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LASER application

in oral and
maxillofacial
surgery .
Prepared by; Shakhawan M.
Ali
S.H.O maxillofacial
department
2nd years diploma student
LASER
 Light
 Amplification by
Stimulated
 Emission of
 Radiation
The Laser will be named according to
it’s:

1.Active medium.
2.Wave lengths

3.System delivery

4.Emission modes

5.Tissue absorption

6.Clinical applications


LASER TECHNOLOGY

Resonator

LASER MATERIAL
(crystal, gas, dye)
Partially
Reflecting mirror
reflecting mirror

Energy
source
Fundamental Idea on working LASER

1. The laser in its non-lasing state


2. The flash tube fires and injects light
into the ruby rod. The light excites
atoms in the ruby.
3. Some of these atoms emit photons.
4. Some of these photons run in a direction
parallel to the ruby's axis, so they bounce back
and forth off the mirrors. As they pass through the
crystal, they stimulate emission in other atoms.
5. Monochromatic, single-phase, columnated light leaves the
ruby through the half-silvered mirror -- laser light!
Properties OF LASER LIGHT

1-Monochromacity: Narrow band of wavelengths


indicating purity of color.

2- Coherence: Laser light waves have the same


frequency, amplitude and phase.

3- Directionality(collimated): There is little


divergence of laser as it exit the laser device and the beam can
travel a considerable distance with very little movement away from
parallelism.

4- Brightness.
 Types of Laser materials
solid state , gas, dye, and semiconductor.

Solid state lasers:


Solid state lasers employ a lasing material
distributed in a solid matrix. One example
is the Neodymium :YAG laser.
The term “YAG” is an abbreviation for the

crystal :Yttrium Aluminum Garnet which


serves as the host for the Neodymium
ions.
This laser emits an infrared beam at the

wave length of 1.064 micrometer.


GAS LASER ;

Gas laser use a gas or mixture of gases within a


tube. The most common gas laser uses a


mixture of Helium and Neon(HeNe), which is a
visible red color.

It was first developed in 1961 and has proved to


be the forerunner of a whole family of gas
laser.
All gas lasers are quite similar in construction

and behavior. For example, the CO2 gas laser


radiates at 10.6 micrometers in the far-infrared
spectrum.

Argon and Krypton gas lasers operate with


multiple frequency emissions, principally in the


visible spectra.
Liquid lasers

These lasers use a laser medium that is usually a


complex organic dye in liquid solution or


suspension.

The most striking feature of these lasers is their


“tunability”. Proper choice of the dye and its


concentration allow the production of laser
light over a broad range of wave length in or
near the visible spectrum.

Dye lasers commonly employ optical pumping,


although some types have used chemical


reaction pumping. The most commonly used
dye is Rhodamine 6G which provides tunability.
Semiconductor lasers (some times referred

to as Diode Lasers)

It consist of two layers of semiconductor material


sandwiched together.
These lasers are generally very small physically

and individually, of only modest power.


The most common diode laser is the Gallium

Arsenide diode laser


Time modes of operation

The different time modes of operation of a laser

are distinguished by the rate


In higher power systems, one is able to adjust

the power.
In low power gas lasers, such as HeNe, the

power level is fixed by design and


performance, usually degrades with long term
use.

Laser type construction Wave length(s) Delivery
 Classification of laser: system(s)

 Argon Gas laser 488,515nm Optical fiber

Traditionally, laser have KTP Solid state 532nm Optical fiber

been classified according Helium-neon Gas laser 633nm Optical fiber


to:
diode Semiconductor 635,670,810,830,980 Optical fiber
1. The type of medium nm

which undergoes lasing Nd:YAG Solid state 1064nm Optical fiber


(e.g Erbium: Yttrium
Aluminum garnet Er,Cr:YSGG Solid state 2780nm Optical fiber

(Er:YAG). Er:YAG Solid state 2940nm Optical fiber


2. The physical articulated arm

construction of the CO2 Gas laser 9600,10600nm Waveguide,articu


laser (e.g ,gas ,liquid, lated arm

solid state, or
semiconductor diode).
 Laser classification according to the
physical construction.
3. The degree of hazard

to the skin or eyes falling


inadvertent exposure.

