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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 50-68

Comparative study of diode laser 940 nm in performing frenectomy in both: Continuous and pulsed modes: An in vivo study


AL-Ramadi and Duhok Specialized Dental Center, College of Dentistry, Baghdad University, Baghdad, Iraq

Date of Web Publication26-Nov-2015

Correspondence Address:
Aws A Al-Khatib
College of Dentistry, Baghdad University, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.158461

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  Abstract 

The Objectives of this Study: The objective of the study was to evaluate the efficiency of diode laser 940 nm in both, continuous and pulsed modes. Then compare the outcomes of frenectomy procedure, and find the best mode that satisfies the patient's and the surgeon's criteria. Materials and Methods: This study was carried out on 14 patients of which 7 were males and 7 were females with age range from 7 to 46 years. Patients underwent diode laser-assisted frenectomy in continuous wave (CW) mode with power ranging from 1.5–3 W and pulsed mode, which was subdivided into comfort pulse 0 (CP0) with 6–10 W peak power; 1.2–2 W average power and CP2with 2–10 W peak power; 1–5 W average power. Anesthesia method and need, the duration of surgery and intraoperative bleeding events were recorded in all cases. In addition, patient preoperative fear, perception and comments were reported. Ratings of the postoperative pain and the functional complications for each patient in a questionnaire survey were reported using the Wong-Baker FACES Pain Rating Scale at operation day throughout the 1st week postoperatively. All patients were examined at 2, 7, and 21 days after the operation in order to assess the surgical wound healing. Results: In the clinical study, seven patients were operated on without infiltration anesthesia (only spray anesthesia) in the pulsed mode while in CW-mode only one patient operated on with spray anesthesia in low power. Intraoperative bleeding events were bloodless to oozing. There was no preoperative fear; patients' perceptions were comfortable with satisfactory comments except in CW cases and some of the CP0 cases. Severe postoperative complications were absent in all subjects. The reported survey results indicated that the patients treated with the laser had normal day activity on operation day, less postoperative pain and fewer functional complications were noticed in the CP2mode. The surgical wound healing was within normal limits in 7–14 days. Carbonization was the main feature of cases treated with CW-mode while it was mostly absent in the pulsed mode. Conclusion: The use of CW-mode of diode laser can be considered no more suitable for performing oral soft tissues surgery. The pulsed mode was found more practical, effective and easy to carry out incisions, cuttings with less intra and postoperative complications considering its advantages in the clinical cases. The CP2pulsed mode laser treatment offers a safe, effective, acceptable, with impressive outcomes particularly for young patients.

Keywords: Carbonization, comfort pulse 0, comfort pulse 2, continuous wave, Diode laser, frenectomy


How to cite this article:
Al-Khatib AA, Al-Azzawi AS. Comparative study of diode laser 940 nm in performing frenectomy in both: Continuous and pulsed modes: An in vivo study. J Dent Lasers 2015;9:50-68

How to cite this URL:
Al-Khatib AA, Al-Azzawi AS. Comparative study of diode laser 940 nm in performing frenectomy in both: Continuous and pulsed modes: An in vivo study. J Dent Lasers [serial online] 2015 [cited 2018 Dec 9];9:50-68. Available from: http://www.jdentlasers.org/text.asp?2015/9/2/50/158461




  Introduction Top


Esthetic concerns have led to an increasing importance of seeking dental treatment, with the purpose of achieving perfect smile. The continuing presence of a diastema between the maxillary central incisors in adults has often been considered as an esthetic problem. The presence of an aberrant frenum is being one of the etiological factors for the persistence of a midline diastema. The focus on the frenum has become essential.[1]

The frena may also jeopardize the gingival health by causing a gingival recession when they are attached too closely to the gingival margin, either because of an interference with the proper placement of a toothbrush or through the opening of the gingival crevice because of a muscle pull.[2] In cases of abnormal insertion of the labial frenulum that cause deleterious effects such as gingival recession, the frenectomy is indicated.[3] The lingual frenulum, a small fold of mucous membrane that connects the middle of the sublingual face of the tongue to the floor of the mouth, interferes in the tongue movements and its functions. Orofacial functions can be altered according to the degree of lingual frenulum alteration.[4],[5],[6],[7]

Lingual frenulum evaluation is required when tongue movements and orofacial functions, such as chewing, swallowing and speech are altered.[8],[9],[10],[11] Different health professionals use their knowledge to evaluate lingual frenulum. In general, anatomy and orofacial functions are evaluated. The use of specific protocols is not common. Surgery is indicated when orofacial functions are significantly altered.[12] Frenectomy is the usual procedure to release the lingual frenulum.[13]

Until, the classical or conventional frenectomy (surgically by scalpel and suturing) was the only way to remove the aberrant frenum. Modern technology now offers an alternative mode of treatment, like laser surgery.[14]

There are different types of lasers according to their different wavelengths and their interaction with tissues. They can be used for the hard and soft tissues in oral cavity. In soft tissue procedures (gingivectomy, frenectomy, lesion removal), CO2, Nd: YAG, Argon, Er: YAG and diode laser were used.[15],[16]

Diode laser is a semiconductor made of gallium aluminum arsenide used in surgery. It emits coherent monochromatic light of wavelength between (810 and 900) nanometer, that is, near infrared. This radiation is absorbed in dark media, as in hemoglobin and, therefore, has a remarkable surgical cutting efficiency in well-vascularized tissues.[17],[18]

The use of diode laser in oral surgery is becoming very popular for several procedures that can be performed quickly, with low morbidity and excellent healing due to the biostimulating effect of this specific laser. The available wavelengths of this laser place it in the invisible nonionizing infrared radiation portion of the electromagnetic spectrum. Pigmented tissues, such as hemoglobin and melanin, very well absorb of these wavelengths. This tendency to transmit depends on the wavelength and the absorption factor of the target tissue.[19],[20],[21]

