Lasers in Orthodontics - Dr. Nabil Al-Zubair


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Lasers in Orthodontics - Dr. Nabil Al-Zubair

  1. 1. Lasers in Orthodontics Dr. Nabil Al-Zubair
  2. 2. Several decades ago: the laser was a DEATH RAY the ultimate weapon of destructionsomething you wouldonly find in a science fiction story
  3. 3. Today the laser is used : - in the scanners at the grocery store, - in compact disc players, and as - a pointer for lecturer and above all - in medical and dental field
  4. 4. ‫أوائل حروف الكلمات‬ Light ‫االسم المختصر‬ Acronym Amplification by for Stimulated Emission of )‫(تضخٌم الضوء بانبعاث اإلشعاع المحفز‬ Radiation“is a mechanism for emitting light within the electromagneticradiation spectrum, via the process of stimulated emission”.
  5. 5. ‫براعة فرٌدة‬ ‫وإمكانات هائلة‬ The Unique Versatility and Vast Potential of Dental Lasers ‫ٌتٌح إجراءات عدٌدة تعزز من نجاح العالج‬ ALLOWS many procedures that enhance overall treatment success Thus, lasers have become an indispensable ‫ال غنى عنه‬ clinical tool in an orthodontist’s‫عتاد‬ armamentarium
  6. 6. History of Lasers begins similarly to much of modern physics, with Einstein
  7. 7. History of Lasers in 1964 The Nobel Prize awarded toTownes, Basor and Prokhovov for the development of the laser
  8. 8. History of Lasers Food and Drug Administration in 1964 The Nobel Prize awarded toTownes, Basor and Prokhovov for the development of the laser
  9. 9. Light is a form of electromagnetic energy = particle and a wave Ordinary light (lightbulb) Laser light monochromatic ‫أحادي اللون‬composed of many wavelengths consists of a single wavelengthunfocused or incoherent Coherent ‫متماسكة‬ (identical in physical size, shape, and synchronicity)
  10. 10. Properties of LASERS1. Coherent: all waves are in certain phase relationship to each other both in space and time2. Mono- chromatic: all waves are of same frequency and wavelength3. Collimated: all the emitted waves are PARALLEL and the beam divergence is very low4. Excellent When a calcified tissue for eg. dentin is exposed toconcentration of the laser of high energy density, the beam isenergy: concentrated at a particular point without damaging the adjacent tissues even though a lot of temperature is produced ie 800-900oC5. Zero entropy Entropy= ‫أدق وصف لإلنتروبً أنها مقٌاس لعدم االنتظام‬
  11. 11. Typical Laser Oscillator energy SOURCEA laser is composed of three principal parts: High reflecting rear mirror Partially reflecting output coupler optical cavity or RESONATOR LASING MEDIUM ‫مادة تولٌد اللٌزر‬ - Gas (CO2) - Liquid (dye) - Solid (Ho: YAG) - Semiconductor (diode) Determine The WAVELENGTH and other properties of the laser
  12. 12. In the case of dental lasers: Hollow Waveguidethe laser light is delivered from the laser to the target tissue via:a fiber-optic cable, hollow waveguide, or articulated arm Articulated Arm
  13. 13. Laser Classification & Types
  14. 14. Classification laser devices are classified according to: their Potential To Cause Biological Damage, as follows:Class 1 Safe under all reasonably laser pointers and anticipated conditions of use supermarket UPC scannersClass 2 - Emits light in the visible laser printers and CD, light spectrum DVD, and BD players - It is presumed that the and readers human blink reflex will be sufficient to prevent damaging exposure, although prolonged viewing may be dangerous
  15. 15. Class 3 - Produces light of such intensity that direct viewing Dental Argon Curing of the beam can potentially cause serious harm. Light - requires special training and eye protectionClass 4 - Produce high-powered light that is hazardous to Nearly all medical and view at all times. dental lasers fall into - Exposure to the eye or skin by both direct and this category scattered laser beams of this intensity, even those produced by reflection from diffusing surfaces, must be avoided at all times
  16. 16. LASERS TYPES
  17. 17. LASERS TYPESI. Based on wavelength With a wave length around 632mm1. Soft Soft lasers are lower power lasers. Eg: Helasers Ne, Gallium arsenide laser These are employed to relieve pain and promote healing eg. In Apthous ulcers Lasers with well known laser systems for2.Hard possible surgical application are called aslasers hard lasers. Eg: CO2, Nd: YAG, Argon, Er:YAG etc.