Laser classification according to the hazards:
Class 1 Presents no hazard

Class 2 Do not present a hazard but



may if viewed for extended

periods of time


Class 3a Do not usually produce a
 hazard if viewed only
momentarily, but may present
a hazard if viewed using
collecting optics.

Class 3b Can produce a hazard if


viewed directly and expect for
high power class 3b, will not
produce hazardous diffuse
Class 4 reflections.
Can produce a hazard not
only from direct or specular
reflections, but also from a
diffuse reflection as well .
 The properties of laser
light depend on
wavelength:

CO2 laser (invisible) at 10.6nm


wavelength, destroy tissues ,….used
in surgery.
Argon laser (visible) at 0.5nm

wavelength does not destroy tissues


but absorbed by pigments such as
melanin,……used in eye surgery
Laser light wavelength (in nanometers )

Alexandrit
e CO2
KTP
Ruby Er:YAG
Excimer Argon
488 - 514 Dye Nd:YAG
190 - 390

577-630
Microwaves

10600
x-rays

2940
1064
694
755
cosmic rays TV and
532

radio
waves

Infrared
Ultraviolet Visible

400 700
Properties of laser
radiation :
The following interactions are possible:

Reflection: Laser energy is reflected by tissue

Transmission: Laser energy passes the tissue


without any interaction

Absorption: Laser energy is absorbed by tissue and leads


to intended interaction effects
Scattering : laser energy is re-emitted in random direction and it
ultimately absorbed over greater volume with less intense
thermal effect .
LASER TISSUE
INTERACTION
 Effects of laser on biological tissues
1- Photo thermal effects:
Warming, coagulation, denaturing, vaporization,

carbonization.

2- Photodistruptive /photo acoustic effects:


Plasma created, disrupts of breaks a part tissue,

fluorescence.

3- Photochemical effects:


initiate chemical reactions-photo polymerization.

Photodynamic therapy: creates a biochemically

reactive form of oxygen.


4- Biostimulation effects:

Provides relief from pain, stimulates wound healing.

Laser effects on biological tissue depend on :


power density, duration of exposure, amount of

cooling, specific wavelength, emission mode, tissue


characteristics.
Cellular Vaporization

Laser energy converted into heat , Cell explodes with water Debris carbonised by laser energy
superboils intracellular fluid increasing vapor,cellular debris and heat and deposited onto surrounding
intracellular pressure released tissue
Potential uses of laser in oral and

maxillofacial surgery ;

Coagulation of angiomatous lesions and


tumors:

It is possible to heat –coagulate vascular lesions or


tumors using the non –contact method with a
hollow fiber or hand piece.
This method appears to be very suitable for

cavernous hemangiomas, particularly those


which have capillary–venous connections alone;
the majority of lesions appear to fall in this
category.

Haemangiomas should be carefully evaluated as to


whether they could be arterially fed as evidenced


by the presence of palpable pulse or bruit
(angiography may be necessary in such
instances).

Excision in very Vascular Tissues (Blended

CO2:Nd:YAG):

The CO2 wavelength is adequate for most


resectional purposes in the oral cavity, although


in certain well vascularized areas, such as
posterior tongue, it is necessary to supplement
the use of the laser by diathermy coagulation of
larger radicals of the lingual artery.

The Combo laser allows the blending of Nd:YAG


with CO2 beam as in the more posterior parts of


the tongue which minimizes the necessity for
diathermy or suturing.
CO2 la se r
-Soft t issue incision and ablat ion.
-Treat m ent of oral ulcers.
-Frenect om y and gingivect om y.
-De-epit helializat ion of gingival t issue during
periodont al regenerat ive procedures.
-Est het ic cont ouring of gingiva.

Argon
-Treatment of oral ulcers.
-Frenectomy,and gingivectomy.
-Resin curing.
-Tooth bleaching.
-Gingival troughing, esthetic countering of gingiva.
 Holmium :Yttrium-Aluminum-Garnet, or
Ho :YAG, Diode (Galliium-Arsenide) laser
& Nd:YAG

-Treatment of oral ulcers.


-Frenectomy and gingivectomy.

-Gingival trouning.

-Esthetics countering of gingival

Er:YAG & Er,Cr:YSGG ( especially in coservative


department).


 Relative Disadvantages of Neodymium: YAG


laser:

The Nd:YAG laser offers the possibility of superior


coagulation in vascular tissue by comparison


with CO2 laser. In view of its low absorption
.however, not only dose the beam have the
potential to penetrate deeply, but there is also
peripheral scatter of radiation which can produce
partial changes in the surrounding tissues.

