Romanian Journal of Oral Rehabilitation Vol. 12, No. 1, January - March 2020

SURGICAL LASERS: A REVIEW OF APPLICATIONS IN THE THERAPY OF

Agop-Forna Doriana1, Mihai Constantin1*, Forna Norina2 1 “Grigore T.Popa” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Dento-Alveolar and Maxillo-Facial Surgery, Universitatii Str.,700115, Iasi, Romania 2 “Grigore T.Popa” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Implantology, Removable Dentures and Technology, Universitatii Str.,700115, Iasi, Romania *Correspondent author: Associate Prof. PhD Mihai Constantin; e-mail:[email protected] Abstract.

In this review are presented literature data collected from a Medline search, regarding the applications of surgical lasers in minor oral surgery. The search of literature data was performed for studies published between 2007 and 2019, regarding the use of lasers in the removal of oral benign mucosa lesions, treatment of oral premalignant lesions and the therapy of oral vascular lesions. Key words: lasers, oral surgery, benign oral lesions, premalignant lesions, vascular lesions

Introduction. In the last decade, the use of 1064nm) is absorbed by hemoglobin, diode surgical lasers in the oral surgery is lasers being used for the removal of oral spreading due to their advantages and benign mucosa lesions or premalignant oral benefits comparing to traditional techniques lesions (5). The limits of the diode lasers are (1). Laser beam cut the target tissues more related to thermic effects to lateral tissues, accurately than scalpel, creating complete so it is suggested that diode lasers should be vaporization, and partial or complete closure used only for the excision of oral lesions of the blood vessels (2). Thus, laser-assisted with diameter over 3 mm to avoid procedures are associated to reduced intra- significant thermic effects (6). Erbium lasers operatory bleeding, lower post-operatory wavelength (2780nm, 2940nm) is absorbed pain and discomfort, lower risk of infection, mostly by water and hydroxyapatite (7). lower need for suture as well as significantly Erbium lasers can be used both for oral shorter healing time (2). The most frequent surgical procedures in soft tissues and bone lasers used in oral surgeries are Erbium tissues with minimal trauma and higher lasers, diode lasers, CO2, and Nd:YAG. incision accuracy, comparing with diode These lasers can be associated to low level lasers. The use of erbium lasers in bone lasers for disinfection and acceleration of surgical procedures has the advantage of healing processes (3). Each type of laser has progressive vaporization allowing lower specific indications in the oral surgical increase of temperature (comparing with procedures related to the oral lesions’ traditional technique), regularization of bone category (4). Diode wavelength (810- ablation area as well as micro-perforations

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Romanian Journal of Oral Rehabilitation Vol. 12, No. 1, January - March 2020 for better revascularization (8). Nd:YAG of scars and healing in maximum 2-3 weeks laser wavelength (1064nm) is highly were recorded for diode laser-assisted absorbed by hemoglobin and melatonin and therapy of oral benign tumors and oral has deep extinction length with lateral tissue mucosa hyperplasia (13). The excision of damage during laser-assisted procedures. fibrous oral lesions can be performed with Also, Nd:YAG lasers allow hemostasis by 808 nm diode laser using power 0,6-2,7W collagen contraction during surgical (6), 940 nm diode laser using power 1,5W procedures (9). Nd:YAG lasers are mostly (12), or 810nm diode lasers using power used for the removal of the vascular lesions. 0,7-0,8W (13). Figures 1.a-c and 2.a-c CO2 lasers wavelength (10600nm) is highly present the excision of mucocele (figures absorbed by water and hydroxyapatite. CO2 1.a-c) and lip papilloma (figures 2.a-c) in lasers can be used in the removal of one single session, by using diode laser moderate and severe oral mucosa lesions, 810nm. The effectiveness of erbium lasers oral benign and premalignant lesions was investigated in the studies presenting surgery as well as treatment of vascular case reports related to the excision of lesions (10). various oral benign lesions, such as (14), lip mucocele (15), Removal of oral benign lesions oral papilloma (16), or oral irritation The use of 808-940 nm diode lasers (17). CO2 lasers were investigated in the removal of oral benign lesions (11) or in the treatment of oral mucocele (18), oral fibromatosis (12) is documented in (19), or giant pyogenic granuloma researches that highlighted the absence of (20). post-operatory complications. The absence

Fig.1.a. Lip mucocele. Pre-operatory clinical aspect

Fig.1.b. Immediate post-operatory clinical aspect

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Romanian Journal of Oral Rehabilitation Vol. 12, No. 1, January - March 2020

Fig.1.c. Post-operatory 7 days healing

Fig.2.a. Lip papilloma. Pre-operatory clinical aspect

Fig.2.b. Intra-operatory aspect

Fig.2.c. Post-operatory 7 days healing

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Romanian Journal of Oral Rehabilitation Vol. 12, No. 1, January - March 2020

