|Year : 2021 | Volume
| Issue : 5 | Page : 19-22
Lasers in maxillofacial surgery – Review of literature
Khadar Vali Shaik1, Mohammed Ibrahim Nazal Alanazi2, Rakan Menwer Albilasi2, Bader Falah Arqoub Albalawi2, Faris Alturqi Alruwaili2
1 Registrar Maxillofacial Surgery, Gurayat Health Affairs, Ministry of Health, Al Qurayyat, KSA
2 General Dental Practitioner, Gurayat Health Affairs, Ministry of Health, Al Qurayyat, KSA
|Date of Submission||27-Oct-2020|
|Date of Acceptance||30-Oct-2020|
|Date of Web Publication||05-Jun-2021|
Khadar Vali Shaik
Registrar Maxillofacial Surgery, Gurayat Health Affairs, Ministry of Health, Al Qurayyat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The availability of different wavelengths of lasers has created a surgical panacea in the last decade and laser technology has become the standard of care for many oral and maxillofacial surgical procedures. In this article, based on literature search, we have reviewed the usage of laser in maxillofacial surgery based on the current evidence available on laser-assisted maxillofacial surgery, in PubMed database.
Keywords: Laser, maxillofacial surgery, oral lesions
|How to cite this article:|
Shaik KV, Alanazi MI, Albilasi RM, Albalawi BF, Alruwaili FA. Lasers in maxillofacial surgery – Review of literature. J Pharm Bioall Sci 2021;13, Suppl S1:19-22
|How to cite this URL:|
Shaik KV, Alanazi MI, Albilasi RM, Albalawi BF, Alruwaili FA. Lasers in maxillofacial surgery – Review of literature. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Nov 30];13, Suppl S1:19-22. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/19/317645
| Introduction|| |
Several types of lasers are currently used in oral and maxillofacial surgery (OMFS). The effects of laser beam on biological tissue depend on the wavelength of the monochromatic light that can be reflected, scattered, or absorbed. Different components of biological tissue absorb light from different wavelength regions, followed by a deposition of energy in the tissue. Several types of laser are used in OMFS, depending on the range of their wavelength and their concomitant absorption by biological chromophores, for example, water and hemoglobin, the lasers are used for different clinical aspects.
CO2 and Er:YAG lasers are mainly absorbed by water, resulting in a minimal penetration depth and fast heating, with effective removal of soft and hard tissues. CO2 lasers are mainly used as laser scalpels for the excision of tumors from soft tissues. In a defocused mode, CO2 lasers are used for superficial tissue vaporization, to treat precancerous lesions in the oral cavity. The Er:YAG laser seems to be a highly efficient tool for cutting both soft and hard tissues with minimal damage to the surrounding tissue. Nd: YAG lasers emit light at a wavelength of 1064 nm, which is in between the absorption maxima of water and blood. The penetration depth is therefore deeper than that of CO2 or Er:YAG lasers and may reach 4 mm, with the possibility of a larger zone of damage to the surrounding tissue. However, due to a higher potency of coagulation, Nd: YAG lasers are recommended for tissue resection in the cases of hemorrhage. Nd: YAG lasers are used for the excision of cancer in a focused mode as well as for the removal of precancerous lesions in a defocused mode.,,
| Principles of Laser Physics for Oral and Maxillofacial Surgery|| |
Albert Einstein in 1917 explained the mathematical relationship of three atomic transition processes, as follows: (1) stimulated absorption, (2) spontaneous emission, and (3) stimulated emission (George et al., 1993). Einstein postulated that light energy can induce energy transition in atoms to move from their ground state to excited stage/activated stage. This is due to the absorption of a quantum of energy called “stimulated absorption.” Because the lowest energy state is the most stable, the excited atom tends to return to normal by spontaneously emitting a quantum of energy called spontaneous emission.
Soft-tissue surgery with a laser is deceptively simple, but grave consequences can result if the principles of appropriate laser physics, beam modulation, and beam delivery are not integrated carefully into the procedure. The most commonly used lasers are the CO2 and Er:YAG, which are absorbed primarily by water. Absorption into the target tissue results in the following four effects:, photo acoustic, photo chemical, photo ablation, and photo thermal.
Gooris et al. emphasized no development of squamous cell carcinoma in the CO2 laser-treated area. Selective removal of the affected epithelium with minimal damage to the surrounding structures is possible using CO2 laser evaporation, followed by excellent wound healing and good functional result. The recurrence rate is low (14.8%) compared with the recurrence rate after surgical excision.