  18. 18. LASERS TYPES excimer =excited dimer ‫ ومثار أي دٌمر مثار‬dimer ‫أختصار كلمتً دٌمر‬ II. Base don the type of active / lasing medium used ”‫والدٌمر ٌعنً "ثنائً الوحدات‬193 nm 1. ArF excimer248 nm 2. KrF excimer ‫لٌزر إكسٌمر‬308 nm 3. XeCl excimer351- 528 nm 4. Argon ion(KTiOPO4) 5. KTP Potassium titanyl phosphate694.3 nm 6. Ruby ‫ٌاقوت‬1064 nm 7. Nd: YAG (neodymium-doped yttrium aluminum garnet 8. HO: YAG 9. YSGG 10. Er: YAG Erbium-doped yttrium aluminium garnet 11. CO2
  19. 19. Laser Interaction with Biologic Tissues
  20. 20. LASER can have four different interactions with a target tissue ،‫انتقال لطاقة اللٌزر مباشرة من خالل األنسجة‬ - weakening of energy ‫بدون أي تأثٌر على النسٌج المستهدف‬ ‫نثر‬ Laser Effects on Tissue ‫انتقال‬- Possible undesirable transfer of heat to adjacent nontarget tissue ‫انعكاس‬ ‫امتصاص‬ ‫إعادة توجٌه الشعاع قبالة سطح‬ ‫األنسجة، بدون أي تأثٌر على النسٌج‬ the interaction that is of primary interest ‫المستهدف‬
  21. 21. Absorption requires: an absorber of light, termed a chromophore ‫حامل اللون‬ The primary chromophores in intraoral soft tissue are: - Melanin - Hemoglobin - Water
  22. 22. LASER EFFECTS 1. Thermal effects: 2. Mechanical effects: 3. Chemical effects:
  23. 23. 1. Thermal effects:The best known laser effect in dentistry is the thermal vaporization of tissueby absorbing laser light i.e. the laser energy is converted into thermal energyor heat that destroys the tissuesTissue Temperature (° C ) Observed effect Denaturation occurs ‫تمسخ‬45° – 60° → Coagulation and necrosis>60° → Water inside tissue Vaporizes100° C → Carbonization and later Phyrolysis with300° C → Vaporization of bulky tissues
  24. 24. Laser Selection for Orthodontic Applications
  25. 25. Selection of the most appropriate laser for orthodontic applications is ideally determined by examining Four Important Factors: - Procedure Specificity‫ - سهولة التشغٌل‬Ease of Operation ‫ - القابلٌة للنقل‬Portability - Cost
  26. 26. Many laser systems are available today ‫اختٌار اللٌزر لتطبٌقات تقوٌم األسنان‬ each with its own set of benefits and drawbacks The most common lasers used in dentistry today are the :- CO2 laser- Nd:YAG laser- Erbium lasers (Er:YAG and Er,Cr:YSGG) - Each produces:- a different WAVELENGTH of light- Diode laser - Generically named for the Active Medium contained within the device
  27. 27. CO2 and Nd:YAG lasers- Not Ideally suited for orthodontic applications Hampered by: their - large size - HIGH COST
  28. 28. ‫اإلربٌوم‬ Erbium lasers ً‫أحد عناصر الالنثٌنٌدات الفلزٌة األرضٌة النادرة ولونه فض‬- extremely Popular in Dentistry today and- hold the singular distinction of being: Able to Perform both Hard and Soft Tissue Procedures Coast= 15000 $
  29. 29. seems most IDEAL for incorporation into the‫لٌزر اشباه الموصالت‬ Diode laser orthodontic specialty practice A laser diode is a laser where the active medium is a semiconductor similar to that found in a light-emitting diode
  30. 30. The Diode Lasera The Active Medium A Solid-state Semiconductor, made of: Aluminum, Gallium, Arsenide, and Occasionally IndiumaWavelengths 810 nm to 980 nm Fall at The Beginning of the Near-infrared Electromagnetic Spectrum and are Invisible to the Human Eye
  31. 31. The Diode Laser Deliver laser energy - Fiber-optic cable ora FIBEROPTICALLY, either by: - Disposable fiberoptic tipa Absorbed Primarily by: Tissue Pigment (Melanin) and Hemoglobin Poorly Absorbed by: Ablation Procedures Can Safely be Performeda Tooth Structure and Metal in Close Proximity to: - Enamel, Orthodontic Appliances, and - Temporary Anchorage Devicesa Excellent soft tissue indicated for :incising, excising, and surgical lasers coagulating gingiva and mucosa