The poor absorption in the surrounding tissues (only 20% of the emitted energy penetrates deeper than 2 mm) allows the surgery to be performed safely.[22],[23] Surgery is usually performed in the continuous mode, but the recently produced super pulsed diode laser allows the surgeon to perform interventions with very high energy levels and frequency up to 20,000 Hz with a pulse duration in the millisecond range. In this way, the thermal damage to the tissue does not progress deeper than 50 µm, and carbonization is reduced to a minimum.[24]


  Procedures Top


It include the material and methods in this study: Laser system and parameters

Laser system

The used laser system in this study was the Epic 10 W diode laser 940 nm, Biolase Company, USA, which is a surgical and therapeutic device at the cutting edge of technology, designed for a wide variety of oral soft tissue procedures and dental whitening, as well as for use in providing temporary relief of minor pain. The Epic 10 utilizes a solid-state diode as a semiconductor source for invisible infrared radiation. The energy is delivered to the treatment site via flexible fiber connected at one end to the laser source and the other end to the Handpiece. Various types of single-use, disposable tips are designed and optimized for different applications. The device is activated by means of a wireless footswitch [Figure 1],[Figure 2],[Figure 3].
Figure 1: Epic Biolase 940 nm diode laser device with the protective goggles of the dentist, assistant and patient

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Figure 2: Disposable tips

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Figure 3: Delivery system and wireless footswitch

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Patients

This clinical trial included fourteen patients requiring surgical removal of labial and\or lingual frenum, attending the Specialized Dental health center of Duhok in Kurdistan and at Al-Ramady Specialized Dental Health Center in Al-Anbar governorate. Dental oral surgeons and periodontists from both dental centers supervised the operations of frenectomy with specialist in laser dentistry. The study was carried out from September 2013 to September 2014.

Samples description

Fourteen patients of both sexes (7 females, 7 males) with age range from 7 to 46 years were asked to undergo the laser therapy in this clinical trial and the details of the procedure, possible complications were explained verbally, and each patient was given a written sheet. Inform consent was obtained.

Inclusion criteria

  • Male or female subjects with pathologic frenum attachment referred from orthodontic, periodontic and Prosthodontic departments, which required removal
  • Operation to be carried out with or without local anesthesia
  • Patient should be able and willing to take part in this study, follow all the instructions, and come back during the observation periods.


Exclusion criteria

  • Medically compromised patients
  • Heavy smokers
  • Patient with bad oral hygiene (negligible patient).


Patient's case sheet

A special case sheets and follow-up sheets were done for each patient; it is presented in the [Figure 4]a and [Figure 4]b.
Figure 4: (a) Information case sheet (b) Patient's follow-up case sheet

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The information case sheet was filled by the operating dentist before and after operation, while the follow-up case sheet was given to the patient or the parents in case of pediatric patient to fill the information for a period of 7 days.

Patient's recall visits

The patients were asked to attend the dental clinic for follow-up visits to check the surgical site of the operation to evaluate the progress of healing and the presence or absence of any complications. The visits were:

  • After 48 h postsurgery
  • After 7 days postsurgery
  • After 21 days postsurgery.


The criteria to be checked in this study were divided into

Dentist related criteria which include

  • Speed of cutting
  • Efficiency of cutting
  • Presence/absence of carbonization
  • Presence/absence of bleeding
  • Need for anesthetic agent
  • Progress of healing
  • Presence/absence of Infection
  • Need for postoperative medicaments (antibiotics and analgesics).


Patient related criteria which include

  • Presence or absence of pain during operation and postoperatively
  • Edema/swelling
  • Ability to talk
  • Ability of mastication
  • Need for analgesics
  • Ability to brush.



  Materials and Methods Top


The procedure of labial/lingual frenum removal using Epic diode laser 940 nm was performed first depending on the device-preset parameters for frenectomy since it has groups of treatment modalities as shown in [Figure 5].
Figure 5: treatment modalities screen

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In soft tissue group, frenectomy item has the following preset parameters [Table 1].
Table 1: Preset parameters of frenectomy

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Most soft tissue surgical procedures require initiation of the fiber tip by the following steps as shown in [Figure 6]:

  • We touch the tip of the fiber to the surface of the initiation block, without activating the laser (we don't press down on the footswitch)
  • Press the footswitch to activate the laser, allowing the tip to sink into the block. Pull the tip out when the metal cannula touches the block, still firing until just before the tip is out of the block
  • Press the footswitch to activate the laser into the air once, a white flash or the tip will glow
  • Repeat initiation process as needed to ensure the tip is initiated.
Figure 6: Tip initiation steps

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The procedure presets installed at the factory are based on clinical recommendations and feedback from experienced laser dentists. A 300 μm tips are recommended for removing thin tissue layers while the 400 μm tips are recommended for removing fibrous tissue (so we used the 400 μm tips in our procedures) [Table 2].
Table 2: Specifications of laser tip used in frenectomy

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Clinical judgment was adopted when selecting power, pulse, length, and pulse interval parameters to ensure optimal clinical results. The recommended settings apply only to the 300 μm and 400 μm tips.