Basically, there are three photothermal techniques for laser use on soft tissues within the oral cavity and on the face, namely incisional procedures, vaporization procedures, and hemostasis.
Incisional and excisional procedures
The technique of using laser to make relatively deep, thin cuts much as one would do with a scalpel blade allows the surgeon to perform almost any intraoral procedure such as incisional or excisional biopsy, lesion removal, or incision for flap access. It is generally ideal to keep the spot size to whatever is the smallest practical spot size possible with a particular laser (usually 0.1–0.5 mm) because this results in the thinnest cut, closely replicating the cut made with a standard scalpel blade.,,
It is always a good idea to begin the procedure by outlining the intended incision line. This outlining can be done on most machines by using an intermittent, pulsed, or gated mode with a rate of 10–20 pulses per second and a low enough fluence per pulse to allow for a superficial mark on the surface of the target without deep penetration. When this procedure is completed, the laser can be changed to a continuous mode, and the dots are connected to create the desired incision. If a single pass is inadequate to obtain the desired depth, a second pass can be performed and repeated as necessary until the appropriate depth is reached, usually the submucosa for most oral lesions.,,,
Closure of incisions and excisions performed with a laser is often at the discretion of the surgeon. Because usually bleeding and scarring are minimized, and postoperative pain does not seem to be related to closure, sutures are absolutely required only for cosmesis, when leaving the wound to granulate slowly would present an unacceptable cosmetic situation. Typical lesions treated by excision and incision and other approaches include the following: fibroma, mucocele, papilloma, gingival lesions, benign salivary gland lesions, salivary stones, malignancy removal, incisional biopsy, excisional biopsy, vestibuloplasty, epulis fissurata, hyperplastic tissue, implant uncovering, peri-implantitis, laser-assisted uvulopalatoplasty, and tongue lesions. Ozen et al. used a photon-plus gallium-aluminum-arsenide diode laser (low-level laser [LLL]) system for a reduction of long-standing sensory nerve impairment following third molar surgery.
Laser excision is most desirable for any solid, exophytic-type lesion. It also yields excellent results in tissue removal for preprosthetic surgery because of the improved visibility and precise control of tissue removal afforded.
Ablation and vaporization procedures
Tissue ablation (also called vaporization) is used when the surgeon wishes to remove only the surface of the target or to perform a superficial removal of tissue. In these situations, the lesion usually is confined to the epithelium or to the epithelium and the underlying superficial submucosa. Standard excision generally leads to removal of tissue deeper than necessary with increased scarring and bleeding, and possible damage to important adjacent structures. Ishii et al. observed that management of oral leukoplakia with this technique prevents not only recurrence and malignant transformation but also postoperative dysfunction. Chaudhary et al. (2011) reported a case of oral submucous fibrosis (OSMF) which is treated with laser (ErCr: YSGG), and this case report highlights the possibility of the first use of this cold laser for treating a moderate case of bilateral OSMF.
During apicoectomy, the apex is exposed by a standard bur or by Er:YAG laser, and then the periapical soft tissue can be removed with the CO2 laser rather than curetted with hand instruments. The standard technique of defocused ablation is used. If the CO2 laser interacts with bone, this may result in minute amounts of necrosis, but is negligeble in comparison with the excellent removal of tissue remnants possible with this technique. For larger surface lesions, such as leukoplakias, histologic diagnosis is best accomplished using multiple biopsy specimens or toluidine blue staining.
Typical lesions treated by vaporization include the following: leukoplakia, dysplasia, lichen planus, papillary hyperplasia, hyperkeratosis, oral melanosis, nicotine stomatitis, papillomatosis, tissue hyperplasia, and actinic cheilitis. Laser vaporization is an effective, nonmorbid, inexpensive, quick, and relatively painless method of managing premalignant lesions.,
Lasers generally result in bloodless surgical fields. The cause of hemostasis is not coagulation of blood, but rather the contraction of the vascular wall collagen. This contraction results in constriction of the vessel opening and hemostasis. It is incumbent on the surgeon to ensure a saliva-free field before beginning lasing of the tissue for hemostasis.,
| Dental Implants|| |
Lasers have been proving to be a valuable tool, with multiple applications for implant surgery. Its unique properties offer significant advantages for soft-tissue management surrounding dental implants, including improved control of possible hemorrhage, less mechanical trauma to the soft and hard tissues, prevention of local infection, less postoperative inflammation and pain, improved healing, and decreased risk of postoperative bacteremia.
