Efficacy and safety of a diode laser in second stage implant surgery


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Efficacy and safety of a diode laser in second stage implant surgery

  1. 1. Clinical Paper Dental Implants Efficacy and safety of a diode laser in second-stage implant surgery: a comparative study K. E. El-Kholey: Efficacy and safety of a diode laser in second-stage implant surgery: a comparative study. Int. J. Oral Maxillofac. Surg. 2014; 43: 633–638. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. K. E. El-Kholey Lecturer, Oral Surgery Department, Ain-Shames University Hospitals, Ibn Sina College for Medical, Jeddah, Saudi Arabia Abstract. For more than a decade, peri-implant tissues have been treated with soft tissue lasers to create a bloodless flap for implant placement and to uncover implants with minimal bleeding, trauma, and anaesthesia. This study was designed to assess if dental implant uncovering is possible with a diode laser without anaesthesia, and to compare its performance with traditional cold scalpel surgery. Thirty patients with a total of 45 completely osseointegrated implants participated in this study. Patients were divided into two groups. For the study group, second-stage implant surgery was done with a 970 nm diode laser. For the control group, the implants were exposed with a surgical blade. Certain parameters were used for evaluation of the two techniques. The use of the diode laser obviated the need for local anaesthesia; there was a significant difference between the two groups regarding the need for anaesthesia (P < 0.0001). However, there were no significant differences between the two techniques regarding duration of surgery, postoperative pain, time for healing, and success of the implants. The diode laser can be used effectively for second-stage implant surgery, providing both the dentist and the patient with additional advantages over the conventional methods used for implant exposure. Keywords: laser; second-stage implant sur- gery; implant. Accepted for publication 2 October 2013 Available online 7 November 2013 With the expansion of implant dentistry and laser technology in clinical practice, surgical lasers have been used with good results in a variety of ways in implantol- ogy, ranging from placement, to second- stage surgery for exposure of the buried implant and gingival management, through to the treatment of peri-implanti- tis.1–6 The diode laser is housed in a small, portable, compact, surgical unit that can be used for a multitude of dental proce- dures, on both soft and hard tissue. These lasers have a wide range of wavelengths that are characterized by good absorption in the chromophores found in soft tissue, such as haemoglobin and melanin, result- ing in excellent soft tissue incisions, abla- tion, and coagulation, as well as antimicrobial effectiveness. Most dental diode lasers employ a flexible optic fibre to deliver the treatment beam to the target area. This optic fibre usually comes in the form of an easily handled headpiece.1,2 In a study on the use of the diode laser to uncover dental implants, Yeh et al.3 con- cluded that the soft tissue diode laser offers an alternative technique for unco- vering dental implants and that the tech- nique provides an efficient, safe, and patient-friendly method for the perfor- mance of second-stage implant surgery, allowing a faster rehabilitation phase. Miller6 used another type of soft tissue laser – the Er, Cr; YSGG laser – for the same purpose, and reported good and encouraging results with the use of this laser on more than 200 patients over 6 years. Miller found that tissue stability appeared to be enhanced when the laser Int. J. Oral Maxillofac. Surg. 2014; 43: 633–638 http://dx.doi.org/10.1016/j.ijom.2013.10.003, available online at http://www.sciencedirect.com 0901-5027/050633 + 06 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
  2. 2. was employed compared to when conven- tional resection techniques were used. In 2010, Gianfranco et al.7 used two laser systems, Er:YAG and a diode laser, to uncover implants in two separate cases, and demonstrated good clinical results regarding patient satisfaction and rapid healing of the tissues. Arnabat-Dominguez et al.8 published a clinical study on the application of the Er:YAG laser in second-stage implant surgery, and observed many advantages with respect to the conventional techni- que. The authors added that the technique described could be used in all cases except situations where aesthetic considerations prevail in anterior areas, or in the event of a lack of keratinized gingiva surrounding the implant. However, a