In this laser device, five types of pulse modes are present in it, as shown in [Figure 7]:

  • Continuous wave (CW) is the CW of laser beam
  • Comfort pulse 0 (CP0) is the comfort pulse with specifications as shown in [Table 4]
  • CP1 is the comfort pulse with specifications as shown in [Table 4]
  • CP2 is the comfort pulse with specifications as shown in [Table 4]
  • P3 pulsed mode which is the standard for most diode lasers currently available to the dental market.
Figure 7: Types of pulse modes in Epic TM 10 diode laser

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Therefore, starting this study with the preset parameters then adjusting the parameters to observe the clinical effects on the surgical area, the patient perception and the dentist optimum parameters for performing frenectomy.

Three groups of parameters were performed in this study, which were:

  • CP2
  • CP0
  • CW.


The used parameters in the study had the following specifications as shown in [Table 3].
Table 3: Pulse modes specifications

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Table 4: Parameters of laser used in the study

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The surgical technique

  • The same surgical technique was used for all patients, who were operated on under topical spray anesthesia with/or without local supraperiosteal infiltration injection
  • The operator, assistant, and patient, wore protective eyeglasses supplied with the laser system during the procedure
  • The diode laser-assisted frenectomy was for orthodontic, periodontal or prosthetic reasons
  • A case sheet filled for each patient and the diagnosis based on the clinical oral examinations and judged by an orthodontist, periodontist, and prosthodontist according to the case condition and patient complain
  • The surgical area was anesthetized using topical anesthesia (Lidocaine Spray 10% (10 mg/dose), AstraZeneca AB, Sweden) 2–3 metered doses
  • Diode laser 940 nm in CW-mode, at power of 1.5 W, 2 W, 2.5 W, 3 W were used
  • The pulsed mode CP2 and CP0 were used in an ascending manner according to the clinical outcomes; the parameters are shown in [Table 4]
  • The frenum was irradiated in contact mode.


Laser surgical technique for labial frenectomy

  • The area was anesthetized primarily with topical spray anesthesia (Lidocaine Spray 10% (10 mg/dose, AstraZeneca AB, Sweden) 2–3 metered doses for pediatric patient and 5 metered doses for adult patient according to manufacturer instructions
  • Infiltration anesthesia (Lidocaine-Hameln 2%, 1.8 ml) was given on need only when patient percept pain during the procedure
  • The upper lip was retracted upward by pulling it with hands; the same was done in case of lower labial frenectomy in adverse direction, that is, downward
  • The disposable tip of laser was initiated and placed directly on the frenum to be removed in contact mode
  • The hand piece with the tip was held perpendicularly in relation to the frenum
  • The laser incision was started from the base of the frenum cervicaly ascending upward until releasing the whole fiber attachments
  • The cutting was inserted deep until touching the bone, and in some cases, the interdental papilla was removed in case of papillary and papilla penetrating frenal attachment
  • Piece of gauze dipped in normal saline was used to gently scrub the wound area to remove any debris or tissue tags that may be present at the wound edges that may interfere with tissue healing
  • Postoperative instructions were given to the patient as described previously in the patient section
  • The patient was advised not to take any antibiotic until the follow-up visit after 48 h postsurgically and only analgesics to be taken on need only
  • The follow-up visits were after 48 h, 7 days and 21 days postoperatively.


Laser surgical technique for lingual frenectomy

  • Topical spray anesthesia applied to the ventral side of the tongue
  • Infiltration anesthesia (Lidocaine-Hameln 2%, 1.8 ml) was given on the need only when patient percept pain during the procedure
  • The tongue was retracted upward and posteriorly.
  • The frenum was grasped by twizer as close to the base of the tongue as possible
  • The procedure was completed by cutting from the base to the ventral surface of the tongue avoiding the vessels and glands in the floor of the mouth
  • At the end of the operation, piece of gauze dipped in normal saline was used to gently scrub the wound area to remove any debris or tissue tags that may be present in the wound edges that may interfere with tissue healing
  • Postoperative instructions were given to each patient as it will be described latter in details
  • The patient was advised not to take any antibiotic until the follow-up visit after 48 h postsurgically and only analgesics to be taken on need only
  • The follow-up visits were after 48 h, 7 days and 21 days postoperatively.


After each laser exposure, the surgical site was wiped off with normal saline wet cotton roll. The duration of surgery and intraoperative bleeding events (bloodless, oozing, mild, moderate, severe bleeding), were recorded in all cases. In addition, the patient's perioperative fear, perception, and comment were recorded.

Postoperative instructions for frenectomy

A postoperative instruction was given to each patient as follows:

  • Stretching exercises - This is the most important part of the child/adult patients successful healing after the procedure. Failure to follow these stretching methods may lead to reattachment and the need for repeated surgery if the area heals back together. Starting at the surgery night and continue for 21 days 3 times a day at least 1 min each time. The goal is to have the frenulum heal and reform as far back as possible. The patient will not be making the surgical sites bigger or causing any damage when he/she stretch either the lip or the tongue revisions
  • Postsurgery a white area (a wet scab) developing in the frenum area. This is normal and not an infection. This is what it will be pressing against during stretches. The healing will be happening under the scab, just like a scrape anywhere else on your body. The white area will get smaller each day
  • Pull the upper lip upward until it touches the nose using enough force to open the entire surgical site and prevent the lip from becoming tied again. Tug it side to side vigorously 3 times
  • If solid foods are being eaten, avoid crispy and spicy foods for 2 days
  • Avoid hot food and drinks for the first 48 h (soft and cold diet)
  • Avoid using dental gargles
  • With a clean finger, rub vigorously under the tongue, side to side and across the middle, 3 times. Place your index fingers on each side of the tongue and forcefully open the diamond shaped area. A sufficient force may be needed to completely open the surgical site to prevent the reattachment. Push downward toward the child's throat. Some bleeding may occur, and this is not a concern.


