7

Lasers in Implant Dentistry

JON JULIAN

Progress in the design and engineering of dental implants postoperative result. Had this same incision been created
has continued over the past several decades. These improve- with more conventional methods, such as with a scalpel,
ments have led to a success rate of 95% or greater at 10 years postoperative redness and swelling would have been major
and beyond.1–3 Thus placement of implants has become an elements of the clinical picture. For the patient, the benefits
extremely successful treatment for the replacement of miss- of reduced pain and swelling and more rapid healing10,12,13
ing teeth.4,5 are invaluable.
In the field of dental education, a survey of the curri-
cula of graduate programs shows that dental implantology is
taught in oral and maxillofacial surgery (OMS), periodon- Laser Wavelengths
tics, endodontics, and prosthodontics. Most general den- Diode Lasers
tistry residency programs and advanced education in general
dentistry (AEGD) programs also include dental implants as Diodes are manufactured in different wavelengths, with
part of their curricula. Even orthodontic programs are using 810, 940, 980, and 1064 nm the most common. The energy
dental implants as anchors to aid in moving teeth.6 from these lasers targets pigments such as hemoglobin and
As dental implants become more common in practices melanin in the soft tissue. The energy generally is delivered
worldwide, the question becomes how to improve the means by a fiber in contact mode. By conditioning, or carbonizing,
of delivering and supporting dental implant treatment. the fiber, the tip heats up to between 500° and 800° C.14
This chapter discusses the therapeutic role of dental This heat is transferred to the tissue and effectively cuts by
lasers in improving the presurgical, surgical, postsurgi- vaporizing the tissue. The tissue is vaporized because of the
cal, and prosthetic phases of implant dentistry. Lasers physical contact of the heated tip of the laser with the tis-
can be particularly useful in dealing with complications sue, rather than from the optical properties of the laser light
of implant therapy. From surgical placement to prosthetic itself.14,15 The 980-nm wavelength is absorbed into water
delivery to treating infected periimplant tissues, lasers have at a slightly higher rate than the 810-nm wavelength. This
proved to be beneficial in many ways. The different wave- higher absorption makes a 980-nm diode laser potentially
lengths of lasers each exhibit unique characteristics that safer and therefore more useful around implants.
enhance the clinician’s approach to implants, as well as the Absorption of the wavelength is the primary desired
patient’s experience. However, the clinician must under- laser–tissue interaction; the better the absorption, the less
stand the benefits that each laser wavelength can provide, the collateral thermal heat directed toward the implant.7
to match the desired goals of a given procedure to the cor- According to Romanos,16 the 980-nm diodes are safe to use
rect wavelength(s). Both soft tissue lasers, such as diode near titanium surfaces even at higher power settings. Studies
and 10.6-μm carbon dioxide (CO2) lasers, and hard tissue show that the 810-nm diode laser creates a high tempera-
lasers, including erbium-doped yttrium-aluminum-garnet ture rise at the implant surface.17 Romanos18 also reported
(Er:YAG), erbium-chromium–doped yttrium-scandium- that 810-nm diode lasers may damage the surface of the
gallium-garnet (Er,Cr:YSGG), and 9.3-μm CO2 lasers, implant. Use of the 940-nm diode wavelength in the setting
may play a role in implant dentistry. of implant therapy has not been documented in the litera-
Generally, lasers aid in obtaining better visualization of ture. For the purposes of this chapter, the 980-nm diode is
the surgical site by decreasing bleeding,7–9 thus often reduc- the only diode considered useful in implant therapy.
ing the duration of a given procedure.10 Lasers also create Diode lasers are considered to be similar to neodymium-
more sterile conditions both during and after surgery, so that doped yttrium-aluminum-garnet (Nd:YAG) lasers in dental
complications and infections are reduced significantly.11 applications. The advantage of a diode is less depth of pen-
Figure 7-1 shows an incision for a sinus lift made etration than with the Nd:YAG.7 This more limited effect
using a 10.6-μm CO2 laser, with the expected excellent allows the operator greater control of the laser and reduces

107
108 CHA P T E R 7  Lasers in Implant Dentistry

A B
• Figure 7-1  A, Large surgical incision made with an ultraspeed CO2 laser for a sinus lift, closed with
continuous, sling-locking sutures. B, Photograph of site 48 h postoperatively. Note normal tissue color and
relaxed sutures, with minimal evidence of swelling.

the risk of lateral thermal damage. Disadvantages include The Nd:YAG laser is useful in periodontal therapy and
slowness in speed of cutting and a gated-pulse delivery mode has had positive effects in pocket therapy.21 However, Block
that translates into potential heat buildup in tissue, leading et al.22 report that the Nd:YAG laser energy can melt the
to lateral thermal damage. The clinician should therefore surface of implants or remove the surface layer from plasma-
be aware of the power density of the diode, especially when coated titanium implants. This laser also produces craters
working close to the surface of implants.17 and cracks on different surfaces of titanium. Furthermore,
The fiber delivery system of diode and Nd:YAG lasers Walsh23 and Chu et  al.24 found contraindications to the
allows debris to build up on the fiber tip. Consequently, use of Nd:YAG lasers near implants. Although anecdotal
frequent cleaning and cleaving of the tip are necessary.19 reports have described use of this wavelength in periimplant
Uncovering implants, if the tissue is relatively thin, is an therapy, and one manufacturer is promoting a specific laser-
appropriate use for a diode. A full-thickness flap or incision assisted periimplantitis protocol, to date, no studies show-
down to the periosteum to place implants is much more dif- ing the safety of this wavelength when used on implants
ficult with a diode than with a CO2 laser. have been performed. Use of this wavelength, therefore, is
In summary, a 980-nm diode laser can be used safely for considered inherently unsafe for implant-related procedures
some implant procedures, but with limitations in the depth or periimplant surgery. Nd:YAG lasers will continue to be
of cut, speed of cut, and efficiency of cutting. The major used successfully in periodontal therapy.16
advantages of a diode laser are its small size and relatively
low cost. Carbon Dioxide Lasers
Neodymium:Yttrium-Aluminum-Garnet Lasers The conventional CO2 laser has a wavelength of 10,600
nm. Its energy can be delivered in continuous-wave mode
The Nd:YAG lasers operate at a wavelength of 1064 nm. or gated-pulse mode and more recently, in extremely short
These lasers are fiberoptic-delivered contact lasers that pulses of high peak power, labeled “superpulsed” and
generate a free-running pulsed beam of energy. This puls- “ultrapulsed” (i.e., ultraspeed) modes. This wavelength is
ing mechanism is more sophisticated and the potential for highly absorbed in water, collagen, and hydroxyapatite19
heat penetration even greater than with a diode laser. The and is therefore extremely efficient for soft tissue vaporiza-
1064-nm wavelength is poorly absorbed in water but read- tion. The delivery system usually is a mirrored handpiece
ily absorbed into tissue pigments such as hemoglobin and (making this a noncontact application) at the end of an
melanin. The Nd:YAG laser is effective at producing coagu- articulated arm or a waveguide. The following discussion
lation and hemostasis but, because of its penetrating depth focuses on this wavelength of CO2 lasers and its various
of up to 4 mm, has the greatest potential for damaging soft pulse parameters.
and hard tissues as well as implant surfaces.16 The energy CO2 lasers have been used for decades in surgical proce-
is delivered through the carbonized tip of a fiber, as with a dures because of their speed and efficiency in cutting soft
diode laser. However, the maximum peak power emitted by tissue.25 They also offer strong hemostatic and bactericidal
the Nd:YAG is much greater than for a diode and therefore effects and create minimal wound contraction, thereby
could penetrate the carbonized debris at the laser tip.20 minimizing scarring. CO2 lasers also have minimal depth
 CHAPTER 7  Lasers in Implant Dentistry 109