This is in contrast to the sharp cut-off of the CO2


laser where peripheral damage may be as little


as 0.2 mm. This means that one would predict
some what more after pain and edema with the
Nd:YAG laser than with CO2.
Advantages of CO2 laser
surgery:
•Healing proceeds with minimal delay.
•Limits trauma and damage to adjacent
tissues.
•Painless procedure
•Rapid haemostasis and improved
visibility.
•Minimal oedema.
•Minimal contraction and scarring.
•Laser procedures are less time
consuming.
•Prevention of tumour seeding.
•Wound sterilization.
•Microscopic and endoscopic control.
•Offer more versatility in treatment.
•More accepted treatment.
Incisions
n Various types of intraoral incisions can be
performed by using laser.
n Nd:YAG lasers have proved to be an
effective surgical instrument for
coagulation and incisions and for
heamostasis and prevention of post
operative pain.
n The laser can also be used as a knife to
assist in gaining access to a lesion for
resection and also to aid in subsequent
reconstruction.
In Preprosthetic Surgery

A. Frenectomies
B. Lingual Frenum
C. Maxillary Tuberosity Reduction
D. DENTURE HYPERPLASIA
E. Sulcus Deepening
Laser In The Surgery of The Temporomandibular Joint (TMJ):
1- Laser in the Arthroscopic TMJ Surgery
the holmium:YAG (HO:YAG) laser seems to have won approval within the
orthopedic community and has been shown to be effective for the TMJ in the
vreduction of synovial and vascular hyperplasias,
vdébridement of fibrous tissues.
vthe release of the anterior capsule
vreduction of chondomalacia
2-Macro/Microlaser-Arthroplasty of the Temporomandibular Joint

The Nd:YAG laser and focused free-beam carbon dioxide


laser can be used in anumber of tasks like incisions , or in
the defocused mode applied to tissues to cause
vaporization , ablations, and hemostasis.
Laser Osteotomy ;

Laser osteotomy has potential advantages over


conventional bone cutting methods that it give aseptic
effects and high level of precision. The Er: YAG laser,
among other laser modalities, is most suited to
osteotomy because it inflicts the least thermal damage
to bone tissues and has the best cutting efficacy
Incisional and Excisonal Biopsy

A laser may offer advantages for cutting or


incising , the biopsy site does not require
dressing or sutering and all the advantages
of the surgical laser will be apparent .
Laser Management of Benign Lesion
Laser have several distinct advantages over the conventional
modalities for removal of benign lesions such as blood less field,
diminished pain and less post operative swelling; and few
disadvantages as well
Ranula
Aphthae (Canker Sores)
Fibroma
Nicrotinic Stomatitis
Pyogenic Granuloma
Laser Management of Precancerous Lesion

Lasers are now a proved method in treatment of


the precancerous lesions .
qCongenital Nevi
qexogenous pigment ( i . e .,
tattoos ).
qhemangiomas
Lasers in Cancer Surgery

The laser treatment of carcinomas of the upper aero


digestive tract is an established procedure. The most widely
used lasers are Nd:YAG and the CO2 laser.
qMobile Tongue and Floor of the Mouth
q
qLesions of the Palate
q
qBuccal Mucosa and Oral Surface of the
Soft Palate
q
qVerrucous Carcinoma
q
qBasal Cell Carcinoma
Laser-Assisted Uvulopalatoplasty

snoring
selected patients with obstructive sleep
apnea syndrome .
Laser Effect on Wound Healing

In a different way , the low -


intensity lasers have the capacity
of altering cell behavior without
an increase in temperature . These
lasers have specific wavelengths
that act in a molecular level . The
biomodulation of cellular behavior
is nowadays known by low - intensity
laser therapy ( LLLT ). The most
important effects of this therapy
are pain suppression and
acceleration of wound healing
Lasers in Aesthetic and Plastic Indications

Lasers have been used for


more than 25 years in
aesthetic surgery of the
face . Superficial vascular
and pigmented lesions are
most commonly treated with
use of argon lasers ; Laser
skin resurfacing may be
performed with ultra pulsed
CO2 laser energy .
Some benefits of laser in
dentistry:
•Minimum or no anesthesia required.
•Reduced stress.
•Reduced post-operative pain or infection.
•Time saving on dental chair.
•No needle, no drill, no pain !!!
•Precise incision, excision or ablation.
•Minimum or no bleeding.
LASER SAFTY
Types of hazards

 They include:

1- Eye: Acute exposure of the eye to lasers can cause


corneal or retinal burns or both.
Chronic exposure to excessive levels may cause corneal

or lenticularopacities (cataracts) or retinal injury.


