy, removal of tattoos, certain pigmented lesions
Photochemical effect - photodynamic therapy (PDT), chemical reaction stimulation, composite resin polymerization
Photothermal effect - laser resurfacing, treatment of vascular lesions, laser hair removal
Photobiostimulative and photobiomodulative effect - low level laser therapy (LLLT), laser acupuncture, collagen
remodeling for aged skin, anti-inflammatory treatments, blue light therapy for acne treatments, accelerated wound
healing
Pandurić DG, Bago I, Zore IF, Sušić M, Katanec D, MilenovićA, Boras VV. Application of diode laser in oral and maxillofacial surgery. In A textbook of advanced oral and
maxillofacial surgery 2013 Jun 26. IntechOpen.

11. Parthiban J, Sargunar B, Prakash CA, Anandh B. Usefullness of Laser in Oral and
Maxillofacial Surgery. Biomedical & Pharmacology Journal. 2015 Oct
1;8(SpecialOct):271.

12. CARBON DIOXIDE LASER
• Developed by Patel, 1964
• Wavelength - 10600 nm
• Medium - mixture of CO2 ,nitrogen, helium
• Uses an articulated arm to deliver beam
• Uses - for excision and ablation of superficial lesions, skin resurfacing
• Most commonly used laser in oral cavity -
1. The chromophore that absorbs the CO2 wavelength is water
2. Shallow depth of penetration 0.2mm
3. Little scatter ,reflection, transmission
ARGON LASER
• Developed by Bridges, 1964, Hughes aircraft research laboratories
• Delivers green blue light beam with wavelength - 488-514nm
• Delivered with fibre optic cable, hand piece
• Argon beam - highly absorbed by hemoglobin, excellent hemostatic laser
• Used to excise gingival soft tissue lesions, treatment of vascular hemangiomas

13. Nd:YAG LASER
• Developed by Guesic, 1964
• Wavelength - 1064 nm
• Neodymium yttrium aluminium garnet
• Delivered by fibre optic cable
• Used with specially designed sapphire or ceramic tips, used as contact laser scalpel or ablation tool, excellent
hemostasis and cutting abilities
• Uses - treatment of vascular lesions, intraoral and extraoral pigmented lesions, openTMJ arthroplasty, malignant lesion
excision
KTP LASER
• Modified version of Nd:YAG laser
• Wavelength - 532nm
• Absorption is similar to argon laser
• Used in treatment of vascular and pigmented lesions, tattoo removal, blepharoplasty, endoscopic procedures

14. Ho:YAG LASER
• Holmium yttrium aluminium garnet
• Wavelength - 2140 nm
• Aiming beam with fibre optic cable used for delivery
• Used in both contact, noncontact mode
• Well absorbed by synovium and joint surface
• Extensively used in endoscopic orthopaedic surgery
• Used inTMJ for lysis of adhesions and sculpting of fibrocartilaginous disk tissue
Er:YAG LASER
• ErbiumYAG laser for facial resurfacing, incision, ablation of soft tissues
• Wavelength - 2940nm
• Advantage - ability to remove superficial skin layers more precisely than CO2 laser
• Allows reorganization of collagen with less total energy

15. ADVANTAGESOF LASER SURGERY
Lasers have stood test of time, in spite of criticism, they are widely used because
• Lasers incise tissue more efficiently than a scalpel - provide the added advantages of sterilization of field of operation,
decrease mechanical trauma by contact-free incision, minimizes postoperative swelling, scarring
• Effectively coagulates blood vessels in the field - maintaining a bloodless field
• Increased precision, accuracy in surgical procedures due to its ablative properties, effective control on the depth of
penetration of laser beam
• Histologically - wound shows less wound contracture, scarring due to reduced myofibroblasts
• Better healing as compared to scalpel wounds
• Reduced need for sutures
Kale LN, Garde JB, Garde SS, Gupta P. Evolution and applications of lasers in oral and maxillofacial surgery. Journal of Dental and Allied Sciences. 2017 Jan 1;6(1):28.

17. DISADVANTAGESOF LASERS
Although lasers have multiple advantages over a scalpel, carries a few disadvantages
• Speed of healing may be delayed
• Incidence of increased pain 4 -7 days postoperatively
• Laser plume generated during procedure may be harmful to persons in operating room
• Scattered and reflected laser beams pose a massive health hazard to operator, assistants, patients
• High cost, operator training
Kale LN, Garde JB, Garde SS, Gupta P. Evolution and applications of lasers in oral and maxillofacial surgery. Journal of Dental and Allied Sciences. 2017 Jan 1;6(1):28.