of penetration, reducing lateral thermal damage.12,16 The trunk fiber and handpiece with a quartz or sapphire fiber
early devices produced significant carbonization because tip. The delivery systems include a water spray to prevent
of the high energy densities created. With the newer heat buildup and to rehydrate the target tissues so that the
pulsed models, however, the energy density is reduced energy will be absorbed more efficiently.
to between 180 and 300 mJ/cm2, delivered at an average The erbium wavelengths are highly absorbed in water
speed of 400 to 800 μsec. These settings create less carbon- and hydroxyapatite. They are good for ablating hard tissues
ization and charring of tissue and improve the working such as tooth structure and bone. When first introduced to
speed and efficiency of the CO2 laser. This technology has the market, the U.S. Food and Drug Administration (FDA)
been further refined with the advent of even shorter puls- cleared the erbium lasers only for hard tissue procedures.
ing with higher peak powers. By increasing the speed of By vaporizing water molecules within the hard tissues,
transmission and decreasing the pulse width, the laser can erbium lasers create microexplosions in the hydroxyapatite
cut deeper and carbonize less tissue. Thus energy density is that break down the hard tissue during the ablation process.
now reduced to between 50 and 300 mJ/cm2, delivered in This effect is achieved without charring or carbonization,
speeds of 30 to 80 μsec. These improvements have created and the heat generated is minimal (see Chapter 10). The
an extremely versatile CO2 laser that can safely treat tissue erbium lasers also will ablate soft tissue, but with limita-
in periodontal pockets and also make surgical incisions up tions. It is most effective in lightly vascularized tissue where
to 4 to 5 mm deep rapidly and efficiently. bleeding will not be an issue. The erbium wavelength is the
The CO2 laser is safe to use around implants because the least effective of all of the dental laser wavelengths in achiev-
energy is absorbed into water and not pigments.26,27 With ing hemostasis.
its effect restricted to the intracellular water of bacteria, the Because its energy is absorbed into water, the erbium laser
CO2 wavelength can safely and effectively treat periimplan- is safe to use around implants and can treat periimplantitis
titis and mucositis,28 because the energy is not absorbed into and mucositis safely.31,32 This laser will leave the bony sur-
the implant’s surface. At the same time, this laser’s hemo- face bleeding (for healing), so curettage is not necessary, but
static properties are excellent, allowing better visualization it will not harm the implant’s surface.33 Erbium lasers have
of the surgical field, often decreasing procedure time and excellent bactericidal properties because the energy ruptures
limiting or preventing postoperative complications (pain, the cell membranes of bacteria when absorbed into intracel-
swelling).29 lular water.
With the newer devices, the energy is safe when it In summary, erbium lasers are versatile, with good hard
comes into contact with bone. When exposed to CO2 laser tissue applications, although their soft tissue applications
energy, the water molecules on the surface of the bone are are limited compared with true soft tissue lasers because of
dehydrated, forming a thin carbon layer of approximately poor hemostasis.13,34
0.1 mm. The resulting surface will no longer absorb energy,
and the damage to bone is clinically insignificant.30 How- Laser Applications in Clinical Practice
ever, if the CO2 energy causes hemostasis of bony structures Preoperative Frenectomy and
during surgery, curetting the bone to reestablish bleeding Tissue Ablation
for healing is indicated. In my experience, the CO2 laser is
the most versatile of all of the soft tissue lasers available for In certain instances, the clinician may need to alter the soft
implant therapy. tissue architecture adjacent to the surgical site before the
A new wavelength of CO2 laser was recently introduced implant is placed. For example, a patient with a high muscle
to the dental market. This wavelength of 9300 nm is deliv- attachment too close to the surgical site would benefit from
ered by means of an articulating arm. To date, no studies a frenectomy, to alleviate any tension on the tissue around
describing the use of this laser in periimplantitis treatment the implant site. The more complex the surgery, such as
have been published; therefore great caution is advised bone grafting with creation of a flap, the more important
regarding this clinical application. It is dangerous to extrap- it is to release the muscle tension. The release of muscle
olate results with the 10.6-μm CO2 laser to justify the use tension provides a greater opportunity for success, without
of the 9.3-μm CO2 laser. For the purposes of this chapter, sutures pulling, with less postoperative pain and swelling. A
the only CO2 laser considered appropriate for treatment of frenectomy can be accomplished using any of the soft tissue
implant/periimplant problems is the conventional 10.6-μm lasers discussed earlier (Figure 7-2).
CO2 laser. Before tooth extraction, the clinician also may need to
alter the soft tissue if it is too thick or uneven in thickness.
Erbium Lasers In Figure 7-3, by ablating 2 to 3 mm of tissue in a broad
area distal and palatal to the upper right second molar, the
The erbium family of lasers includes two similar wave- resulting tissue thickness can then conveniently accommo-
lengths: the Er:YAG laser emitting at 2940 nm and the date the abutment and crown with hygienically manage-
Er,Cr:YSGG laser at 2780 nm. Both lasers are operated able architecture. The ability to remove tissue easily without
in a free-running pulsed mode. The method of delivery is bleeding, swelling, or postoperative pain is a tremendous
by mirrored handpiece and articulated arm, waveguide, or advantage to both the clinician and the patient.
110 CHA P T E R 7  Lasers in Implant Dentistry

A B

C D

E F
• Figure 7-2  A, Pretreatment occlusal view of planned implant surgery site. B, Immediately after muscle
release and frenectomy. Note that periosteum is intact. C, Midcrestal incision performed with an ultraspeed
CO2 laser and placement of the implant. D, Tissue former is placed and tissue sutured into place with two
single sutures. No dressing was placed on the tissue. E, Radiograph of the implant with tissue former in
place. F, Final crown seated on implant 4 months after placement.

Preparation of Surgical Site

contamination of the surgical site by saliva during the pro-
Site preparation is the first step of implant surgery. To pre- cedure, simply reapplying the laser in the area will reestab-
vent contamination of the surgical site, clinicians have used lish sterility, so that the procedure can continue with the
a variety of antimicrobial rinses, including chlorhexidine, greatest chance for success. The erbium and diode wave-
before the procedure.35,36 Such decontamination efforts lengths can accomplish decontamination if the contact laser
have been only partially effective, however, because of the physically “touches” every square millimeter of the surface
immense bacterial load in the oral cavity. Furthermore, if the to be sterilized.7,38 For this purpose, a slow, deliberate appli-
site were to become contaminated with saliva during surgery, cation technique is required; the larger the osteotomy site,
it would not be practical or effective to stop and rinse again. the longer the sterilization procedure.
  
