Case SeriesThe Integration of a Dual-Wavelength Super PulsedDiode Laser for Consistent Tissue Ablation in the EstheticZone: A Case Series
Nur Hafizah Kamar Affendi ,1 Rohana Ahmad,1 Farhad Vahidi,2 Mohd Zulkifli Hassan,3
and Siti Nadia Rahimi4
1Unit of Prosthodontics, Centre of Restorative Dentistry Studies, Faculty of Dentistry, Universiti Teknologi MARA,Sungai Buloh Campus, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia2Department of Prosthodontics, New York University, College of Dentistry, 205 E. 64th St., Ste 403, New York, NY 10065, USA3Universiti KebangsaanMalaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia4Faculty of Dentistry, Islamic Science University of Malaysia (USIM), Malaysia
Correspondence should be addressed to Nur Hafizah Kamar Affendi; [email protected]
Received 29 July 2020; Revised 13 November 2020; Accepted 26 November 2020; Published 4 December 2020
Introduction. A diode laser is one of the universally compact accepted laser systems used fundamentally for soft tissue applications.Most diode laser devices have a single wavelength of either 810 nm for superior coagulation or 980 nm for tissue ablation. In thesecase series, the use of dual wavelengths (810 nm and 980 nm) in combination with super pulsing has provided a cleaner cut (nocharring) with faster healing that eases the placement of the final restoration in the esthetic zone. Case Description. The presentcase series describe four cases in the esthetic zone that achieved hemostasis ablation without collateral damage to enhancegingival balance of definitive restoration. The gingivoplasty and gingivectomy modes are used to achieve efficient tissue ablation.Although there is no specific mode indicated in the FDA laser requirement for gingival depigmentation, the procedure could besafely performed with the dual-wavelength diode laser Result. All four patients revealed a good esthetic outcome and reportedno pain postoperatively. Healing was uneventful, and definitive restoration was delivered within two to four weekspostoperatively. Conclusion. Within the limitation of these case series, the dual-wavelength super pulsed diode laser has thecapacity to deliver peak powers resulting in efficient cutting and less tissue charring and also as an alternative tool for removalof gingival pigmentation. Prospective clinical research with larger sample size is needed for conclusive results.
1. Introduction
Lasers have been widely used in dentistry since the 1980s asan adjunct therapy for the removal of pathologic lesionsand for esthetic procedures [1]. One of the universally com-pact accepted laser systems is the diode laser that is primarilyused for soft tissue applications. The near-infrared (NIR)wavelength that radiates from this laser is absorbed by chro-mophobes (mainly hemoglobin and melanin), which pro-duces hemostatic ablation of the targeted tissue [2, 3]. TheNIR produces efficient cutting that seals well-vascularizedtissue resulting in low morbidity and excellent healing as
compared to traditional scalpel and electrocautery [4, 5].Dry field surgery is permitted, and suturing is usually notnecessary, resulting in an improved treatment outcome andpatient comfort [6].
Nevertheless, the slow cutting effect as a result of the lim-itation associated with the watts and single wavelength usedhas been a major concern of dental practitioners. To over-come the cutting inefficiency, a “continuous wave” was usedinstead to provide constant energy, but this will inevitablyproduce collateral damage to the soft tissues [7]. This collat-eral damage includes tissue necrosis and delayed woundhealing, which affect the tissue management in the esthetic
HindawiCase Reports in DentistryVolume 2020, Article ID 8883156, 6 pageshttps://doi.org/10.1155/2020/8883156
zone. Therefore, a new generation of a diode laser with asuper pulsed mode was developed to achieve efficient cuttingwith low heat output and decreased collateral damage [8].The beam is modulated with high energy levels (up to20000Hz) with very short pulses in milliseconds for opti-mum clinical results [9–11]. Additionally, the incorporationof dual wavelengths of 810 and 980nm in one unit hasenhanced the coagulative and cutting efficiency which trans-lates into cleaner cut, less charring, and better soft tissuemanagement [11, 12]. Therefore, the purpose of these caseseries was to demonstrate excellent tissue management withsuper pulsed dual-wavelength diode lasers, which provideconsistent ablation to create gingival harmony in the estheticzone.
2. Methods
These case series were based on four patients who werereferred to the prosthodontics department for hard and softtissue aesthetic management of their maxillary anterior teeth.For soft tissue management, minimally invasive excision ofgingival tissue was performed with a super pulsed dual-wavelength diode laser of 810 and 980nm (Gemini Ultra-dent, USA), using the parameters listed in Table 1. Thesurgical procedure with the diode laser and its possible com-plications were explained to the patients, who then gave theirconsent. The operator, patient, and assistants wore safetyglass to protect their eyes and avoided the use of mirroredsurface instruments to prevent laser beam reflections. Thefiber tip was initiated with a carbon paper provided in thepackage. The surgical area was first dried, and gingivectomyperformed with a maximum peak of 2W, in a super pulsedmode under local anaesthesia (xylocaine 2% with adrenaline,1 : 200000). The tip was cleaned regularly with damped gauze(in normal saline) to remove any tissue debris. No periodon-tal dressing was used and no medication prescribed. Postop-erative healing was uneventful, and no pain was reported.The final restorations were delivered within two to fourweeks after surgery.