  32. 32. Laser SafetyProtective EyewearProtection of Nontarget TissueProtection of infection
  33. 33. While most dental lasers are relatively simple to use Certain Precautions should be taken to ensure their safe and effective operation
  34. 34. Only authorized persons who have received training in the proper operation of the laser equipment shall work with such equipmentLaser HAZARDS may be listed as follows:• Optical• Nontarget oral tissue• Skin• Chemical• Fire• Other collective hazards
  35. 35. • Of extreme importance is the use of: Protective Eyewearby ANYONE in the vicinity of the laser while it isin use: ‫قُرب‬ - the doctor, - chairside assistants, - the patient, and - any observers such as family or friends
  36. 36. It is CRITICAL that all Protective Eyewear worn is Wavelength-Specific Consequently,- Sunglasses or- Safety glasses designed for use with visible dental curing lights are: - INEFFECTIVE at protecting the eye from potentially irreversible damage as a result of exposure to dental laser light
  37. 37. Accidental Exposure of Nontarget Tissue Can be Prevented by:Limiting access to the surgical Attention is Required to focus the beam onto the targetenvironment tissue and avoid accidently damaging adjacent tissuesMinimizing reflective surfaces - Glass mirrors should not be used because they absorb heat from the laser energy and may shatter. - Stainless steel or Rhodium mirrors may be used safely, providing measures are taken to minimize possible unwanted reflection - Dull, Nonreflective, or matte-finished instruments should be employed - Surfaces that minimize specular reflections, including exposed watches and jewelryEnsuring that the laser is in good working order with all manufactured safeguards in placeParallel monitoring of the adjacent tissues by all dental staff present at the time oftreatment is to be ensured
  38. 38. To prevent possible exposure to infectious pathogens: - High-volume suction should be used to evacuate any vapor plume created during tissue ablation, and - Normal infection protocols should be followed
  39. 39. CONTROL MEASURES Requirements and recommendations for laser safety- Use of protective eyewear by anyone in the vicinity of the laser- Limit access to the surgical environment- Minimize reflective surfaces- Ensure that the laser is in good working order- Ensure all manufacturer safeguards are in place- Use of high-volume suction- Follow normal infection control protocols- Designated staff member as Laser Safety Officer- Staff training
  40. 40. Diode Laser SetupFiber Preparation Basic Power Settings
  41. 41. Fiber Preparation The diode laser transmits laser light from the laser to the target tissue via or a fiber-optic cable disposable fiber-optic tip 400-micron‫سهل التفتٌت‬ ْ َ a 400-micron optical fiber is recommended, as smaller diameter fibers tend to be more In the case of a fiber-optic cable friable and breakable
  42. 42. Fiber Preparation ‫ٌجب إزالة جزء كاف من الكسوة الخارجٌة الواقٌة‬ Prior to use- A sufficient portion of protective outer cladding must be removed with:an appropriately sized Stripping Devicein order to expose the inner glass fiberThe amount of outer cladding removed is determined by:- the LENGTH of the HANDPIECE supplied with the laser,such that any exposed fiber iscompletely contained within thehandpiece
  43. 43. Then- The fiber is inserted into the handpiece, and- a disposable plastic tip is fitted over the fiber tip and placed on the end of the handpiece, leaving approximately 3 mm of fiber exposedBefore each patient use:- 2-3 mm is cut off the end of the fiber withceramic scissors or a cleaving stone in orderto avoid cross-contamination