Lasers present an excellent solution to the problem of
surgical site contamination. All lasers are bactericidal. The CLINICAL TIP
clinician simply needs to expose the surgical site to the laser With a contact laser, the best way to speed up the sterilization
energy for a few seconds. The bactericidal effects are pro- procedure is to use a large-diameter fiberoptic cable. Most
found and almost instantaneous, and an implant site can clinicians who own Nd:YAG or diode lasers have just one- or
be sterilized.37 Before osteotomy development, the soft tis- two-fiber diameters, usually 300 to 400 μm. A decontamination
sue can be sterilized much more effectively with a laser than procedure is most effective with use of a fiber diameter of 800
or 1000 μm.
with rinsing or swabbing. Furthermore, with accidental
 CHAPTER 7  Lasers in Implant Dentistry 111

A B

C D

E F

G
• Figure 7-3  A, Excessive tissue thickness distal and palatal to upper right second molar, which is to be
extracted and replaced with an implant. B, Ultraspeed CO2 laser was used to reduce the tissue contours
where indicated. C, Extraction socket immediately after extraction of root. D, Socket with osseous graft-
ing material in place. E, Postoperative view of extraction/graft site and tissue reduction at 24 h. Note
good pink color of tissue and lack of tension on sutures. F, Surgical site at 5 months postoperatively.
G, Radiograph of implant with tissue former.

Decontamination and Implant Placement

increase the spot size on the tissue even more. Steriliza-
A CO2 laser has a distinct advantage over contact lasers: tion of a large osteotomy site with a CO2 laser takes mere
Because CO2 lasers are noncontact, it is a simple pro- seconds. As the surgery progresses, the clinician and the
cedure to place a wide-aperture handpiece on the CO2 assistant should be diligent in keeping the surgical site free
laser to apply the laser beam out of focus, which would of saliva. In most single-implant scenarios, this aim can
112 CHA P T E R 7  Lasers in Implant Dentistry

easily be accomplished. In large-scale surgical procedures Figure 7-6 illustrates a similar situation with an upper
with multiple implants or large incisions, however, it left first premolar planned for extraction and implant place-
may be difficult to maintain a sterile environment. When ment. Both the internal and the external aspects of the sur-
necessary, laser energy can be redirected to the tissues to gical site are decontaminated with the laser. An abutment is
decontaminate the surgical site as often as the surgeon placed so that the patient can wear a temporary fixed pros-
deems necessary, using an appropriate power setting for thesis in that quadrant. A soft tissue troughing procedure is
sterilization (Figure 7-4). performed on the molar. At 4 months, the soft tissue sur-
Another clinical situation requiring decontamination rounding the implant is recontoured for a better esthetic
involves extraction of teeth followed by immediate place- result.
ment of implants into the extraction site. In some cases,
Osteotomy
the presence of infected tissues is obvious, and the clini-
cian notices soft tissue around the apices of roots or in the Soft Tissue
furcation area of molars. Even if infection is not readily The next objective in laser implant surgery is the prepara-
apparent, however, a prudent approach is to assume that it tion of the osteotomy, with different considerations for
might compromise the results of the procedure. The surgi- cutting through soft tissues versus hard tissues. The cli-
cal goal is to eliminate all diseased soft tissues in the extrac- nician must first decide on the desired pattern of entry
tion site and to decontaminate all bony surfaces within the through the soft tissue. In some cases a minimal entry,
site. A spoon curette can be used to remove gross amounts often referred to as a “punch procedure,” is the goal. The
of soft tissue easily and quickly, with subsequent laser exci- soft tissue is removed as a 3- to 4-mm-diameter “plug”
sion to remove any tissue tags. The entire inner surface of down to the crest of bone. This soft tissue may be 1 to
the extraction socket can then be decontaminated with a 2 mm or 3 to 4 mm thick, depending on location and
laser. biotype. If the tissue is relatively thin (1 to 2 mm), any
As with decontaminating the soft tissue of the surgical site wavelength is acceptable. If the tissue is thicker, using
immediately before raising the flap, it is difficult to “touch” a diode or Nd:YAG laser may take minutes versus sec-
all of the surfaces of the socket with a diode or Nd:YAG onds for erbium and CO2 lasers. Depending on the tissue
fiber. Of course, neither diode nor Nd:YAG lasers are indi- quality, bleeding may be an issue with erbium lasers. By
cated for use on bone. The erbium wavelengths are effective quickly and efficiently cutting through the tissue and cre-
in removing the remaining soft tissue and decontaminating ating optimal visibility for the surgeon, the duration of
the bony surfaces at lower power settings with a water-cool- the procedure often may be reduced compared with that
ant spray.13 Because they are not as effective as other wave- for conventional techniques.
lengths in creating hemostasis, erbium wavelengths would Other designs for tissue entry include small envelope
leave the bone surfaces bleeding, which enhances healing of flaps, often used to gain tissue height (as in anterior implants
the socket, whether an implant or a graft is placed, or the and other areas) and to provide better-quality tissue around
socket may simply be left to fill in. The CO2 lasers also are the abutment-crown complex (Figure 7-7).
a good choice because they also will remove soft tissue tags As the entry site increases in size and the flap design
and decontaminate bony surfaces, again at low power densi- becomes more complex, going through multiple layers of
ties.39 However, CO2 laser energy is an excellent hemostatic both attached (keratinized) and nonattached (mucosal)
wavelength, so the effect of hemostasis39 on the tissues must tissues becomes a significant consideration in choosing
be overcome for healing.35 the proper wavelength. Speed of cutting reduces proce-
The clinician should gently curette the bone to reestab- dure time, as does hemostasis, which also enhances vision.
lish bleeding and maximize the healing potential of the Thus, as more soft tissue is involved, diode and Nd:YAG
implant or graft site. The laser energy must be delivered lasers become less effective—these are contact lasers, so to
to all of the bony surfaces within the extraction site. If cut through larger amounts and more layers of soft tissue,
a severely dilacerated root poses a barrier to the opera- more time is required to make the incision. Erbium lasers
tive line of sight for access of the laser beam, the clini- do not provide hemostasis as well as other wavelengths for
cian should make the decision to allow the body’s natural larger incisions. The unobstructed vision, excellent hemo-
defense mechanisms to heal the site over weeks and make stasis, and efficiency of cutting through all tissue biotypes
it safe for reentry to perform the implant or grafting proce- and thicknesses make the CO2 laser most suitable for these
dures. Figure 7-5 illustrates the procedure for decontami- procedures.39
nating a surgical site and socket, involving an upper left
central incisor planned for extraction. An important con- Laser Advantages
sideration in this scenario is the proximity of the frenum Using laser energy to make any incision has several benefits.
to the surgical site. A laser frenectomy is performed to First, a sterile cut is less likely to become infected. Lasers
ensure no tension on the tissues immediately surrounding incise tissue without creating the cascade of events that
the site. After sterilization of the bony crypt and surround- leads to swelling and inflammation. Because lasers seal off
ing marginal tissue, the implant is placed with confidence lymphatics and blood vessels, a clinically measurable reduc-
that the soft and hard tissues of the surgical area are free of tion in pain, swelling, and other postoperative complica-
disease and bacteria. tions has been documented for these incisions.40,41 With
A B C

D E

CHAPTER 7  Lasers in Implant Dentistry

F G
• Figure 7-4  A, Preoperative photograph of implant site for replacing upper left central incisor. B, Surgical
site decontaminated with an ultraspeed CO2 laser. C, Midcrestal incision made with the laser. D, The flap
is elevated and the osteotomy site is being prepared. Note excellent visualization of the surgical site with
no bleeding to obscure the surgeon’s vision. E, Implant being placed into osteotomy site. F, Completed
implant placement. G, Immediate temporization of implant with abutment and temporary crown, and
tissue reapproximated with two single sutures.

