3
Lasers in Oral Surgery

Georgios E. Romanos

Stony Brook University, School of Dental Medicine, Stony Brook, NY, USA

3.1 Introduction

The application of the laser as a surgical method is comparable to that of the scalpel, and it has become an important component of modern clinical dentistry. The different effects of certain laser systems can apply for the removal of soft tissue tumors, soft tissue cysts, and precancerous lesions, such as leukoplakia. Frenectomies, pre‐prosthetic surgical procedures, like vestibuloplasties, treatment of gingival hyperplasia, and removal of vascular benign tumors or malformations are other clinical indications.

Exact knowledge of the benefits of the laser light and the effects of the respective wavelength on biological structures are essential for the achievement of an optimum effect (see also Chapter 1). Only under these requirements is it possible to achieve a positive effect of the laser beam on the tissue and to accomplish excellent wound healing without complications.

The indications of the lasers in oral surgery vary from the common excision, biopsies, and coagulation of blood vessels to the complicated therapy of the removal of precancerous lesions and the treatment of vascular tumors and peri‐implantitis, which indeed seems to be very promising for the future (see also Chapter 6).

This chapter intends to provide an overview about the application of various laser wavelengths with different clinical indications for the surgically oriented clinician.

In oral soft tissue surgery, the most used and accepted laser systems at the moment are the CO₂, the Nd:YAG, and the diode lasers. The argon ion, the Ho:YAG and the Er:YAG lasers can be also applied under special circumstances and depending on the clinical indication.

3.2 Basic Principles

The power and energy density in laser therapy must be defined precisely. A vaporized, a necrotic zone, and a zone of reversible thermal changes may be generated by the effect of the laser beam on the tissues.

In comparison to Nd:YAG, diode, or argon lasers, there is a stronger absorption of CO₂ laser beams from fair and slightly inflamed tissues. Due to the effect that granulation tissue contains a high number of blood vessels and capillaries, the high hemoglobin tissue content leads to a higher absorption of the Nd:YAG laser beam.

This means that with the same beam’s energy, on the one hand we achieve quicker surgical excision in the inflamed area, and on the other hand, we have less risk of a pronounced tissue necrosis and/or bone dehiscence in cases of incautious or uncontrolled work using this laser wavelength. From the physical point of view, a slow application will result in a drastic increase of the respective energy density, which is dependent on the entire irradiation period and must be controlled at every surgical intervention.

3.3 Excision Biopsies

Several laser systems are used today in order to excise biopsies, especially the CO_2, the diode, and/or the Nd:YAG pulsed laser. The incision occurs according to the surgical principles considering that thermal effects occur in variable degree in each case. A focus diameter of 0.2 mm generates a zone of thermal impact, which amounts to 50–200 μm with the CO₂, and 500 μm–3 mm with the Nd:YAG laser (deep penetration into the tissue for the Nd:YAG laser) (Figure 3.1).

When the handpiece is focused and vertically applied on the tissue, a distinct marking appears, due to thermal damage (carbonization). This represents the “incision line.” The tissue elevation starts from the peripheral area of this marking and is directed in the depth of the lesion, until the tissue can be lifted easily from its base (Figure 3.2).

At this point, the handpiece is held perpendicular or in a slightly tilted direction to the tissue in order to separate the pathological tissue from the healthy basis. In cases of use of a diode laser, initiation of the fiber before surgery using an articulated paper (black or blue color) or a cork concentrating the maximum energy in the fiber tip is fundamental to control the peripheral thermal damage. The simultaneous coagulation allows a bloodless incision and excision (Table 3.1).

The lesion after removal with the laser must be referred to an oral, maxillofacial pathologist with the explanation of “laser excision,” in order to better illustrate the potential thermal effects and to avoid misdiagnosis. Only after histopathological confirmation of the diagnosis, can the complete excision of the lesion be performed, dependent on the laser wavelength and the type of lesion using a focused or defocused mode. The decrease of the distance between handpiece and tissue under constant power changes modifies the focus and therefore the power density, influencing cutting depth. In contrast to that, the increase of the distance of the handpiece decreases the power density and provides as a result the tissue ablation, so‐called vaporization, without distinctive thermal damage. This is of clinical significance in the removal of wide lesions, such as leukoplakia, lichen planus, or other pathological lesions.

Schematic illustration of differences in penetration depths between CO2 laser and Nd:YAG laser. — **Figure 3.1** Differences in penetration depths between CO₂ laser and Nd:YAG laser (the penetration of the light using the Nd:YAG laser is 10 times higher than CO₂ laser with a high absorption of the connective tissue (chromophores, hemoglobin, etc.).

Photo depicts perpendicular irradiation using a focused CO2 laser allows a clean separation of the pathologic tissue from the surrounding tissues. — **Figure 3.2** Perpendicular irradiation using a focused CO₂ laser (noncontact) allows a clean separation of the pathologic tissue from the surrounding tissues.

*Source:* Dr. Georgios E Romanos.

Table 3.1 Operation mode and clinical procedure.

Type of Procedure	Mode of Operation	Operative Mode	Applicator
Excision/incision	Focused beam	CW or pulsed	Angled
Ablation	Defocused beam	CW or pulsed	90°
Coagulation	Defocused beam	Pulsed	90°

Photo depicts superficial irradiation of the tissue after excision to create a small, coagulated zone. — **Figure 3.3** Superficial irradiation of the tissue after excision to create a small, coagulated zone. This may control the postoperative pain and provide an excellent wound dressing.

*Source:* Dr. Georgios E Romanos.

Suturing and special postoperative surgical measures are usually not necessary. Directly after excision of a lesion with the CO₂ laser, a superficial irradiation of the tissue to create a small, coagulated zone (using the defocused beam) is clinically recommended (Figure 3.3) because this may significantly reduce postoperative pain and protect the wound from infection (wound dressing).