18. LASER SAFETY IN SURGERYANDANESTHESIA
Field preparation
• Alcohol to be avoided
• If not - alcohol should vaporize completely before draping
• Protection of patient’s throat, oral tissues from accidental beam impact
• Hair near field can ignite - kept moist
• Use wet gauze packs, towels to avoid reflection from shiny metal surfaces
• Adequate high speed evacuation used to capture laser plume - biohazard
Specular reflection
• Surgical beam tested for alignment prior each use of machine
• No instruments passed across intended path of laser
Anesthetic agents
• Inflammable agents - ether, cyclopropane - absolutely contraindicated in
laser surgeries
• Instead - halothane, enflurane, isoflurane, sevoflurane
• Surgery along the airway - oxygen <40%
Care should be taken to ensure
complete coverage of the face and area
around the surgical site with wet towels
A warning sign should be placed on
the operating room door to prevent
personnel from inadvertently
entering during laser surgery

19. Eye
• Use glasses for eye protection (patient, operator,
assistants)
• Retinal damage - even if eyes closed it can penetrate eye
lids
• Normal saline is used to lubricate eye, petroleum based is
avoided
Metallic goggles are used during laser procedures on surface skin
Endotracheal tubes
Nonmetallic
• Red rubber, silicon, (PVC - not recommended)
• Tubes wrapped with metallic foil - mucosal injury (wrapped with metallic tape of copper,
silver)
• Silver anode sheet that has spongy water-absorbent material outside, adhesive inside
• Ceramic coated endotracheal tube
Metallic
• Cuffed metallic tubes
• Water injected in to cuff to inflate
Patel A. Anesthesia for Laser Airway Surgery. InBenumof and Hagberg's Airway Management 2013 Jan 1 (pp. 824-858).WB Saunders.
Cuffed metal tube

20. Airway Laser Hazards
• High energy of laser, its potential for combustion - can cause an airway
fire when surgical field is near to airway
• When laser strikes unprotected external surface of a tracheal tube
during laser airway surgery, surface starts to disintegrate, can catch fire
• If fire is not recognized, laser continues to be applied - hole in tracheal
tube, expose the burning surface to oxidant-rich gas within anesthesia
system
• At this stage - explosive blowtorch-like fire may occur, rapidly spread in
distal, proximal manner
• Any airway fire - life-threatening complication, but blowtorch fire is
especially feared
• An open basin of sterile water with an irrigating syringe should be
available in case fire develops
An airway fire results when a laser strikes
the polyvinyl chloride endotracheal tube

21. PATIENT SELECTION
• Take History to find out -Immunocompromised status, especially diabetes, isotretinoin use
• Active local or systemic infections especially recurring herpes simplex infection (Acyclovir or valacyclovir given 1 day
prior to, 5–14 days post treatment)
• Tendency of keloid scarring
• Personal or family history of vitiligo
• Prophylactic antibiotics, antivirals for ablative procedure
• To minimize post laser hyperpigmentation -2 weeks before, 8 weeks after laser - 2% Hydrocortisone, 4%
Hyroxyquinone
• Anesthesia -Topical anesthetic ointment for 1 hour, for ablative procedures - nerve blocks
Absolute
• Active bacterial, viral or fungal infections
• Unrealistic expectations
• Uncooperative patients
• Malignancy
Relative
• Immunocompromised - Diabetes, HIV, Hepatitis B, HepatitisC
• Oral isotretinoin
• History of keloid
• Patients taking gold salts are at the risk of chrysiasis (gold
related skin discoloration)
Contraindications

22. APPLICATIONS
• Hemostasis
• Malformations
• Pre-prosthetic surgeries
• Pre-cancerous lesions
• Cysts
• Benign tumors
• Scar corrections
• Gingivectomy, frenectomy
• Removal of granulation tissue
• Removal of melanin pigmentation, tattoos
• Subgingival debridement and curettage
• Osseous re-contouring, implant surgery
• Maintenance of implants
• Low Level LaserTherapy
Use of Laser for soft tissue surgery
Exposure of impacted teeth

23. SURGICAL LASERTECHNIQUE
• Photocoagulation technique
• Incisional and excisional technique
• Ablation or vaporization technique
• Contact laser technique
PHOTOCOAGULATIONTECHNIQUE
• CO2 laser - used to coagulate vessels smaller than 500 um in diameter
• Laser - used in defocused mode to a spot size of approximately 2mm with power density
less than 5W
• CO2 laser is absorbed readily by water, area must be relatively dry for effective
coagulation of vessels
• Increasing exposure time heats tissue to critical temperature needed for haemostasis
• As haemoglobin is a major chromophore - blood components directly lased, surrounding
vessel damaged by collateral heat after being coagulated
• Crisscross or circumferential pattern, defocused mode