recent study reported that implant rehabilitation of the anterior sector, despite the important aesthetic demands involved, can benefit from the advantages of second-stage sur- gery by laser in contrast to the traditional cold scalpel technique.9 This study was designed to assess if dental implant uncovering is possible with a diode laser without anaesthesia and to compare its performance with traditional cold scalpel surgery. Patients and methods Thirty healthy patients participated in this study; 19 were women and 11 were men, and they ranged in age from 25 to 54 years. The study was carried out in accordance with the guidelines of the Declaration of Helsinki on medical protocol and ethics and with the approval of the regional ethics review board. Details of the treat- ment were discussed with the patients, and all signed an informed consent agreement. Forty-five implants were inserted in these patients using a two-stage technique. The implants were inserted through a small crestal incision, except two implants that were inserted with the use of a punch. After 12 weeks the patients attended appointments for the second-stage sur- gery. At that time, the implant sites were examined for the presence of adequate healthy keratinized tissue surrounding the implant site and only those patients with this criterion were enrolled in the present study. The patients were then divided into two groups using a simple randomization procedure. For allocation of the subjects, a computer-generated list of random numbers was used, with a randomization ratio of 1:1, using Random Allocation Software (version 1.0, May 2004). One nurse, blinded to the study protocol, enrolled all participants and assigned them to one of the two groups outlined below. The control group comprised 15 patients, with 22 implants. For these patients, the implants were exposed through a circular incision using a No. 15 surgical blade. After infiltration anaes- thesia of the soft tissues covering the implant site and with the help of the surgical guide used during implant inser- tion, a small circular area of the tissues less than the size of the implant was excised to precisely determine the site of the implant. At that time, the circular incision was widened to completely uncover the implant, then the healing abutment was attached. The study group comprised 15 patients, with 23 implants. For these patients, the second-stage surgery was done using a 970 nm diode laser system (SIROlaser; Sirona Dental Systems GmbH, Germany). The programme for implant uncovering was selected by moving between the inte- grated programmes in the device. The power used was 4 W, the mode was con- tinuous emission, and the optic fibre used was 320 mm. The implant sites were assessed with the help of the surgical guides used for the insertion of the implants, then the laser was used to create a small opening, which was increased until any part of the cover screw appeared. Next, ablation of the tis- sue over the implant was performed until the surgical opening became just large enough to allow removal of the screw. After this step, the cover screw of the implant was removed and a suitable heal- ing abutment was attached. While the laser was in use, an assistant was asked to hold the suction tip near the area of surgery, and a saline drip was applied to the surgical site. Application of the laser was intermittently stopped every 20–30 s to examine the tissues for any burning effects to the gingiva and to avoid any increase in soft tissue or bone temperature. In most of the patients, no injectable anaesthesia was used, only topi- cal anaesthesia; however, one patient felt some pain, so local anaesthetic was infil- trated. Postoperatively, no patients in either group were prescribed antibiotics. For analgesia, paracetamol 500 mg four times daily was prescribed only when necessary. The patients were asked to return after 1 week for the clinical assessment of heal- ing. All implant placement and surgery for implant exposure in both groups was per- formed by the author. The evaluation of tissue healing after the second-stage 634 El-Kholey 35 paƟents were assessed for eligibility 5 paƟents were not eligible: 2 paƟents did not meet the inclusion criteria 3 paƟents declined to parƟcipate 15 paƟents were assigned to the study group, in whom the diode laser was used to expose the implants 15 paƟents were assigned to the control group, in whom the scalpel was used to expose the implants 30 paƟents underwent randomizaƟon Analysis PaƟents analyzed = 15 PaƟents excluded from analysis = 0 PaƟents analyzed = 15 PaƟents excluded from analysis = 0 Fig. 1. Consort flow diagram.
