Lasers Coming of Age: Lasers Coming of Age: There are two types of dental lasers

Lasers Coming of Age: Lasers Coming of Age: 21 Years of Enlightenment 21 Years of Enlightenment Changing the Patient laser experience Using the*S...
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Lasers Coming of Age:

Lasers Coming of Age:

21 Years of Enlightenment

21 Years of Enlightenment

Changing the Patient laser experience

Using the*Solea Isotropic CO2 Hard & Soft Tissue Laser in Pediatric Dentistry : A 6 month report

Disclosure and Acknowledgements

ALD Annual meeting ScottsDale Arizona 2014

I have assisted in the development of a variety of laser products ,including Innovative optics (laser glasses) T4M ( videos and webinars) , Schick(Serona digital radiography),I am an investor in the development of the Solea CO2 laser and as such I am also on their professional advisory board . For all of these, I have been a beta tester of new products. I receive honoria or supplies for my participation.

Lawrence Kotlow DDS Kiddsteeth.com Practice limited to pediatric dentistry

Manufactured by Convergent Dental 2/5/14

Objectives of today’s presentation 1. How I became involved ,with Convergent Dental & the development and use of the Solea hard & soft tissue laser. 2. Introduction to the CO2 laser @ 9300nm 3. Identify key features of this laser that change much of what we have know about hard tissue lasers. 4. How this lasers compares and differs fom erbium lasers. 5. Example of hard and soft tissue procedures using C02 @ 9300nm

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There are two types of dental lasers

Hot Lasers

Combination Hard and Soft tissue lasers

The Erbium Family of Lasers Carbon Dioxide @ 9.250 nm

Cold Lasers

Soft Tissue lasers Diodes CO2 Nd:YAG

PDT Aiming Beams Caries-Detection Fluorescence Photobiostimulation 4

Is everything we hear over the internet true: Examining the facts

• Click to edit Master text styles

Creating the perfect dental laser One laser for both soft and hard tissue procedures 1.Excises or incises tissue rapidly 2.Reduction for the use of local anesthetics 3.Allowed tissue to heal rapidly 4.Produces little post-surgical swelling or discomfort 5.Excellent hemostasis 6.Is able to produce precise surgical incisions 7.Provides easy use to access any area of the oral cavity 8.Precise controllable surgery 9.Easy to use 10. Reliable Lawrence Kotlow DDS 2014

I have been a member of the Academy and using Laser since 2000

Lasers I have used and owned 1.Hoya DElight Erbium Laser (Fully upgraded) 2. Hoya VersaWave Erbium Laser 3.Fotona PowerLase AT Erbium & Nd:YAG Laser 4.Fotona LightWalker Erbium Laser 5.Hoya 810 Diode Laser 6.Hoya 980 Laser 7. Xlase 1064 Diode Laser 8. 5 different Low Level Photbiomodulating lasers

Lawrence Kotlow DDS 2013-14

The perfect dental laser One laser for both soft and hard tissue procedures 1.Reduce or eliminate the need for local anesthesia 2.Removes dental hard tissue rapidly 3.Minimizes need for conventional dental handpieces 4.Easy access any area of the tooth and oral cavity 5.Precise removal of dental hard tissues 6.Provides a mechanism to reduce enamel solubility 7.Make existing enamel or dentin less permeable,blocking out or slow down decalcified tissues 8.Easy to use 9. Reliable

Carbon Dioxide Laser @ 9300 nm

Approximate Net Absorption Curves Of Key Target Tissues Wavelength (nm) 1000

100

2013

2010

Computer Aided Preparation (CAP) Variable foot pedal is also computer driven and determines the speed

To this

Absorption Coefficient (1/cm)

The Solea Laser introduced in August 2013 uses a CO2 beam super pulsed laser @ 9300nm for the removal of hard and soft tissues of the oral cavity.

