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Lasers in Surgery and Medicine 37:144148 (2005)

In Vivo Animal Trials With a Scanning CO2 Laser Osteotome


Mikhail Ivanenko,1* Robert Sader,2,3 Said Alal,1 Martin Werner,1 Martina Hartstock,3 nisch,5 Stefan Milz,4 Wolf Erhardt,5 Hans-Florian Zeilhofer,2,3 and Peter Hering1,6 Christian von Ha 1 center of advanced european studies and research, 53175 Bonn, Germany 2 Division of Cranio-Maxillo-Facial Surgery, Clinic for Reconstructive Surgery, University Hospital, 4031 Basel, Switzerland 3 Center of Advanced Studies in Cranio-Maxillo-Facial Surgery, Klinikum Rechts der Isar, University Hospital, 81675 Munich, Germany 4 Anatomical Institute, LMU University of Munich, 80336 Munich, Germany 5 Institute of Experimental Oncology and Therapy Research, Klinikum Rechts der Isar, University Hospital, 81675 Munich, Germany 6 Institute of Laser Medicine, University of Duesseldorf, 40225 Duesseldorf, Germany

Background and Objectives: We report rst results of animal trials using an improved laser osteotomy technique. This technique allows effective bone cutting without the usual thermal tissue damage. Study Design/Materials and Methods: A comparative in vivo study on mandibles of seven canines was done with a mechanical saw and a CO2 laser based osteotome with a pulse duration of 80 microseconds. The laser incisions were performed in a multipass mode using a PC-controlled galvanic beam scanner and an assisting water spray. Results: A complete healing through a whole bony rearrangement of the osteotomy gap with newly build lamellar Haversian bone was observed 22 days after the laser operations under optimal irradiation conditions. Conclusions: An effective CO2 laser osteotomy without aggravating thermal side effects and healing delay is possible using the described irradiation technique. It allows an arbitrary cut geometry and may result in new advantageous bone surgery procedures. Lasers Surg. Med. 37:144 148, 2005. 2005 Wiley-Liss, Inc. Key words: laser osteotomy; CO2 laser; animal trials INTRODUCTION Noncontact cutting of bone tissue without mechanical stress is an old dream of surgeons and a laser beam is an instinctive choice for this. It can be tightly focused and its position controlled electronically, so that precise narrow cuts with sophisticated geometry can be exactly planned and performed. Early attempts to cut bones with lasers have failed, however, because of strong thermal side effects in case of continuous wave (cw) and long-pulsed carbon dioxide (CO2) lasers [15] or very low cutting rate with excimer lasers [69]. One third of the compact bone tissue volume consists of hard minerals, which melt only above 1,0008C [10,11]. The minerals are embedded on the other side in a sensitive collagen matrix, which will be charred after evaporation of the internal bone liquid and tempera 2005 Wiley-Liss, Inc.

ture rise above 1508C. Living bone cells will be irreparably damaged at even lower temperatures. The common laser cutting, as known from material processing, is therefore unsuitable for bone surgery. A successful laser osteotomy has to be based on an effective tissue ablation process, which does not takes place at very high temperatures and is much faster than the heat diffusion in the bone. Little thermal damage has been demonstrated, for example, in ex vivo studies with short CO2 laser pulse durations of 0.12 microseconds [1214]. With an additional use of an air-water spray, the collateral thermal damage remains small even after prolonged tissue irradiation with such laser systems [15]. The ablation rate is, however, not high for such short pulses (510 mm/pulse, see refs. above). A relatively fast and clean tissue removal (up to 100 mm/ pulse) is possible with 100500 microseconds pulses of an Er:YAG laser at the wavelength of 2.94 mm [1620]. A zone of thermal necrosis after Er:YAG laser incision in cortical bone is small, 2050 mm, according to [2123], so that healing observed in animal trials is similar to one after the use of a mechanical saw [22]. Essential details of the bone ablation mechanism are probably similar for Er:YAG and CO2 lasers. At high intensity of the light pulse, the energy will be accumulated very quickly in the tissue and conned initially in the form of heat in a very thin absorption layer. That overheated layer explodes after high internal pressure is built up (ultimate tensile strength is about 1,000 bar for compact
Robert Saders present address is University of Frankfurt, Klinikum fu r Kiefer- und Plastische Gesichtschirurgie, TheodorStern-Kai 7, 60596 Frankfurt am Main, Germany. *Correspondence to: Dr. Mikhail Ivanenko, caesar, LudwigErhard-Allee 2, 53175 Bonn, Germany. E-mail: ivanenko@caesar.de Accepted 20 May 2005 Published online 29 August 2005 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/lsm.20207