  3. 3. surgery and determination of the appro- priate time for taking impressions was done by discussion with the college prosthodontic staff who were blinded to the technique used for implant uncover- ing. For comparison of the two techniques, the following parameters were assessed: (1) the need for local anaesthesia and the amount used during surgery (in ml); (2) the duration of surgery (in min); (3) intrao- perative bleeding, rated by the surgeon on a three-point category rating scale (1 = minimal bleeding; 2 = normal bleed- ing; 3 = excessive bleeding); (4) subjec- tive pain, which was evaluated with the aid of a 100-mm visual analogue scale (VAS), with 0 anchored by ‘no pain’ and 100 anchored by ‘worst pain imaginable’. The patients were instructed on how to use the VAS and recorded the intensity of postoperative pain daily for the first 3 days. The patients were also asked to record their use of analgesic medication during the postoperative period. A clinical assessment of the peri- implant tissues was made at the end of surgery and again 7 days after the opera- tion, to evaluate the healing status and the possibility of taking an impression. The absence or presence of soft tissue inflam- mation, oedema, gingival bleeding, and pain was assessed. Statistical analyses were undertaken using SPSS version 15 for Windows soft- ware (SPSS Inc., Chicago, IL, USA); the level of significance was set at P 0.05. Results A total of 30 patients agreed to participate in this trial. All of the patients who parti- cipated were treated identically except for the implant uncovering technique, and none dropped out (Fig. 1). For evaluation of the two techniques used in this study for implant exposure, certain parameters were recorded (see Table 1). Oncomparingthelaser-treatedpatientsto thepatients managed witha blade,therewas a significant difference between the two groups regarding the need for anaesthesia (P < 0.0001). Only one of the 15 patients in thestudygroupneededinfiltrationofasmall amount of local anaesthetic (0.4 ml) and the rest of the patients tolerated the procedures withonlytopicalanaesthesia.Incontrast,all the control patients required infiltration of anaesthesia in the buccal and lingual or palatal side (the mean volume of local anaesthetic used was 0.9 ml). Intraoperatively, no bleeding was encountered during the laser surgery and there was a clear view of the surgical site, while for the control group, some normal bleeding occurred that could be controlled by application of a pressure dressing for a few minutes before attaching the healing abutments; the difference in intraoperative bleeding was not significant (P = 0.11). Regarding the duration of surgery, laser surgery was comparable to that done by Diode laser in second-stage implant surgery 635 Table 1. Summary of the parameters evaluated for comparing the outcome of surgery by diode laser and surgical blade. Parameter Group Study group Control group P-value Patients who had infiltration anaesthesia, n (%) 1 (6.6%) 15 (100%) 0.0001* Duration of surgery, min, mean Æ SD 5.6 Æ 0.46 4.6 Æ 0.25 0.14y Intraoperative bleeding score, mean Æ SD 1.13 Æ 0.35 1.67 Æ 48 0.11y Postoperative pain score, mean Æ SD 11.96 Æ 0.96 12.33 Æ 0.90 0.40y Time of impression taking, days, mean Æ SD 7.13 Æ 0.35 12.0 Æ 0.53 0.06y SD, standard deviation. * P-value of Fisher’s test. y P-value of the Student’s t-test. Fig. 2. (a) Tissue ablation by laser for an implant at site 47 in patient 1. (b) Healing abutment in place with complete soft tissue healing in patient 1, at 1 week after laser surgery. (c) Complete soft tissue healing after removal of the healing abutment before impression, at 1 week after implant exposure in patient 1.
  4. 4. blade (P = 0.14). Postoperatively, no patient in either group suffered from sig- nificant pain: the mean pain scores were 11.96 and 12.33 for the study group and control group, respectively. The pain scores were in the faint to weak area, with no significant difference between the two groups (P = 0.40). A peri-implant soft tissue evaluation was performed 7 days after surgery. In the laser-treated group, all the surgical sites had healed completely at the 7-day appointment and there were no signs of inflammation, redness, burning, or oedema. The patients needed no post- operative analgesics. The impressions could be taken at 1 week after the laser surgery. In the control group, healing was satisfactory at 7 days after surgery, but there was some oedema at the gingival margins; therefore the impressions were taken after an additional 5 days. The mean time to the taking of impressions for the laser-treated patients was 7.13 days, while it was 12.0 days for the control group. The difference between the two groups regard- ing this variable was not significant (P = 0.06). Figures 2–4 show the results in some of the cases. Six months later, radiographic and clinical follow-up of the cases showed no failure of any implants, whether the patient was treated by laser or by blade. Discussion The second-stage surgery of submerged implants can be performed with a scalpel, or by electrosurgery or laser.10 With the 636 El-Kholey Fig. 3. (a) Complete healing of the soft tissue in patient 6, at 1 week after the laser surgery; impression coping in place for impression taking. (b) Complete soft tissue healing after removal of the healing abutment in patient 6. Fig. 4. (a) Healing abutment immediately after surgery by scalpel in patient 3. (b) Some soft tissue oedema at 1 week after surgery in patient 3.