113
114 CHA P T E R 7  Lasers in Implant Dentistry

reduced swelling, sutures will not pull through the tissue or Hemostasis
are less likely to come undone. Analgesics and antibiotics Another advantage of laser use is the relative safety of such
are needed less frequently, and often in less potent formula- approaches in patients who are anticoagulated with com-
tions (with fewer drug interactions), because patients expe- mon medications such as aspirin, clopidogrel (Plavix), and
rience a significantly less traumatic postoperative course. warfarin (Coumadin). Some patients also take herbal rem-
These benefits apply for both minor and major surgical edies that can significantly alter their clotting time. The
procedures. main question with anticoagulated patients is whether their

A B

C D

E F

G H
• Figure 7-5  A Clinical, and B, radiographic, pretreatment views of tooth #9 with internal root resorption
and inevitable extraction. C, Tissue recontouring and frenectomy performed with an ultraspeed CO2 laser.
D, Postextraction view. Bony crypt is sterilized with surrounding marginal tissue using an ultraspeed CO2
laser. E, Implant is placed immediately after the extraction. F, Before impression taking 3 months later, site
is evaluated for tissue height and thickness. G, Impression coping is in place. H, Abutment is seated 4
months after extraction.
 CHAPTER 7  Lasers in Implant Dentistry 115

J
• Figure 7-5, cont’d  I, Final crown is seated; clinical view shows excellent soft tissue contours. J, Radio-
graph shows excellent bone height.

D F
• Figure 7-6  A, Pretreatment site where tooth #12 is to be extracted and an implant placed. B, Tooth
has been extracted, and laser decontamination of the site is performed both externally and internally.
C, Radiograph of the immediately placed implant. D, Abutment is placed and temporary bridge seated
from #14 to the implant. E, At 4 months after initial treatment, the necessary tissue modifications were
achieved using the same settings as for previous troughing. F, Final three-unit bridge cemented in place.
116 CHA P T E R 7  Lasers in Implant Dentistry

A B

C D E
• Figure 7-7  A, An ultraspeed CO2 laser creating incision for implant placement for tooth #20. B, Reflect-
ing small envelope flap with minimal bleeding. C, Flap reflected. Note excellent visualization of surgical site.
D, Beginning osteotomy site with bone drills. E, The 3.5-mm implant is placed 2 mm below the crest of
bone, with excellent visualization maintained throughout the procedure.

medication should be stopped before surgery. The clinician tranexamic acid mouthwashes all can be used to help con-
needs to be aware of the individual patient’s circumstances trol hemorrhage.42 These treatments become unnecessary
and consult with the primary care physician. Before any during laser surgery. The lack of hemorrhage control with
dental surgery, the patient’s health history must be reviewed the scalpel leads to obstruction of vision at the surgical site
and updated. With any concern regarding the patient’s and the need for more assistant time suctioning the area and
medications, the appropriate laboratory work, including maintaining a dry field.39
an international normalized ratio (INR), must be ordered. Figure 7-8 shows an elevated flap with excellent visual-
Recent studies on altering a patient’s medications before ization and an essentially bloodless incision in a patient in
dental surgery reveal few if any reasons to change the antico- whom the upper right lateral incisor is congenitally missing.
agulant regimen if the INR is less than 4.0,42,43 although the The implant is placed after bone grafting for a facial osseous
final decision rests with the primary care physician. Patients defect. A laser also is used to make a bloodless releasing inci-
receiving anticoagulant therapy will benefit more from the sion at the distal aspect of the upper right canine.
use of lasers in dental surgical procedures than healthier
patients. Most lasers have excellent hemostatic properties Hard Tissue
that lead to decreased bleeding, so intraoperative hemor- Once access is gained through the soft tissue, the clinician
rhage control is less of an issue. must decide how to deal with the hard tissue. To ablate
Also, the use of lasers leads to decreased postopera- bone, the erbium family of lasers is used. An erbium laser
tive swelling and superior tissue healing. This benefit can can remove bone to begin the osteotomy. Laser ablation of
be attributed to decreased tissue damage, a less traumatic bone is less damaging to osseous tissues than conventional
wound, more precise control of the depth of tissue damage, techniques, because this is a noncontact procedure with
and fewer myofibroblasts in laser wounds compared with no friction between laser tip and bone. Friction from the
scalpel wounds.25 The traditional scalpel does not induce bone-cutting drills may overheat the bone and potentially
hemostasis, so the control of bleeding must be addressed cause necrosis at the bone-implant interface. The tempera-
by more conventional means. For example, application of ture increase in osseous tissue associated with use of an
pressure by biting on gauze or tea bags, suturing, placing erbium laser is minimal as long as the clinician is familiar
oxidized cellulose, applying topical thrombin, and using with the proper laser parameters and uses an adequate water
 CHAPTER 7  Lasers in Implant Dentistry 117

A B

C D

E F

G H
• Figure 7-8  A, Pretreatment photograph of congenitally missing tooth #7. B, Sterilizing surgical site with
an ultraspeed CO2 laser, 2.0 W at 80 Hz for 10 sec. C, By increasing power to 4.5 W at 80 Hz, a midcrestal
incision is accomplished. D, Bloodless incision allows good vision as flap is elevated. E, Implant placement
with bone grafting for a facial defect. Note releasing incision distal to #6, also done with the laser. F, Flap is
closed and sutured. G, At 72 h, tissue color is normal and swelling nonexistent. H, At 2 weeks, temporary
crown is in place and tissue is healing uneventfully.

spray. Thus controlled ablation without thermal damage is Block Graft Procedure
achieved. Studies show better healing and faster new bone
formation when erbium lasers are used versus conventional In the performance of any surgical procedure, focused con-
bone drills13,44–46 (Figure 7-9). In time, it may be possible centration on each step is essential. For example, while mea-
to use the 9.3-μm CO2 laser for these procedures as well; suring points on a bony surface to cut or prepare, the clinician
to date, however, research on the safety and efficacy of this who looks away even for a moment may lose orientation,
wavelength in implant osteotomies has yet to be done. necessitating remeasuring and refocusing with the potential
Laser technology has not yet advanced to the point that for loss of precision. If, however, the measurements could be
the entire osteotomy can be completed with lasers. However, “drawn” on the bone with an indelible marker, the procedural
manufacturer-based research is under way, with the goal of map thus created could guide all subsequent steps and also
replacing bone drills with erbium “drills” for osteotomies. allow the clinician to regain focus in the event of distraction.
118 CHA P T E R 7  Lasers in Implant Dentistry

A B

C D

E
• Figure 7-9  A, Laser incision for osseous graft procedure. B, Decortication of bone using erbium
laser. C, At 24 h, postoperative photograph shows good color and relaxed sutures with no swelling.
D, Implants placed 4 months after graft procedure. E, Final restorations in place.