Recall visits, clinical observation, and evaluation

  • All patients were examined at 48 h, 7, and 21 days after surgery to assess edema, infection, necrosis of the operation site, fibrin layer thickness and formation, functional complications (speaking, eating, and brushing) and the overall surgical wound healing progress
  • The same operator during examination did the clinical observations and assessments. In addition to the data collected from the questionnaire sheets including the patient's notes in the operation day and during the 1st week postoperatively.


Assessment of pain

Assessment of pain was done using the Wong-Baker FACES Pain Rating Scale, the severity of pain was assessed using scale of 0 (no pain) to 5 (severe pain) a copy of which was given to each patient to allow daily recording of pain at the day of operation and the first 7 postoperative days. In addition, postoperative pain was assessed according to systemic analgesic usage.

Assessment of swelling

Subjective assessment of swelling was done by applying the following edema scale that was developed by the researcher and the supervisor:

  • Mild: Edema involving the inner side of the involved lip or surrounding site of surgery
  • Moderate: Edema involving the inner and outer sides of the involved lip (the entire lip), hiding the philtrum of the upper lip, and in the lower lip hiding the labiomental crease (a horizontal depression passes across the lower lip in an inverted U-shaped line, which intraorally corresponding to the depth of the gingivolabial sulcus)
  • Severe: Edema involving the inner and outer sides of the involved lip and extending beyond the corner (commissures) of the mouth and the nasolabial folds laterally, involving (reaching) the nose in upper or the chin (lower border of mandible) in lower. In addition, the duration of the swelling subsiding was recorded.


Assessment of postoperative infection and necrosis of the operation site

The researcher did clinical assessment of the wound infection and necrosis during the postoperative period at 2, 7 and 21 days.

Assessment of functional abilities

In the follow-up appointments, the operator was asking each patient to describe and rank their functional abilities that include speaking, eating, and brushing whether were normal, limited, painful or hardly. In addition to the data collected from the questionnaire sheet.

Assessment of surgical wound healing

  • Surgical wound healing was assessed by clinical examination depending on inspection and palpation of the wound
  • Fibrin layer formation and its thickness and integrity
  • In addition, the duration of a clinically healed wound was recorded.



  Results, Discussion and Conclusions Top


Results of continuous wave parameters

The results were subdivided into instant results of the operation and follow-up visits results. These were tabulated to compare the outcomes of different parameters.

The direct operative results

[Table 5] and [Figure 8],[Figure 9],[Figure 10] demonstrate the outcomes of CW parameters during operation. The grades of each parameter in the table were:

  • Pain = 0 no pain, 1 slight annoying, 2 little pain, 3 more than little pain, 4 lots of pain, 5 very strong pain
  • Type of anesthetic agent = spray or infiltration injection
  • Carbonization = 0 no, 1 little, 2 carbonization, 3 heavy carbonization
  • Speed of cutting = 0 very slow, 1 slow, 2 fast, 3 very fast
  • Bleeding = 0 no, 1 little bit, 2 bleeding, 3 heavy bleeding
  • Coagulation = 0 no, 1 little, 2 good, 3 very good
  • Patient perception = comfortable, moderate comfortable, very uncomfortable
  • Duration of operation (in minutes).
Table 5: Results of CW parameters during operation

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Figure 8: Frenectomy with continuous wave mode diode laser with powers 1.5, 2 and 2.5 W where (a) Preoperative (b) Postoperative immediately (c) After 2 days (d) After 1-week (e) After 21 days

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Figure 9: Frenectomy with diode laser continuous wave mode with 3 W power, (a) Postoperative, (b) 2 days (c) 1-week, (d) 21 days follow-up images

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Figure 10: Another case of frenectomy with 1.5 W continuous wave mode diode laser. (a) Preoperative (b) Immediately postoperative (c) 2 days later (d) 1-week later (e) After 21 days from operation

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Follow-up visits results

The follow-up results of the patients were recorded as shown in [Table 6] and the parameters to be checked were:

  • Pain (as mentioned above)
  • Edema (swelling): Subjective assessment of swelling was done by applying the following edema scale that was developed by the researcher and the supervisor:


    • Mild: Edema involving the inner side of the involved lip or surrounding site of surgery
    • Moderate: Edema involving the inner and outer sides of the involved lip (the entire lip), hiding the philtrum of the upper lip, and in the lower lip hiding the labiomental crease (a horizontal depression passes across the lower lip in an inverted U-shaped line, which intraorally corresponding to the depth of the gingivolabial sulcus)
    • Severe: Edema involving the inner and outer sides of the involved lip and extending beyond the corner (commissures) of the mouth and the nasolabial folds laterally, involving (reaching) the nose in upper or the chin (lower border of mandible) in lower
    • Follow-up visits were at 48 h, 7 days, 21 days.




Results of CP2 pulsed mode of 940 nm diode laser
Table 6: Follow-up results for CW diode laser frenectomy

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We started from the device parameters, which is 2 W CP2 pulsed mode for frenectomy and changed the parameters in an ascending mode. In CP2 mode, the pulse duration was 1 msond on, pulse interval 1 msond off and duty cycle (time on/time off) is 50%.