  5. 5. use of a scalpel for incision or excision, there may be some bleeding, pain, and discomfort during and after surgery. Electrosurgery may damage the implant surface dramatically, disturbing osseoin- tegration and leading to implant failure. The application of a surgical laser to the soft tissues surrounding or covering the implant offers a series of potential advantages, as there is improved vision due to good homeostasis, less mechan- ical trauma to the soft and hard tissues, elimination of the need for injectable anaesthesia and suturing, prevention of local infection, inflammation, and post- operative pain, improved healing, and a shortening of the time needed prior to taking the impression. The acceptance of this simple and comfortable technique by the patient cannot be forgotten.3–10 The only limitations to the use of the laser to uncover implants are the lack of adequate zones of keratinized tissue and knowledge of where the implant has been placed.3,8 In the present study, a 970 nm diode laser system was used to uncover 23 implants in 15 patients and the results were encouraging. Several advantages of the use of this technique were demon- strated. Among these advantages were the elimination of the need for a flap or suture, no postoperative pain, and rapid healing of the tissues, with the possibility of taking the impression immediately after surgery. This latter advantage was a result of the fact that there was no contamination due to the absence of bleeding and because changes to the tissue margins after surgery were expected to be absent or minimal. In addition injectable anaesthesia was not needed in most cases and the total time required to finish the prosthesis was shor- tened for the patient. The results obtained in the laser-treated patients agree with those of some other trials and studies done with the diode or other laser systems to uncover implants.3,6–9 All of these trials and stu- dies concluded that soft tissue lasers can be utilized effectively and safely for sec- ond-stage implant surgery, providing additional advantages over the conven- tional methods of flap or punch techni- ques. Moreover, there is potential interest in the clinical use of the diode laser, which has excellent properties for incision, exci- sion, and coagulation of the soft tissues. Intraoperative and postoperative clinical findings were excellent, due to its satis- factory cutting abilities, precise incision margin, good coagulation effect, and extremely small zone of thermal necrosis in surrounding tissues.10 In the control group, the second-stage surgery was carried out using conven- tional surgical instruments to expose the implant, by excising a circular area of the tissues covering the implant. Punch inci- sions were not used (although this method is simpler) because of a possible deviation of the resultant incision from the site of the implant. The author thinks the insignifi- cant difference in the time to complete healing and impression-taking between the two groups (although healing was faster in the laser-treated group) could be due to the similarity in the amount of tissue manipulated in the two surgeries. Arnabat-Dominguez et al.,8 in discussing the results of their study on the use of laser versus creating a small flap in the second phase of implant surgery said, ‘‘if in some cases of this study, the punch technique had been used then the healing process may have been faster, and the time elapsed before impression taking would have been similar to the laser-treated patients, because the punch technique does not usually require suture placement’’. When comparing the soft tissue cutting ability of diode lasers versus electrosur- gery units, Christensen11 cited the advan- tages and disadvantages of each alternative and concluded that the diode laser has become a staple of many dental practices due to its many advantages, such as the elimination of the need for anaes- thesia, good homeostasis, less postopera- tive pain and oedema, and faster healing of the tissues. He added that the diode laser can be used safely around metals, in the exposure of implants and even in the management of ailing implants, without any fear of damaging the implant surface or the surrounding bone. The old concern about damaging the implant surface or bone surrounding the implants due to an increase in temperature