2- Skin : Acute exposure to high levels of optical


radiation may cause skin burns, while carcinogenesis


may occur for ultraviolet and near ultraviolet
wavelengths.

3- Chemical : Some lasers requires hazardous or toxic


substances to operate (i.e. chemical dye ,Excimer


lasers).
4- Electric shock :Most lasers produce high voltages
that can be lethal.

5- Fire hazards: The solvents used in dye lasers are


flamable. High voltage pulse or flash lamps may
cause ignitation. Flamable materials may be ignited
by direct beam or specula reflections from high
power continuous waves (CW) infrared lasers.

Maximum Permissible Exposure (MPE):


It is the level of laser radiation to which a person
may be exposed without hazardous effect or adverse
biological changes in the eye or skin.
 COMPLICATION AND SIDE EFFECTS OF
LASER SURGERY

 Thermal injuries:
Any laser produces heat in the target tissues with an
ideal of instaneous vaporization with out effect on
contiguous tissues.
Correctly controlled and applied laser energy produces a

relatively narrow width of vaporized tissue and permits


early repair, comparable to that produced by scalpel
incision and better than that produced by electro-
coagulation.

 Over lasing the surgical target:


 A char is produced during lasing that must be wiped
away to prevent it being released. If a char is exposed to
continuing laser energy, temperature measuring in the
range of 4000C are generated which will conduct
damaging thermal injuries to the contiguous normal
tissues.

 The results include undesired side effects of


delayed repair, pain, and edema.

Reflected Laser Energy:


The principal hazard to personnel in the vicinity of

an operating laser results from specular


(mirror-like) reflections.

The surgical team:


If surgeon and staff members interrupt the laser

beam path, they may suffer burns as a


result .

Explosive Potentials:
Materials with an explosive potential when

exposed to an igniting heat, such as inhalation


anesthetic agents and topical anesthetic skin-
free spray preparations, absolutely should not be
used in conjunction with laser surgery and
should not be stocked in cabinet that may be
exposed to laser beam.

Ocular injuries:
The photo-ablative and thermal characteristics of

the laser can produce, corneal or retinal


burns.
The injury either to the lens or to the retina may

be acute or incurred over time on a chronic


basis .

General Anesthetic airway:


Laser surgery on the airway is associated with a

greater risk of fire and explosion than with


its use elsewhere in the body with possible
exception of an unprepared large bowel.

Inhalation of the plume:


The impact of laser beams on tissues produces

a plume of superheated water vapor that


contains particulate cellular matter.
Protection from the plume an irritant to the

pulmonary tree and a carrier of particles of


tissue and of m.o. is controlled by evacuation
systems.

 Surgical site :
 There is possibly of augmentation of undesired side effects
of tissue responses and postoperative pain,
comparable to that associated with surgery with a
scalpel, especially if the application of the laser energy is
not exact.

 Hypertrophic cutaneous fibrosis:


Following laser surgery through cutaneous tissues
,hypertrophic scarring is the most frequent
undesirable side effect.
The greater the depth of necrosis by the laser, the greater

the alteration in the contiguous tissues.


 Post operative discomfort


 The greater the penetration of the laser energy, the greater
the inflammatory response and the more intense the
hyperplasia .
 Infection:

The usual preoperative and postoperative care of the


surgical site as for many type of surgery, should be
performed.
Because the laser itself is able to act as sterilization

medium. Most soft tissue infections that do occur are


caused by a break in asepsis post operatively from an
external source.
A systemic infections secondary to laser surgery may be

thwarted by the sealing of blood and lymphatic vessels


during the vaporization of tissue.

 Unfounded concerns:
The aura of new technology may produce unfounded
apprehensions and claims of complications in relation to
laser surgery.
There is no scientific basis for believing lasers could be

hazard to a fetus. The misunderstanding probably is an


outgrowth of confusion between laser radiation and
ionizing radiation.
 Thank You
For
Listening

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