105 104 103 102 101 1 10-1 10-2 10-3 10-4

“soft” tissue lasers

H 2O

“soft” tissue laser

Courtesy of Don Coluzzi enhanced version

How & why this wavelength is so different

★ 9300nm wavelength has the highest energy transfer, 9600nm has highest absorption in dental hard tissues. (Hydroxyapitite)

★ Heats up the dental hard tissue to very high temperatures by directly heating the mineral (carbonized hydroxyappatite)within

★ Both the temperature and depth of penetration are controlled by “ pulse duration” , tissue properties & Percentage of Power.

★Phase transitions in the dental enamel change the mineral composition and liberates and ejects the molten surface layer.

From Laser ablation of dental hard tissues Seka,Rechmann,Featherstone and Fried

Lawrence Kotlow DDS 2013-14

Nd:YAG/ Diode 810 980 diode 1064

Er,Cr:YSGG Er:YAG 2780 2940

CO2 CO2 9300 10600

Solea CO2 : Know your laser Articulated arm Emergency Stop Touch-screen monitor Galvanometer

the hard tissue.

Collagen

Tooth enamel

KTP 532

( Hard Tissue ablation (removal)

“ALL” tissue lasers

Melanin

Hb

Lawrence Kotlow DDS 2104

Isotropic Co2

10000

Water reservoir

Internal mechanisms Self container air compressor Internal battery UPS Water refill alerts will tell when water is low

Locking front wheels Variable Foot pedal Lawrence Kotlow DDS 2013-14

2.Spot Preparing your laser for treatment: Understanding the start-up screen

Start - up Turn on rear switch

1. ChooseTissue Type

Once front light goes on amber press to turn green

Enamel,Dentin, Soft tissue

2.Spot size

After self testing the screen will ask for pin code

.25,50,75,1.0mm

3.Pulse Duration

Choose tissue type for treatment For hard tissue message will warn the priming will occur :OK

1-500usec

4.Choose water spray In most instances stays at 100%

Once water is exiting handpiece press OK Test fire into water

5. Set percentage of power “Fluence” or J/cm2 Lawrence Kotlow DDS 2013-14

CAP computerized foot pedal. Varies the Hz, eliminates the need to focus or defocusing

Unique “Accelerator “pedal Variable speed power control

Galvanometers (Galvos): Computerized motors move up to 10K times/sec Manipulate beam for precision cutting User selectable spot sizes Optimized patterns and pulsing for each tissue type

6.Easily place a limit on % of power

Usually leave 100% unless you have specific reason to lower

Lawrence Kotlow DDS 2013-14

Co2 compared to Erbium CO2 hard tissue

Erbium Hard tissue

FDA approved for both soft and hard tissue

FDA approved for both soft and hard tissue

Foot pedal - computerized variable power

Foot pedal -either on or off

Future software upgrades

Future software upgrades ?

Beam size .25,5,75, 1 mm Ablation controlled by changing pulse durations and total percent of power

Fixed beam size @ .5 0r .9mm Tips @ range (.3-1.5)

Ablation controlled by altering Hz and Mj

Lawrence Kotlow DDS 2013-14

Co2 compared to Erbium CO2 hard tissue

Erbium Hard tissue

Lasing medium molecule of isotopic CO 2 gas which has expected life of Lasing medium YAG crystal doped with periodic table Erbium 32k hours ( about 60 years @ 10 hrs/week)

Lawrence Kotlow DDS 2013-14

Co2 compared to Erbium CO2 hard tissue Greater absorption in Hydroxyapatite

Erbium Hard tissue Absorption is primarily

Text in water (OH)

Absorption in enamel is 10x that of erbium,93% of enamel

Absorbed in water, 4% of enamel

Green aiming beam

Due to peak absorption in enamel vaporizes it through photothermal effect

Photoacoustic explosion of water

Battery back-up for laser screen

Reboot laser when power interrupted

Vaporized enamel rather than chipping effect

Explosion of water results in chipping effect

Internet diagnosis and software updates

No internet diagnostics

Computer assisted beam control & galvos

Single beam

Pulse duration can be varied from 1-500usec

Maximum of 5 set pulse durations(Fotona) 50,100,300,600,1000usec , Biolase 60, & 700usec