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bone [24]). If the pressure built-up time is shorter than thermal relaxation time of the tissue, then most of the energy is consumed for this thermomechanical ablation process and removed from the tissue together with the hot ablation products. The water spray prevents tissue parching and cools it additionally. A very promising way to avoid an accumulation of a rest heat in the bone tissue is the multipass cutting. A fast repeated motion of the focused beam along a predened cut trajectory can be realized conveniently using a PCcontrolled galvanic beam scanner. We use this technique, since it allows an effective clean osteotomy with relatively long (about 100 microseconds) powerful CO2 laser pulses, at pulse repetition rates of several hundreds hertz and average laser power of several tens of watts [25]. For example, at the pulse energy of 68 mJ, every laser pulse removes up to 500 mm of compact tissue, so that at the average laser power of 40 W, we reach a cut rate of 40 mm/minute for a 6-mm deep and 0.2-mm broad incision. Ex vivo incisions with such a laser system have previously been examined histologically [26]. The incisions were not accompanied with carbonization. At the cut border, a 50-mm broad zone with in part empty cell lacunae and damaged osteocytes was presented. Intact osteocytes were, however, observed also very near to the cut surface. Polarized light microscopy showed no alterations in the inorganic structure of the bone at the cut borders. In the present report, we describe rst experience of in vivo application of this scanning laser osteotomy technique and preliminary results of the operations on seven beagle canines. A complete report on the healing process and a detailed evaluation of the histological examinations will be given later. MATERIALS AND METHODS In the animal trials, a prototype CO2 laser osteotome was used, which was developed by the center of advanced european studies and research (caesar) in Bonn. The laser osteotome is based on a RF-excited slab CO2 laser system with wavelength of 10.6 mm. Laser pulses of 80 mJ energy and of 80 microseconds duration are delivered to the application site through an articulated mirror-arm with an action radius of 1.5 m. The preoperative planning of the incision and control over all the functions of the osteotome are done with a PC. Exact positioning and motion of the beam is fullled with a PC-controlled galvanic X-Y-scanner. The scanner is mounted on a 5-axis mechanical adjustment unit, which is xed at the operation stand near patient. The unit is used for initial manual focus positioning and cut orientation relative to the bone. Two red pilot beams are helped by the adjustment: one of them is collinear with the CO2 laser beam; the other one crosses it in the focus plane 159 mm below the scanner. The focusing optic provides a spot diameter of about 200 mm on the tissue (1/e2 intensity level) and is protected against ablation products, blood, and water droplets with a pressurized airow. Two ne spray-nozzles are mounted sideward to irrigate the incision continuously with isotonic NaCl solu-

tion during the osteotomy (throughput about 3 ml/minute by every spray). The velocity of the beam focus on the tissue in the multipass osteotomy was 480 mm/second. To assess the in vivo healing of bone in response to the laser osteotomy versus a conventional mechanical saw, we carried out a comparative study on the mandibles of seven beagle canines. The mechanical incisions were done with a Osseoscalpel micro saw with oscillating hub according to Sachse and blades of 0.35-mm thickness (Medicon eG, Tuttlingen, Germany). The canines were chosen, because their mandible contains, like in humans, a central artery with centripetal nutrition and homogenous spongiosa architecture. From its size, form, and hardness, the bone is comparable with the human one. Also the physiological reaction is similar, as secondary osteons can be detected during bone healing process. At the beginning of the study, four male and three female canines, from breeding facilities of the German National Research Center for Environment and Health, were between 2 and 8 years old and 12.519 kg heavy. The canines were accommodated in groups of up to three animals in 12 m2 large ventilated double boxes. Also an access to walking area was granted to them. The temperature in the areas was 19238C and relative air humidity 5070%. The illumination changed automatically between day and night phases. The animals were inoculated, dewormed, and free from specic pathogens. Feeding took place once daily. There was no feeding 18 hours prior to the operation. The animal head was xed during the operation with non-invasive headrest pad and tape. A 58 mm long laser incision and similar in geometry saw incision were made in pairs in the ventral aspect of the lower margin of both left and right mandibles of each canine under general anesthesia. The distance between the laser and saw incision at each mandible side was about 10 mm. To avoid laser damage of the soft tissue, a metal shield was placed behind the bone during the irradiation. Two animal groups were built randomly to evaluate different irradiation settings. A special scan procedure [27] has been applied to dilate the laser cut and so to increase the cutting efciency in the rst group. The beam focus was positioned 6 mm below the front bone surface in this case. The pulse repetition rate was 400 Hz and the duration of the irradiation varied between 45 and 90 seconds, depending on the cut length and thickness of mandibles (710 mm). In the second group, narrow cuts without the dilatation at the repetition rate of 200 Hz and the focus position 2 mm below the bone surface were done. The cut duration was 60155 seconds. Seven laser incisions were done in every group: three canines belong to the rst group, three to the second and one animal became dilated laser incision at the left mandible side and narrow incision at the right one (e.g., belongs to both groups). Both types of laser cutting procedure were at rst carefully tested and optimized in ex vivo models. The used slit dilation technique allows to shorten the cut time about 1.5 times for 8-mm thick mandible and to fulll deeper incisions. The optimal positioning of the beam focus