2.1. Case 1. A healthy 20-year-old female was unhappy withthe shape and color of her maxillary anterior tooth. She hasa congenitally missing upper right central incisor that wasreplaced with the lateral incisor, moved orthodontically intothe place and built up with composite resin to resemble acentral incisor (Figure 1(a)). Although this procedure wasrelatively successful in closing the anterior gap, there wasnoticeable discrepancy in shape, color, and gingival architec-ture with those of the contralateral central incisor. In addi-tion, the overhanging margin of the composite build-up hasresulted in inflammation of the gingiva and the interdentalpapilla (Figure 1(b)). The composite resin was removed andthe tooth prepared for a porcelain veneer. To ablate theexcess gingival tissue, a preset gingivoplasty mode was usedwith pulse duration of 140μs. The remnants of the inflamedtissue were removed and conditioned with wet sterile gauze(Figure 1(c)). The final impression for the veneer was madeimmediately after the procedure, and the patient was recalledafter 3 days. Excellent healing has occurred, and the patient
reported no pain. The lithium disilicate veneer was cementedtwo weeks later, and the patient expressed immense satisfac-tion with the outcome (Figure 1(d)).
2.2. Case 2. A young male patient complained of unevensmile and discoloration of his front teeth. Upon examination,it was noted that he has mild anterior crowding, spacing, andpeg-shaped right lateral incisor restored with compositeresin. The maxillary right central and lateral incisors wereendodontically treated (Figure 2(a)). Various treatmentoptions were discussed including tooth realignment withorthodontics. He declined orthodontic treatment and optedfor partial and complete coverage restorations. The maxillaryright central and lateral incisors and maxillary left centralincisor were prepared for crowns and veneer, respectively.Gingivoplasty was then performed with a diode laser on thelateral incisor to gain tooth structure for a ferrule effect(Figures 2(b) and 2(c)). Impression was made immediatelyafter gingivoplasty, and no periodontal dressing was neces-sary. Uneventful healing occurred after 5 days. The patientwas ecstatic of the final outcome (Figure 2(d)).
2.3. Case 3. A female patient aged 54 years complained ofunsightly appearance and requested prosthesis to replaceher missing maxillary teeth. Clinical examination revealedseveral missing teeth and moderately worn down dentitionresulting in shortened clinical crown and gingival contourdisharmony (Figure 3(a)). Gingivectomy on the maxillaryanterior teeth was planned to increase the crown height andimprove the gingival contour before final tooth preparationand fabrication of a fixed prosthesis. A preset gingivectomymode with a diode laser was chosen to correct the gingivalzenith. Periodontal examination and bone sounding werefirst performed to ensure that the biologic width was pre-served. The sulcular epithelium was removed under local
Table 1: The parameters used for the diode laser device.
anaesthesia by using the optic fiber tip at about 30-degreeangle and passed along the marginal gingiva (Figure 3(b)).The postoperative event was uneventful, and healing of thegingival tissue was observed after two weeks (Figure 3(c)).The fixed prostheses were delivered a month after sur-gery, and the patient was satisfied with the final outcome(Figure 3(d)).
2.4. Case 4. A 49-year-old female patient complained of darkgingiva and corroded crown margins and requested replace-
ment of the metal ceramic crowns (Figure 4(a)). The gingivalpigmentation has a score of 3 according to the gingival pig-mentation index, with diffuse brown/black pigmentation onthe attached and marginal gingiva [13]. Gingivoplasty wasplanned to remove the pigmentation, and new all ceramiccrowns were fabricated to replace the unesthetic crowns.The preset gingivoplasty mode was selected to remove themelanin pigments on the marginal and attached gingiva atthe output power range of 1.0 to 2.0 watts under local anes-thesia (Figure 4(b)). A depigmentation procedure was carried
(a) (b)
(c) (d)
Figure 1: (a) Right lateral incisor in the position of the central incisor and built up with composite resin. (b) Gingival inflammationunderneath the overhanging composite restoration. (c) Gingivoplasty with a diode laser. (d) Cemented veneer with excellent postoperativegingival healing.
(a) (b)
(c) (d)
Figure 2: (a) Overlapping of maxillary central incisors and a peg-shaped lateral incisor built up with composite resin (arrow),(b, c) gingivoplasty on a lateral incisor, and (d) restored maxillary incisors and healed gingiva.
3Case Reports in Dentistry
out on the marginal and attached gingiva at the output powerrange of 1.0 to 2.0 watts (Figure 4(c)). The ablation was per-formed with a steady brushing stroke, and the tip was kept inmotion all the time. Remnants of the ablated tissue were
removed using sterile gauze dampened with saline solution.Postoperative healing was uneventful after 5 days, and thecrowns were cemented in a supragingival manner a monthlater. She was recalled after a year, and very minimal melanin
(a) (b)
(c) (d)
Figure 3: (a) Moderately worn down maxillary anterior teeth and missing a right lateral incisor. (b) Gingivectomy performed with the diodelaser. (c) Final tooth preparation on healed gingiva. (d) Final prosthesis cemented showing good crown length and gingival harmony.