3.4 Removal of Benign Soft Tissue Tumors

In clinical practice, the surgically oriented dentist and/or specialist is confronted with small or big, stalked and superficial soft tissue tumors. The most frequent benign tumors of the oral cavity are the following:

fibromas
papillomas
lipomas
pyogenic granulomas

The most frequent wide tumors or soft tissue pathologies of the oral cavity are papillomatosis (especially in the palate), symmetric fibromas, vascular lesions and malformations, precancerous lesions (i.e. leukoplakia as well as oral lichen planus) (see also Figure 3.4). The surgical removal of papillomatosis of the palate, as well as the symmetrical fibromas and denture‐related fibromas, is often indicated in oral surgery from the pre‐prosthetic perspective. In comparison to the scalpel, the surgical laser permits the removal of such abnormalities with particular advantages for patients and surgeons.

3.4.1 Surgical Protocol for Removal of Small Tumors

In general, the incision design is similar to the conventional surgical method, but in comparison to that, there is only a small number of instruments necessary (Figure 3.5).

Clinical Cases

Clinical Cases Excision Biopsy of a White Lesion (Leukoplakia)

A 65‐year‐old patient was referred with the request of diagnostic clarification of the white pathological lesion at her oral mucosa in areas # 22 and 27 (Figure 3.4a). After topical anesthesia with xylocaine spray 2%, the pathological tissue was excised completely with the noncontact CO₂ laser handpiece and power of 4 W in a continuous mode (Figure 3.4b). The excision succeeded free of blood and without any other intraoperative complications. Directly after the biopsy, the whole area was ablated, in order to form a distinctive coagulation. Suturing was not necessary. The tissue was examined histopathologically. The diagnosis was a common leukoplakia. There were no complications during the healing period and after three weeks there were no pathological findings (Figure 3.4c). Four years after excision, the mucous membrane was still free from any recurrence (Figure 3.4d).

Figure 3.4 Hyperkeratosis of the mandible (a); the pathological tissue was excised with the noncontact CO₂ laser (power: 4 W; continuous mode) (b). The excision succeeded free of blood and without any other intraoperative complications. Directly after the biopsy removal, the whole area was ablated, in order to form a superficial coagulation. The histopathological diagnosis was a common leukoplakia. No complications were observed during the three weeks of postoperative period (c). Four years after excision, the oral mucosa was healthy without any recurrence (d).

Source: Dr. Georgios E Romanos.

Photo depicts necessary instruments for conventional laser-assisted surgical procedures. — **Figure 3.5** Necessary instruments for conventional laser‐assisted surgical procedures.

*Source:* Dr. Georgios E Romanos.

After a topical or local anesthesia, a wedge‐shaped excision will be performed with the laser handpiece. For the removal of the tissue, the handpiece is used in a focused mode. After the removal of a soft tissue tumor, the margins of the adjacent tissues should be ablated in order to achieve smooth excision margins. Afterwards the entire wound should be coagulated using a defocused beam and lower power settings (Table 3.2).

The noncontact CO₂ laser is used with straight or angulated handpieces based on the location of the lesion. The articulated arm with the integrated glass mirror system is associated with some loss of power. This effect may lead to a local overheating at the end of the handpiece, particularly in cases of longer lasting surgical interventions. During surgical procedures under local (or general) anesthesia, there is a small risk of tissue overheating in the adjacent healthy tissues. For this reason, a periodical checking of the fiber condition is absolutely necessary to avoid complications (Figure 3.6).

In case of the Nd:YAG or diode laser application, the blood vessels and/or capillaries will be coagulated with a defocused (noncontact) beam. The risk of secondary bleeding, postsurgical discomfort, and edema is in general significantly reduced. The carbonized surface, which is formed directly after surgery can protect against an infection, and after three to four days there are no pathological changes of the mucosa to be observed. After the formation of a temporary thick fibrin layer (Figure 3.7), the healing is completed within three to four weeks.

Table 3.2 Chronological order in laser surgical procedures.

Treatment	Laser
Medical/dental history (update)
Clinical examination/informed consent
Anesthesia (topical and/or local)
Laser safety measures – test firing
Excision	Focused beam (CW or pulsed)
Marginal ablation	Defocused beam (CW or pulsed)
Coagulation	Defocused beam (pulsed/low power)
(Histopathological examination)
Postoperative instructions
Follow‐up

Photo depicts intraoperative burn of the lower lip of a patient during laser-assisted periodontal therapy at the right mandibular teeth. The glass was broken fiber within the handpiece, and the laser was irradiating the wrong area. — **Figure 3.6** Intraoperative burn of the lower lip of a patient during laser‐assisted periodontal therapy at the right mandibular teeth. The glass fiber was broken within the handpiece, and the laser was irradiating the wrong area (procedure was performed under block anesthesia).

*Source:* Dr. Georgios E Romanos.

The use of lasers with glass fibers, like diode and Nd:YAG lasers, provide an easier control of the tissue irradiation, since dentists, in general, feel comfortable having contact with the tissue in routine clinical dentistry.

Therefore, excisions can be performed when the glass fiber is in contact with the tissue, compared to other laser wavelengths like the CO₂ laser or the Er:YAG laser, where a noncontact handpiece provides tissue removal.

However, knowledge of the penetration depth of the laser light within the tissue should be considered during incision. When a glass fiber of 300 μm in diameter is applied, a continuous contact with the tissue should be avoided in order to provide possible cooling of the tissue (thermal relaxation effect).

During the surgical procedure with the laser, surgical forceps should hold the soft tissue tumor, which is excised from the base with the laser glass fiber. The blood‐free surgical area permits an optically accessible treating of the tissue, whereas carbonization is not so pronounced in comparison to irradiation with the CO₂ laser. Suturing is not necessary, and a soft/liquid diet is recommended for the first two to three postoperative days to avoid removal of the superficial wound layer. Local tissue irritation, as for example by a toothbrush, should be avoided particularly during the first three days (stage of a fibrin layer deposition), so that postoperative bleeding, associated with pain and wound healing problems, is avoided. For preventive antibacterial purposes, rinsing with chlorhexidine or other mouth rinses is advised.

Depending on the clinical indication of laser use, different parameters and power settings are recommended by the manufacturers. Clinical experience shows that a power up to 3.0 W (for the Nd:YAG laser) is good enough for use in private practice. The pulse frequency may vary between 40 and 100 Hz. High power settings or slow movement of the glass fiber under irradiation may lead to wound healing complications resulting in scar tissue formation or necrosis (Figure 3.8).

