|Year : 2015 | Volume
| Issue : 1 | Page : 38-43
Comparing the impact of using erbium yttrium aluminum Garnett laser or conventional scalpels and burs for the surgical removal of partially erupted mandibular third molars on pain, swelling, trismus, and anxiety
Erol Kucukkeles, Bahar Gursoy
Department of Oral and Maxillofacial Surgery, Institute of Health Sciences, Marmara University, Istanbul, Turkey
|Date of Web Publication||22-May-2015|
Kardelen Evleri E Blok K: 4 D: 9, Levazim Mahallesi Muhtarligi, Birlik Sokak, Istanbul
Source of Support: None, Conflict of Interest: None
Aim: Standard method of extraction of partially impacted lower third molars is with a scalpel, and a drill. The aim of this study is to use Er:YAG laser for partially impacted lower third molar removal, and compare anxiety, pain, swelling, and trismus observed after the procedure, with the standard method. Materials and Method: The study was performed on 40 patients who applied to our clinic for the extraction of their partially impacted lower third molars. None of the patients included in the study had any systemic illnesses, and had an age range of 18-40. The patients were divided into 2 groups of 20, and the first group had their procedures done with the Er:YAG laser whereas the second group had their procedures done with scalpels and burs. All the patients filled out the STAI survey preoperatively. In addition, measurements of distances between reference points on the face, and maximum mouth opening were recorded from all patients preoperatively. The patients filled out visual analogue scales every 2 hours for the first 12 hours and then at the 24th hour. All the measurements were repeated when the patients came for suture removal, and then these values were compared with the preoperative values. Results: Laser group had less swelling and trismus compared with the control group, and the difference was statistically significant. Pain values of the laser group were lower when compared with the control group, the difference was not statistically significant. There was no statistical difference of the anxiety levels.
Keywords: Er:YAG, laser, swelling, third molar, anxiety
|How to cite this article:|
Kucukkeles E, Gursoy B. Comparing the impact of using erbium yttrium aluminum Garnett laser or conventional scalpels and burs for the surgical removal of partially erupted mandibular third molars on pain, swelling, trismus, and anxiety. J Dent Lasers 2015;9:38-43
|How to cite this URL:|
Kucukkeles E, Gursoy B. Comparing the impact of using erbium yttrium aluminum Garnett laser or conventional scalpels and burs for the surgical removal of partially erupted mandibular third molars on pain, swelling, trismus, and anxiety. J Dent Lasers [serial online] 2015 [cited 2020 Sep 20];9:38-43. Available from: http://www.jdentlasers.org/text.asp?2015/9/1/38/157598
| Introduction|| |
Over the last 20 years, laser devices have been widely used in many different branches of surgery such as Dermatology, General Surgery, Ophthalmology, Otorhinolaryngology, Plastic Surgery, etc. In oral and maxillofacial surgery, lasers have been mostly utilized for soft tissue surgery and not for dental or osseous surgery. In the 1980's, ruby and CO2 lasers were used to cut dental hard tissues and bone, but the studies demonstrated that these lasers were not suitable for the cutting of these tissues. Histological examination of the specimens obtained using these lasers showed some seriously adverse biological effects which can be listed as; serious thermal damage, severe carbonization and delayed bone healing. , Since then, the development of solid-state, short-pulsed, infrared laser systems have made it possible for these hard tissues to be cut by laser without these devastating consequences.
Erbium-yttrium aluminum Garnett (Er: YAG) laser is a solid-state (Er: Y3 Al 5 O 12 ) laser with a working wavelength of 2940 nm, which is an infrared wavelength. This wavelength matches the absorption peak of water,  and the hydroxyapatite crystals in both dental hard tissues and bone can also absorb it. This enables the Er: YAG laser to efficiently cut dental hard tissues as well as bone to a superficial level of a few micrometers. 
The aim of our study was to compare the postoperative complications (edema, trismus, pain) and preoperative anxiety between using Er: YAG laser for the incision and bone cutting, and using conventional scalpels and tungsten burs mounted on a hand piece during the surgical removal of partially impacted mandibular third molars.
| Materials and Methods|| |
This prospective study was conducted in a total of 40 healthy male and female patients with partially impacted mandibular third molars who came to the Department of Oral and Maxillofacial Surgery in the Marmara University Faculty of Dentistry. The patients were chosen to participate in the study regardless of their gender, socioeconomic status or race. Exclusion criteria included; anti-coagulant usage, immunosuppression, systemic or local osseous diseases, radiotherapy, systemic disease (metabolic or otherwise), pregnant and lactating mothers. In addition, all the patients had the same type (vertical) and depth of impaction that were all class 2, position B according to Pell-Gregory classification.