Either CO2 or erbium wavelengths can be used at a low ridge involves a long incision starting from the distal aspect
energy setting to mark measurements on the bone surface, of the second molar and extending along the crest of the
creating an indelible marking. An “x marks the spot” place- ridge mesially to the cuspid area.47 Here, a vertical releasing
ment of implants can then be accomplished. The receptor site incision is made. The CO2 laser is most efficient for making
for a block graft can be visualized with this technique, and such an incision.
the donor block can be outlined and measured before cutting. After the flap is elevated and the bony aspect of the sur-
After the block of bone is cut and sized, the screw gical site visualized, the clinician prepares to cut a window
holes can be created with an erbium laser, thus eliminat- in the bone. By drawing this window outline, as previously
ing the mechanical and frictional stresses of using a drill. discussed for the bony surface, the surgeon is then prepared
The block can be sanded and modified with the erbium to cut the bone with a bur in a handpiece, or with a piezo-
laser as well, also eliminating the mechanical and frictional tome, to enter the sinus cavity. Using the CO2 or erbium
trauma from a bur. laser to “draw” on the bone creates a visible marking on the
surface without damaging the bone’s integrity.48 The erbium
Lateral Window Sinus Lift lasers are then used to cut through the bone, especially if
Lasers can enhance the sinus surgery that builds a founda- the bone covering the sinus is thin, approximately 1 mm in
tion of bone for the eventual placement of dental implants. thickness; however, the erbium laser also will cut soft tissue,
A typical lateral window approach in a posterior edentulous a potential problem.49
 CHAPTER 7  Lasers in Implant Dentistry 119

B C

D E
• Figure 7-10  A, Pretreatment view of recipient site for block graft. B, Releasing incisions performed with
laser. Large flap exposes the bony defect. C, Flap is created at donor site, which is measured and marked
with the laser. Slight char layer on bone could be described as an indelible marker. D, Bone saw cutting on
laser-drawn lines to obtain block of bone. E, Donor block removed from donor site.

The first goal of a well-performed sinus lift is to gain bone with a bur and a handpiece requires skill and prac-
access through the bone without damaging the schneiderian tice to create the window without damaging the membrane.
membrane (nasal mucous membrane). The second goal is Perhaps the most promising tools for this purpose are the
to deposit graft material in sufficient quantities to support piezo surgical devices, which cut by vibration through the
the future implant placement.50 Once exposed, the schnei- bone and will not cut soft tissue.53
derian membrane is carefully and gently elevated away from The true benefit of lasers in the block graft procedure
the inferior and medial surface of the sinus floor. If kept lies in the postoperative effects. The minimal inflammatory
intact, this membrane helps to contain the graft material response by the soft tissues increases patient comfort and
and prevent migration of the graft particles freely in the minimizes swelling. Sutures stay relaxed and intact. Prophy-
sinus cavity. If this membrane is cut or damaged, however, lactic antibiotics may be used against postoperative sinus
the graft material can migrate elsewhere to cause a foreign infections as the clinician sees fit, but localized infections at
body response, leading to complications or infection and the surgical site are rare (Figures 7-10 and 7-11).
possibly a failed graft procedure. Although a damaged
membrane can be repaired, this issue simply complicates Uncovering Implants
the procedure and introduces more risk.51,52
The erbium lasers cut hard tissue and soft tissue, so it is When the clinician needs to uncover an integrated implant
not possible to penetrate bone without penetrating the soft after healing is complete, occasionally the implant body
tissue that is intimately attached to the bone. Cutting the is covered not only by soft tissue but also by newly formed
120 CHA P T E R 7  Lasers in Implant Dentistry

F G

H I

J K
• Figure 7-10, cont’d  F, Donor site after harvesting of the graft. G, Screw hole created safely in the block
with erbium laser. H, Screw in place to secure block. I, Particulate graft placed over block. J, Resorbable
barrier membrane fitted over graft site. K, Flap is sutured in place, and frenectomy is performed to prevent
tension on surgical site.

bone up to 2 to 3 mm thick. After location of the implant uncovering process. The bone and the implant surface will
has been ascertained radiographically, the soft tissue must be remain unharmed (Figure 7-14).
removed. This removal can be accomplished with any laser In implant dentistry, having too much soft tissue archi-
wavelength except the Nd:YAG, because of its adverse effects tecture has not been a common problem. In fact, the most
on implants. If the tissue is not too thick (1 to 2 mm), all common issue is trying to preserve more soft tissue. With
wavelengths except Nd:YAG work well. With significantly some implant designs, however, the characteristic result
deeper tissue, the diode laser would become too slow and includes large volumes of soft tissue. This tissue must be
inefficient. With extremely vascular tissue, the erbium laser sculpted and shaped to allow for impression taking, abut-
may be a poor choice because bleeding might impair visibil- ment seating, and crown cementation. Maintaining a dry,
ity. For thick tissue, the CO2 wavelength is most efficient to clear visual field is imperative. Lasers are excellent tools for
remove significant tissue quickly and to maintain excellent these cases (Figure 7-15).
visualization of the surgical site (Figures 7-12 and 7-13).
If bone has formed over the top of the implant, the cli- Mucositis and Periimplantitis
nician must decide on the best approach. The CO2 laser
could affect a thin layer of bone to facilitate its removal with The most serious complication in implant dentistry may be a
a hand instrument.39 For any thickness of bone, however, late-stage infection after the implant has integrated with the
the erbium lasers can efficiently and safely accomplish the bone. Mucositis is simply a soft tissue infection around the
 CHAPTER 7  Lasers in Implant Dentistry 121

B C

D E F

G H I
• Figure 7-11  A, Pretreatment view of recipient site for block grafts. B, Recipient site marked with laser.
Note the light, indelible markings on the bone. C, Recipient site for a J-graft showing light indelible char
marking on the bone. D, J block marked with laser. E, J-graft block being cut with erbium laser. F, J-graft
block cut complete. Note that complete cut is smooth and atraumatic to the bone. G, J-graft block seg-
ment secured into recipient site with one screw; screw hole created with erbium laser. H, Membrane over
J-graft block. I, Dual-block graft site with flap sutured. Note laser frenectomy to prevent tension on flap.
122 CHA P T E R 7  Lasers in Implant Dentistry

Unfortunately, the success rates with conventional tech-

nologies are not good. Leonhardt58 reported a 42% implant
failure rate with conventional therapy for periimplantitis.