The direct operative results

The operative results are directly taken as shown in [Table 7].
Table 7: Direct operative information of the CP2 pulsed mode 940 nm diode laser parameters for frenectomy operation

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Follow-up visits results

The follow-up results were recorded at 48 h, 7 days and 21 days as shown in [Table 8] and [Figure 11] and [Figure 12].
Table 8: Follow-up results of CP2 parameters of diode laser 940 nm frenectomy

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Figure 11: Frenectomy with CP2 pulsed mode diode laser with powers 2 W, 4 W and 10 W. (a) preoperative (b) Postoperative immediately. (c) 2 days follow-up. (d) 1-week follow-up. (e) 21 days follow-up

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Figure 12: Lingual frenectomy with CP2 pulsed mode diode laser, in this case, two power parameters were used to complete the operation, 6 W and 8 W CP2 pulsed mode diode laser. (a) preoperative photo for the lingual frenum. (b) Postoperatively. (c) normal tongue mobility after operation immediately. (d) 2 days later. (e) 1-week (f) 21 days, follow-up

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Results of CP0 pulsed mode of 940 nm diode laser

In CP0 mode, the pulse duration was 10 μs on, the pulse interval 40 μs (off) and the duty cycle (time on/time off) was 20%.

The direct operative results

The operative results are directly taken as shown in [Table 9] with the same parameters to be checked.
Table 9: Direct operative information of the CP0 pulsed mode 940 nm diode laser parameters for frenectomy operation

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Follow-up visits results

The follow-up results were recorded at 48 h, 7 days and 21 days as shown in [Table 10] and [Figure 13] and [Figure 14].
Table 10: Follow-up results of CP0 parameters of diode laser 940 nm frenectomy

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Figure 13: Frenectomy with CP0pulsed mode diode laser with power parameters 6 W, 7 W and 8 W. (a) preoperative. (b) Postoperative. (c) 2 days later. (d) 1-week. (e) 21 days follow-up

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Figure 14: Frenectomy with CP0pulsed mode diode laser with power parameters 9 W and 10 W. (a) Preoperative. (b) Postoperative. (c) 2 days. (d) 1-week. (e) 21 days follow-up

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Summary of the results

Surgeon's results

The visible clinical results could be described as followed:

Table 11: Carbonization percentages in the three modes

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Table 12: Coagulation percentages in the three modes

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Table 13: Bleeding percentages in the three modes

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Table 14: Speed cutting percentages in the three modes

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On pictures taken after the surgical procedure, the wound areas looked much nicer when pulsed mode laser did the treatment. The cutting margins had sharper edges; the cut was straighter and seemed to go deeper into the tissue with one movement.



The following days there was a swelling of the treated soft tissue in different sizes noticed for the laser systems.
Table 15: Swelling 2 days postoperative percentages in the three modes

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After 2 days, there was only a mild swelling left after pulsed diode laser treatment but in the CW-mode group 40% of the patients still had a moderate swelling. One-week after laser treatment, there was no swelling left in both laser groups.

Table 16: Fibrin layer 2 days postoperative percentages in the three modes

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Table 17: Fibrin layer 1-week postoperative percentages in the three modes

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1-week postoperative there was more reduction of fibrin layer in the CW-group while the pulsed mode group still had a partial fibrin covered area in 20% of the patients in CP2 and CP0 modes.

Patient's results

Pain

During laser treatment and directly after laser treatment no patient felt pain or discomfort because there was anesthesia given in every treatment case. There were more patients without pain, and the pain strength was on a lower level in the pulsed group type CP2[Table 18].
Table 18: Pain 2 days postoperative percentages in the three modes

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Now there were no patients with pain grade 2 in the CP2 and CP0 pulsed mode group and less patients with pain grade 2 in the CW-mode group.

After 1-week, all patients in CP2 group were free of pain, the CP0 group and the CW-group still has pain grade 1 [Table 19].
Table 19: Pain 1-week postoperative percentages in the three modes

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Table 20: Analgesic drugs needed postoperative percentages in the three modes

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Table 21: Reduced function occurred postoperative percentages in the three modes

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Table 22: Difficulties in oral hygiene occurred postoperative percentages in the three modes

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N.B. All the results are specific for each patient, especially the pain parameter and need for analgesic medicament. This depends on every patient pain threshold, which is the ability to tolerate pain that may vary from patient to other depending on different factors like:

  • Gender
  • Age
  • Physical condition
  • Hormonal factors
  • Race.



  Discussion Top


Soft tissue surgery by diode laser was in progress in the last years. There are many advantages:

For the surgeon:

  • Efficient and precise cutting with a calculated depth of cut
  • Good hemostasis-so nearly or completely without bleeding and therefore better visibility of the place of interest
  • mostly no sutures needed
  • only minimal destruction of the adjacent tissue (in pulsed mode)
  • uncomplicated handling due to fiber and variety of parameters
  • Shorter treatment time.


For the patients:

  • they mustn't be sutured
  • no or only little postoperative edema
  • bactericidal reduction of the wound area
  • no secondary bleeding
  • low level of scar forming
  • patients with hemorrhagic diathesis can be treated without or with only little substitution
  • shorter treatment time
  • biostimulation of the surrounding area
  • Reduced application of drugs because of pain reduction intra-and postoperatively.[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46]


Discussing the results from the study one certain thing has to be remembered, the CW-mode laser had been used in an ascending pattern for the power and the peak and average power had always be the same; in every procedure. That's the main difference to the pulsed laser which had been used with different parameters; for the CP2 mode from 2 to 10 W peak power; 1–5 W average power; 1 ms pulse duration and 50% duty cycle while for the CP0 mode; 6–10 W peak power; 1.2–2 W average power, 10 µs pulse duration with 20% duty cycle. The used peak power was sometimes higher than the peak power of the CW-mode laser. In this study, we used a 940-nm diode laser because it has maximum absorption by hemoglobin and oxyhemoglobin, compared to 810 nm [Figure 15].[47] When compared to 980-nm diode lasers, the higher thermal effect of these wavelengths (<100 μs) can very often cause necrosis.[48]
Figure 15: Schematic presentation showing absorption of 940-nm diode laser compared to other wavelengths