Green aiming beam (532nm)

Position paper March 2007 ALD *

Lawrence Kotlow DDS 2013-14

Co2 compared to Erbium CO2 hard tissue Ejected material molten tissue particles

★CO2 -the absorption of laser light in the ejected tissue (Plume)

★The

plume from the CO2 laser light is not

scattered, but may continue to heat the expanding plume, resulting in loss of energy for tissue ablation and ablation efficiency. The$combina,on$of$the$use$of$uniform$ aluminum$material$and$ultra4high$vacuum$long$ life$indium$seals$keeps$the$gas$cool$and$leads$to$ extended$life.$All$aluminum$CO2$gas$lasers$are$ virtually$sealed$for$life$with$a$Mean$Time$ Between$Failures,$MTBF,$being$30,000$hours$or$ 3.5$years$running$the$laser$24/7/365.$For$a$ typical$dental$installa,on$the$30,000$hours$ equates$to$19.5$years.

Erbium Hard tissue

Ejected material vaporized water Text and ejected particles

Lawrence Kotlow DDS 2013-14

Co2 compared to Erbium CO2 hard tissue

Erbium Hard tissue

Primarily end cutting ,but allows for easy widening of cavity preparation

spot and beyond that defocuses and Text

The CO2 beam remains collimated and in focus for a long distance

End cutting and requires perpendicular cutting to enamel rods

Repetition rate 1-10,000 pulses (Hz)per second, quieter (avg 2400) Requires acid etching for sealant or composite placement

When ablation hard tissue usually in the are of 12-15 Hz (louder) Requires acid etching for sealant or composite placement

★Absorption of further light energy is negligible in Erbium ablation since the water is transformed to a vapor.

★The plume of ejected material may scatter the Erbium beam but further radiation is not absorbed by the ejected material.

Photonic energy result of Flash Lamp stimulation of dopant with in a solid Quartz crystal

*Numerous papers have been published indication increased enamel resistance to solubility Hydroxyapatitie Ca10 (HA) Position paper March 2007 ALD *

The Erbium beam needs to find a “sweet” reduces the cutting ability

No increase in caries protection

27 years of research on the CO2 laser 9300-9600nm

27 years of research on the CO2 laser 9300-9600nm

Inhibition of caries progression of from 40% to 85% was achieved over the range of laser conditions tested. At 9.3 and 9.6 µm, 25 pulses at absorbed fluences of 1 to 3 J/cm2 produced inhibition on the order of 70% with minimal subsurface temperature elevation (< 1°C at 2 mm depth), comparable with inhibition produced in this model with daily fluoride dentifrice treatments.

Low microsecond-pulsed carbon dioxide lasers with a 9.3- or 9.6-μm wavelength have great potential for efficient and effective ablation of sound and pathological hard tissues, as well as modification of the mineral to increase resistance to caries attack.

CO2 Laser Inhibition of Artificial Caries-like Lesion Progression in Dental Enamel J DENT RES June 1998 77: 1397-1403,

The laser treatment produced 46% demineralization inhibition for the 4week and a marked 87% inhibition for the 12-week arm. This study shows, for the first time in vivo, that the short-pulsed 9.6 μm CO2-laser irradiation successfully inhibits demineralization of tooth enamel in humans. Caries inhibition in vital teeth using 9.6-μm CO2-laser irradiation Author(s): Peter Rechmann; Daniel Fried; Charles Q. Le; Marcia L. Rapozo-Hilo; Beate M. T. Rechmann; John D. B. Featherstone; Gerald Nelson Published: 1 July 2011; 7 pages;

CONCLUSION: Specific microsecond short-pulsed 9.6 µm CO2 -laser irradiation markedly inhibits caries progression in pits and fissures in comparison to fluoride varnish alone over 12 months. Lasers Surg. Med. © 2013 Wiley Periodicals, Inc.