24. INCISIONALAND EXCISIONALTECHNIQUE
• Carbon dioxide laser - light scalpel
• Near bloodless field - excellent visualization of specimen during surgical removal
• Point to be considered during biopsy - lateral zone of thermal necrosis
• Zone of necrosis - generally less than 500um when using carbon dioxide, contact Nd:YAG laser
• Topical, local, general anaesthesia administered as procedure indicates
• Area dried to increase accuracy of absorption of energy
• To outline specimen - single or slow repeating pulse mode, mark area of incision
• A row of dots can be used to outline the specimen with desired margin
• Power density adjusted, incision made to desired depth
• Advancing handpiece into incision keeps spot size, distance constant
• Hemostasis is achieved
• Gentle tension on specimen with a forceps on lesion as it is surgically removed
• Lesions can be left open
• Specimen should be handled in usual manner, pathologist informed use of laser
Outlining of planned incision in a low power
intermittent
mode allows for greater control with incision
placement

25. ABLATION ORVAPORIZATIONTECHNIQUE
• One of the greatest advantages of laser is its ability to ablate or vaporize lesions layer by layer
• It is useful in removing discrete benign lesions, eradicating multiple, diffuse lesions of oral cavity
• An anaesthetic plan implemented as type of procedure indicated
• 5 to 10 W of power on carbon dioxide laser is adequate for efficient and controlled ablation of a lesion layer by layer
• Lesion outlined
• Crisscrossing patterns of horizontal, vertical, oblique lines can be used when clearing wound of char between passes
CONTACT LASERTECHNIQUE
• Contact laser has several advantages over traditional
beam
• Nd:YAG & Ho:YAG LASERS are commonly used
contact lasers
• The specially designed tips of contact lasers allow for
transmission of laser energy to tissue directly from tip
surface
• Effect of laser is concentrated to just around tip
surface
• There is less tissue penetration, less collateral tissue
damage
• Helpful in lysis of adhesions withinTMJ

26. WOUND HEALING AFTER LASER SURGERY
Hendrick DA, Meyers A. Wound healing after laser surgery. Otolaryngol Clin North Am. 1995 Oct;28(5):969-86. PMID: 8559583.
• Laser tissue interaction involves many cellular and subcellular events
• There is vaporization of intra cellular fluid that helps disintegrate cell structure almost instantaneously, the subcellular structures
often vaporize
• This likely occurs without normal cascade of cytokines seen in acute inflammation
• Slower healing due to delayed epithelial migration, decreased scar formation
• Nerve endings are histologically sealed which causes decreased post operative pain
• Finding of fewer myofibroblasts at wound edges after laser surgery has been postulated as the reason for lessened scarring

27. Laser hemostasis
• In modern societies - increasing number of older patients, who take anticoagulant drugs
• Over the past years - lasers hemostatic properties have been established
• Due to deeper penetration in soft tissues - Nd:YAG and diode laser - effective
• To reduce thermal effect - pulsed lasers are used
• Once it is ensured that the surgical field is dry and saliva-free - laser is directed over tissues in defocused mode till the bleeding is
arrested
• Optical characteristics of blood result in scattering and dispersion of laser light - reducing the adverse effects on bony tissue
• The cause of this effect is not coagulation of blood - rather the contraction of vascular wall collagen
• The contraction results in constriction of vessels and hemostasis
• Very useful for removal of vascular lesions in the oral and maxillofacial region
APPLIEDASPECTS

28. Vascular lesions
• Chromophore - Oxy-haemoglobin
• Absorption wavelengths - 418, 542, 577 nm
• Laser of Choice: FPPDL or CO2 - wavelength -
585, 590, 595, 680 nm
• Fluence - 5-14 J/cm2
• Spot Size - 2-10 mm
• Density - Less than 10%
• Pulse Duration - 1.5-40 milliseconds
• Delay between pulses - 10-500 milliseconds
Apfelberg DB, Maser MR, Lash H &White DN (1985) Benefits of the CO2 laser in oral hemangioma excision. Plastic and Reconstruc-tive Surgery 75, 46-50.

