N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me May-June 2021 | No. 3, Vol. 11 Laser-assisted prophylaxis around zirconia implants France-based dentist Dr Fabrice Bau- dot has specialised in periodontics, laser-assisted surgery and implant dentistry and has a particular inter- est in zirconia implants. In this in- terview, Dr Fabrice Baudot, founding member and scientifi c leader of the European Academy of Ceramic Im- plantology (EACim), explains why dental lasers have become an es- sential part of his daily practice and sheds light on the clinical benefi ts of combining laser-assisted surgery and ceramic implantology. Peri-implantitis is an increasing problem in today’s dental im- plantology. It is especially associ- ated with titanium implants. What treatment benefi ts does the laser offer in this context? Indeed, peri-implantitis is a real scourge for which we do not yet have good therapeutic solutions. Dr Stefan Renvert, in his 2012 book titled Peri-implantitis, said, “As in all pathologies, the best form of treat- ment is very often prevention and peri-implantitis is no exception.” From this point of view, the Er:YAG laser can provide us with certain solutions for the daily practice. The cause of peri-implantitis might be multifactorial, but the microbio- logical aspect and the contamina- tion of implant surfaces by biolms seems to be a key point. With its well demonstrated bactericidal proper- ties, the Er:YAG laser is an excel- lent complementary instrument to conventional instrumentation for regulating the development of bio- fi lm around implants and cleaning contaminated implant surfaces. We capitalise on two major effects of the Er:YAG laser in the management of peri-implantitis: fi rstly, there are photo-ablative effects of the laser, which are used for the micro-abla- tive cleaning of implant surfaces and the removal of infl ammatory tissue. These ablative effects allow us to clean so-called peri-implant wounds; secondly, there are pho- toacoustic effects, which are based on shock waves generated by the Er:YAG laser emission that agitate the water-based antiseptic irrigation solutions that can be used to clean the peri-implant space. When it comes to oral surgeries, we usually exploit the photo-ablative effects of the Er:YAG laser. If we com- pare the Er:YAG laser to air polishers, which appear to be the reference for cleaning implant surfaces, the Er:YAG laser shows similar results on rough titanium surfaces, but with- out leaving powder debris on the surgical site. It can be argued that it is as effective and at the same time cleaner than conventional instru- ments. As opposed to other lasers, the Er:YAG laser is the only laser that can safely treat hard and soft tissue simultaneously without generating uncontrolled thermal effects. It can particularly be used on bone without the risk of thermal damage and even in conned spaces, as is often the case in dental implantology. In peri-im- plant maintenance, we exploit the photoacoustic effects, leading to an emulsifying of biofi lm without alter- ing the delicate tissue–implant inter- face. The shock waves generated by Er:YAG radiation with a wavelength of 2,940 nm cause a 3D expansion of the irrigation solution, and the agita- tion effect of the solution destabilis- es the biofi lm in a way well beyond what conventional instrumentation is able to achieve. These repeated pre- ventive measures which are tailored to the patient’s individual physiol- ogy make it possible to maintain peri-implant homoeostasis without altering the surrounding tissue en- vironment. The treatment protocols are very simple to follow and clinical application only takes a few minutes. Ceramic implants are not particu- larly associated with peri-implant inammation. Are there useful laser applications designed for ceramic implants too? What is possible and what isn’t? I use the Er:YAG laser for peri-im- plant maintenance on a daily basis. This concept of clinical application is based on the emulsion of biofi lm that develops around the transgingi- val part of implant restorations and even beyond, in cases of peri-im- plantitis. Dr Kenneth S. Kornman’s article “The host response to the microbial challenge in periodontitis: Assembling the players”, published in 1997 in Periodontology 2000, made me realise the importance of exposing pathogens to defence sys- tems to preserve periodontal and peri-implant homoeostasis. The Er:YAG laser and its photoacoustic effects enable the meeting between the pathogenic agents and the im- mune defence system, as explained by Kornman in his article. In an ex- cellent journal article (“The effect of material characteristics, of surface topography and of implant compo- nents and connections on soft tis- sue integration: A literature review”) published on 1 September 2006 in Clinical Oral Implants Research, Belgium-based Prof. Eric Rompen elaborated on the importance of im- plant materials regarding the nature of tissue attachment. Only titanium and zirconia allow hemidesmosome attachment, creating