When the CO₂ laser is used, a continuous beam or pulsed mode with short pulse duration and high‐pulse energy is recommended. During excisions, the handpiece is applied without tissue contact, with an average output power of 4–6 W. There is a variety of ceramic or metal tips with different diameters (e.g. 0.4 or 0.8 mm), which can be used in the handpiece for small focal spots in order to create precise incisions and excellent coagulation.

Photos depict coagulation of the blood vessel tumor in the papilla number 6–7 (a) using a noncontact diode laser (pulsed, 4 W) (b) and after conventional scaling and root planing of the site, a gingivoplasty to create normal tissue morphology (c). — **Figure 3.7** Coagulation of the blood vessel tumor in the papilla #6–7 (a) using a noncontact diode laser (pulsed, 4 W) (b) and after conventional scaling and root planing of the site, a gingivoplasty was performed to create normal tissue morphology (c).

*Source:* Dr. Georgios E Romanos.

Photo depicts scar tissue formation due to the use of high-power diode laser perpendicular to the soft tissue six weeks after laser surgery. — **Figure 3.8** Scar tissue formation due to the use of high‐power diode laser (980 nm) perpendicular to the soft tissue six weeks after laser surgery. The high power and the 90° angle to the soft tissue during excision should be avoided.

*Source:* Dr. Georgios E Romanos.

3.4.2 Surgical Protocol for Removal of Larger Soft Tissue Tumors

The most common larger soft tissue tumors and wide lesions in the oral cavity are fibroepithelial hyperplasia of the palate, and, in general hyperplasia, symmetric fibromas, granulomas, lipomas, hemangiomas, and last but not least adenomas. The removal of vascular lesions and malformations as well as precancerous lesions will be separately dealt within this chapter. Depending on the size of the lesion, a combination therapy of tumor excision with a scalpel and subsequent laser coagulation is sometimes recommended. Large fibromas or symmetrical fibromas can be excised today conventionally, and advanced bleeding can be controlled using the laser.

The CO₂ laser in a continuous mode and with no contact to the tissue is mainly used for the treatment of wide (flat) pathologies of the oral soft tissue causing burning symptoms (e.g. oral lichen planus). A power of 6–10 W permits a quick ablation or vaporization of the pathological tissue when the laser is applied in a defocused mode. A small incision biopsy is necessary before the complete tissue is removed in layers (ablation). The decision of whether vaporization or excision of the lesion is indicated will be taken intraoperatively; however, it depends on the size and thickness of the lesion.

Erythematous pathological alterations localized at the palate (the so‐called fibroepithelial hyperplasia of the palate) is often associated with a poorly fitting prosthesis and secondary Candida superinfection. The tissue can be removed in layers with a CO₂ laser in defocused mode, continuous beam, and a power of approx. 6–10 W. A sample incision biopsy of a clinically suspicious area must be carried out before complete ablation. For a better determination of the depth extension of the lesion, the carbonized tissue is continuously wiped away with wet gauze or cotton swabs. After that, a rinsing with hydrogen peroxide solution (3%) is very helpful. The prosthesis of the patient is then soft relined for the first two to three weeks, and the final relining will be performed at a later time.

Sachs and Borden (1981) were the first who treated such clinical recurrent lesions of the palate using the CO₂ laser without observing any recurrences.

Some clinical applications of the CO₂, diode, and Nd:YAG lasers in surgical treatment of benign soft tissue tumors are demonstrated in the following clinical cases.

Clinical Cases

Clinical Cases Removal of a Fibroma of the Maxilla

The 62‐year‐old patient was referred for removal of a soft tissue tumor in the maxilla in area #8–9 (Figure 3.9a). After local infiltration anesthesia, the tumor was excised with the continuous wave (CW) CO₂ laser, and power of 4 W (Figure 3.9b).

The coagulation during the whole surgical area permitted a good view of the surgical site. Possible charring (carbonization) was removed later using wet gauze (Figure 3.9c). After controlling of the smooth margins, the treatment was finished. The specimen was histologically examined (Figure 3.9d) and confirmed the clinical diagnosis of a fibroma of the oral mucosa. Two weeks after surgery, an excellent healing was observed (Figure 3.9e), and there was no reported postoperative pain.

Figure 3.9 Excision of a soft tissue tumor in the maxilla (a) using a continuous wave (CW) CO₂ laser, and power of 4 W (b). After removal of charring (carbonization) with a wet gauze (c), the histological examination confirmed the clinical diagnosis (d) of a fibroma. The wound was healed completely in two weeks (e).

Source: Dr. Georgios E Romanos.

Removal of an Irritation Fibroma

A 74‐year‐old patient was referred for the removal of a large irritation fibroma before the fabrication of a new complete denture (Figure 3.10a). The tumor was excised under local anesthesia with the noncontact CO₂ laser and a power of 4–5 W (CW). The surgical intervention took place under concurrent coagulation and subsequent carbonization of the entire area (Figure 3.10b). The specimen was histologically examined. The diagnosis was an irritation fibroma in the anterior part of the mandible. The denture could be used immediately after surgery. Five days later, a fibrin deposition covering the entire wound area was observed(Figure 3.10c). Three weeks postoperatively excellent wound healing was observed (Figure 3.10d). Postoperative swelling, pain, bleeding, or contraction of the wound with scar tissue formation were not observed.

Figure 3.10 Removal of a soft tissue tumor in the vestibule of the anterior mandible (a) using a CO₂ laser; (b) providing sufficient coagulation (c); and no postoperative recurrence (d).

Source: Dr. Georgios E Romanos.

Removal of an Irritation Fibroma in Combination with a Local Vestibuloplasty

A 68‐year‐old patient was transferred for the removal of a pedunculus soft tissue tumor (irritation fibroma) in the vestibular fold of the anterior mandible before the treatment of a new full denture (Figure 3.11a). After local anesthesia, the tumor was excised with a power of 4 W (noncontact, continuous CO₂ laser beam). A local extension of the vestibulum depth was performed in this area (secondary intension). The muscle fibers were sharply dissected and separated from the underlying periosteum. The preparation of the tissue occurred without complications, as the blood‐free area allowed a good overview of the surgical site. The handpiece of the laser was used in focus, at a distance of approximately 1 cm from the excised tissue in order to remove the fibroma and, later on, in a defocused mode for adequate coagulation.