29. Genovese WJ, dos Santos MT, Faloppa F & de Souza Merli LA (2010) the use of surgical diode laser in oral hemangioma: a case re-port. Photomedicine and Laser Surgery 28,147-51.
Diascopic maneuver Delimitation of the surgical area with laser Fiber passing parallel to the mucous membrane

30. Patient after 3 months
Application of low-level laser irradiation in exudates
Application of low-level laser irradiation after the
removal of the roof of the lesion

31. Venous malformation Port-wine stain
Telangiectasia
(A) Before and (B) after picture of a patient with nevus
of Ota treated with the Q-switched ruby laser

32. Premalignant lesions of the oral mucosa
• Malignant transformation of pre-malignancies such as oral leukoplakia, oral lichen planus occurs in up to 28% of these lesions
• Surgery of these lesions is mostly performed conventionally, but using laser for the removal of the pre-malignancies has been proven
very effective being associated with recurrence rates of less then 20%
• It allows precise excision together with some of the underlying connective tissue
• The heat generated reaches the deeper-lying cells and renders very low recurrence rates
• A delay in healing caused by thermal laser energy is an hindrance for the patient
• As an alternative to the scalpel - CO2 laser has been used for more then 25 years
• Recent studies - very low recurrence rates were observed with the Nd:YAG and diode lasers when treating above mentioned lesions -
probably due deep penetration of the light through the tissue
Pandurić DG, Bago I, Zore IF, Sušić M, Katanec D, MilenovićA, Boras VV. Application of diode laser in oral and maxillofacial surgery. In A textbook of advanced oral and
maxillofacial surgery 2013 Jun 26. IntechOpen.

33. Leukoplakia of tongue
• No prophylactic antibiotics administered
• Dorsal tongue lesion vaporized with true rapid super-pulsedCO2 laser, 46 PPS, average power of 20W, spot size of 2.0 mm, fluence of approximately 435
mJ/pulse width, peak pulse power of 500W, pulse width of approximately 4.2 ms, and an interpulse distance of 19 ms
• Two rasters applied with target tissue being wiped free of debris between applications
• Almost no char, no bleed, removed with same laser at 30W average power using the handpiece in focus at 0.3 mm spots for incision, defocused to control
bleeding
• Wound sutured closed
• Estimated blood loss for resection 15 mL
• Reepithelization of surface of the tongue 100% complete at 27 days
• Hyperkeratosis present immediately after healing complete
1. Leukoplakia affecting majority of surface area of dorsal tongue
2. First, horizontal, raster used to remove surface epithelium. HeNe aiming spot of
approximately 2.0-mm diameter. Rastering half completed.
3. Debris removed by wiping with gauze.Yellow color in central portion where vaporization was
done especially in center area.
4. Surface re-epithelized at 3 weeks. Mature mucosa shown at 9 weeks.
1
2
3
4

34. Benign oral lesions
• For soft tissue surgery several wavelengths including Er:YAG, CO2, Nd:YAG and diode lasers - investigated over past years
• Excision of benign lesions - fibroma, papilloma, mucocele, gingival lesions, benign salivary glands lesions, salivary stones, epulis
fissuratum, tongue lesions, hyperplastic tissue excisions
• Removal of these lesions using lasers is minimally invasive, can make the surgery less extensive, may reduce the need for general
anesthesia or in-patient hospital care, resulting in the lowered overall costs

35. Fibroma
• Commonly appear on buccal mucosae, inner surface of the lip, lateral surfaces of the tongue
• Presumably their origin is from trauma, particularly lip or cheek biting
• May result as the final involution form of a pyogenic granuloma

36. Excision of mucocele using diode laser in lower lip
Swelling in the left labial
mucosal region
Application of laser -
parameters, 940 nm and 1.5W,
continuous mode, 400 microns
Photograph showing
immediate postoperative day
Photograph showing
postoperative view: Day 45
Ramkumar S, Ramkumar L, Malathi N, Suganya R. Excision of mucocele using diode laser in lower
lip. Case reports in dentistry. 2016 Dec 21;2016.