as a result of laser application has been investigated widely and there is evidence that the diode laser, with its wavelength group, is one of the safest types of laser for use around implants as it does not influ- ence the structural implant surface adversely. This may be related to the wavelength, the minimal depth of pene- tration of these types of laser, and to the reflection of the laser away from the implant surface.5,12,13 It has been shown by scanning electron microscopy that the diode laser can be applied to peri-implant tissues without changing the implant sur- face pattern.14,15 In this respect, Kato et al.16 noted that irradiation of the implant does not significantly increase the tem- perature of the implant body and that this temperature does not negatively influence the attachment of fibroblasts or osteoblasts to the implant surface. In conclusion the present study showed that the use of a diode laser in second- stage implant surgery can minimize sur- gical trauma, eliminate the need for anaes- thesia, improve visibility during surgery due to the absence of bleeding, and elim- inate postoperative discomfort. The time needed for tissue healing is short, which results in a shorter time to rehabilitation of the patient. The only limitation to the use of this technique is a lack of sufficient keratinized tissues around the implant. Funding None. Competing interest None. Ethical approval The study was approved by the Regional Ethics Review Board of Ibn Sina College for Medical Studies. Patient consent Patient consent was obtained for the study. Acknowledgement. The author thanks the members of staff of the fixed prosthodon- tic department for their help and support in completing this work. References 1. Pirnat S. Versatility of an 810 nm diode laser in dentistry: an overview. J Laser Health Acad 2007;4:1–9. 2. Lomke MA. Clinical applications of dental lasers. Gen Dent 2009;57:47–59. 3. Yeh S, Jain K, Andreana S. Using a diode laser to uncover dental implants in second- stage surgery. Gen Dent 2005;53:414–7. 4. Parker S. Surgical laser in implantology and endodontics. Br Dent J 2007;202:377–86. 5. Martin E. Lasers in dental implantology. Dent Clin North Am 2004;48:999–1015. 6. Miller RJ. Lasers in oral implantology. Dent Pract (Cincinnati) 2006:112–4. 7. Gianfranco S, Francesco SE, Paul RJ. Erbium and diode lasers for operculisation in the second phase of implant surgery: a case series. Timisoara Med J 2010;60: 117–23. 8. Arnabat-Dominguez J, Espana-Tost AJ, Ber- ini-Aytes L, Gay-Escoda C. Erbium:YAG laser application in the second phase of implant surgery: a pilot study in 20 patients. Diode laser in second-stage implant surgery 637
  6. 6. Int J Oral Maxillofacial Implants 2003;18: 104–12. 9. Arnabat-Domı´nguez J, Bragado-Novel M, Espan˜a-Tost AJ, Berini-Ayte´s L, Gay- Escoda C. Advantages and esthetic results of erbium, chromium:yttrium–scandium– gallium–garnet laser application in second- stage implant surgery in patients with insuf- ficient gingival attachment: a report of three cases. Lasers Med Sci 2010;25:459–64. 10. Romanos GE. Treatment of periimplant lesions using different laser systems. J Oral Laser Appl 2002;2:75–81. 11. Christensen GJ. Soft tissue cutting with laser versus electrosurgery. J Am Dent Assoc 2008;139:981–4. 12. Smith TA, Thompson JA, Lee WE. Asses- sing patient pain during dental laser treat- ment. J Am Dent Assoc 1993;124:90–5. 13. Kreisler M, Al Haj H, d’Hoedt B. Tempera- ture changes induced by 909 nm GaAIAs laser at the implant–bone interface during simulated surface decontamination. Clin Oral Implants Res 2003;14:91–6. 14. Romanos GE, Everts H, Nentwig GH. Effects of the diode (980 nm) and Nd:YAG (1064 nm) laser irradiation on titanium discs. A SEM examination. J Periodontol 2000;71:810–5. 15. Romanos GE, Everts H, Nentwig GH. Alterations of the implant surface after CO2- or Nd:YAG-laser irradiation. A SEM examination. J Oral Laser Appl 2001;1: 29–33. 16. Kato T, Kusakari H, Hoshino E. Bactericidal efficacy of carbon dioxide laser against bac- teria-contaminated titanium implant and subsequent cellular adhesion to irradiated area. Lasers Surg Med 1998;23:299–306. Address: Khalid E. El-Kholey Oral Surgery Department Ibn Sina College for Medical Studies Jeddah 21418 Saudi Arabia Tel: +966 55 6679608; Fax: +966 2 6375344 E-mail: Alkoley@hotmail.com 638 El-Kholey