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16 ◊Page 15 mCME Dental Tribune Middle East & Africa Edition | 2/2018 This zone is most often between 3 and 7 feet, but some diodes can have extended NOHZ ranges of 40 feet. Orthodontic patients will often ex- hibit gingival hyperplasia when in brackets that can make it difficult to work on them. This overgrowth of tissue can be due to poor oral hygiene, space-closing mechanics, excess cement or a combination of factors. The diode laser can be used for gingivectomies to safely remove and recontour the excess tissue and healing can be remarkable in a very short period of time (Figs. 2–4). Ability to work around dental im- plants safely Various laser wavelengths that are available today can offer the clini- cian who needs to expose an implant during second stage surgery an alter- native to traditional methodologies. The ability of the diode laser to ablate tissue, at times without the need for local anesthetic, while controlling hemostasis, provides the clinician a great view of the surgical site. In addition, the diode wavelength, like all laser wavelengths, provides for decontamination of the implant site through its antibacterial actions. Bacterial reduction with the diode laser can lead to an almost sterile op- erative field (98 percent reduction of pathogenic bacteria). Finally, there is a growing body of evidence that sug- gests that lasers used at lower energy settings can have a biostimulatory effect on tissue, which in turn can re- duce postoperative discomfort, im- prove healing and shorten healing times while even improving early osseointegration.8–12 As an aside, there have been clini- cians who routinely use monopolar electrosurgery units to expose im- plants. It is imperative to realize that although more expensive bipolar (two electrodes) electrosurgery units can be used safely around implants, that the more commonly purchased single electrode (monopolar) units may damage the implant surface and can cause complete loss of osse- ointegration with resulting implant failure with contact times as short as three seconds.13,14 Lasers, in contrast, can be used safely with tremendous coagulation and a reduction in pain postoperatively for the patient15 (Figs. 5,6) consistently complete soft tissue ablation with only a stronger topical anesthetic. In fact, the literature has shown that a variety of soft-tissue procedures (even frenectomies) can be completed with only topical anes- thetic16–18 (Figs. 13–16). Diode lasers are also useful when it comes time to seat the final abut- ment and restoration. Tissue man- agement around dental implant restorations can be difficult, be it for the initial cementation or, even worse, if an implant-restored crown comes loose. Tissue quickly slumps onto the abutment, and subgingival margins can be almost impossible to retrieve with traditional method- ologies. The laser can truly be a “life- saver” for these situations where soft tissue must be safely and quickly removed to allow for ideal cementa- tion of the implant retained crowns onto the abutments (Figs. 7–12). Reduced need for anesthetic Monopolar electrosurgery units do not have the ability to be used rou- tinely without local anesthetic. In contrast, diode lasers can often be used either with low wattages or in pulsed modes to remove minor to moderate amounts of soft tissue with only topical anesthetics. Al- though at times this may not seem significant to the clinician, there are many instances where soft tissue acts as a barrier to ideal restorative treatment, and if local anesthetic can be eliminated it becomes a big sell- ing point to patients. Many patients are looking for alter- natives to local anesthetic, and when the occasion allows for the procedure to be completed without the patient being numb, the overwhelming majority of patients are grateful for this. Situations such as laser gingival crown troughing for tissue manage- ment around endodontically treated teeth, exposure of partially erupted canines for orthodontic brackets and gingivectomies around moderately sized Class V lesions in geriatric pa- tients are all situations where the au- thor has been able to routinely and Ability to do gingivectomies and crown troughing with less reces- sion White et al. have mentioned that laser gingivectomies are the most common soft-tissue procedure done with diode lasers,19 and when combined with esthetic porcelain restorations, the simple recontour- ing of tissue can take a good case and make it great.20–24 A key difference from electrosurgery ablation of soft tissue is that alterations to the sym- metry of the soft-tissue contours in the maxillary anterior teeth can be safely and precisely completed on the same day as the preparation and impressions of these teeth. The risk of recession and exposure of mar- gins can be far less with a diode laser than with other techniques, particu- larly when adequate magnification (e.g., 4.0X loupes) and cautious set- tings (0.6–0.9 w continuous wave) are used for the recontouring. When biologic width is respected, and adequate attached and kerati- nized tissue exists, then judicious recontouring of the gingiva on the same day as the preparations can yield stunning results (Figs. 17–19). The diode laser has become a popu- lar technology as an alternative for tissue management compared to