37. Selected malignant lesions
• Selected patients with oral squamous cell carcinoma - lasers play role in excision of lesion
• Thermal laser energy supposed to be of value in cancer surgery - thermal laser energy may seal arteries, veins, lymphatic vessels
• Advantages of laser surgery seem to be more attributable to technical handling during surgery than to oncologic parameters
Fluorescence spectroscopy and photodynamic therapy (PDT)
• Laser-induced fluorescence (LIF) spectroscopy - non-invasive technique that has been used in various fields to differentiate tissues -
important tool for cancer diagnostics
• Differentiation of benign and malignant tissues using this method is possible with a sensitivity above 80%
• PDT can optimize conventional surgery in cases of squamous cell carcinoma using a new photosensitizer meta
• tetrahydroxyphenylchlorine (m-THPC)
• Intraoperative fluorescence-guided resection followed by PDT seem to be highly promising in improving the radicality of tumor
resection combined with a conventional therapeutic approach

38. Miyaguchi, M., & Sakai, S.-I. (1994). The Contact Nd-YAG Laser for Oral and Oropharyngeal Malignant Tumors. Auris Nasus Larynx, 21(4), 226–231. doi:10.1016/s0385-8146(12)80085-x
Singh GB, Tiwari M, Shukla HS, Pandey M. Nd:YAG laser therapy of carcinoma lip (stage I squamous cell carcinoma): a retrospective evaluation. Indian J Otolaryngol Head Neck Surg. 2009
Sep;61(3):179-84. doi: 10.1007/s12070-009-0062-0. Epub 2009 Sep 27. PMID: 23120631; PMCID: PMC3449982.
• Carried out as outpatient procedure under local anesthesia
• The power of the Nd:YAG laser set between 30–50 watts, duration of pulse at one second, pulsed mode
• The lesion fully coagulated with the laser - followed by surface cooling of lesion for maximum absorption of heat in lesion Entire lesion
coagulated in a punctate manner at 8 mm of interval for 1–2 seconds each
• The fulgurated site left to granulate, undergo healing by secondary intention
• In post-laserization period - patients prescribed analgesics (ibugesic + paracetamol combination for 5 days), mouthwash only
• Patients encouraged to take normal meals after the procedure
• The overall 5-year survival rate - 88.14% , the 3-year SR was 100% - 46pts - 1yr recall

39. TONGUE - CONTACT ND:YAG LASER SCALPEL

40. Laser osteotomy
• Experimental laser osteotomies were performed in vitro and in vivo with use of different wavelengths including excimer lasers,
Er:YAG, CO2 and Ho:YAG lasers
• The laser light emitted by Er:YAG and CO2 lasers are well absorbed by water
• The wavelength of the Er:YAG laser, also well absorbed by hydroxyapatite, CO2 laser is highly absorbed by collagen
• These wavelengths seem to play an increasingly important role in OMF surgery
• Light microscopy, histologic sections and SEM revealed no charring, very thin basophilic zone next to cut surface, while cutting the
trabecular structures resulted in coagulation zone’
Dental implantology
• May be useful in pre-implant treatments when mucogingival surgery is required
• Most important indication of laser treatment in implantology - peri-implant soft tissues, decontamination of the implant surfaces in
order to treat peri-implant bony defects, rehabilitate failing implants
• Not all laser systems available in dentistry are of value in this regard
• Nd:YAG laser can change the implant surfaces, cause melting of implant microdesign
• Better results - CO2 laser - modify the implant surface, temperature changes are clinically acceptable, bacteria reduction significant
Clinical use of the diode laser - not able to change the implant surface, excellent properties for incision, excision, coagulation of soft
tissues
• RECENTLY - PDT with toluidine blue plus diode laser light - treatment of peri-implant diseases
• Lasers have been used for implant site preparation
• Laser irradiation has a biostimulating effect on osteoblasts - promoting the osseointegration process of dental implant, healing of
bony defect after augmentation procedures

41. • Er:YAG laser used with a spot size of 0.9 mm at a distance of about 10 mm from the bone surface
• The laser settings used for bone cutting - pulse energy of 1,000 mJ, pulse duration of 300 s and a frequency of 12 Hz (energy density
157 J/cm 2)
• Pulse profiles are nearly square shaped, approximately constant power within the pulses, water spray level was 40–50 ml/min
Stübinger, S., Ghanaati, S., Saldamli, B., Kirkpatrick, C. J., & Sader, R. (2009). Er:YAG Laser Osteotomy: Preliminary Clinical and Histological Results of a NewTechnique for
Contact-Free Bone Surgery. European Surgical Research, 42(3), 150–156. doi:10.1159/000197216
Clinical situation after laser
osteotomy of a bone graft in
the chin region.The
circumferential gap of the
bone block is shown. Note the
characteristic craggy and
clean surface structure after
laser osteotomy without any
signs of bony particles and
debris.
Harvested bone graft after
loosening with chisels
from the chin region.The
bone graft is without any
signs of carbonization,
there is no charred tissue.
Clinical situation after fixation of
the bone graft with 2 titanium
screws in the left upper jaw.The
bone graft was necessary
because of the massive loss of
bone volume prior to dental
implant placement. After a
healing period of 3 months, the
implant can be placed into the
augmented region.
Typical intraoperative situation
during laser ablation of bone.The
red pilot beam and the additional
water spray are clearly visible. In
this case, the alveolar crest is
flattened by laser osteotomy after
multiple tooth extractions in the
left upper jaw.