The working distance or the focus localization of the laser beam was constantly changed depending on the thickness of the tissue to control the power density so that the periosteum or the underlying bone was not injured. An incorrect application could lead to dehiscence, resorption, or bone necrosis, and possibly other postsurgical complications. The whole surgical area was subsequently superficially coagulated (Figure 3.11b). Four days later, a fibrin layer deposition could be observed (Figure 3.11c). A soft lining of the prosthesis was not necessary. Complications like bleeding, swelling, or pain were not observed. Four weeks after surgery (Figure 3.11d), the clinical condition was unremarkable. A cicatrization or functional difficulties did not occur.

Removal of an Irritation Fibroma in the Mandible

A lingual fibroma (Figure 3.12a) excision was performed with a focused noncontact CO₂ laser and 6 W average power setting (Figure 3.12b) under local anesthesia. The wound was coagulated (defocused beam) in order to reduce the postoperative pain (Figure 3.12c). The specimen (Figure 3.12d) was examined histologically. No postoperative complications were reported. The follow‐up in three weeks presented fibrin formation covering the entire wound area (Figure 3.12e). The healing was uneventful six weeks after therapy (Figure 3.12f).

Figure 3.11 Irritation fibroma in the vestibular fold before the laser surgery (a); laser excision with a noncontact (CW) CO₂ laser and power of 4 W (b); fibrin layer wound coverage was observed four days after surgery (c); excellent wound healing four weeks after surgery (d).

Source: Dr. Georgios E Romanos.

Figure 3.12 Lingual fibroma (a) excised with a focused non‐contact CO₂ laser and 6 W average power (b). The wound was coagulated (defocused beam) to reduce the postoperative pain (c). The specimen (d) was examined histologically. Three weeks postoperatively a fibrin layer covered the wound (e). Uneventful healing was observed six weeks after surgery (f).

Source: Dr. Georgios E Romanos.

Removal of a Fibroma of the Buccal Mucosa

This clinical case presents a 55‐year‐old patient who was transferred with a small fibroma at the buccal mucosa (Figure 3.13a). The tumor was excised under topical anesthesia (xylocaine spray 2%) with the pulsed Nd:YAG laser (Figure 3.13b). The specified parameters were: power 2.0 W and frequency 30 pps (pulses per second). The coagulation was, in spite of the low energy settings, very good. One week later, a fibrin layer was present covering the entire wound surface. Four weeks after surgery, excellent wound healing without scarring could be observed (Figure 3.13c).

Figure 3.13 Fibroma at the buccal mucosa (a) removed with contact pulsed Nd:YAG laser (b). The wound healing completed after four weeks without complications and scar tissue formation (c).

Source: Dr. Georgios E Romanos.

Removal of a Fibroma of the Tongue with an Er:YAG Laser

An excision of a fibroma in the tongue (Figure 3.14a) was performed after local anesthesia using an Er:YAG laser (Figure 3.14b). The glass fiber was used in contact (focused beam) with an average power 2.5 W (250 mJ and 10 Hz). The bleeding was not easy to control (Figure 3.14c) using these parameters, and a suture was performed with absorbable suture material (Figure 3.14d). One week postoperatively the healing was uneventful (Figure 3.14e).

Figure 3.14 Excision of a fibroma in the tongue (a) using an Er:YAG laser (b) in a focused beam with an average power 2.5 W (c). The hemostasis was not adequate due to the strong tissue vascularization and therefore a suture was required (d); one week postoperatively the healing was uneventful without scar tissue formation (e).

Source: Dr. Georgios E Romanos.

Removal of a Fibroma in the Maxillary Alveolar Ridge

A 63‐year‐old female patient presented with a large soft tissue tumor at the alveolar ridge (Figure 3.15a). The tumor was excised with a CO₂ laser (continuous beam; power of 6 W), after local anesthesia (Figure 3.15b). The whole area was finally sufficiently coagulated (Figure 3.15c). Wound healing succeeded with no complications, and a fibrin layer covered the wound one week after surgery (Figure 3.15d).

Removal of a Palatal Adenoma

A 43‐year‐old, hepatitis C–positive patient exhibited a round, approximately 8 × 10 mm wide soft tissue tumor (Figure 3.16a). The tumor had a normal consistency, was not painful at palpation, and showed, according to the patient, a relatively slow growth. The surgical excision occurred with the CO₂ laser to control bleeding because of the high risk of infection. After local anesthesia, the tumor was removed with the noncontact handpiece of the CO₂ laser and a continuous beam (power: 5 W) (Figure 3.16b). A strong coagulation took place during the entire surgical procedure (Figure 3.16c). The surface was finally smoothed with the defocused beam, and the specimen was sent for histopathological examination (Figure 3.16d). Based on the pathology report the diagnosis was an adenoma of the small palatal salivary glands. Oral rinses with 0.12% chlorhexidine di‐gluconate (three to four times daily) were recommended. Wound healing succeeded without any complications.

Figure 3.15 Soft tissue tumor of the alveolar ridge (a); excision with the CO₂ laser (b) and coagulation of the wound (c); fibrin coverage one week after surgery (d).

Source: Dr. Georgios E Romanos.

Removal of Fibroepithelial Palatal Hyperplasia

A 57‐year‐old patient was referred for surgical treatment of a wide lesion at his palate (Figure 3.17a) before fabrication of a new complete denture. After local anesthesia, a biopsy was taken with the CO₂ laser (focused beam) and the lesion was removed in layers with the defocused, continuous handpiece and power of 6 W (ablative mode). Finally, the entire wound area was coagulated (Figure 3.17b). The existing complete denture was soft‐lined immediately after surgery. Further postoperative measures were not necessary. The histopathological examination confirmed the clinical diagnosis. Wound healing succeeded without postoperative pain or bleeding. After one week, a thin fibrin layer was formed and covered the wound (Figure 3.17c), and after three weeks, wound healing was uneventful (Figure 3.17d).