a kind of bar- rier against biolm. Other materials used for transgingival connections, such as gold or red ceramics, do not favour attachment. A real pocket is formed around this type of connec- tion, which can pose a risk factor for the development of peri-implantitis. Deep laser-assisted peri-implant maintenance is particularly indi- cated around gold or UCLA-type red ceramic connections. With zirconia and titanium connec- tions, the attachment is of better quality and the use of the Er:YAG la- radiation from three different lasers on zirconia. The carbon dioxide laser seems to alter the surface of zirco- nia, and the Er:YAG laser penetrates the surface of zirconia. The diode la- ser appears to be more suitable, but this study has not been confi rmed yet by other studies. The clinical ap- plication of the diode laser seems to me, when looking at it in vitro, much more problematic than the Er:YAG laser, especially in areas close to the bone as is systematically the case in implantology. The risk of collat- eral thermal effects especially on the bone is of major concern with diode laser radiation. Alterations of the implant surface under the effect of laser radiation ap- pear to occur only at powers well be- yond those effective in destroying bi- ofi lm and organic material. Owing to its peak water absorption, the wave- length at 2,940 nm of the Er:YAG laser is effective at the lowest energy levels and therefore cannot, in clini- cal use, signifi cantly alter the implant surface. The important thing is to be able to manipulate Er:YAG radiation under visual control at high magnifi - cation to optimise power settings at the lowest effective energy levels and at tangential incidence to the surface to limit the concentration of energy transmitted to the implant support and thus limit the potential effects of the radiation on the implant surface to be treated. The clinical experience and mode of use of the laser is fun- damental and deserves to be widely studied to confi rm the safe clinical effi cacy of lasers on zirconia implant surfaces. Editorial note: This article was fi rst published laser—international magazine of laser dentistry, vol. 12, is- sue 2/2020. in About the author Dr Fabrice Baudot He is a French dentist specialised in peri- odontics and implantology. He currently leads a practice that is specialised in laser- assisted microsurgery. His therapeutic approach is always based on minimally invasive surgery. Dr Baudot is frequently invited to speak at international dental conferences, and he is the author of nu- merous scientifi c publications. Impasse des Trois Pointes 65 34980 Saint-Gély-du-Fesc, France Phone: +33 4 99060060 dr.baudot34@orange.fr t o d u a B e c i r b a F r D © “I use the Er:YAG laser for peri-implant maintenance on a daily basis.” ser is less justifi ed when it comes to maintenance. When treating estab- lished peri-implantitis, the Er:YAG la- ser with its micro-ablative properties makes, in my opinion, a real differ- ence compared with conventional instrumentation. Again, it is a very clean and effi cient tool. It disinfects the treated sites without altering the adjacent surrounding tissue. Numerous studies have shown its safety on titanium, but there are, as far as I know, very few studies show- ing the effects of the Er:YAG laser on zirconia implants. I have only in vitro experience under an operating microscope of the use of the Er:YAG laser on zirconia implant surfaces (Z-Systems and CERALOG) because I have not had to deal with any cases of peri-implantitis around these implants. According to my observa- tions, the implant surface of zirconia implants appears to be completely inert to Er:YAG radiation and reacts much less than titanium. The or- ganic materials which are present on a ceramic implant surface are liter- ally vaporised owing to the micro- ablative effect of the Er:YAG laser, leaving a perfectly clean and visibly unaltered surface as a result. It there- fore appears that the Er:YAG laser is very effective in cleaning ceramic implants. Are there any material-specifi c fac- tors that need to be particularly considered when treating ceramics with lasers? In my opinion, the only laser that is truly effective and safe in peri-im- plant spaces is the Er:YAG laser. As has been done for titanium implants, the effects of laser radiation should be tested at different power levels, under different circumstances and for different exposure times. Micro- ablative effects on zirconia should be observed by means of a scanning electron microscope (SEM) and pos- sible surface alterations, especially in the microtexture, should be evaluat- ed. One thing that seems fundamen- tal to me is the aspect of the thermal rise of zirconia under the effect of Er:YAG radiation. There is only one in vitro SEM study, conducted by Dr Stefan Stübinger in 2008 (“Effect of Er:YAG, CO2 and diode laser irradia- tion on surface properties of zirconia endosseous dental implants”; La- sers in Surgery and Medicine), which shows and evaluates the effect of