As the use of lasers in implant dentistry has grown, much concern has been raised regarding the hazards of laser applications. Thermal damage also has been implicated in implant failures with adjunctive laser surgery. Er:YAG laser produced preparations with regular and sharp edges, without bone fragments and debris, in a shorter time, and with less generated heat. Thermal alterations in the treated surface were minimal.,,
| Temporomandibular Joint Disorders|| |
LLL therapy (LLLT) is suggested for the management of temporomandibular joint disorder through its analgesic, anti-inflammatory, and biostimulative effects. Even though the mechanism of analgesic effect of LLLT is not well understood, it is thought that increased pain thresholds through the alteration of neural stimulation and firing pattern and the inhibition of medullary reflexes are involved. Infrared laser is effective for reducing pain and tension in masticatory muscles, especially in the cases of trismus.
| Vascular Malformations|| |
Crisan et al. conducted a study to evaluate the efficacy of 980-nm diode laser and Er:YAG laser for photocoagulation treatment of oral and maxillofacial hemangioma and vascular malformations. The range of reduction in size varied between 45% and 95%, and no complications or reperfusion of the lesions was noted. The authors stated that photocoagulation with diode laser or Er:YAG laser of hemangioma and vascular malformations is an effective treatment for correctly selected patients and concluded that when properly applied, these techniques can achieve reduction in the size of these lesions without compromising function and cosmetics.
Vensnaver and Dovsak demonstrated that if used properly, Nd: YAG laser is a safe and effective tool for the treatment of large vascular lesions.
| Cosmetic Laser Surgery|| |
A common procedure performed in cosmetic laser surgery is cosmetic skin resurfacing. This procedure treats facial lesions and skin wrinkles by removing the surface layer of the epidermis and superficial papillary dermis, contracting the dermal collagen and allowing the skin to epithelialize in a more uniform manner. Lisa et al.'s cosmetic implications in the treatment of photo-aging and facial rejuvenation and CO2 and Er: YAG laser resurfacing have generated much interest. It has replaced dermabrasion and medium and deep chemical peels in many clinical settings. The best technique or combination of techniques for any given treatment will depend on the judgment and experience of the skilled clinician. Neukam introduced the use of lasers in tumor surgery, which has several advantages: Remote application, precise cutting, hemostasis, low cicatrization, reduced postoperative pain and swelling, can be combined with endoscopic, microscopic and robotic surgery. Healing occurs rapidly without scarring, even if the entire epidermis of the face is removed. Examples of cosmetic and facial dermatologic uses of the laser include the following: epidermal nevi, tissue tags, lentigines, seborrheic keratosis, superficial pigmentation, solar cheilitis, skin wrinkles, blepharoplasty, endoscopic brow lift, and scar revision.,,
| Head-and-Neck Tumors|| |
These lesions may be especially amenable to photodynamic therapy (PDT) because they are likely readily accessible to illumination with the current laser technology, and treatment of multiple primary tumors can be easily managed. There is currently sufficient experience so that indications for PDT can be proposed. It appears that the treatment of large tumors is not feasible, but possibilities for eradication of widespread preneoplastic and neoplastic tissues are appealing. Successful therapy of intralaryngeal and upper digestive tract sites has been reported, with excellent response rates.
| Hazards of Laser Surgery|| |
Because the clinical lasers photovaporize or photocoagulate tissue, they all have the potential to damage the eye.
The most common mishap occurs when the laser operator's or assistant's hands pass in front of the working laser beam, causing a burn.
Special care must be taken to prevent the tube from coming into contact with the laser during surgery because ignition of the endotracheal tube produces a tire with a blowtorch effect inside the patient's airway.,,
Of all the laser surgical-related hazards, electrical hazards have the greatest potential to be lethal, with reports from several facilities since the initiation of the use of lasers in surgery.,,
One of the few negative aspects of using lasers in surgery is the resulting smoke or laser plume – a by-product of laser surgery. The laser plume is primarily composed of vaporized water (steam), carbon particles, and cellular products, which combine to produce a malodorous scent. This smoke has been found to be irritating and toxic to those operating room personnel who come in contact with it.,,,
| Conclusion|| |
Lasers have not only allowed surgeons to enhance the current surgical options for treatment, but also contributed to the evolution of a variety of new procedures that are now common place in OMFS. Advances in laser technology undoubtedly will yield new procedures and have a major role in the future of minimally invasive surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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