42. Kurtzman GM, DICOI D. Diode Laser for Implant Uncovery and SoftTissue Modification.
• Diode laser set at 0.8 watts and increased slowly to 2.5 watts in continuous mode until the fibrous tissue overlaying the implant cover screws cut
• An initiated tip placed at center of the depression from pontics of provisional bridge in soft tissue above implants cover screw, moved in an increasing
circular motion moving outward until entire cover screw was exposed
• The diode cuts desired soft tissue, coagulate bleeding from cut edges
• Cover screws removed from both implants -Open tray implant impression abutments placed into the implants, seating verified radiographically
• Healing abutments placed into the implants
Buccal view of the anterior maxilla
demonstrating preservation of the
papilla due to the provisional bridge
Diode laser removing soft
tissue to uncover the implants
cover screws
Uncovery of the implants
and healing screw removal
Healing abutments placed
into the implants

43. Frenectomy
• Accomplished using incision and/or ablation
• Either CW mode at 3 to 5W with a 0.2-mmspot size for incision, a pulsed mode at 20 W, 50 to 60pps, and 2.0-mm spot for ablation size can be
used
• Topical anesthetic is usually adequate, infiltration technique maybe preferred
• Upper lip everted, the frenum stretched taut, short (3-5 mm), vertical incision made through mucosa of mid portion of frenum
• Horizontal releasing incisions - developed through mucosa on both sides of frenum, extend to periosteum - diamond-shaped wound developed - lip-
mucosal attachment is released
• Fibrous band between central incisors vaporized
• Saline with hydrogen peroxide rinses prescribed, No dressing is necessary
• Wound develops fibrinous coagulum in 24 hours, re-epithelialization occurs in 5 weeks
• Contact Nd:YAG , fine scalpel tip at 8 to 12W CW may be used, same surgical technique

44. Exposure of impacted teeth
• Easily accomplished using local anesthesia, loop cautery
• Less swelling, less postoperative pain, less chance of thermal injury to the exposed tooth if free beam CO2 or contact Nd:YAG
laser used
• CO2 laser used at PD of approximately 10,000 W/cm2 at 50 PPS, 10W average output power and 0.3mm spot size - incise around
impacted crown of tooth
• Mucosal flap is elevated, Crown of impacted tooth exposed, absence of bleeding
• Mucosa well healed at 3weeks
• Bonded bracket - start tooth movement
• Nd.YAG laser in contact mode using a short scalpel tip at 5 to 10W average output power - excise the gingival cuff
• Rapid identification of the crown permits the operator to avoid inadvertently damaging - excessive heating from the scalpel tip

45. Temporomandibular joint laser-assisted surgery
• Arthroscopic surgery - treatment of choice for internal derangements ofTMJ using Er:YAG, CO2 and Ho:YAG lasers
• Using this technique procedures such as discectomy, discoplasty, synovectomy, hemostasis, posterior attachment contraction,
eminectomy - performed on an out-patient basis through two incisions less than 2mm each
Esthetic and plastic indications
• Lasers used for more 25 years in cosmetic surgery
• Superficial vascular, pigmented lesions - most commonly treated with use of argon laser
• Nd:YAG laser - treatment of deep vascular lesions and tumors
• CO2 laser indicated for vaporization of exophytic lesions
• More common procedures performed with laser is cosmetic skin resurfacing by removing surface layer of epidermis, superficial
papillary dermis, conctracting dermal collagen, allowing skin to re-epithelialize in more uniform manner
• Advantage of laser surgery in cases of esthetic and plastic surgery - based on hemostasis, decreased scarring, decreased postoperative
disability

46. Boyden DK. A brief overview of noninvasive lasers in cosmetic
maxillofacial surgery. Oral and Maxillofacial Surgery Clinics.
2004 May 1;16(2):231-7.