Figure 3.16 Soft tissue tumor in the palate (a). The surgical excision occurred with excellent bleeding control using the CO₂ laser (b, c). The specimen was examined histologically (d).

Source: Dr. Georgios E Romanos.

Figure 3.17 Palatal soft tissue lesion (a); using an ablative mode, the lesion was removed with excellent hemostasis (b); a thin fibrin layer was formed and covered the wound surface after one week (c), and after three weeks the tissue presented a completely healthy condition (d).

Source: Dr. Georgios E Romanos.

Removal of Large Palatal Fibromas

A 52‐year‐old patient was referred by her dentist because of a large fibromatous tissue growth (approx. 4 × 2 cm) in the palatal aspect, respectively to teeth #1–4 (Figure 3.18a). The tumor was excised under local anesthesia with a scalpel due to the large size of the tumor, the bleeding (from the branches of the palatal artery) was controlled by the CO₂ laser (Figure 3.18b, c), and finally a eugenol‐free periodontal pack (Coe‐Pak^®) was placed. The tumor was examined histologically to confirm the clinical diagnosis (Figure 3.18d). The diagnosis was a fibroma. Wound healing succeeded without complications.

Figure 3.18 Excision of soft tissue tumor (a) with a scalpel and a CO₂ laser to control bleeding (b, c) followed by a SRP of the periodontally involved teeth.

Source: Dr. Georgios E Romanos.

Removal of Large Palatal Fibromas

A 67‐year‐old male patient presented for fabrication of a new complete denture in the maxilla. During the clinical examination, asymptomatic, bilateral soft tissue tumors with the clinical diagnosis of symmetric fibromas (Figure 3.19a) were observed. The surgical procedure was performed using the superpulsed CO₂ laser (Figure 3.19b). The patient denied use of any local anesthesia (he was afraid of needles) and confirmed that the surgery was acceptable only with topical anesthesia. The CO₂ laser was applied with 4 W continuous wave (CW) mode for both sites, excising the two fibromas and coagulating at the same time the underlying tissues. An extensive coagulation was achieved after surgery with the defocused ablative handpiece (Figure 3.19c). The two specimens were examined by an oral pathologist, who confirmed the clinical diagnosis. The tissue healed without any complications, and in the first two weeks a fibrin layer covered the entire wound. Six weeks after treatment the tissue was completely healthy (Figure 3.19d), and the next steps were done in order to deliver the final prosthesis.

Figure 3.19 Clinical diagnosis of symmetric fibromas (a). The surgical procedure was performed using the superpulsed 4 W continuous wave CO₂ laser (b). An extensive coagulation was achieved after surgery (c). Six weeks after treatment the tissue was completely healthy (d).

Source: Dr. Georgios E Romanos.

Removal of a Pyogenic Granuloma

A 37‐year‐old patient was referred for diagnosis and treatment of a mucous alteration or rather a tumor of the right side of her lower lip (Figure 3.20a). She reported slight pain, recurring bleeding, and a continuous growth of the tumor during the last two to three weeks. The clinical diagnosis was pyogenic granuloma. The tumor was excised under local anesthesia with the pulsed Nd:YAG laser and power of 6 W, and a histopathological examination took also place (Figure 3.20b, c). The surgical removal occurred mostly without pain and without any postoperative bleeding. Wound healing occurred without complications. The clinical situation after one month revealed a slight scar tissue formation (possibly due to the used relatively high‐power settings), but without any other complications (Figure 3.20d).

Removal of a Fibroma at the Buccal Mucosa Using a Diode Laser

An excision of a fibroma in the buccal mucosa (Figure 3.21a) was performed under topical anesthesia using a diode laser (810 nm) with a 200 μm glass fiber in contact with the soft tissue. The fiber was initiated before surgery using an articulating paper. The tissue was excised completely (average power 2.5 W) for histological examination (Figure 3.21b). The coagulation was sufficient with the same fiber in noncontact, defocused beam (Figure 3.21c). No suture was necessary. Two weeks postoperatively, the healing was uneventful (Figure 3.21d).

Removal of a Fibroma at the Buccal Mucosa Using a CO₂ Laser

An excision of a fibroma in the buccal mucosa (Figure 3.22a) was performed under topical anesthesia using a CO₂ laser with a noncontact focused beam and a ceramic tip at a distance of 3–4 mm from the lesion. The tissue was excised completely (average power 4 W), and the excision line was within the healthy mucosa in order to preserve the complete size of the lesion for a better histological examination (Figure 3.22b). The coagulation was sufficient with the same handpiece in a defocused beam (Figure 3.22c). No suture was mandatory. Three days postoperatively the healing was uneventful, and a layer of thick fibrin covered the wound surface (Figure 3.22d).

Figure 3.20 Pyogenic granuloma of the lower lip (a). The tumor was excised with the pulsed Nd:YAG laser and power of 6 W (b). The specimen was examined histologically (c). Due to tissue overheating, one month postoperatively, a slight scar tissue formation was demonstrated but without any other complications (d).

Source: Dr. Georgios E Romanos.

Figure 3.21 Fibroma in the buccal mucosa (a). The excision was performed using a diode laser (810 nm) with a 200 μm glass fiber and initiated tip in contact with the soft tissue (b). The coagulation was sufficient with the same fiber in noncontact, defocused beam (c). Two weeks postoperatively the healing was uneventful. Slight scar tissue was observed (d).

Source: Dr. Georgios E Romanos.

Figure 3.22 Fibroma of the buccal mucosa (a) excised with a CO₂ laser with a noncontact focused beam at a distance of 3–4 mm from the lesion (b). The coagulation was sufficient with the same handpiece in a defocused beam (c). No suture was mandatory. Three days postoperatively, a thick layer of fibrin covered the entire wound surface (d).

Source: Dr. Georgios E Romanos.