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beneath the bone surface brings further improvement in the cut rate. There was no difference between the two animal groups in relation to saw incisions. During the healing period, three different intravital stains were injected one after the other to mark the surface of new-bone growth for uorescence microscopy. By this, after the animals were sacriced 22 days following the surgery, the tissue response was examined by polychrome sequential labeling and undecalcied paragon-stained ground sections. In addition, contact radiographic and micro-radiographic examinations were performed. The study met the requirements of the German law for the animal protection and was approved from the District Government of Upper Bavaria. RESULTS The laser osteotomy was in general unproblematic. Small bleeding did not prevent the cutting, while the blood was blown out of the incision with the spray and due to the explosion-like action of repetitive laser pulses. Only a relatively strong bleeding has led once to the fail of the laser procedure. In one other case, the lasing has been interrupted, because the canine twitched. In the rst group, the dilated incisions, like in Figure 1a, with an entry width of 1 mm were performed. They were wedge-shaped, that is, the cut slit at the exit site was 3 4 times narrower as at the entry site. By the very rst incision, a carbonization at the medial end of the cut channel occurred. The thickness of the carbonized zone amounted to about 300 mm. It was caused by a strong back light reection from the dorsal metal shield, which was positioned in direct contact with the jaw. To avoid this, we used in further operations, in both animal groups, metal plates with enhanced absorption and more homogeneous light scattering, which were positioned 23 mm apart from the bone. No carbonization was found in this case. As an interesting subsidiary result, it was observed that it did not come to a callus formation by the rst laser group. It can be interpreted as a missing induction of a secondary fracture healing and associated with relatively large width of the dilated laser incisions as compared to the saw incisions with 0.5 mm width. In the second group, we have reduced the laser cut width down to 0.20.3 mm at the entry side (Figs. 1b and 2a). The duration of the cuts increased up to 70%. There were no visible traces of tissue carbonization immediately after the irradiation. The incision boarders were clean and plain. Twenty-two days post-operative, the histological specimens did not show any noticeable thermal damage at the border of the laser cuts (Fig. 2). A complete healing through a whole bony rearrangement of the osteotomy gap with newly build lamellar Haversian bone was observed in this laser group. Scanning acoustic microscopy of the laser incision (Fig. 1c) conrmed that the newly built bone possessed elastomechanical properties, which are very similar to the neighboring bone tissue. Contrary to this, the sawed mandibles demonstrated persistent supercial defect at

Fig. 1. a: Examples of 1-mm broad laser incisions in canine mandible (ex vivo) with a special cut slit dilatation procedure. b: Narrow (0.25 mm) in vivo incision in canine mandible with the scanning CO2 laser osteotome. c: Scanning acoustic microscopy of the laser incision (b) 22 days postoperative. Arrows indicate the cut margins. The incision gap is completely bridged, its acoustic properties indicate that the newly built bone is similar to neighboring bone tissue.

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In most other in vivo experiments with CO2-lasers reported so far, carbonization and an extended necrosis zone in the treated bones have been described. For example Horch et al. stated early that the CO2 laser osteotomy is not promising because of the collateral thermal damage [4,28]. They worked with a continuous cw CO2 laser with 34 W of average power. A gas jet has been used for cooling. Severe carbonization has led to an impairment of the healing process of more than 12 weeks. The bad results of these and other authors [15] were responsible for the fact that most research groups were looking for a new laser system for osteotomy. Actually, more understanding of the ablation process and careful optimization of the irradiation parameters were necessary. By this, the average laser power used before was quite similar to that we used now. The reported irradiation technique provides, however, more effective ablation and prevents accumulation of the rest heat in the tissue. The experiences of this trial also show that further improvements are necessary to grant an acceptance of the laser in the eld of osteotomy. One important goal will be a prevention of the laser action on tissue behind the bone. In the present study, it was done with a small shielding metal plate. An optimal way, however, is recognition of a bonesoft-tissue interface by changes in the acoustical signal [29,30] or by changes in optical emission accompanying the ablation process. The entire laser system has also to become more surgeon-friendly and compact. Special surgeonoriented software and combination with robotic or haptic guidance and computer-assisted navigation will make the positioning of the beam on the tissue much easier. The absence of a tactile feedback with the present laser technique makes this especially important. If these improvements are done, the laser osteotomy may result in new