47. TATTOO REMOVAL
Guttenberg SA, Emery 3rd RW. Laser dermatopathology. Oral and maxillofacial surgery
clinics of North America. 2004 May;16(2):189-95.
Ho SG, Goh CL. Laser tattoo removal: a clinical update. Journal of cutaneous and aesthetic
surgery. 2015 Jan;8(1):9.
Showing good resolution of dark blue tattoo
using the QS Nd:YAG laser after 5 treatments.
Noticed textural changes and mild post
inflammatory hyperpigmentation and
silhouette of old tattoo

48. Recent Advances
• Waterlasesystem - revolutionary dental device that uses laser energized water to cut or ablate soft and hard tissue
• Periowave - photodynamic disinfection system utilizes nontoxic dye (photo sensitizer) in combination with low intensity lasers
enabling singlet oxygen molecules to destroy bacteria
• Photodynamic therapy (PTD) - currently being evaluated for the treatment of head and neck, skin, intraabdominal, other types of
cancers
• Carbon dioxide laser, other lasers - used in the micro anastomosis of nerve and vascular tissue with some success
• Excimer laser - useful tool in the treatment of vitiligo - achieving excellent results in a few months rather than months to years
• Non-ablative skin rejuvenation - laser to improve the appearance without injuring the surface of the skin
 Nd :YAG (1320 nm)
 Diode (1450 nm)
 Er-glass laser (experimental)
• Confocal laser scanning microscopy (CLSM) - diagnosis and marginal Clearance without biopsy
• Optical coherence tomography (OCT) - new noninvasive imaging technique
• Photobiomodulation therapy - high potential treatment modality for COVID-19

49. Brandon MS, Strauss RA. Complications of CO2 laser procedures in oral and maxillofacial surgery. Oral and Maxillofacial Surgery Clinics. 2004 May 1;16(2):289-99.
General complications of laser surgery of the head and neck
• Postoperative infection
• Contact dermatitis
• Postoperative pain
• Promotion of malignant transformation by laser energy
• Airway fire
• Ocular injuries
• Injury to staff
Cutaneous fungal infection after
laser cosmetic skin resurfacing
Squamous cell carcinoma arising in an area
of tissue previously ablated with laser
Application of stainless steel eye
shields for periocular procedures

50. Complications unique to extraoral laser surgery of the head and neck
• Hyperpigmentation
• Hypopigmentation
• Erythema
• Hypertrophic scarring
• Milia and acne outbreaks
• Ectropion
Acne outbreak following laser skin
resurfacing
Prolonged erythema
associated with poor
hygiene following laser
skin resurfacing
Poor postoperative
hygiene contributing to
long term complications
Cutaneous
hypopigmentation
after laser cosmetic
skin resurfacing
Cutaneous
hyperpigmentation after
laser cosmetic skin
resurfacing

51. Complications unique to intraoral laser procedures
• Moderately severe or severe postoperative pain - tends to peak at postoperative day 1 or 2 and frequently does not subside for 7 to 9
days. Narcotic analgesia is often required.
• Postoperative edema - airway disturbances
• Blood vessels too large to be effectively constricted are cut - bleeding may occur
• Pitting of the enamel
• Pulpal tissues in teeth can undergo irreversible damage with sufficient increases in temperature
• Laser surgery can be associated with a range of complications
• Many procedures now routinely performed with lasers have significantly lower rates of complications than comparable
• procedures performed with the scalpel (Example - frenectomies, treatment of hemangiomas)
• Some procedures are unique to laser surgery, would not be possible without their use (Example - laser resurfacing, ablation of large
mucosal lesions)
• These benefits have resulted in increasing use, expanding scope of lasers in oral and maxillofacial surgery
• With a thorough understanding of possible complications, clinicians can minimize occurrence through proper patient selection,
preoperative preparation, appropriate technique, vigilant postoperative care

52. • Measurement of temperature, ask possible symptoms of patients
• Bed sheets, head rest covers disposable, must be replaced for every treatment
• Bathrobes, gowns used during laser hair removal procedures – disposable, dumped into biohazards bags
• Hand washing practice implemented before, after every treatment, eye, nose, mouth hand contact should be avoided
• Patients - disinfect hands with 60% to 70% isopropyl alcohol, provide verbal consents, wear surgical masks
• Working surfaces sanitized with hospital-grade disinfectant between every treatment
• Gloves, dry high-filtration media masks must be worn by handling physicians and nurses
• Adequate eye protection considering that exposed mucous membranes, unprotected eyes can increase risk of SARS-CoV2
transmission
• Machine body can be covered with disposable sheet/cling film for each procedure with the exhaust fan area open
• Eye shields and connected straps as well as lens optics should be cleaned with 70% ethyl alcohol
• Avoid laser gel contamination between patients by using disposable cups for each patient
• Disinfect the entire laser hand piece between patients
• Proper fitting high-filtration masks to be used by the surgical team during procedures
• A smoke evacuator should be used while doing laser procedures that generate plume (Example - viral warts, epidermal nevi, laser
ablation, laser hair reduction)
• Maintain good general ventilation in the clinic to dilute any contaminants that skipped in the air
Insights into laser safety considerations during COVID19 pandemic
Elsaie ML, Nada HA. Insights into laser safety considerations during COVID 19 pandemic. DermatologicTherapy. 2020 Sep;33(5):e13777.

