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Implant Therapy Using UltraspeedCO, Lasers Jon M. Julian,DDS PriuatePracnce McPherson,Kansas

Abstract: Althoughlaser use in dentistry is still in its infmtcy, the poten. tial applications are very beneficial clinically. As the technology imprwes, different wavelengths and laser med.huns exhibit a.d.vontages and disadctantagesin those clinical applications. The purpose of this article is to discuss the use of the COrUtraSpeedlaser for implant dentistry as well as hut it co'nl'lpolres, in the author's opinion, to other soft tissue Iaser wavelengths. l-T.ihis

author has been a laserdentist for over 6 yearsand currently has different wavelengthsrepresentedin his office.Of the 3 soft tissue 4 | lasers(diode, Nd:YAG, and COr), this author has found that the I CO, UltraSpeed Lasef is the most versatile and efficient tool currently available for soft tissue therapy. Using sapphire resonator technology, the CO, UltraSpeedLasercan generatepeak power of 320 W with pulsedurations of up to 30 pm.' In simple terms, accordingto the manufacturerthis lasercan be toned down to fractionsof a watt for safe,comfortablesoft tissue treatments,such as ffeating herpesand aphthouslesions,or it can be usedat settingsof up to 6 W to very expedientlycreatesurgicalincisions through the most stubborntissue.This laserusesan articulatedarm with a seriesof mirrors to deliver a 100% efficient sourceof energy,which, according to the manufacturer,is unlike the optic fibersthat the other previously mentioned lasersuse to deliver energy.It is this author'sopinion that the coagulumand debris that accumulateon the optic fiber tip as it comesin contact with the soft tissuereducesthe efficiencyand causesfluctuationsin energydelivery. The CO, UltraSpeed Laser delivers appropriate amounts of energy to accomplishtasksrapidly,and its 0.5-mm tissuepenetrationand rapid absorption by water makesthis laserextremelysafein all applications.tThe benefits of sealingblood vesselsand lymphaticson incision resultsin little or no bleeding as well as markedly reduced pain and inflammation compared to traditional surgerywith a scalpel.tThis author has experiencedthesebenefits in applications such as frenectomies,troughing for crown preparations (for impressions),incisionsfor surgicalprocedures,excision of soft tissue pathologysuch asfibromas,treating periodontaldisease,and treating ailing (sufferingfrom infection or inflammation) or failing implants. The potential usesfor the CO, UltraSpeed Laser are too numerous to mention in this article, so the focuswill be on implant therapy applications. In this author's opinion, the advantagesof the CO, UltraSpeed Laser in implant therapy include safety of the laser beam in close proximity to the implant body (in fact, there is no harm, such asoverheatingof tissuesleading to osteonecrosisand damageof soft tissues,if the laser energy contacts the implant or abutment); a clean visual surgicalfield becauseof the significant reduction in bleeding when comparedto that of a scalpel;a reduction in pathogensat the surgical site becauseof contact with the laser energy (reducing the potential for secondaryinfections); and the significant reduction in postoperative pain and swelling, thus reducing the morbidity and allowing the patient a more pleasantexperiencepostsurgically. 'DEKA LaserTechntrlogies,LLC. 954.585.6000;uww.dekalasers.com

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placed. Figure1-The toothwasextracted atrau-Figule Figure 2-The imp implant isi placed. matically. A granuloma waspresent.

Gase 1 Sludy The authorwaspresentedwith a situationin which an upperbicuspidneededto be extracted (tooth No. 5). The patient electedan implantsupportedcrown for the treatment plan. The tooth was extracted without loss of bone or trauma to soft tissueand a granuloma(a localized focus of infection) was found (Figure 1). The possiblepresenceof bacterialpathogensis a serious concem when grafting or placing implantsbecausea secondaryinfection can prevent osseointegration of the implant, thus leading to failure.' Therefore, neutralizing these pathogensis the key to success in implant therapy, as with any surgicalprocedure.The CO, laserwas setat 2.4 W and 80 Hz. Using a 50mm surgical handpiece at a distance greater than 12 mm (out of focus),the laserbeam was waved continuouslywithin the extraction slte for 20 seconds.At this setting,the laserenergy will ablateany soft tissuewithin the socketand neutralizeany remainingpathogens.According to the manufacturer,the energy density transmission onto the tissue at that setting is between60 mJ/cm']and120 mJ/cm'.Then the tissueimmediatelysurroundingthe extraction site was lasedin the samernannerfor an additional 10 to 20 seconds,alsoto sterilizethe surrounding tissue.Next, the implant (Ankylos@r', 4.5 mm x 11 mm) was placed (Figure 2). Grafting material (PepGen" P-15 particulateb) wasthen placedand a barriermembrane(Gore ' DENTSPLY Fri"J.,., C.r,,M*J, 80042o-?8 l6; wwrv.cerrmcJ.c.rrn

Figure 3-Grafting material isplaced anda barrier membrane issutured intooosition.

Resolut@Adapt') was sutured into position (Figure 3). The final restoration (Procera@ Z crowno)exhibited a healthy and estheticresult at 4 months posttreatment(Figure4).