Position Paper: Science and Research Committee, Academy of Laser Dentistry Adopted March 2007 Steven P.A. Parker, BDS, LDS, MFGDP (Committee Chair); Arun A. Darbar, BDS; John D.B. Featherstone, MSc, PhD; Giuseppe Iaria, DMD, PhD; Gabi Kesler, DMD; Peter Rechmann, Prof. Dr. med. dent.; Michael D. Swick, DMD; Joel M. White, DDS, MS; Harvey A. Wigdor, DDS, MS

In-vivo occlusal caries prevention by pulsed CO2 -laser and fluoride varnish treatment-A clinical pilot study. Peter Rechmann, Daniel A Charland, Beate M T Rechmann, Charles Q Le, John D B Featherstone

Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California at San Francisco, 707 Parnassus Avenue, San Francisco, California, 94143. Lasers in Surgery and Medicine (Impact Factor: 2.46). 06/2013; DOI:10.1002/lsm.22141 Source: PubMed

J Laser Dent 2007;15(2):78-86

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Lawrence Kotlow DDS

In my office

Lawrence Kotlow DDS

Using your lasers on hard tissues with Children 1.Sealants 2.Photobiostimulating analgesic effect 3. Preventive resin restorations 4. Class I restorations 5. Class II restorations 6. Class III restorations 7. Class IV restorations 8. Class V restorations 9. Direct and Indirect pulpcaps 10. Crown preps 11. Removal or cutting of bone 12. Can you remove composites and alloy ?

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Changing the Patient experience using the C02 laser @ 9300nm

Reduction in the need for local anesthesia Complete multiple restorative quadrants without the need to have to consider local anesthetic dosages. 2.Effective is due to Photobiomodulation or Low level laser ability 1.

Appears to be almost 100% in primary teeth

E Typical initial settings 75-90 pulse duration, water off. Use the variable power foot control 0 to 30-40% . Limit power (Hz) setting to 30-40 %, .25 spot size. Soft tissue settings less than 70 pulse duration tissue is not heated adequately and may not prevent bleeding. 25

Lawrence Kotlow DDS

Sealants CO2 @9300nm

Tooth analgesia CO2 @9300nm

Typical initial settings Dentin Tissue Choice, 100-125 pulse duration, 15-45 seconds, water on, air on, Power 100%, spot size .5 mm. Use the variable power foot control to adjust percentage of power from 50-100%. Keep all parameters at subablative power. Lawrence Kotlow DDS

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Lawrence Kotlow DDS

Typical initial settings Dentin Tissue Choice, 75-125 pulse duration, water on, air on, Power 100%, spot size .25-.5mm . Use the variable power foot control to adjust percentage of power from 50-100%. Maintain power control to just etch enamel surfaces 27

Lawrence Kotlow DDS

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Class I Restoration CO2 @9300nm

Class I Restoration CO2 @9300nm

Tooth # 19

Typical initial settings Dentin Tissue Choice, 75-250 pulse duration, water on, air on, Power 100% . Initially .5 spot size, finish using .25. Use the variable power foot control to adjust percentage of power from 50-100%. 29

Lawrence Kotlow DDS

Class II II restorations CO2 @9300nm

Tooth # K

Typical initial settings Dentin Tissue Choice, 75-200 pulse duration, water on, air on, Power 100% . Initially .5 spot size, finish using .25. Use the variable power foot control to adjust percentage of power from 50-100%. 31

Lawrence Kotlow DDS

Typical initial settings Dentin Tissue Choice, 75-200 pulse duration, water on, air on, Power 100% . Initially .5 spot size, finish using .25. Use the variable power foot control to adjust percentage of power from 50-100%. 30

Lawrence Kotlow DDS

new

Class IIb restorations CO2 @9300nm

Tooth # T

Typical initial settings Dentin Tissue Choice, 75-200 pulse duration, water on, air on, Power 100% . Initially .5 spot size, finish using .25. Use the variable power foot control to adjust percentage of power from 50-100%. 32

Lawrence Kotlow DDS

C02 9300 nm Class II adult tooth

Class III restoration CO2 @9300nm

Teeth F,G

Tooth # 30

Lawrence Kotlow DDS

Typical initial settings Dentin Tissue Choice, 100-222 pulse duration, water on, air on, Power 100% . .25 -.5 Spot size. Use the variable power foot control to adjust percentage of power from 50-100%. 33

Typical initial settings Dentin Tissue Choice, 75-150 pulse duration, water on, air on, Power 50% . . 25 Spot size. Use the variable power foot control to adjust percentage of power from 0-50%.