Fig. 2. Typical histological slices of (a) laser incision (10) and (b) saw osteotomy (2.5). Canine 4, right mandible side, undecalcied, paragon-stained.

the impact site and steady delay of the healing process. The saw-osteotomy gaps were not completely bony bridged after the 22 days. DISCUSSION The results of these trials prove that effective osteotomy without aggravating thermal side effects is possible with a pulsed CO2 laser under optimal irradiation conditions. These conditions include pulse duration of 80 microseconds, use of an air-water spray, and fast multipass beam scanning along the cut trajectory. The scanning velocity has to be high enough to shift the beam focus on the tissue at half of its diameter or more in the time between consequent laser pulses. Such a multipass cutting cannot be done per hand because of the fastness and very high demands on the reproducibility of the beam focus position and beam orientation at the every pass.

Fig. 3. An example of a self-stabilizing laser incision in compact bone tissue (ex vivo).

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IVANENKO ET AL. 15. Ivanenko MM, Fahimi-Weber S, Mitra T, Wierich W, Hering P. Bone tissue ablation with sub-ms pulses of a Q-switch CO2 laser: Histological examination of thermal side effects. Lasers Med Sci 2002;17(4):258264. 16. Bonner R, Smith P, Leon M, Esterowitz L, Strom M, Levin K, Tran D. Quantication of tissue effects due to a pulsed Er:YAG laser at 2.94 mm with beam delivery in a wet eld via zirconium uoride bers. Proc SPIE 1986;713:25. 17. Nuss RC, Fabian RL, Sarkar R, Puliato CA. Infrared laser bone ablation. Lasers Surg Med 1988;8(4):381391. 18. Nelson JS, Yow L, Liaw LH, Macleay L, Zavar RB, Orenstein A, Wright WH, Andrews JJ, Berns MW. Ablation of bone and methacrylate by a prototype mid-infrared erbium:YAG laser. Laser Surg Med 1988;8(5):494500. 19. Waisn J, Jr., Deuiscn IP. Er:YAG laser ablation of tissue: Measurement of ablation rates. Lasers Surg Med 1989;9(4): 327337. 20. Hibst R, Keller U. Experimental studies of the application of the Er:YAG laser on dental hard substances: I. Measurement of the ablation rate. Lasers Surg Med 1989;9:338344. 21. Nelson JS, Orenstein A, Liaw LH, Berns MW. Midinfrared erbium:YAG laser ablation of bone: The effect of laser osteotomy on bone healing. Lasers Surg Med 1989; 9(4):362374. 22. Scholz C. Neue Verfahren der Bearbeitung von Hartgewebe in der Medizin mit dem Laser. In: Mu ller G, editor. Advances in Laser Medicine, Vol. 7. Landsberg, Lech: Ecomed. 1992. 203p. 23. Kautzky M, Susani M, Leukauf M, Schenk P. [Holmium:YAG and erbium:YAG infrared laser osteotomy]. Langenbecks Arch Chir 1992;377(5):300304. 24. Duck FA. Physical properties of tissue. London: Academic Press. 1990. 25. Alal S, Ivanenko M, Werner M, Hering P. Osteotomie mit 80 ms CO2-Laserpulsen. Fortschritt-Berichte VDI 2003;17 (231 Biotechnik/Medizintechnik):164169. 26. Frentzen M, Gotz W, Ivanenko M, Alal S, Werner M, Hering P. Osteotomy with 80-ms CO2 laser pulses-histological results. Laser Med Sci 2003;18(2):119124. 27. Hering P, Mitra T, Ivanenko M; Laserschneiden. Patent DE10133341A1; 2001. 28. Horch HH. Laser-Osteotomie. Habilitationsschrift. Munich; 1978. 29. Rupprecht S, Tangermann-Gerk K, Wiltfang J, Neukam FW, Schlegel A. Sensor-based laser ablation for tissue specic cutting: An experimental study. Lasers Med Sci 2004;19(2): 8188. tzer-Scheibe A, Klasing M, Werner M, Ivanenko M, 30. Ra Hering P. Akustische Kontrolle der Knochenablation mit kurzgepulstem CO2-Laser. Aktuelle Methoden der Laser-und Medizintechnik. Berlin: VDE Verlag; 2005. pp 281286.

advanced bone surgery techniques, for example, a selfstabilizing osteotomy in Figure 3. Such a complicated and precise incision would never be possible with a hand-held system.

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