2 Gase Study A patient presentedwith a healthy ridge with good tissuewhere tooth No. 12 had been missingfor severalyears.The patient wanted to have an implant-supported crown. The author's goal was to do this efficiently and atraumatically.The CO, laserwas set at 5 \X7 and 80 Hz, and the 50-mm surgicalhandpiece was used.The laserwas usedin focus approximately 10 mm from the surgical site. This allowed a quick incision to be made in the tissue, without any bleeding,that was just large enough to allow clear accessto the bone for the drills. Using a surgicalstent to guide the placementarea,a circular3-mm site was targeted,and the tissuewithin this site wasablated to the bone (Figure 5). The clean, sterile surgicalsite wasenteredwith a seriesof osseous drills, and the implant (Ankylos,3.5 mm x 11 mm) was placed. There was no postsurgical trauma or bleeding (Figure6), and the patient postsurgically. did not requireany analgesics

Case 3 Study When a sinuslift is indicated,a largeincision is reauiredto accessthe malar eminence and to 'W.L. Gore & Associirtes,Inc, 888.914.4671;wwwgore.com 'Nobel BiocareUSA lnc, 800-991-8100;www.nobelbiocarc.com

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Figure4-The finalrestoration, 4 m0nthsFigure 5-A circular 3-mmsiteis targeted, Figure6-ToothNo.12 immediately after postsurgery, exhibits a healthy andestheticandthetissuewithinthissiteis ablated to theimplant is placed. Notethatthereis no result. postsurgical thebonewitha C0,laser. trauma or bleeding. Vol.26,No.9 (Suppl 2)

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Figute7-Slowlydrawing thelaserbeamFigure 8-Theflapisreflected 9-Thesiteis closed witha locking andthesinusFigure across theridgecrestandintothemucosaliftprocedure isperformed. continuous slingsuture. creates thereleasino incision.

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createa flap entry largeenough to createa window in the bone. For this case,a 6-mm-highby lO-mm-longwindow was created.For this procedure,the CO, laserwassetat 6 W and 100Hz and the 50-mm surgicalhandpiecewas usedin focus.At thesesettings,an efficientcut through the tissueand the periosteumwasaccomplished. The laserbeamwasdrawnslowlyacrossthe ridge crestand into the mucosato createthe releasing incision (Figure 7). This was accomplishedin less than 60 seconds,and the incision went through the periosteumand stoppedat the bony crest. The flap was reflected and the sinus lift procedurewas performed(Figure8). Note the cleansurgicalfield wlth very little bleeding.The site was closeclwith a krcking continuoussling suture,which is a singlecontinuousinterlocking suturewith loops approximatelyone eighth of an inch apart(Figure9). This is the sametype of suturingthat would have beendone had a similar incision been made with a scalpel.The patient was seen {or a }4-hour postoperative appointment,at which time it was noted that there was no evidenceof swelling,redness,or irritation. Analgesicsgiven in the first 12 hor"rrs consistedof 2 extra-strengthacetaminophen and 2 ibuprofen taken together,and the patient did not need to take anv analsesicsafter the first 12 hours.

surgicalswellingof tissuecan causefailureof the suturesand prolongwound healing.) The 3. CO, lasercauseslittle to no postoperative pain. The author'sstandardanalgesicis a combination of 2 acetaminophenand 2 ibuprofentaken immediatelyafterthe procedure (including sinus lifts). He has found that few patientsneedto take any analgesics after 12 hours. \X/hen comparedto similar surgicalproce4. dureswith a scalpel,thereis reducedswelling and rednessof tissueand reducedpostoperative infectionswhen the CO, laseris used. The CO, UltraSpeedLaseris a very versatile soft tissuelaserthat can be effectivelyusedin all surgicalas well as nonsurgicalsoft tissuetherapies.Particularlywith implant therapy,this laser reducesthe time spent in surgeryby increasing vision in the field.The inflarnmatoryresponsers pain and limited, which reducespc.rstoperative swelling. Laser energy kills pathogens,which reducespostoperativeinfections and thereby increasesthe chance for success.There is no danger if the laserenergytouchesan implant, which, in this author'sopinion, makesthis one of the safestlasersavailablein implant therapy. Thesebenefitsmakethis laserpotentiallybeneficial to any dental practice but especiallyto practicesdoing implant therapy.

Conclusion

Disclosure

After performingmany casesinvolving the proceduresdiscussedin this article, the author has found the following clinically relevant findings to be consistentin his experience: 1. Using the CO, lasercreatesa clean,almost bloodlesssurgicalfleld that increasesvision and reducesthe time spent performing a particular procedure. 2. The CO, lasercauseslittle or no postoperative swelling,which is significantboth in patient comfort and successful suturing.(Post.

The author receives honoraria from DENTSPLY International and DEKA Laser Technologies,LLC.

2005 Gompendium / September

Relerences 1. JustenC. An overviewof lasers indentistry.DEKA position paper.2003. 2. Research,Science, and Therapy Committee of the American Academy of Periodontology.Lasersin periodonrics.J P eiodontol. 2007;73 :123 l -1239. 3. Deppe H, Horch HH, Henke J, et al. Peri-implirnt care of rriling implants with the carbon diode laser. lnr ./ Oral Maxilkf oc Implants.ZA0I ;l 6:659-667 .

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Compendium Article by Julian