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The tip was initiated to facilitate the formation of a small amount of carbon at the tip, referred to as the "hot tip effect". It focuses a large amount of energy at the contact point and allows accelerated tissue incision. However, then the tip must be inspected frequently to avoid it becoming a ragged branding iron due to the collection of ablated tissue.[49] Laser-assisted frenectomy is very easy to perform. The patient hardly noticed any discomfort, and there was absolutely no bleeding in certain parameters. We used pulsed mode, as CW-mode causes a rapid rise in temperature in the target tissue. Pulsed mode provides time for the tissues to cool down and prevents the collateral tissue damage incident to excessive heat production.[49] The frenum was eliminated completely, and the patient could protrude her tongue up to 10–12 mm in case of lingual frenectomy [Figure 12]. The excellent hemostasis and absence of postoperative swelling was attributed to increased platelet activation by lasers [50] and sealing of lymphatic vessels.[51] Furthermore, using near-infrared lasers on soft tissue, there is minimal or no bleeding due to a combination of sealing of small vessels through tissue protein denaturation and stimulation of factor VII production in clotting. The heat buildup also allows for the sealing of small lymphatic and blood vessels, which results in reduced postoperative bleeding and edema.[52] There was no need to suture, as there is complete hemostasis and improved wound healing [Figure 8] and [Figure 14]. In addition, the laser's sterilization of the surgical wound reduces the need for postoperative care and antibiotics.[49] The patients who underwent laser frenectomy reported that they did not need analgesics beyond 24 h postoperatively in most power parameters used in this study with exception of some of the CW parameters and CP0 parameters; they needed analgesics for few days. The used peak power in CP2 pulsed mode was sometimes higher than the peak power of the CW-mode laser; and even the average power was more than nearly double (1.67 times higher). Regarding this there was no doubt that the CP2 pulsed mode laser would cut much easier and faster than the CW-mode laser. On the other hand, the used powers were high that normally a CW-mode user would expect more thermal damage and necrosis of the tissue with a lot of carbonization.[46],[53],[54],[55],[56] But in the pulsed mode of operation there was less carbonization and less damage of the adjacent tissue, which had been proven histologically in vitro by Bach etal. in 2008.[57] Bach used a CW-mode diode laser, a pulsed mode diode laser and a super pulsed diode laser with Ppeak 30 W; Pavg 9, 99 W; 20,000 Hz to make soft tissue cuts in pig jaws. Unfortunately, he didn't mention the pulse duration. Peak power was lower in this study, average power also lower in this study and the frequency was the same in both studies. Still the results were much better for the super pulsed laser than for the CW-mode laser. Maiorana and Salina did a clinical study with a super pulsed laser on three patients in 2006.[24] Parameters were 23, 33 W peak power in average; 16667 Hz in average; 10 µs pulse duration in average; Pavg not mentioned. The conclusion was clean cut without thermal side effect; instant coagulation; excellent postoperative conditions with minimal pain and swelling; minimal involvement of the adjacent tissues during surgery. The parameters were different in this study, the peak power was significantly higher and the number of patients was only three. However, the summary of both studies correspond with the results achieved in this study. The results out of this comparative in vivo study are sometimes not very different for the used lasers, but sometimes very significant, so in case of the:{Figure 12}

Cutting speed

The use of high powers, short pulse durations and high frequencies offered a high speed for cutting and a deeper cut as it did in CW-mode. The margins of the cut were more defined and straighter using super pulsed mode.[45],[58],[59] When using the super pulsed diode with high power and frequency for cutting the first time, the normal treatment behavior had to change; the movement speed of the fiber had to be increased because of the rapid cutting velocity. When using the CW-diode laser the cut was flattish, and the cutting speed was low in low powers. As known the cutting efficiency of an 810 nm diode laser is better than it is with a 980 nm diode (Gutknecht N; script M6-Master of Science in Lasers in Dentistry, ED2006; AALZ-Aachen; 02/2008). The 810 nm diode has less penetration into the depth, a lower absorption in water, a lower absorption in HbO2 and nearly the same absorption in Hb as a 980 nm diode. The 980 nm diode creates more thermal energy at the surface and penetrates more into depth. The zone of necrosis is larger and it is more dangerous for cutting. In this study, we used 940 nm wavelength diode laser because of better absorption as mentioned in [Figure 15]. Surprisingly Bach et al. could prove 2008 in vitro studies, that there was no difference from the histological point of view between 810 nm and 980 nm diode lasers, when both are used in the same mode of operation.[58] If we assume that Bach's results were correct, and we neglect the difference between in vitro and in vivo studies, we can conclude together with the attained results from this study that super-pulsed mode of operation will lead to faster cutting speed and a more precise cut with less tissue damage. There are a lot more parameters apart from the wavelength, power, frequency, pulse duration, fiber diameter and mode of operation that will influence the cutting ability, so as e.g.: Kind of tissue, pigmentation, race, blood circulation in tissue, applied dose, treatment time etc. However, these parameters are of subsidiary relevance in this study.