Treatment of oral premalignant lesions operatory complications and complete rehabilitation of the oral functions in 1 A wide array of conditions is month following the laser-assisted treatment considered premalignant, including oral (26, 27, 28). In one study, Er:YAG laser , , , treatment of nondysplastic oral leukoplasia , or other hereditary (1.5 W, 150 mJ, 10 Hz, 500-μs pulse disorders (21). duration, 0.9-mm spot size) was compared Diode lasers are effective in the with scalpel technique (29). At 5 years treatment of oral lichen planus. A research follow-up, the complete healing and the presented clinical cases of oral lichen planus absence of recurrence was observed in treated by 940nm diode laser in weekly 52,9% cases, with the absence of significant sessions for 2 months, with complete differences between groups. The conclusion remission of burning sensation and pain and was that Er:YAG laser is as effective as no recurrence of burning sensation at 7 traditional technique in terms of healing, months follow-up (22). Also, complete with the same rate of recurrences in a 5 remission of oral symptoms following years follow-up. Also, another study found 980nm diode laser therapy was recorded in that Er:YAG laser appeared to be faster and another case report study (23). Er:YAG laser less painful than traditional scalpel, was used in the treatment of oral lichen especially in the gingiva and (31). planus with parameters as follows: 80-120 Considering the scores for quality of life mJ; 6-15 Hz; 0,9mm spot size diameter; 100 test, Er:YAG laser was better accepted by μsec (VSP) to 300 μsec (SP) ; 12.6-18.9 patients, than traditional scalpel. The most J/cm2. Authors report fast healing process, effective lasers in the therapy of oral very low level of discomfort during and leukoplakia are CO2 lasers (32). The after intervention, as well as the rapid treatment with CO lasers or diode lasers of disappearance of symptoms (24). CO2 laser oral leukoplakia was effective in 58% cases therapy was effective (improvement in at 22 months mean follow-up, with lesions size, pain and clinical response) in recurrence observed in 27.5% patients, 85% cases of oral lichen planus (comparing development of new lesions recorded in to 100% in cases treated by low-level laser 10% patients and malignant transformation therapy), 3 months posttreatment, following detected in 5% patients (32). A meta- 5 sessions every other day (25). analysis regarding malignant transformation of oral leukoplakia treated with CO2 lasers The benefits of diode lasers in the found an 4,5% overall rate of malignant treatment of oral leukoplakia were proved transformation, a little higher than 3,5% by several researches. The conclusions of mean value for overall malignant these studies were diode lasers are safe and transformation of oral leukoplasia, but with effective tools for the therapy of low effect on malignant transformation, homogenous leukoplakia or recurrent whether oral leukoplakia patients underwent verrucous leukoplakia, with absence of post- laser surgical treatment or not (33).

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Erythroplakia can be also effectively treated of the operatory field conducts to a lower with erbium lasers (34). Oral erythroplakia working time and the increase of patients’ treated by CO laser excision has, at 29 comfort by the absence of suture (38). Fewer months follow-up, a postoperative recurrent complications and satisfactory results were rate of only 16.7% (35), with area of repported on clinical cases with oral erythroplakia highlighted as predictive hemangioma located on and oral factor for postoperative recurrence. mucosa treated with Nd:YAG laser (39). Low morbidity, minimal patient discomfort, Treatment of oral vascular lesions and satisfactory aesthetic results were The oral vascular lesions are a group reported following Nd:YAG laser of benign oral neoplasms that include photocoagulation of benign oral vascular haemangiomas and vascular malformations. lesions, with 80% cases presenting complete These lesions can be treated with diode resolution of lesions after one session of lasers by transmucosal thermocoagulation or laser treatment (40). Nd:YAG laser is intralesional photocoagulation (36, 37). effective in the treatment of large oral However, the most effective laser-assisted vascular lesions (surface diameters more procedures are provided by Nd:YAG lasers than 3 x 3 cm) (41). Also, the effectiveness and CO lasers. The use of Nd:YAG lasers of CO lasers in the treatment of allow the selective destruction of abnormal lymphangioma was proved in one study vessels and the decrease of haemorragic risk (42). In figures 3.a-c. are presented clinical by photocoagulation effect associated with aspects in the treatment of a lip hemangioma forced dehydration. The incision speed with with 810nm diode laser. Nd:YAG is lower but the increased visibility

Fig. 3.a. Lip hemangioma. Pre-operatory aspect

Fig.3.b. Laser therapy session

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Fig.3.c. Post-operatory 21 days healing Conclusions. of lasers and intra-operatory parameters must be selected accordingly to the oral The application of surgical lasers in lesions category. Diode lasers are preferred oral surgery has implications for by most dentists, while high cost and significantly improvement of intra-operatory volume of erbium, CO2, or Nd:YAG lasers conditions, patients’ experience, post- limits the use of these lasers in current operatory quality of life (lower pain and practice of dental medicine. discomfort), shorter healing time. The type

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