The scope for the use of lasers in implant therapy can start right from the planning stages, with the use of all-tissues lasers to help in atraumatic extractions, and socket preservation techniques, as well as being helpful in sinus augmentation procedures. Of course, low level laser therapy can also be a useful adjunct after any of these procedures to help in the healing process (Park et al). In fact, the erbium lasers, being safe and effective on bone, are even used in split-ridge techniques and implant placement. Studies using the Er;YAG have shown greater length of bone-to-implant contact in comparison to bur drilling (Kesler et al), and Er:YAG prepared implant sites have demonstrated comparable healing to that of piezoelectric or drill osteotomy (Stubinger et al). The Er,Cr:YSGG was used to prepare bone beds in pigs, and the implant stability quotient values compared with those of drilling – again, the results were comparable (Lee et al).
However, despite these promising clinical findings, the adaptation of using lasers for implant preparation as routine is not there yet. It is more time consuming than conventional drilling, and it certainly required a skilled operator to avoid the risk of damage to nerves, blood vessels and sinus floor. However, an option can be the use of an erbium laser to condition the osteotomy site after initially using bone drills, and this has been found to improve early stability (Luk & Seto).
Low level laser therapy has been found to lead to faster and increased osteointegration of implants in animal studies (Omasa et al, Khadra et al). An interesting review article on the subject of PBM around implants has been published by Tang and Arany 2013.
Socket Preservation using Er,Cr:YSGG to degranulate and decontaminate the socket (Glen Van As)
All the laser wavelengths can be used to uncover implants prior to restoration. This obviously has the advantage of a bloodless field, and so the impression can be taken on the same day. Other advantages include a precise cut and subsequent rapid healing with less pain and soreness. Of course, this is all dependent on using safe and effective parameters that minimise bleeding but avoid excess thermal damage to the tissues. However, it should be noted that the Nd:YAG laser can damage the titanium surface, causing pitting and melting, and so if being used in exposure, needs to be done so with great care.
Diode laser being used for final soft tissue contouring prior to cementation of implant retained crown (Glen Van As)
Implant treatment and preparation of hard and soft tissues using Er:YAG and diode (Walid Altayeb)
Peri-implantitis is a destructive inflammatory condition initiated by bacterial insult. Subsequent biofilm formation and the activation of inflammatory cells and release of inflammatory mediators and cytokines then lead to destruction of the surrounding tissues, with soft tissue inflammation and progressive loss of supporting bone beyond that of biological bone remodelling. Risk factors contributing to peri-implantitis include patients with active periodontitis or a previous history of periodontitis, smokers, poor plaque control or inability to clean effectively, residual cement, and also possibly occlusal factors, genetics, diabetes, alcohol consumption and rheumatoid arthritis.
The prevalence is estimated to be 10% of implants and 20% of patients during 5-10 years after implant placement (Mombelli). To date, there is not consensus on how to treat peri-implantitis. Numerous case reports and clinical trials have demonstrated efficacy, or not as the case may be, of a vast number of protocols and technologies, ranging from cleaning implant surfaces with cotton pellets and water to the use of air-abrasion systems and systemic antibiotics. Some have obviously been found to be more effective than others, but as yet, there is no one protocol that is considered gold standard.
Lasers have had mixed reviews in the literature – some showing efficacy and benefit, and others not so much. There is a great deal of literature on the use of CO2 lasers, which has certainly been shown to be effective in decontamination and minimal damage to the implant surface. Generally, morphological changes are not common in safe parameters due to the high reflection rate of titanium to wavelengths of around 10um, although there is a risk of temperature increase and carbonisation of adjacent bone. Melting and other surface changes can of course arise, particularly in super-pulsed mode(Schwarz et al 2009). Diodes can be used as a bactericidal tool, either directly (non-contact mode) or with the use of a photosensitizer (PDT); however, heat can be an issue with the former, and so care of course is needed to avoid an increase in bone temperature. The Nd:YAG laser has almost been consistently found to result in pitting and melting of the implant surface and a risk due to temperature rises, although there is a manufacture- based protocol currently being marketed, with no clinical trial to date to back it up (LAPIP), but certainly showing some cases of bone fill around the implants in this flapless surgical procedure. Diodes and Nd:YAG, with their beneficial low level laser effects could certainly prove useful after surgical management of peri-implantitis to promote healing and re-osteointegration.
Radiographs showing bone fill following LAPIP procedure (G Van As)
Surgical treatment of Peri-implantitis using Er,Cr:YSGG laser (R Al-Falaki)
Lastly, the erbium lasers (Er:YAG and Er,Cr:YSGG), are potentially the most useful in their ability to raise flaps, remove granulation tissue, remove biofilm calculus, and cement from the implant surface and decontaminate the implant surface with no surface damage and minimal temperature rise, again within certain safe parameters and with use of water spray. The use of radial firing and side-firing implant tips available with the Er,Cr:YSGG may allow for flapless access (minimally invasive surgery) and has been shown to be an effective treatment protocol in some cases. As with all procedures and protocols, good training and education are paramount to the safe and effective use of lasers.
Treatment of an abscess around an implant (R Al-Falaki)
Peri-implantitis treatment using Er,Cr:YSGG and end-firing tips (R Al-Falaki)
Flapless treatment of peri-implantitis using radial firing tip
Diode (810nm) being used as part of peri-implantitis treatment protocol to decontaminate pocket (Glen Van As)