  44. 44. The fiber tip is then “INITIATED” by placing some form of PIGMENT on the end of the fiber in order to create a hyper-focus of usable laser energy at the tipOne of the most effective waysto deposit pigment on the tip is: to lightly tap the end of the fiber onto a sheet of articulating film while the laser is activated uninitiated tip will fail to focus enough energy at the end of the fiber to adequately ablate tissue
  45. 45. Basic Power Settings
  46. 46. the Academy of Laser Dentistry recommends: using the Least Amount of Power To prevent collateral thermal damage to adjacent tissue:Power Settings Procedure1.2 watts For most soft tissue ablation Result in excellent tissue removal with minimal procedures° → thermal degeneration of1.4 watts Areas of denser tissue, such as adjacent tissue the palate and the fibrous tissue distal to the lower second molars1.6 watts Frenectomy
  47. 47. Surgical Procedure Anesthesia
  48. 48. Adequate soft tissue anesthesia required for laser-assisted tissue removal Anesthesia Application of a compounded Topical Anesthetic Gel such as: In most cases Profound PET (prilocaine 10%, lidocaine 10%, tetracaine 4%, and phenylephrine 2%) 3 – 4 minutes Produces profound anesthesia in a relatively Denser Tissue short amount of time - Distal of an erupting lower second molar injection of local anesthetic solution - Palate
  49. 49. Surgical ProcedureThe operator activates the laser with a foot pedal and gently moves thetip of the fiber across the target tissue in a lightcontact mode
  50. 50. Surgical Procedure- Careful attention must be paidto the interaction of the laserenergy with the target tissue Leaving the fiber tip in one spot too long will result in: - CARBONIZATION and - unnecessary collateral damage, While moving the tip too quickly will result in: - an insufficient absorption of energy to produce ablation
  51. 51. Surgical ProcedureDuring the procedure,it is imperative that high-volume aspiration is used to:- Evacuate vapor plume and objectionable odors at thesite of ablationOnce satisfactory tissue removal has beenachieved:- any remnants of slightly carbonized tissue remaining at the surgical margins are removed with light pressure using a micro-applicator brush soaked in 3% hydrogen peroxide solution
  52. 52. Clinical Applications
  53. 53. Clinical Applications in ORTHODONTICS Specific procedures include :
  54. 54. Exposure of Unerupted and Partially Erupted Teeth
  55. 55. Exposure of Unerupted and Partially Erupted Teeth Lengthy orthodontic treatment times are often the result of: - Delayed eruption of teeth - compromised Bracket Positioning due to gingival interference
  56. 56. Exposure of Unerupted and Partially Erupted Teeth Using the diode laser both unerupted and partially erupted teeth can be : - exposed for bonding, and - tissue interfering with ideal bracket placement can be removed
  57. 57. Canine exposureCanine exposure in labial sulcusCanine exposure on palatal aspect
  58. 58. Canine exposure in labial sulcusLabially erupting canines are: Common Malocclusion Conventional exposure with scalpel based method leads to:- Extensive bleeding and- the field of operation requires special hydrophilic moisture insensitive primers to bond orthodontic attachments
  59. 59. The use of a 810 nm diode laser ensures:- Easy exposure with Minimal Bleeding and- least patient discomfort The Clear Bloodless Field ensures Fast Predictable Bonding Enabling fast correction of malocclusion