Class V restoration CO2 @9300nm

Multiple teeth restored CO2 @9300nm

Teeth E,F,G

Tooth # H

Typical initial settings Dentin Tissue Choice, 75-150 pulse duration, water on, air on, Power 100% . .25 Spot size. Use the variable power foot control to adjust percentage of power from 50-100%. Lawrence Kotlow DDS

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Lawrence Kotlow DDS

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Typical initial settings Dentin Tissue Choice, 75-150 pulse duration, water on, air on, Power 100% . .25 Spot size. Use the variable power foot control to adjust percentage of power from 50-100%. Lawrence Kotlow DDS

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Permanent Anterior tooth Class V Preparation CO2 @9300nm

Typical initial settings 100-140 pulse duration, water 100%,air on, Use the variable power foot control to adjust percentage of power from 50-100%., Spot size varies from .25-.5 as 37 needed Lawrence Kotlow DDS

Posterior Primary Stainless Steel Crown Preparation CO2 @9300nm

Permanent Anterior tooth Class III Preparation CO2 @9300nm

Typical initial settings 90-140 pulse duration, water 100%,air on, Use the variable power foot control to adjust percentage of power from 50-100%, Spot size .25 38

Lawrence Kotlow DDS

Maxillary Frenectomy CO2 @9300nm

Tooth B

Typical initial settings as high as 350 pulse duration, water 100%,air on, Use the variable power foot control to adjust percentage of power from 50-100%., Spot size varies from . 39 25-1mm as needed Lawrence Kotlow DDS

Typical initial settings 75 pulse duration, water off. Use the variable power foot control 0 to 30-40% . Limit power (Hz) setting to 30-40 %, .25 spot size. Soft tissue settings less than 70 pulse duration tissue is not heated adequately and may not prevent bleeding. 40 Lawrence Kotlow DDS

Lingual Frenectomy CO2 @9300nm

Breastfeeding infant with lingual frenum and lip tie BD:11/ 10/13 Surgery 12/30/13

Post surgery exam 1/7/14

Typical initial settings 75-90 pulse duration, water off. Use the variable power foot control 0 to 30-40% . Limit power (Hz) setting to 30-40 %, .25 spot size. Soft tissue settings less than 70 pulse duration tissue is not heated adequately and 41 may not prevent bleeding.

CO2 @9300nm Pulse duration 77/ 40%/.25 spot size

Lawrence Kotlow DDS

Toddler with lingual frenum and lip-tie BD: 12/21/12 Surgery 12/16/13

Maxillary Frenum lip revision BD:1/17/08

Presurgery 12/30/13

Surgery 12/30/13

Post surgery 12/16/13

BD 12/11/07 Surgery 12/12/13

CO2 @9300nm Pulse duration 77/ 40%/.25 spot size

k.paschall

Lingual frenum revision

Post surgery exam 1/7/14

Post 12/20/13

CO2 @9300nm Pulse duration 77/ 40%/.25 spot size

Exposure of tooth under soft tissue CO2 @9300nm

Biopsy CO2 @9300nm

1 week post surgery

6 days post surgery

Typical initial settings 75-90 pulse duration, water off. Use the variable power foot control 0 to 30-40% . Limit power (Hz) setting to 30-40 %, .25 spot size.

Typical initial settings 75-90 pulse duration, water off. Use the variable power foot control 0 to 30-40% . Limit power (Hz) setting to 30-40 %, .25 spot size.

Soft tissue settings less than 70 pulse duration tissue is not heated adequately and may not prevent bleeding. 45

Lawrence Kotlow DDS

McGarry

Lawrence Kotlow DDS

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Thank you for your attention

Lawrence Kotlow DDS

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Lawrence Kotlow DDS

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