Informed consent was obtained from all the patients, and the study was thoroughly explained. Detailed histories were taken from all the patients, and they were all subjected to routine clinical and radiographic examinations. It was made sure that all the patients had the same type of impaction so the surgical procedure was as standardized as possible to make sure that the comparative results would be reliable.
The patients were randomized into two equal groups of 20 (group 1: Scalpel and bur, group 2: Er: YAG laser) who had their partially impacted mandibular third molars surgically removed using scalpels and tungsten burs mounted on a hand piece or with the Er: YAG laser (Fidelis PlusII, Fotona, Ljubljana, Slovenia) using standard operative methods for the surgical removal of impacted teeth. All the operations were done under local anesthesia, the envelope flap was used in all the patients, and the lingual nerve was protected. In group 1; mucoperiosteal flap was elevated following an incision (retromolar, sulcular on no. 8, and 7) performed by a regular no. 15 scalpel, and then bone was removed on the buccal and distal-occlusal surfaces with a tungsten surgical round bur (#6) using ample irrigation with normal saline. In group 2, mucoperiosteal flap was elevated following an incision performed by the Er: YAG laser's (retromolar, sulcular on no. 8, and 7) R-14 contact mode hand piece with these parameters: 150 mJ, 20 Hz in long pulse mode without any irrigation. Following flap elevation, the parameters were changed to 350 mJ, 20 Hz in super short pulse mode with ample irrigation with sterile water for the removal of bone, and if necessary the sectioning of the tooth. The R-14 hand piece was used for both the incision and the cutting of bone and tooth, which was used in a contact mode. Both the surgical team and the patients all wore protective glasses throughout all the laser procedures. The laser tip was used in a contact mode meaning the crystal tip was in contact with the tissues during all cutting procedures. Same method of extraction was used in this group as well, meaning a trough was created on the buccal side and the tooth was delivered via an elevator that was placed in the trough taking care of the curvature of the roots (4 of the cases required sectioning in the Er: YAG group, 2 required sectioning in the bur group). The remaining sockets were curetted to remove all granulation tissue and follicles, all sharp bony margins reduced following which the socket was inspected for any remaining fragments then irrigated with normal saline, and the flap was closed with 4-0 silk sutures using interrupted sutures.
Clinical parameters such as pain, postoperative swelling, and trismus were recorded for both groups. All patients were given visual analog scales right after surgery to give a score ranging from 0 (no pain) to 10 (the maximum possible amount of pain) every 2 h for the first 12 h, and finally give a final score on the 24 th h. They were told to mark the times when they took any pain medication so it could be taken into evaluation as well. All the patients brought their filled out forms at the appointment for suture removal, any patients that failed to bring his/her form were excluded from the study.
In addition, all the patients filled state-trait anxiety inventories (STAI) survey right before surgery following a brief explanation of the differences of the Er: YAG laser from the conventional scalpel and metallic burs. These surveys were used to compare and evaluate the difference of anxiety between the two groups.
Objective assessment of postoperative swelling was done by measuring the linear distance between corner of mouth, and the center of tragus of ear and angle of mandible (gonion) and the lateral canthus of eye pre and postoperatively (day 3) to quantify facial swelling which did not include lingual swelling. , Trismus was assessed by measuring the distance between the upper and lower central incisors incisal edges in maximum mouth opening [Figure 1] [Figure 2] [Figure 3].
|Figure 2: Lateral canthus of eye-mandibular angle distance measurement for swelling|
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|Figure 3: Measurement of interincisal distance for trismus in maximum mouth opening|
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All patients were required to fill out the STAI surveys given to them right before the operation. These surveys were used to assess patients anxiety levels right after the difference of the Er: YAG laser from scalpel and bur was explained to them.
| Results|| |
All the procedures were done with no serious or persistent complications such as dry socket, pus discharge, and change in color of mucosa, incessant pain and swelling, altered sensation (hyperesthesia, paresthesia, anesthesia), lymphadenopathy, etc. We used the contact mode hand piece in our study, which limited the application of the laser beam from some angles; unrestricted cutting patterns were not possible. The laser beam did not damage surrounding tissues.