(a) (b)
(c) (d)
Figure 4: (a) Gingival pigmentation and discolored crown margins. (b) Gingivoplasty with a diode laser. (c) Immediate postoperative state ofgingival peeling. (d) One-year recall showing minimal redeposition of melanin and minimal gingival recession.
4 Case Reports in Dentistry
redeposition was seen on the attached gingiva and the muco-gingival junction (Figure 4(d)).
3. Discussion
Gingival health is one of the essential components that createthe harmony of smile in the esthetic area. To create balancein a clinical situation which displays surplus of the gingiva,a preprosthetic gingival procedure with a diode laser hasshown to be precise, sterile, and suture-less and providessuperior healing [14–17]. When compared to a retractioncord for the gingival displacement technique, the diode laseris more effective and simpler to use and causes less pain [18].As shown in cases 1 and 2, hemostatic ablations from thediode laser permit a dry field and enable gingival troughingto be done for margin accessibility and ease of impressionmaking within the same visit. In addition, the diode laserproduces wider gingival sulci, less epithelial injury, and post-treatment gingival recession as compared with the use of aconventional presaturated retraction cord prior to impres-sion making [19, 20]. However, it has been reported thatthe difference in the amount of recession associated withthe use of either a diode laser or a retraction cord is not sig-nificant, with an average loss of gingival height of 0.26mmfor the cord technique and 0.27mm for the diode laser [21].The difference was probably due to the double-cordtechnique applied and the single wavelength used with a con-tinuous pulse. Hence, larger samples with more variablesincluding tissue thickness, keratinized tissue, wavelengths,and type of pulses used are needed for a more conclusiveresult.
A histological study on an animal model showed that thediode laser causes more tissue damage and delayed healing ascompared to erbium, chromium-doped yttrium, scandium,gallium, and garnet (Er: Cr, YSGG) and scalpel [22]. Anotherin vivo study has shown that histologic specimens from thediode laser cause more degenerative changes to the epithe-lium and stromal cells as compared to a scalpel and electro-cautery in the gingivectomy procedure [17]. However, theresult should be interpreted cautiously as the lateral heatmay impede histologic interpretation in small lesions(<3mm diameter) [23]. When comparing patient percep-tion, less discomfort and pain were recorded with the diodelaser [12, 24, 25], but a few studies found a higher pain valuein the laser group [26, 27]. These contradictory findingscould be due to the different parameters used such as wave-length, laser mode, and surgical technique. Nonetheless, asshown in case number 3, the dual-wavelength diode laserhad provided efficient cutting and good bleeding controlwithout the need for suture or dressing.
One of the remarkable advantages of the diode laser wasthe capability to remove a thin layer of a pigmented epithe-lium while preserving the connective layer and capillaryvessel as shown in case 4 [28]. It was demonstrated to havea lower pain score, superior bleeding control, and less inci-dence of repigmentation [29, 30]. A clinical study thatcompared different wavelengths has found that melanin pig-ments effectively absorb the diode laser energy, enhance fas-ter peeling, and cause no relapse as compared to an erbium
laser. [31]. Although no specific mode for depigmentationis available in the system, it showed that this procedure couldbe performed safely with the dual-wavelength diode laser.Further prospective studies with a longer follow-up are nec-essary to confirm this “gingivoplasty” mode as one of theoptions to remove gingival pigmentation.
Diode laser devices have a single wavelength that rangesbetween 810 and 980nm. The lower wavelength closer to810 nm is reported to be better at coagulation, while thehigher 980 nmwavelength diodes are better at tissue ablation.As documented in these case series, the combination of dualwavelengths (810 nm and 980nm) into one unit has provideda clean cut (no charring) with uneventful healing that easesthe placement of the final restoration within a month[12, 32]. While continuous and traditional pulse modes canbe effective, a featured advantage of a super pulsed modeallows a more precise cut without a thermal side effect andminimal involvement of the adjacent tissue [7]. However,further studies are recommended to confirm the efficacy ofthe dual-wavelength approach with low laser power settingsto achieve more conclusive results.
4. Conclusion
Within the limitation of these case series, the followingconclusion could be drawn: the dual-wavelength superpulsed diode laser has the capacity to deliver peak powersresulting in fast cutting and minimal tissue charring andas an alternative tool for the removal of gingival pigmen-tation that was well tolerated by patients. Prospectively,it is suggested to have larger sample sizes with histologicalstudies to explore the different impacts of wavelengths andpulse on the gingival tissue.
Data Availability
The case series data used to support the findings of this studyare included within the article.
Conflicts of Interest
The authors reported no conflict of interest related to thisstudy.
Acknowledgments
The authors would like to thank Ultradent Inc. (USA/Malaysia)for providing the diode lasers used in these case series.
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