Laser-Assisted Therapy
Lasers provide a new treatment modality for patients with
mucositis and periimplantitis. If an erbium laser is used, the
steps may proceed as follows:
• Access to the implant is obtained through an appropriate
A laser incision.59
• Once the implant and the surrounding bone are exposed,
the diseased tissue is vaporized by laser energy.
• The implant surface and bony crypt are decontaminated
by the laser.60
• By ablating a thin layer of bone, necrotic bone is removed
and the area decontaminated.
Thus debridement and decontamination are accom-
plished with a single instrument. Bone grafting, if neces-
sary, can then be performed. Healing is enhanced because of
reduced inflammation and postoperative pain.12
B
If a CO2 laser is used, the procedure begins with an appro-
• Figure 7-12  A, Multiple implants partially covered by soft tissue. priate laser incision to expose the implant body, the bone,
B, Implants exposed with laser. and the diseased soft tissue. This tissue is easily ablated and
the implant surface safely decontaminated. The bony sur-
abutment-crown-implant complex, typically at the cervical faces also are decontaminated, but CO2 laser energy causes
third of the implant. Periimplantitis is an infection around carbonization of the bone, with resulting hemostasis. Before
the body or apex of the implant that leads to loss of bone.54 grafting, the bony surface is mechanically scraped free of the
Both of these conditions are characterized by an inflamma- carbonization layer with a curette, and bleeding is reestab-
tory reaction to anaerobic plaque bacteria associated with a lished. Bone grafting may then be performed. The success
biofilm. Typically, this results in swelling and inflammation rate is greatly improved because a more sterile environment
of the soft tissues and loss of bone surrounding the implant. has been created. Figure 7-16 shows CO2 laser debridement
Many causative factors include tissue quality surround- of a periimplantitis site, with healthy tissue response.
ing the implant, design of the implant, surface texture of A diode laser also can be used to remove the granulation
the implant, alignment of the implant, mechanical load- tissue and decontaminate the implant surface. Figure 7-17
ing of the implant in occlusion, and the presence of bac- shows diode laser debridement and decontamination at the
teria. Clinical manifestations of infection may include site of a fistula above an upper left cuspid implant, with
inflammatory or color changes in the surrounding tissue, excellent healing at 1 year.
bleeding, suppuration, possibly fistula formation, and
radiographic bone loss. In severe cases, the implant may Nonsurgical Therapy
need to be removed. Nonsurgical treatment of crestal mucositis with bone loss
also has been studied. Deppe and Horch39 explored ster-
Conventional Therapy ilizing exposed implant surfaces with lasers to rehabilitate
“ailing implants.” In a clinical study of 16 patients with 41
If the implant is still stable and the bone loss is not too ailing implants, a CO2 laser was used in a closed (nonflap)
severe, the infection can be treated. Surgery with debride- procedure. After 4 months, statistically better results were
ment is the treatment of choice, accompanied by adminis- demonstrated for the implant sites decontaminated with a
tration of antibiotics, attempted mechanical removal of all CO2 laser and soft tissue resection than for the sites decon-
diseased tissues from around the implant, and eradication taminated by conventional means.
of as much bacteria as possible. Therapeutic tools include
plastic instruments, citric acid, chlorhexidine, and topical Erbium Laser
tetracycline.55–57 After debridement, bone grafting material
is placed in the void in the bone in an attempt to regenerate Schwarz et al.61 used an Er:YAG laser to treat lesions in 20
the periimplant hard tissues. The dentition is evaluated for patients who had at least 1 implant with moderate to advanced
possible mechanical overload, which is corrected if present. periimplantitis, for a total of 40 implants. An Er:YAG laser
Finally, the patient’s oral hygiene is reevaluated and possibly was used on half the implants and mechanical debridement
improved. with plastic curettes and antiseptic therapy with chlorhexidine
 A B

C D E

CHAPTER 7  Lasers in Implant Dentistry

F G H
• Figure 7-13  A, Healed implant site ready to be uncovered. B, Laser beginning to uncover implant.
C, Tissue being ablated by laser. D, Implant uncovered after 30 sec of exposure to laser energy.
E, Device to remove sealing screw in position. F, Sealing screw easily removed. G, Impression coping
placed easily with no hemorrhaging. H, Final crown seated 4 weeks later.

123
 124 CHA P T E R 7  Lasers in Implant Dentistry
A B C

D E F

G H I
• Figure 7-14  A, Photograph of healed implant site ready to be uncovered. B, Radiograph of site is used
to help locate the integrated implant and reveals bone growth over implant. C, Incision in soft tissue down
to bone with single pass of laser. D, Bone over implant exposed. E, Removal of bone with erbium laser.
Total laser exposure time was 2 min. F, Transfer coping in place. G, Tissue former in place. No suturing was
done. H, Final radiograph of abutment and crown placed into integrated implant 1 month after uncovering.
I, Clinical photograph of final crown on day of cementation.
 CHAPTER 7  Lasers in Implant Dentistry 125

B C

D E
• Figure 7-15  A, Laser uncovering an implant. B, Incisal view of modified tissue. Sufficient tissue was
removed to allow placement of larger-diameter tissue former without blanching tissue. C, Tissue for-
mer removed and tissue recontoured. D, Contour resulting from the new tissue former. E, Restoration
cemented in place.

A B

C D

• Figure 7-16  A, Periimplantitis affecting implant in upper right second premolar space. B, Radiograph of
bone loss. C, Area after closed ultraspeed CO2 laser debridement of periimplant tissue. D, Excellent tissue
response to laser and healthy periimplant tissue.
126 CHA P T E R 7  Lasers in Implant Dentistry

B C

D E
• Figure 7-17  A, Fistula (arrow) above the upper left cuspid implant. B, After conventional access was
obtained using a scalpel, the site was exposed. C, Diode laser (980 nm) is used to debride soft tissue and
decontaminate site. D, Osseous graft placed over decontaminated site with a resorbable membrane in
place. E, Postoperative photograph at 1 year shows excellent healing.

digluconate (0.2%) on the other half. The criteria evaluated deep bony lesions, leading to a more thorough decontami-
were plaque index, bleeding on probing, probing depth, gin- nation of the implant site. This creates better conditions for
gival recession, and clinical attachment level. After 3 and 6 healing and reosseointegration.
months, the sites decontaminated with the laser exhibited Deppe et  al.26 showed in beagle dogs that decontami-
more improvement than conventionally treated sites. nation of ailing implants is optimized with the CO2 laser
and can lead to periimplant bone growth. The procedure is
Carbon Dioxide Laser performed by placing a CO2 tip into the sulcus. The laser
Romanos16 showed that a power setting of approximately energy is delivered circumferentially around the implant
3 W with a CO2 laser will decontaminate a periimplantitis- body. The diseased soft tissue is vaporized and the bacterial
affected restoration. He theorized that the CO2 laser may be count significantly reduced. No bone grafting procedure is
reflected off the implant surface and vaporize the bacteria in done and no flap raised. As suggested by my own clinical
 CHAPTER 7  Lasers in Implant Dentistry 127

A B C

D E F
• Figure 7-18  A, Pretreatment radiograph of upper left lateral incisor to be extracted. B, Radiograph
showing implant site being prepared immediately after extraction. C, Radiograph of immediately placed
implant loaded with temporary crown. D, Bone loss to fourth thread. E, Radiograph at 1 month after treat-
ments. F, Radiograph at 10 months after cementation. Bone has regenerated to within 1 mm of top of
implant. No flap was raised and no grafting was performed.

experience, this procedure, which takes only minutes to a bone grafting procedure. If the problem is more complex
perform, should be repeated three or four times every 7 to or involves the apical portion of the implant, a laser-assisted
10 days. This interval coincides with the time it takes for surgical approach is appropriate, typically involving inci-
a complex subgingival biofilm to form.62 With repeated sions, flaps, and bone grafting. With either approach, the
interruption of formation of this biofilm over 3 to 4 weeks, results to date are promising and appear to have a higher
the body’s natural defenses and immune response are able success rate than for traditional methods.39,64
to heal the lesion. With resolution of any other causative Figure 7-18 shows an implant with temporary crown for a
factors, such as mechanical overload and suboptimal oral left lateral incisor. When the patient returned for dental care
hygiene, the pathologic process will be stopped, and in after having left the area for 6 months, mucositis was evident,
some cases, regeneration of bone will occur. Although the and nonsurgical treatment with a CO2 laser was instituted.
extent is not yet predictable, with decontamination of “ail- The laser tip was positioned circumferentially and laser energy
ing implants” with bone loss of up to 6 mm, regeneration of was applied for 30 sec on the facial, lingual, mesial, and dis-
1 to 4 mm of new bone has been demonstrated, with resto- tal aspects of the involved soft tissue. Three additional treat-
ration of healthy periimplant soft tissue as well.26,63 ments were given at 1-week intervals. At 1 month, the final
To conclude, the most conservative early- to middle- abutment and crown were seated and the tissue was treated
stage treatment of a mucositis involving bone loss at the cer- once more. After another extended absence, the patient again
vical aspect of the implant is a nonsurgical approach using returned for clinical evaluation; bone regeneration was seen at
laser energy, without an incision or flap and not requiring 10 months after cementation (see Figure 7-18F ).
128 CHA P T E R 7  Lasers in Implant Dentistry