Carbonization

Next point to view is the carbonization of the tissue. If there is a lot of carbonization, the destruction of the surrounding tissue is large.[53],[58],[60],[61] Carbonization is changing the absorption of the treated tissue; it is increasing due to the dark color, which absorbs the diode laser light much better than light colors do. This means there is more thermal energy applied to the surface and necrosis of the adjacent structures is created. As we can see from the study, the changing of parameters could influence the degree of carbonization and coagulation.[45] In 1999 Goharkhay et al. stated that the horizontal and vertical dimension of the tissue destruction is neither addicted to the diameter of the fiber, nor related to the mode of operation (CW or pulsed) but is only depending on the average power used.[62] Both assumptions could be rebut until today. Using the same power settings the dose applied in a defined treatment time is lower with a larger fiber diameter. In using smaller fiber diameters the applied energy is distributed in a smaller area, the dose is higher, the effect is larger, there is more thermal energy brought into the tissue. The risk of carbonization is increasing. So the tissue destruction is certainly related to the diameter of the fiber. The used average power in case of CW-mode diode laser was the same as the peak power reached at max parameter in this study 3 W; in case of the pulsed mode CP2, maximum average power reached was 5 W. According to Goharkhay, the tissue damage must be larger when using the CP2 mode because of the higher average power, but it was just the opposite, because the mode of operation was changed. Also, a much smaller degree of carbonization and destruction is described when using pulsed instead of CW-mode.[24],[36],[45],[57],[59],[62],[63],[64] This can be consolidated by the results achieved here. The CW-mode laser produced carbonization in almost every treatment case, 80% except at low power 1.5 W. The CP2 pulsed diode laser in total 60% with different grades of carbonization of the cases and 40% in total in CP0 group. No patient with heavy carbonization in both pulsed groups. In the CW-mode group, 20% had heavy carbonization; the total amount of carbonization was much higher in the CW-mode group. Maybe carbonization could have been less in the super pulsed group regarding the treatment practice because the fiber had to be moved much faster as in CW-mode and the surgeon had to adapt to the new procedure technique. The fiber diameter is another factor for the applied dose, and perhaps the carbonization could have been decreased using a larger fiber; but for better comparison both modes of diode laser were used with 400 µm fibers. All other parameters, which could influence the degree of carbonization, such as peak power, average power, frequency, pulse duration etc., were accepted in the way the manufacturers had programmed the diode laser unit.

Coagulation

Next aspect to discuss is the coagulation ability of both modes of operation. In this study the coagulation efficiency is described as little, good [23],[38],[45],[69],[70],[71],[72] to very good [26],[41],[60],[65],[66] for CW-mode. For super pulsed mode the coagulation mentioned is very good [23],[63],[67] and good.[59] Geldi C et al.[63] described 2006 in a study that super pulsed diode lasers have a larger coagulation area but smaller carbonization area as CW-mode diode lasers. In this study, the gained results from the surgeon's questionnaire demonstrated in direct comparison that coagulation was stronger using CP0-mode. During treatment, the coagulation was very good in 80% and good in 20% of the treated patients with CP0 mode. For CW, there was very good coagulation in 60% and good in 20% and little coagulation in 20% of the treated patients, which meant that a few patients had a minimal bleeding in low power CW-mode, which was 1.5 w. In pulsed mode, there was none. In this often no bleeding after surgical treatment is mentioned [23],[36],[41],[60],[68],[69],[70] but there was an oozing bleeding in the CW-group patients after surgery. This result was different from the results obtained by Dr. Ralf Borchers 2008[71] in a study where the gained results from the surgeon's questionnaire demonstrated in direct comparison that coagulation was stronger using CW-mode. The coagulation was very good in 42,86% of the treated patients and good in 57,14%. For super pulsed there was no very good coagulation, but 83,33% good and 16,67% little coagulation where a few patients had a minimal bleeding. In CW-mode there was none, while there was an oozing bleeding in 21,43% of the CW-group patients after surgery and also in 41,67% of the super pulsed group after finishing the surgical treatment, which is a significant difference. This difference between the current study and Ralf study could be explained by means of power parameter, Ralf used in his study single CW power parameter that was stable for all patients, which was 2.5 W which is significantly higher than 1.5 W parameter used in the current study where bleeding occurred with, while in higher powers there were no bleeding at all. This might have been a derivation of the higher thermal damage of the CW-mode laser. The blood vessels were sealed better by the influence of the larger amount of thermal energy delivered by the CW-mode of operation.

Swelling

Swelling of the wound area and adjacent tissue 2 days after surgery was significantly less in the super pulsed group. It was 100% mild swelling in both CP0 and CP2 pulsed modes while in CW-mode it was 60% mild and 40% moderate. The reason for this could be the degree of tissue damage caused by laser irradiation. Regarding the lower degree of carbonization and thermal damage in the super pulsed group, it was explainable that there was less swelling. Swelling is a result of the inflammation reaction of the body.

Pain

A second characteristic sign of inflammation is pain. During and directly after laser treatment there was no pain because all patients had been given local anesthesia. Surgical treatment with a diode laser always requires anesthesia, because the thermal energy always applied generates pain. In this study classifications of pain were 0 no pain, 1 slight annoying, 2 little pain, 3 more than little pain, 4 lots of pain, 5 very strong pain. All authors agree that the degree of pain is reduced after laser treatment in comparison to classical treatment by scalpel. Looking to the results of the questionnaire only patients treated with CW-mode had the higher degree of pain, which was grade 5 that occurred 1-day after treatment. The percentage was 20% while none of the patients treated with pulsed mode had pain grade 5. In the next 48 h from treatment pain grades were between zero, one and two. The best mode in results of pain was the CP2 mode where its percentages were as the following 50% pain-free, 50% pain grade 1. The CP0 had 20% pain-free, 80% grade 1 and the CW-mode 20% pain-free, 40% grade 1, 40% grade 2. After 1-week, still CP2 had the best results, which were 100% pain-free. The CW and CP0 still had pain with lower percentages. Saaleh et al.[60] noticed an average of 3 days of pain for all patients in their study after CW-mode treatment. One week after surgical laser treatment, no patient felt pain any longer (exception: The very algesic patient on grade 5).