Group 1 (scalpel and bur) had 8 females (%40), and 12 males (%60) and group 2 (Er: YAG laser) had 15 males (%75), and 5 females (%25). All the patients had the same type, and depth of impaction, which was class 2 positions B according to the Pell-Gregory classification, and all of them had vertical inclination.
Statistical analysis of the comparison of the pain and anxiety values of both groups showed no significant difference. However, patients in the laser group were a lot more comfortable intra and postoperatively compared to the bur group. The patients in the bur group complained of the noise and vibration. Some of the patients in the laser group had previous impacted tooth extractions done with burs and stated that the Er: YAG laser was a much better alternative in terms of patient comfort. Some patients in the laser group were anxious of the sound of the Er: YAG laser (a repetitive snapping sound), and more than that the presence of smoke and the burnt tissue smell caused them some discomfort. The pain values in the laser group were lower, but the sample size was too small to create a statistically significant difference. Objective measurements for swelling and mouth opening were taken preoperatively and 3 days postoperatively. Comparison of the swelling and mouth opening values among the groups showed a statistically significant difference favoring the laser group [Table 1], [Graph 1].
|Table 1: The statistically significant differences between groups for swelling and trismus |
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| Discussion|| |
The usage for any laser's light can be determined by its wavelength. The Er: YAG laser's clinical effects differ from that of CO2, Nd: YAG and Ho: YAG lasers.  The CO2 laser emits infrared radiation that is mostly absorbed by water, and so is a very effective cutting tool when working on soft tissues. However, there's almost no water in bone tissue, therefore the CO2 laser is not absorbed by the tissues, so it just causes the temperature to rise immensely (up to almost 1000°C) which can have some severely adverse effects such as carbonization, and delayed bone healing.  Buchet et al. studied the differences of Er: YAG laser and Ho: YAG laser osteotomies in the tibias of rats.  Ho: YAG group showed pseudoarthrosis whereas Er: YAG laser group showed minimal thermal changes and normal healing. Another study demonstrated that healing was similar both with Er: YAG laser and mechanical bur osteotomies. 
Bone tissue is composed of two main parts, an organic matrix, and inorganic minerals. The organic matrix in adults is mostly comprised of about %95 collagen, and the inorganic elements are mostly made up from hydroxyapatite crystals. There's very little water in bone tissue for the Er: YAG laser beam to be absorbed by, however all the main components of bone tissue are very absorbent of infrared irradiation within a range of wavelength 2.9-3.3 µm, which includes the wavelength of Er: YAG (2.94 µm). All of this makes Er: YAG laser a promising, and efficient cutting tool for dental hard tissues as well as bone.
All oral and maxillofacial surgical procedures include some kind of osteotomy stage, with the exception of strictly soft tissue operations. For 100's of years, mostly saws and mechanical drills have been used for bone cutting. Despite the advancements in their technology, metallic cutting instruments still have been reported to cause deposition of debris, vibration,  heating,  noise, and discomfort. Nowadays, the development of lasers have put them in demand due to their obvious advantages such as sterilization of the surgical field while cutting tissues, simultaneous hemostasis of small vessels resulting in significantly decreased bleeding, reduced postoperative pain, swelling, and scarring.  Another advantage; the wounds produced by lasers demonstrate better, and quicker healing because of the fact that blades and mechanical drills cause wide-spread damage to the cells surrounding or adjacent to the wound whereas these cells remain undamaged and healthy when the wounds are produced with lasers.
One of the most life quality reducing complications following the removal of impacted teeth is pain. Our study revealed reduced postoperative pain in laser treated patients, but the difference was not statistically significant. Abu-Serriah et al., and Romeo et al., have reported similar results in their studies as well. , The reason for reduced pain in laser treated patients can be theorized as the disruption of nerve terminals in osseous tissues and degeneration of nerve endings. In addition, the vibration caused by burs is almost 100 times higher than that caused by the Er: YAG laser.  This higher frequency of vibration's spectrum is very close to the peak sensitivity of hearing which acts as a potential cause of discomfort and pain sensation.