the traditional methodology of plac- ing a single or double retraction cord in the sulcus. The diode laser can be used in almost all instances to pro- duce gingival retraction as an alter- native to cord with excellent results both in terms of gingival retraction and margin delineation for the labo- ratory. Unlike electrosurgical units where recession can be an issue, as can postoperative pain, diode lasers offer the clinician the ability to precisely remove overhanging, inflamed tis- sue while creating a gingival trough that is not likely to cause damage to bone, cementum or pulp tissue like electrosurgical units can. In addition, there is research that suggests that the lateral thermal damage done with lasers is significantly lower than that with electrosurgery.25 Ability to photocoagulate vascular lesions and treat oral lesions One of the advantages of a diode la- ser is the ability to treat oral lesions, including: recurrent aphthous ulcers (RAU), venous lake lesions of the lips and herpetic lesions. Research has shown that lasers can be safely used to treat these lesions,26–28 and in addi- tion it is possible that if caught early during the prodromal stage that her- petic lesions can be aborted or signif- icantly reduced in terms of length of time they are present.29 In addition, it has been the author’s experience that, once treated with the laser, the lesions are often less likely to reap- pear in the same area. In fact some evidence suggests that herpetic le- sions treated in the early stages with the diode laser can cut the healing time in half and create a remission period that is twice as long before it reoccurs.30,31 Vascular lesions called venous lakes or hemangiomas can occur on soft tissue-areas including the upper and lower lips, buccal mucosa and palate. These lesions can be difficult to treat with traditional methods where significant bleeding may occur. The diode wavelengths are rapidly ab- sorbed by hemoglobin and therefore can be used to coagulate and eradi- cate these esthetically undesirable purplish lesions often with only top- ical anesthetic. Literature has shown that the diode can be used in almost 100 percent of cases to eliminate these lesions, most often in only a single session lasting only a couple of minutes32–35 (Figs. 20–22). Anti-bacterial capabilities of lasers Many articles in the literature have demonstrated the tremendous abil- ity of all lasers with respect to the re- duction of bacterial and even fungal infections.36–43 The excellent antibac- terial capabilities make lasers effec- tive and desirable in many areas in the oral cavity where the risk of post- operative infection may be reduced. Electrosurgical units do not typically possess the same ability to provide bacterial reduction as lasers do. Par- ticular interest is now occurring with the role of lasers in endodontic, peri- odontic and peri-implantitis cases where there is need to reduce bacte- rial loads without such a great reli- ance on antibiotics. Although more research is needed on how the bactericidal capabilities of the diode laser might be benefi- cial in these areas, there is no debat- ing that all lasers can help healing through decreasing the risk of infec- tion through laser light alone (Figs. 23–25). In addition, growing research has demonstrated that the risk of high bacterial loads in periodontal pockets and in particular in endo- dontic situations may be reduced by lasers. This latest research has implications for improving traditional meth- odologies locally where used, and in helping to reduce the potential greater systemic health risks gener- ally. The role of lasers continues to be researched today, but present re- search has shown that diode lasers can be used safely within root canals with minimal fear of developing iatrogenic complications when con- servative settings are used.44–48 Conclusion The diode laser has become the “soft- tissue handpiece” in many dental of- fices. The advantages of being able to work around metals including den- tal implants, a reduced need for an- esthetic, a reduced risk of recession postoperatively, the ability to reduce bacteria, and to use the diode to pho- tocoagulate vascular lesions have all provided dentists with a new alter- native for soft-tissue surgery. ÿPage 17 Fig. 14: Topical gel placed on soft tissue prior to gingi- vectomy to uncover soft tissue. Fig. 15: Pulsed mode at 1.4 w shows removal of at- tached tissue to expose canine. Fig. 16: Brackets in place on both canines — immedi- ate post-op view Fig. 17: Pre-op prior to maxillary incisor veneers. Fig. 18: After recontouring of lateral incisors and la- ser crown troughing for tissue management prior to impressions. Fig. 19: Immediate postoperative result for four Emax veneers. Fig. 20: Pre-op view of venous lake on lower lip. Fig. 21: Immediate post-op appearance. Fig. 22: Two-week healing of lesion on lip is complete. Fig. 23: Diode direct pulp cap to lower bacteria count on MO cavity preparation Fig. 24: Diode laser in gingival sulcus lowering bacte- ria count (image of diode pulse captured with video camera on operating microscope — typically the im- age is not visible to the human eye). Fig. 25: Diode laser used to reduce bacterial counts inside a DB canal of upper right second molar after completion of instrumentation and prior to obtura- tion of the canals.