Removal of Hyperplastic Gingiva Underneath Bar Restoration

A 78‐year‐old patient was referred with the request to remove a hyperplastic gingiva underneath the bar restoration in the #22–27 teeth (Figure 3.23a). Because of the presence of the gingival hyperplasia, the oral hygiene of the patient was clearly affected, in such a way that the long‐term prognosis of the abutment teeth #22 and #27 was questionable (very deep periodontal pockets, so‐called pseudo‐pockets were present). The hyperplastic tissues were excised under local anesthesia with the continuous noncontact beam of the CO₂ laser with an average power of 6 W (focused) (Figure 3.23b). After that the margins were smoothed in a defocusing beam. The hemostasis was sufficient, and wound healing was completed without any complications (Figure 3.23c). The surgical site was healed three weeks later, and the plaque control was optimized (Figure 3.23d).

Removal of Hyperplastic Peri‐implant Mucosa Underneath Bar Restoration

The case presented hyperplastic and inflamed mucosa with bleeding on probing around implants underneath a bar implant‐retained restoration (Figure 3.24a). The excision was performed using a CO₂ laser and defocused beam in a continuous mode and 4–5 W average power setting. In addition, a partial vestibuloplasty was performed to improve the vestibule depth for better plaque control (Figure 3.24b). An excellent coagulation was achieved using this laser wavelength. Painkillers (Tylenol^®) and antibiotics (Penicillin V®) were prescribed postoperatively (3x/die). After one week of healing (Figure 3.24c), a fibrin layer covered the entire wound surface. No swelling or other complications were observed. The tissue condition was evaluated after 1.5 months, and the prosthesis was relined permanently in order to improve the soft tissue quality (Figure 3.24d). The patient’s oral hygiene was optimized after the procedure using interdental brushes underneath the bar restoration (Figure 3.24e).

Figure 3.23 Surgical excision of the hyperplastic gingiva underneath the bar restoration (a) using a CO₂ laser with an average power of 6 W and focused beam (b); a good hemostasis (c) and an excellent wound healing was observed after three weeks (d).

Source: Dr. Georgios E Romanos.

Figure 3.24 Hyperplastic and inflamed peri‐implant mucosa with bleeding on probing around implants underneath a bar implant‐supported restoration (a). The excision was performed using a CO₂ laser and defocused beam (CW) and 4–5 W average power (b). A partial vestibuloplasty was performed to improve the depth of the vestibule for better plaque control. An excellent coagulation was achieved using this laser wavelength. After one week of healing (c), a fibrin layer covered the entire wound. The tissue condition was evaluated after 1.5 months, and the prosthesis was relined permanently (d). Plaque control was optimized using interdental brushes (e) (Surgery: Drs. G. Romanos and B. Katz, Stony Brook, NY).

Source: Dr. Georgios E Romanos.

Removal of an Ossifying Fibroma Using a CO₂ Laser

A soft tissue tumor was present for almost two years according to the dental history of the patient (Figure 3.25a, b). The size of the lesion was 21 × 23 mm and was expanded in the palatal aspect as well (Figure 3.25c). Radiographical evaluation demonstrated a periodontal crestal bone loss as well as mineralized, calcified areas within the soft tissue tumor (Figure 3.25d). The excision was performed using the CO₂ laser under local anesthesia and an average power setting of 6 W in a continuous, noncontact handpiece and a focused mode (Figure 3.25e). During the entire surgical procedure, a hemostat was holding the tumor in order to visualize the underlying tissues during laser irradiation (Figure 3.25f). After excision a sufficient hemostasis was accomplished with the CO₂ laser in a defocused beam. In addition, irregularities of the tissue morphology, such as extensive frenulum and thick mucosa, were excised with the CO₂ laser in an ablative mode (Figure 3.25g). Sufficient coagulation was achieved in order to avoid postoperative bleeding (Figure 3.25h). The specimen (Figure 3.25i) was examined by an oral pathologist, who confirmed the diagnosis of the lesion. It was an ossifying fibroma. A follow‐up of the case was not possible since the patient moved elsewhere.

Figure 3.25 Clinical and radiographical examination of a patient with an ossifying fibroma of the gingiva (a–d). The excision was performed using the CO₂ laser under local anesthesia and an average power setting of 6 W in a continuous, noncontact handpiece and a focused mode (e, f). Sufficient bleeding control was accomplished with the CO₂ laser in a defocused beam. Irregularities of the tissue morphology, such as extensive frenum and thick mucosa, were excised with the CO₂ laser. Sufficient hemostasis was achieved in order to avoid postoperative bleeding (g). The specimen was examined by a maxillofacial pathologist, who confirmed the diagnosis of the lesion as an ossifying fibroma (h).

Source: Dr. Georgios E Romanos.

Removal of an Ossifying Fibroma Using a Diode Laser

The soft tissue tumor of a female 25‐year‐old patient was present for almost three years in the same area (#8) and was associated with some bleeding (Figure 3.26a). The tumor was excised under local anesthesia and the use of a 980 nm diode laser (Figure 3.26b) with the glass fiber in contact with the lesion. The average power was 4 W (CW) with initiated handpiece. The surgical site was coagulated, and the margins of the defect were smoothed using the noncontact defocused beam and the same power. A conventional scaling and meticulous root planing were also performed (Figure 3.26c). The final result after six weeks presented excellent healing without recurrence (Figure 3.26d).

Removal of a Papilloma of the Lip

A soft tissue tumor of the lip (Figure 3.27a) was removed using an 810 nm diode laser (initiated tip) with contact handpiece and average power of 2 W (Figure 3.27b). The excision and coagulation were performed without complications (Figure 3.27c), and a suture was not necessary. The histopathological examination confirmed the diagnosis of a papilloma.

Figure 3.26 Soft tissue tumor of the gingiva associated with some bleeding (a). The tumor was excised under local anesthesia using a 980 nm diode laser (b) and glass fiber in contact with the lesion (average power: 4 W/CW/initiated tip). The surgical site was coagulated, and the margins of the defect were smoothed using the noncontact defocused beam and the same power (c). The final result after six weeks presented excellent healing without recurrence (d).

Source: Dr. Georgios E Romanos.

Removal of a Papilloma of the Lip

A 23‐year‐old female patient came with the request of the removal of a small tumor of her upper lip (Figure 3.28a). According to the medical history, the lesion was asymptomatic and existed for approximately three months. The clinical examination revealed a round lens‐size and relatively hard superficial tumor with a wide base. It was excised, after local anesthesia, with the Nd:YAG laser. A contact fiber with a diameter of 300 μm, a power of 3 W, and a frequency of 30 pps was used for the excision (Figure 3.28b). Wound healing proceeded without complications (Figure 3.28c). The clinical result remained stable and showed six months later no esthetic complications (Figure 3.28d).