Another life quality altering the consequence of impacted third molar removal is postoperative swelling which, when occurs in significant amounts, can even affect the level of pain, mouth opening, and rate of wound healing. Our study showed that the postoperative swelling observed in the bur group was significantly greater when compared with the Er: YAG laser group. Abu-Serriah et al., and Romeo et al., have reported similar results with their studies, which investigated the effects of using Er: YAG laser only for bone removal and tooth sectioning. , It's also been reported that laser irradiation causes dilation of vessels while decreasing their permeability, and increases the absorption of proteins by activating macrophages, regulating hydrostatic and capillary pressure, and stimulating the absorption of interstitial fluids which consequently results in a reduction of swelling. ,
In our study, the mouth opening values of the laser group were greater than those of the bur group postoperatively meaning that the trismus observed with the bur group was greater. Statistical analysis revealed that the difference was significant favoring the laser group. These results are similar with some studies in the literature and contradictory to the rest. For example, Abu-Serriah et al., and Passi et al,. found that the trismus was greater in the laser group and persisted for a longer duration of time. , However, Romeo et al., reported that the Er: YAG laser group presented with lesser trismus values compared to the bur group and the difference was statistically significant.  The extent of trismus is usually dependent on the severity of the procedure, amount of tissue destruction, duration of operation, amount of manipulation of the flap with the retractor, and etc. We believe the difference between the groups' trismus values may arise from the fact that in our study Er: YAG laser was also used for incision in addition to bone removal and tooth sectioning (no other study in the literature similar to ours ever used Er: YAG for incision in addition to bone removal/tooth sectioning). Doing the incision with the Er: YAG laser allowed the operator to reflect the flap without cutting any muscular tissue (only the mucosa was incised in the retromolar incision in the laser group) whereas this proved more difficult with the scalpel and in some patients the buccinator had to be cut to allow flap reflection. Even though the buccinator isn't a masticatory muscle, the inflammatory response that is produced from its dissection may have been the reason for greater restriction of mouth opening in the scalpel/bur group. Another reason may have been the fact that the operating times were fairly short in both groups because the impactions were not very deep, and there wasn't a lot of bony retention in either group.
Almost all patients around the world are anxious about the surgical removal of their impacted third molars. This has almost become an urban legend in most countries among the population. This has been a big problem for the oral and maxillofacial surgeons whose most common procedure is the surgical removal of impacted third molars for many years. In our study, we wanted to evaluate the anxiety and stress of the patients preoperatively after explaining the advantages of the Er: YAG laser. The patients in the scalpel/bur group were not informed about the availability of the Er: YAG laser. Most patients were open to the idea of trying this new device for the extraction of their impacted mandibular third molar following the explanation of its advantages over the conventional blades and mechanical drills. However, some patients were scared of the term "laser," and decided to leave the clinic once they discovered their extraction was going to be done with the Er: YAG laser. All the patients filled out STAI survey preoperatively, and the results of these surveys were analyzed statistically. The results showed no significant differences between the groups, but the patients in the Er: YAG laser group were much more comfortable during the operation as well as the healing period compared to those in the scalpel and bur group. Almost all the other studies in the literature have similar results to ours in this aspect. Abu-Serriah et al. Passi et al. Romeo et al., all reported that the patients in the laser groups were a lot more satisfied with the ease of the procedure compared to the patients in the bur group. ,,
| Conclusion|| |
In our study, we compared the removal of partially impacted vertically inclined mandibular third molars using scalpels and burs and Er: YAG laser for incision and bone removal/tooth sectioning. Our study demonstrated that the Er: YAG laser allows precise osteotomies with decreased postoperative pain, swelling, and trismus.
The only disadvantages of the Er: YAG laser we encountered were; lack of tactile sensitivity, restriction of angling the laser beam, difficult safety measures and high-cost factor. In addition, using water spray during bone removal and tooth sectioning with the laser caused a significant amount of blood spatter. There may be some risk of creating an air embolism in the tissue, due to the air-induced water spray.
As a result, we can conclude that the possibility of using Er: YAG lasers instead of both scalpels and mechanical drills is feasible. The Er: YAG laser can be considered as an alternative tool to the scalpels and surgical burs in patients with moderately easy impactions. However, we recommend that the Er: YAG laser not be used for difficult impactions, and mostly for partial impactions or small bony retentions.
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[Figure 1], [Figure 2], [Figure 3]