53. REFERENCES
• Fonseca, oral and maxillofacial surgery, vol. 1
• Lasers in maxillofacial surgery - Clayman, Lewis
• Kale LN, Garde JB, Garde SS, Gupta P. Evolution and applications of lasers in oral and maxillofacial surgery. J Dent Allied Sci 2017;6:28-31.
• Parthiban J, Sargunar B, Prakash CA, Anandh B. Usefullness of Laser in Oral and Maxillofacial Surgery. Biomedical & Pharmacology Journal. 2015 Oct 1;8(SpecialOct):271.
• GuttenbergSA, Emery 3rd RW. Laser physics and tissue interaction.Oral and maxillofacial surgery clinics of NorthAmerica. 2004 May;16(2):143-7.
• Pandurić DG, Bago I, Zore IF, Sušić M, Katanec D, Milenović A, BorasVV.Application of diode laser in oral and maxillofacial surgery. In A textbook of advanced oral and maxillofacial
surgery 2013 Jun 26. IntechOpen.
• Patel A.Anesthesia for Laser Airway Surgery. InBenumof and Hagberg'sAirway Management 2013 Jan 1 (pp. 824-858).WB Saunders.
• Hendrick DA, MeyersA.Wound healing after laser surgery. OtolaryngolClin NorthAm. 1995 Oct;28(5):969-86. PMID: 8559583.
• Apfelberg DB, Maser MR, Lash H &White DN (1985) Benefits of the CO2 laser in oral hemangioma excision. Plastic and Reconstruc-tive Surgery 75, 46-50.
• Genovese WJ, dos Santos MT, Faloppa F & de Souza Merli LA (2010) the use of surgical diode laser in oral hemangioma: a case re-port. Photomedicine and Laser Surgery 28,147-51.
• Ramkumar S, Ramkumar L, Malathi N, Suganya R. Excision of mucocele using diode laser in lower lip. Case reports in dentistry. 2016 Dec 21;2016.
• Miyaguchi, M., & Sakai, S.-I. (1994).The Contact Nd-YAG Laser for Oral and Oropharyngeal MalignantTumors. Auris Nasus Larynx, 21(4), 226–231. doi:10.1016/s0385-8146(12)80085-
x
• Singh GB,Tiwari M, Shukla HS, Pandey M. Nd:YAG laser therapy of carcinoma lip (stage I squamous cell carcinoma): a retrospective evaluation. Indian J Otolaryngol Head Neck Surg.
2009 Sep;61(3):179-84. doi: 10.1007/s12070-009-0062-0. Epub 2009 Sep 27. PMID: 23120631; PMCID: PMC3449982.
• Stübinger, S., Ghanaati, S., Saldamli, B., Kirkpatrick,C. J., & Sader, R. (2009). Er:YAG Laser Osteotomy: PreliminaryClinical and Histological Results of a NewTechnique for Contact-
Free Bone Surgery. European Surgical Research, 42(3), 150–156. doi:10.1159/000197216
• Kurtzman GM, DICOI D. Diode Laser for Implant Uncovery and SoftTissue Modification.
• Boyden DK.A brief overview of noninvasive lasers in cosmetic maxillofacial surgery. Oral and Maxillofacial SurgeryClinics. 2004 May 1;16(2):231-7.
• GuttenbergSA, Emery 3rd RW. Laser dermatopathology.Oral and maxillofacial surgery clinics of NorthAmerica. 2004 May;16(2):189-95.
• Ho SG, Goh CL. Laser tattoo removal: a clinical update. Journal of cutaneous and aesthetic surgery. 2015 Jan;8(1):9.
• Brandon MS, Strauss RA. Complications of CO2 laser procedures in oral and maxillofacial surgery.Oral and Maxillofacial Surgery Clinics. 2004 May 1;16(2):289-99.
• Elsaie ML, Nada HA. Insights into laser safety considerations duringCOVID 19 pandemic. DermatologicTherapy. 2020 Sep;33(5):e13777.