Figure 3.27 Soft tissue tumor of the lip (a) removed using an 810 nm diode laser with contact handpiece and average power of 2 W and initiated tip (b). Excision and coagulation performed without complications (c).

Source: Dr. Georgios E Romanos.

Removal of a Lipoma in the Buccal Mucosa

The buccal mucosa of a male patient demonstrated a soft tissue tumor without symptoms but with hard consistency and slight yellow color (Figure 3.29a). The excision was performed with the CO₂ laser under local anesthesia (Figure 3.29b) and a power of 4 W in a CW mode. The coagulation was excellent. The specimen (Figure 3.29c) was examined by an oral pathologist to confirm the diagnosis. This was a lipoma of the buccal mucosa. The healing was performed by secondary intension, and fibrin covered the entire surgical area for the first two weeks (Figure 3.29d). No complications were found after three months of healing. A small scar was present but without any other clinical findings (Figure 3.29e).

Removal of a Lipoma of the Tongue

A 63‐year old male patient presented with unusual swelling of his tongue (Figure 3.30a). The lesion had been there for many years according to the medical history, completely asymptomatic except sometimes in the last few weeks slight hypesthesia at the left tongue side. The motoric condition of the tongue was completely normal. Clinical examination showed a relatively round and hard lesion directly underneath the mucosa of the tongue. The patient was informed about the possible postoperative complications. Under local anesthesia, the CO₂ laser with a continuous wave mode and 6 W power setting was used in order to prepare and remove the lesion (Figure 3.30b). During the procedure, a round tumor was removed without bleeding but with an excellent dissection using the noncontact handpiece and a ceramic tip (Figure 3.30c). The tumor size was approximately 30 × 28 mm and was sent for histopathological examination (Figure 3.30d). The normal healthy mucosa covering the tumor was preserved, and after surgery was secured in place with 3‐0 silk suture material. A complete closure of the wound was not intended due to the presence of a carbonized layer on the wound surface, which had to be exposed in a later stage (Figure 3.30e). The patient followed up after one week for suture removal. After five weeks, he presented excellent wound healing without complications or sensation complaints. The diagnosis was confirmed as a lipoma of the tongue (Figure 3.30f).

Figure 3.28 Small tumor of the upper lip (a). An Nd:YAG laser with contact fiber and diameter of 300 μm, power of 3 W, and frequency of 30 pps (b) was used for the excision. Wound healing completed without complications and scar tissue formation (c). The clinical result remained stable and presented six months later with no esthetic complications (d).

Source: Dr. Georgios E Romanos.

Removal of a Giant Cell Granuloma of the Gingiva

A soft tissue tumor of the gingiva with signs of inflammation was present for almost one year but in the last three months showed progressive growth (Figure 3.31a). For that reason, the patient came for consultation and further treatment. We examined clinically and radiographically the lesion, and we decided to excise the tumor under local anesthesia using an Nd:YAG laser and power of 4 W, in a pulsed mode with 100 Hz frequency in order to provide sufficient coagulation during surgery (Figure 3.31b). The tumor was excised completely buccally and palatal, and a meticulous scaling and root planing was performed in order to plan the root sufficiently (Figure 3.31c). The interdental defect at #6–7 was coagulated using the noncontact fiber of the Nd:YAG laser (Figure 3.31d). The specimen (Figure 3.31e) was examined by an oral pathologist who confirmed the diagnosis of a giant cell granuloma (Figure 3.31f). The tissue presented delayed wound healing in the first two weeks with a fibrin layer covering the entire excision area (Figure 3.31g). Three months after surgery the tissue presented no further signs of inflammation (Figure 3.31h). The black triangle was present due to the absence of marginal bone due to the tumor infiltration. Further follow‐ups were not possible since the patient relocated, but the patient was informed about possible recurrence risks.

Figure 3.29 Soft tissue tumor of the buccal mucosa without symptoms (a). The excision was performed with the continuous wave CO₂ laser (b) and a power of 4 W providing excellent coagulation. The specimen (c) was examined histologically. The healing was performed by secondary intension. Fibrin covered the entire surgical area within the first two weeks (d). No complications but slight scar tissue formation was found after three months of healing (e).

Source: Dr. Georgios E Romanos.

Figure 3.30 Soft tissue asymptomatic tumor of the tongue (a). Clinical examination showed a relatively round and hard lesion directly underneath the mucosa of the tongue. The patient was informed about the possible postoperative complications and the tumor was excised (b) with the CO₂ laser (continuous wave mode, 6 W power). An excellent preparation of the tumor and separation from the surrounding tissues (c) was possible. The tumor was sent for histological examination (d). The mucosa was sutured with 3‐0 silk (e). Follow‐up after five weeks presented excellent wound healing and no signs of complication or further sensation complaints (f).

Source: Dr. Georgios E Romanos.

Figure 3.31 Soft tissue tumor of the gingiva (a); excision of the tumor using an Nd:YAG laser and power of 4 W, in a pulsed mode of 100 Hz frequency in order to provide sufficient hemostasis during surgery (b). The tumor was excised completely buccally and palatal and a meticulous scaling and root planing was performed (c). The interdental defect at #6–7 was sufficiently coagulated (d). The specimen (e) was examined by an oral pathologist who confirmed the diagnosis of a giant cell granuloma (f). Delayed wound healing was presented in the first two weeks (g). Three months after surgery the tissue presented no further signs of inflammation (h).

Source: Dr. Georgios E Romanos.