Diode Versus Carbon Dioxide Laser

Treatment Scenarios
Conclusions
If an implant was placed below the crest of the bone and the Lasers bring significant benefits to modern clinical den-
bone remained intact at the crest, the result would be a large tistry, especially implant dentistry. Diode, CO2, and erbium
volume of tissue surrounding the implant body. This tissue lasers have the potential to improve the clinician’s ability to
might need to be sculpted in one of several approaches: sim- deliver the highest quality of care while providing a more
ply seating a tissue former or healing abutment; changing comfortable experience for the patient, with fewer postop-
to a larger-size tissue former after initial healing; seating the erative problems. Each laser emits a different wavelength in
final abutment, depending on its size and shape; or seat- the electromagnetic spectrum, and each has unique effects
ing the final crown. In each case, hemorrhage control indi- on hard and soft tissues. Therefore each wavelength has
cates that use of a diode or CO2 wavelength would be most advantages and disadvantages, depending on the clinical
appropriate. The CO2 laser would have the benefit of speed goals, skill, and experience of the dental practitioner and on
and efficiency over the diode instrument. the target tissue type.
Also, if an impression was needed of an abutment in As emphasized in this chapter, most if not all of the steps
place whose margins were below the tissue crest, a trough- in implant procedures can be accomplished or enhanced
ing procedure with a CO2 or diode laser would create a with lasers. It is incumbent on the clinician to learn about
good environment for obtaining an impression, while being the available choices. An embrace of laser technology by
less traumatic to the tissue than the traditional retraction the dental profession will lead to impressive clinical benefit
cord technique (see Chapter 6). Furthermore, cementa- with improved patient outcomes, and experienced clinicians
tion of crowns below the tissue crest can irritate the tissue if undoubtedly will find further uses for lasers as technology
some cement was not removed beforehand. In such cases, a continues to improve. Any dentist placing or restoring den-
troughing procedure around the crown to visualize all of the tal implants will find lasers invaluable in making procedures
margins would be beneficial. The CO2 wavelength would be easier and more successful.
the logical choice because of its hemostatic effects, because
it is less traumatic to tissue than other soft tissue lasers, and
because it is less likely to alter the marginal tissue, so that References
esthetics would be preserved.
1. Marder MZ: Treatment planning for dental implants: a ratio-
nale for decision making. Part 1. Total edentulism, Dent Today
Future of Lasers in Implant Dentistry 24(5):74–76, 78, 80–83, 2005.
2. Karoussis I, Brägger U, Salvi G, et al.: Effect of implant design
As clinicians become more experienced with laser technol- on survival and success rates of titanium oral implants: a 10-year
ogy in their practice, the adjunctive uses expand. The use prospective cohort study of the ITI Dental Implant System, Clin
of lasers in implant dentistry is even more promising. The Oral Implants Res 15(1):8–17, 2004.
ability to control depth of cutting would allow the use of 3. Lindh T, Gunne J, Tillberg A, Molin M: A meta-analysis of
erbium lasers in osteotomy site preparations, instead of implants in partial edentulism, Clin Oral Implants Res 9(2):80–90,
bone drills. The mechanical action of a drill creates friction 1998.
with the potential for overheating the bone.47 A nonster- 4. Jivraj S, Chee W: Rationale for dental implants [abstract], Br
ile drill can contaminate the surgical site. An erbium laser Dent J 200:661–665, 2006.
could make the same cut in the bone without mechanical 5.  American Academy of Implant Dentistry: Dental implants
preferred option for aging bridges [news release], May 2008;
trauma. Also, because lasers sterilize as they cut, using a laser
http://www.aaid-implant.org.
in the osteotomy site would reduce the risk of postoperative 6. Ismail S, Johal A: The role of implants in orthodontics, J Orthod
infection and promote a successful outcome.13 29(3):239–245, 2002.
El-Montaser et al.65 showed that healing in an implant 7. Swick M: Laser-tissue interaction. I, J Laser Dent 17(1):28–32, 2009.
site prepared with an erbium laser was better than a bur- 8. Adibi S: Er,Cr:YSGG laser use for soft tissue management dur-
prepared site. Their results demonstrated that bone abla- ing the restoration of an implant: a case report, J Laser Dent
tion with the Er:YAG laser promotes ingrowth of new bone 17(1):34–36, 2009.
around titanium metal implants and that osseointegration 9. Coluzzi DJ: Soft tissue surgery with lasers: learn the fundamen-
can occur. For erbium lasers to replace current implant drills, tals, Contemp Esthet Restorative Pract, 1–2, May 2007.
precision in the depth and diameter of cut is necessary. 10. Convissar R: The top ten myths about CO2 lasers in dentistry,
In another area of application, low-level laser techniques Dent Today 28(4):70, 2009.
11. Raffetto N, Gutierrez T: Lasers in periodontal therapy, a five-year
are thought to improve wound healing, with evidence of
retrospective, Calif Dent Hyg Assoc J 16:17–20, 2001.
accumulated collagen fibrils, accelerated cell reproduc- 12. Aoki A, Mizutani K, Takasakim AA, et  al.: Current status of
tion, and increased prostaglandin levels.66 More stud- clinical laser applications in periodontal therapy, Gen Dent 56(7):
ies are needed, but the science is sufficiently encouraging 674–684, 2008.
to support the likelihood that such laser technology will 13. Bornstein ES: The safety and effectiveness of dental Er:YAG
accelerate wound healing and enhance patient comfort (see lasers: a literature review with specific reference to bone, Dent
Chapter 15). Today 22(10):129–133, 2003.
 CHAPTER 7  Lasers in Implant Dentistry 129