  60. 60. Canine exposure on palatal aspectPalatally impacted canines are Difficult Situation requiring: - surgical raising of an extensiveMUCOPERIOSTEAL FLAP - Sutures at the end and - an extensive postoperative discomfort and swelling
  61. 61. Diode laser allows: - exposure without any extensive flap and - generally no sutures are required after the procedure - The patient experiences minimal pain or discomfort - In addition, a Bloodless Field ensures instant bonding of orthodontic attachment
  62. 62. Frenectomies
  63. 63. A high or thick labial frenum is often of concernwhen the attachment:- Causes a midline diastema or- Exerts a traumatic force on the marginal gingiva Laser permit : PAINLESS excision of frena, without - Bleeding, - Sutures, - Surgical packing, or - Special postoperative care Typical power settings: 1.4 to 1.6 watts in continuous wave mode
  64. 64. Frenectomy for midline diastema correctionIt is an accepted Contemporary View that:- Midline Diastema first should be Corrected with orthodontics and THEN- Frenectomy so that Scarring that results after conventional scalpel based frenectomy doesn’t interfere with tooth movement
  65. 65. With a diode laser: Frenectomy can be done orBEFORE complete closure AFTER Healing of laser wound doesn’t involve any scarring
  66. 66. Miscellaneous Tissue Removal
  67. 67. Removal of Odontomein maxillary anterior region preventing eruption of permanent incisor
  68. 68. Replacing the need for aTissue Punch when placing MINISCREWS in unattached gingiva
  69. 69. Aesthetic Gingival Recontouring
  70. 70. Orthodontic fixed appliances good oral hygiene maintenance In many cases we notice Gingival Hyperplasia
  71. 71. The gingival margins of the upper central incisorsand upper cuspids should be:- approximately level with each other and- slightly superior to the gingival margins of the upper lateral incisorsWith: Uneven Gingival Contours causing someteeth to:appear too short and others to appear too long
  72. 72. Such enlargementfurther impedes good hygiene and is commonly associated with bleeding
  73. 73. Gingival aesthetics play A VITAL ROLE in the appearance of a finished orthodontic case- Excessive gingival display - significantly diminish the- Uneven gingival contours, and aesthetic value of even the- Disproportionate crown heights and widths most perfectly aligned teeth
  74. 74. Diode laser can be used effectively in such situationsGingivoplasty
  75. 75. Removal of Inflamed and Hypertrophic Tissue
  76. 76. assisted salvaging of orthodontic microimplant ‫إنقاذ‬ inflammation of tissue around the implant A diode laser was used at 0.5 W to: - decontaminate and allow healing of tissue around microimplant The implant survived and served its orthodontic purpose
  77. 77. Laser-assisted circumferential supracrestalmfibrotomy/ LACSF/ pericisionControl of Tooth Rotation correction in orthodontics from relapse is always a challengePermanent lingual bonded retention is essential It is also suggested to do Circumferential Supracrestal Fibrotomy Allow Elastic Fibres to reorganize favorably without causing relapse of correction Conventional scalpel-assisted CSF - associated with bleeding and - requires infiltration anaesthesia.
  78. 78. A diode laser can also be used as Low Level Therapy during Orthodontic Tooth Movement especially during a situation whereHeavy Orthopedic Forces are applied as in Rapid Maxillary Expansion
  79. 79. Finally ‫ضرورة دراج اللٌزر فً الممارسة الروتٌنٌة لتقوٌم‬ ‫األسنان‬ The incorporation of lasers in routine orthodontic practice is the order of the day The practices that embrace this technology will surely flourish ‫الممارسات التً تبنً هذه التكنولوجٌا ســــــــوف تزدهر بالتأكٌد‬