The controversy here was the CP0 mode results. In this mode were the pulse duration shorter than the CP2, 10 µs for CP0 and 1 ms for CP2. So the amount of laser energy applied to the tissue in contact logically was large, condense and thermal damage to the tissue was minimal due to short exposure time. However, the results here showed that CP2 mode was better in the pain parameter, In spite the fact that pulse duration is longer in this mode.

Need for drugs

After laser treatment the patients had been supplied by an analgesic drug, Ponstane cap 500 mg. The patients in the CW-group and CP0 needed medication more than the patients in the CP2 mode group. These results corresponded to the findings for pain that have been done before. In general, we can say that the pain sensation was less in the pulsed group. These results and the following conclusions for reduced masticatory and lingually function so as the difficulties in oral hygiene were subjective and will differ by treating other patients because the degree of sensation is very different from person to person. There will be no reproducable results but only a hint to the right direction.

Reduced masticatory and lingually function

In order to the traumata, set during laser treatment there was a functional reduction for masticatory and/or lingually function in both groups. In the CW-group, every patient was affected except for one. In the pulsed group, type CP0 60% of the patients had no functional limitations while 20% had it for 2 days and 20% for 1-week. The best results again were for the CP2 mode were 100% of the patients were symptoms free. That corresponded once again to the study of Saaleh et al.,[60] who described a 3-day period of painful mastication and speech after CW-mode treatment.

Difficulties in oral hygiene

Nearly the same results for oral hygiene. In CW-mode limitations ranging from one to whole week, while for CP0 only 40% suffered limitation. Again the best results were 100% no limitations for CP2.

The fibrin layer

The building of fibrin is a part of the secondary hemostasis, a part of the plasmatic hemostasis. A dense network of fibrinous fibers connected the thrombocytes. The grade of fibrin layer relies in a certain extent to the grade of healing. The faster the fibrin layer is removed, the faster the wound healing is in progress. After 2–4 h trauma the extravasation starts, a coagulum is built with blood and plasma cells on the wound surface. Fibrin fibers are connecting the thrombocytes and build a dense network of fibers. This normally lasts to the 4th day. Then proliferation starts, granulated tissue is build, and the fibrin fibers are reduced. From the 5th day on regeneration starts and there is no more fibrin layer. The faster the fibrin layer is removed, the faster the wound healing is in progress. The observed results regarding the fibrin layer differed from the normally seen wound healing after classical treatment by scalpel. In this study, 14 patients were treated, no suture was needed, so there was secondary wound healing or second intention, and visible fibrin layer could be seen. On 48-h postoperation, thick fibrin layer was seen on the wounds in 100% of all patients. In comparison to healing after conventional surgical treatment, there was a delay of healing time, because fibrin layer building started later and needed more time to cover the wounds. In conventional surgical treatment, primary intention was obtained by suturing. In consequence of delayed wound healing, there was still a fibrin layer seen after 1-week in 20% of the pulsed group and in 0% of the CW-group. Delayed wound healing after surgical diode laser treatment has been described in literature already [36],[70],[72] and as we could see from the results above the wound healing of the CW-group started later and lasted even longer as the prolonged wound healing of the super pulsed group. This might have been an effect of the stronger thermal damage and increased carbonization in the CW-group. The cells and blood vessels in the adjacent tissue were much more damaged and needed longer to reorganize for healing. Super pulsed treatment left more intact tissue at the wound margins, so healing could begin earlier as in CW-mode. Even if there was an improvement in healing time, there was still a difference to normal healing, where fibrin layer removal begins already at the end of the 4th day. Therefore, the intactness of the tissue seemed to be essential for regular wound healing. Super pulsed diode laser treatment did not cause much carbonization, but there was as well coagulation, which meant applied thermal energy on the blood vessels and cells; causing damage and therefore delayed healing.

As option for surgical laser treatment an Er: YAG laser with water spray and air can be used instead. The Er: YAG laser also generates a soft tissue cut, but with a resulting bleeding. There will be no carbonization and nearly no coagulation, therefore, no or only minimal damage to the tissue and as effect a much quicker and nicer wound healing and less discomfort for the patient as after diode laser treatment. In summary we can say that super pulsed diode laser treatment is contrary to CW-mode diode laser treatment much more gentle for the tissue (less damage, quicker healing), more comfortable for the patient (less pain and swelling) and an improvement for the surgeon (more precise and deeper cut, less burnt smell, shorter treatment time). Only the coagulation ability of the super pulsed diode laser seems to be minimal inferior of the CW-mode diode laser. In combination with the findings of the Bach study [57] and the case reports of Maiorana and Salina [24] we can conclude that super pulsed diode lasers should be the state-of-art treatment nowadays if there is spoken about surgical diode laser treatment. Of course, these are only 2 further studies, and the results have to be reconfirmed by various studies with a larger amount of patients, but the direction to go is clearly given.


  Conclusion Top


Clinical in vitro and in vivo studies have shown that soft tissue surgery done by super pulsed diode lasers is more reasonable as doing the same procedures by CW-mode diode lasers. Carbonization and thermal damage to the adjacent tissue can be reduced to a minimum, the soft tissue cut can be generated faster, and the cut is more precise. Because of the lower amount of tissue destruction, the healing is faster as in CW-mode. It is more comfortable for the patients regarding the postoperative pain and swelling, the patients will need less drugs, and the functional abilities are not reduced as much as in CW-mode. In terms of Bach's histological investigation of the treated soft tissue [57] we probably have to share his opinion, that CW-mode diode lasers are no longer suitable for soft tissue cutting in dentistry. The advantages of the super pulsed diode lasers in soft tissue surgery are evident and with the meanwhile achieved peak powers, the very short pulse durations and the high frequency the surgical treatment can be improved and probably the range of treatment can be expanded.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21], [Table 22]


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