14. Gregg R: Laser resource and reference guide, Dent Today, March 38. Stuart C: The use of lasers in periodontal therapy, Gen Dent
2006. http://www.dentistrytoday.com/technology/lasers/1366. 56(7):612–616, 2008.
Accessed October 2014. 39. Deppe H, Horch H: Laser applications in oral surgery and
15. Fasbinder D: Dental laser technology, Compend Contin Educ implant dentistry, Lasers Med Sci 22:217–221, 2007.
Dent 29(8):459, 2008. 40. Dederich D, Bushick R: Lasers in dentistry: separating science
16. Romanos G: Laser surgical tools in implant dentistry for the long- from hype, J Am Dent Assoc 135(2):204–212, 2004.
term prognosis of oral implants, Int Congress Series 1248:111, 2003. 41. Locke M: Clinical applications of dental lasers, Gen Dent
17. Yousif A, Zwinger S, Beer F, et al.: Investigation on laser dental 57(1):47–59, 2009.
implant decontamination, J Laser Micro/Nanoeng 3(2):119–123, 42. Wahl M: Myths of dental surgery in patients receiving anticoagu-
2008. lant therapy, J Am Dent Assoc 131(1):77–81, 2000.
18. Romanos G: Question 1: is there a role for lasers in the treatment 43. Pototski M, Amenabar J: Dental management of patients receiv-
of peri-implantitis? J Can Dent Assoc 71:117–118, 2005. ing anticoagulant or antiplatelet treatment, J Oral Sci 49(4):
19. Coluzzi D: Fundamentals of dental lasers: science and instru- 253–258, 2007.
ments, Dent Clin North Am 48:751–770, 2004. 44. Matjaz L, Marincek M, Grad L: Dental laser drilling: achieving
20. Coleton S: Lasers in surgical periodontics and oral medicine, optimum ablation with the latest generation Fidelis laser systems,
Dent Clin North Am 48:937–962, 2004. J Laser Health Acad 7(1):1–3, 2007.
21. Cobb CM: Lasers in periodontics: a review of the literature, 45. Kesler G, Romanos G, Koren R: Use of Er:YAG laser to improve
J Periodontol 77:545–564, 2006. osseointegration of titanium alloy implants: a comparison of
22. Block CM, Mayo JA, Evans GH: Effects of the Nd:YAG den- bone healing, Int J Oral Maxillofac Implants 21:375–379, 2006.
tal laser on plasma-sprayed and hydroxyapatite-coated titanium 46. Walsh Jr JT, Flotte TJ, Deutsch TF: Er:YAG laser ablation of tis-
dental implants: surface alteration and attempted sterilization, sue: effect of pulse duration and tissue type on thermal damage,
Int J Oral Maxillofac Implants 7:441–449, 1992. Lasers Surg Med 9:314–326, 1989.
23. Walsh LJ: The use of lasers in implantology: an overview, J Oral 47. Miloro M, Ghali GE, Larsen P, Waite P: Peterson’s principles of
Implantol 18:335–340, 1992. oral and maxillofacial surgery, vol 2, Hamilton, Ohio, 2004, BC
24. Chu RT, Watanabe L, White JM, et al.: Temperature rises and Decker.
surface modification of lased titanium cylinders (special issue), 48. Rayan G, Pitha J, Edwards J, Everett R: Effects of CO2 laser beam
J Dent Res 71:144, 1992. on cortical bone, Lasers Surg Med 11(1):58–61, 1990.
25. Strauss R, Fallon S: Lasers in contemporary oral and maxillofacial 49. Van As G: Erbium lasers in dentistry, Dent Clin North Am
surgery, Dent Clin North Am 48:861–868, 2004. 48:1017–1059, 2004.
26. Deppe H, Horch H, Helmut G, et al.: Peri-implant care with the 50. Kaufman E: Maxillary sinus elevation surgery, Dent Today, Sep-
CO2 laser: in vitro and in vivo results, Med Laser Appl 20:61–70, tember 2002.
2005. 51. Pikos MA: Maxillary sinus membrane repair: report of a tech-
27. Pang P: Lasers in cosmetic dentistry, Gen Dent 56(7):663–664, nique for large perforations (abstract), Implant Dent 8(1):29–34,
2008. 1999.
28. Swift J, Jenny J, Hargreaves K: Heat generation in hydroxyap- 52. Shlomi B, Horowitz I, Kahn A, et al.: The effect of sinus mem-
atite-coated implants as a result of CO2 laser application, Oral brane perforation and repair with Lambone on the outcome of
Surg Oral Med Oral Pathol 79(4):410–415, 1995. maxillary sinus floor augmentation: a radiographic assessment
29. Israel M: Use of the CO2 laser in soft tissue and periodontal sur- (abstract), Int J Oral Maxillofac Implants 19(4):559–562, 2004.
gery, Pract Periodont Aesthet Dent 6:57–64, 1994. 53. Vercellotti T, De Paoli S, Nevins M: The piezoelectric bony win-
30. Forrer M, Frenz M, Romano V, et al.: Bone-ablation mechanism dow osteotomy and sinus membrane elevation: introduction of a
using CO2 lasers of different pulse duration and wavelength, Appl new technique for simplification of the sinus augmentation pro-
Phys B Lasers Opt 56(2):104–112, 1993. cedure, Int J Periodont Restorative Dent 21(6):561–567, 2001.
31. Schwarz F, Bieling K, Sculean A, et al.: Treatment of periimplan- 54. Chen S, Darby I: Dental implants: maintenance, care and treat-
titis with laser or ultrasound: a review of the literature, Schweiz ment of peri-implant infection, Aust Dent J 48(4):212–220,
Monatsschr Zahnmed 114(12):1228–1235, 2004. 2003.
32. Kresiler M, Al Haj H: d’Hoedt B: Temperature changes at the 55. Mombelli A, Lang NP: The diagnosis and treatment of peri-
implant-bone interface during simulated surface decontamina- implantitis, Periodontol 2000(17):63–76, 1998.
tion with an Er:YAG laser, Int J Prosthodont 15(6):582–587, 56. Mombelli A: Microbiology and antimicrobial therapy of peri-
2002. implantitis, Periodontol 2000(28):177–189, 2002.
33. Lee D: Application of laser in periodontics: a new approach in 57. Santos V: Surgical anti-infective mechanical therapy for peri-
periodontal treatment, Hong Kong Med Diary 12(10):23–25, implantitis: a clinical report with a 12-month follow-up, Gen
2007. Dent 57(3):230–235, 2009.
34. Walsh L: The current status of laser applications in dentistry, Aust 58. Leonhardt A: Five-year clinical, microbiological, and radiological
Dent J 48(3):146–155, 2003. outcome following treatment of peri-implantitis in man, J Peri-
35. Fonseca R: Oral and maxillofacial surgery, vol 6, Philadelphia, odontol 74(10):1415–1422, 2003.
2000, WB Saunders. 59. Yung F: The use of an Er:YAG laser in periodontal surgery: clinical
36. Scortecci G, Misch C, Benner K: Implants and restorative den- cases with long-term follow up, J Laser Dent 17(1):13–20, 2009.
tistry, New York, 2001, Martin Dunitz. 60. Miller R: Treatment of the contaminated implant surface using
37. Kojima T, Shimada K, Iwasaki H, Ito K: Inhibitory effects of a the Er,Cr:YSGG laser, Implant Dent 13(2):165–170, 2004.
super pulsed carbon dioxide laser at low energy density on peri- 61. Schwarz F, Bieling K, Bonsmann M, et  al.: Nonsurgical treat-
odontopathic bacteria and lipopolysaccharide in vitro, J Periodont ment of moderate and advanced periimplantitis lesions: a con-
Res 40(6):469–473, 2005. trolled clinical study, Clin Oral Invest 10:279–288, 2006.
130 CHA P T E R 7  Lasers in Implant Dentistry

62. Quirynent M, Vogels R, Pauwels M, et  al.: Initial subgingival 65. El-Montaser M, Devlin H, Dickinson M, et al.: Osseointegration
colonization of “pristine” pockets, J Dent Res 84(4):340–344, of titanium metal implants in erbium-YAG laser prepared bone,
2005. Implant Dent 8(1):79–85, 1999.
63. Stubinger S, Henke J, Donath K, Deppe H: Bone regeneration 66. Sun G, Tunér J: Low-level laser therapy in dentistry, Dent Clin
after peri-implant care with the CO2 laser: a fluorescence micros- North Am 48:1061–1076, 2004.
copy study, Int J Oral Maxillofac Implants 20(2):203–210, 2005.
64. Deppe H, Horch HH, Neff A: Conventional versus CO2 laser–
assisted treatment of periimplant defects with the concomitant
use of pure-phase beta-tricalcium phosphate: a 5-year clinical
report, Int J Oral Maxillofac Implants 22(1):79–86, 2007.