Removal of an Adenoma of the Sublingual Salivary Gland

A 73‐year‐old male patient presented a soft tissue tumor in the mouth floor causing a disturbance in the secretory function of the right sublingual salivary gland. A sialolith was not demonstrated radiographically. According to the clinical findings, the clinical diagnosis was adenoma of the sublingual salivary gland (Figure 3.32a). Demonstration of the duct was performed initially with a dull needle (Figure 3.32b), and later on during the tumor preparation a plastic tube was inserted into the duct to demonstrate the duct orientation. The tumor was excised with the contact mode handpiece and at a power setting of 8–10 W (continuous wave) of a 980 nm diode laser because of the large tumor size (approximately 3 × 2 cm); finally the salivary gland was removed (Figure 3.32c). The hemostasis as well as the incision quality was excellent using this power (Figure 3.32d). The margins of the wound were sutured with Vicryl^® suturing material. Postoperative medication with a wide spectrum of antibiotics (penicillin 3x/day) and painkillers was recommended. Postoperatively, no bleeding was observed. Only minor swelling was observed in the first three days (Figure 3.32e, f). The specimen (Figure 3.32g) was examined by an oral pathologist, who confirmed the diagnosis of an adenoma. The tissue was covered by fibrin during the first 10 days of healing. Six weeks after surgery there was complete healing without scar tissue formation or sensory/functional disturbances (Figure 3.32h).

Figure 3.32 Soft tissue tumor in the mouth floor (a); a sialolith was not demonstrated radiographically. Demonstration of the duct with a dull needle (b); the tumor was excised in toto with the contact mode handpiece and at a power setting of 8–10 W (continuous wave) of a 980 nm diode laser (c, d); suturing of the wound margins with Vicryl absorbable material (e); the specimen (f) was examined histologically; Fibrin layer covers the wound (g); six weeks after surgery complete healing without scar tissue formation or sensory/functional disturbances was observed (h).

Source: Dr. Georgios E Romanos.

3.5 Removal of Drug‐Induced Gingival Hyperplasias and Epulides

3.5.1 Removal of Drug‐Induced Gingival Hyperplasias

A gingival hyperplasia can be caused by systemic treatment with diphenylhydantoin‐containing drugs (e.g. for epilepsy), cyclosporine‐A (for immunosuppression after organ transplantations), calcium antagonists (for control of hypertension), and in particular nifedipine, but also diltiazem and amlodipine. A possible cause is the dysfunctional collagen degradation as a result of a limited functional ability of the fibroblasts (Scully et al. 1996).

The gingival hyperplasia has, as a result, difficulties in plaque control and, if combined with insufficient oral hygiene, can lead to inflammatory reactions and further bone loss. The therapy of choice is the removal of the hyperplastic tissues. This is possible, according to the size of the hyperplasias, either with the CO₂ laser (Pick et al. 1985) alone, or in combination with Kirkland and Orban gingivectomy knives.

Initially, a measurement of the probing pocket depth with the Kaplan marking forceps allows determining the incision line. Two to three millimeters submarginal of this line, the incision will be initiated with the laser (see Figure in chapter 5) in the focused mode. Because of the strong carbonization and the resulting hemostasis, the incision line is usually visible. For small‐sized hyperplasias, the power of 4–6 W (CO₂ laser beam, CW) is sufficient for excellent cutting and coagulation. At the same time, the antimicrobial effect of the laser beam leads to a distinctive bacteria reduction in the entire surgical field (Pick et al. 1985; Pick 1993). For more extensive gingival hyperplasias, the excision is carried out in combination with conventional gingivectomy knives, in order to shorten the surgical procedure.

To protect the tooth surfaces, it is recommended (Neiburger and Miserendino 1988; Sievers et al. 1993) that metal matrix or special flat instruments (e.g. spatula, gingivectomy knives) be used, which can be placed within the periodontal pockets during excision. In order to control the potential risk of overheating due to the reflection of the laser beam from the metallic surfaces, other options have been recommended. Since the CO₂ laser beam is highly absorbed by wet surfaces, the use of a glycerin solution (or Vaseline®) over the tooth surface for further protection of the surrounding structures is strongly recommended.

After gingivectomy, the patients can be followed up in a strict recall program only when gingivoplasties can be successfully carried out with the help of a defocused laser beam, especially for medically compromised patients. The final hemostasis of the entire surgical area controls the bleeding and postoperative discomfort. The use of a periodontal pack (e.g. Coe‐Pak, Peripak®) is not actually required. After approximately one week, new capillaries and blood vessels are formed. Two weeks after surgery wound healing is usually completed. If the medication can be substituted by another drug, no recurrences are expected. If a substitution is not possible, the regular application of the laser is of importance especially during whole periodontal maintenance appointments. From the clinical experience, three‐ to four‐month intervals are recommended, where only topical anesthesia small, localized gingivectomies or gingivoplasties can be carried out.

3.5.2 Removal of Epulides

A frequent application of laser is performed for surgical removal of gingival epulides. As with the external gingivectomy, these lesions of the oral cavity can also be excised with the focused laser beam of CO₂, Nd:YAG, diode, or the Er:YAG laser. At the moment, there are no longitudinal studies to determine the long‐term results after the removal of such tumors with different laser systems. The frequent recurrence after the removal of an epulis, without radical osteotomy of the adjacent bone and the extraction of the affected tooth, is given in the literature as between 5 and 70.6% (Giansanti and Waldron 1969; Eversole and Rovin 1972; Anderson et al. 1973; Benkert et al. 1982; Lee et al. 1986; Macleod and Soames 1987; Katsikeris et al. 1988; Mighell et al. 1995). A study of Gaspar and Szabo (1991) reported a recurrence rate of about only 7.9% after five years, if after the tumor excision with the CO₂ ‐laser, an additional bone curettage and osseous decortication is carried out (Gaspar and Szabo 1991).

Tags: Advanced Laser Surgery in Dentistry

Nov 13, 2022 | Posted by mrzezo in General Dentistry | Comments Off

Pocket Dentistry

Fastest Clinical Dentistry Insight Engine

in Oral Surgery

3
Lasers in Oral Surgery

3.1 Introduction

3.2 Basic Principles

3.3 Excision Biopsies

3.4 Removal of Benign Soft Tissue Tumors

3.4.1 Surgical Protocol for Removal of Small Tumors

3.4.2 Surgical Protocol for Removal of Larger Soft Tissue Tumors

3.5 Removal of Drug‐Induced Gingival Hyperplasias and Epulides

3.5.1 Removal of Drug‐Induced Gingival Hyperplasias

3.5.2 Removal of Epulides

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