54 The Dentist April 2010
equipment
Restorative applications
Mark Cronshaw reviews the effectiveness of a new laser.
A
mong the many clinical uses
of the latest type of Erbium
all tissue lasers is the ability
to prepare cavities and cut enamel,
dentine and composite. Historically
lasers used for these applications
have been associated with adverse
thermal effects and relatively slow
rates of cutting. These problems have
now been successfully overcome:
by use of an appropriate wavelength
(2780-2940nm) the Erbium lasers cut
by virtue of the expansive power of
water rather than by heat coagulation
or carbonisation. By exposing the
target tissue to a laser wavelength
that activates the water and hydroxyl
groups present the tissue is efficiently
The water spray acts as a coolant
so there is no charring or any
adverse thermal effects.
broken apart. The schematic in the
figure illustrates this process which
is described technically as ablation.
Once exposed to the laser the water
and hydroxyl element of the tissue
becomes highly agitated such that
there is a volumetric increase of
1600x in a fiftieth of a second. The
exploding pockets of water drive the
tissue apart without any significant
thermal damage to the tissues. In fact
research shows as opposed to the
laser irradiated tissues being heated
up there is actually a degree of local
cooling, and there is significantly
less local heat generated than a
Mark Cronshaw
is a private practitioner in
Cowes, Isle of Wight.
conventional turbine.
The Erbium lasers also
incorporate a water
spray which provides
additional water for the
laser to target in tissues
with a low water content
such as enamel; this
water spray also acts
as a coolant so there
is no charring or any
adverse thermal effects.
This is a significant
advance over earlier
generations of lasers
which were associated
with considerable heat
generation resulting in
poor clinical results.
There are many clinical
benefits to using an
Erbium laser to cut dental
tissues not the least of
which is the ability to cut
many cavities without a
local anaesthetic. In part
this is due to the absence
of vibration as the laser
lThe Waterlase MD has a 2780nm laser wavelength which
is a non-contact cutting stimulates water and hydroxyl molecules. The resultant rapid
instrument. Also the zone expansion of the water breaks the tissue apart. This is highly
of destruction is tightly localised so there is no thermal trauma.
confined as the laser
beam is highly focussed, laser to use as it achieves peak
so the trauma to the adjacent vital power for the shortest duration at
tissues is minimal. In addition, the the optimum wavelength (2780nm).
laser has a profound physiological In consequence, sensitivity is less
effect on the pulpal tissues which frequently a problem in comparison
has an analgesic effect. The typical to the other machines on the market.
patient experiences at most slight Even in inexperienced hands at
cold sensitivity which is probably least half of all small to medium
due to the coolant water spray. sized cavity preparations can be
There are limitations to what can be comfortably achieved without LA with
reasonably achieved without a local the Waterlase MD and with training
anaesthetic and success relies on a and practise this rises easily to 80
proper understanding of how best to per cent. Many patients intensively
operate the laser. Due to differences dislike the drill and/ or an injection
in the technical profile of the machine and practices that have incorporated
the Waterlase MD is the best Erbium the laser attract many new patients
 57 The Dentist April 2010

equipment

and are growing despite the current recession.

Lasers do not cut through amalgam or other metals and
a further limitation is they do not ablate glass ionomers.
They do however have a high affinity for composites
and this offers a big advantage over conventional
rotary instruments as the composite goes white as it is
denatured and as a result it is easy to see the boundary
between where an old composite remains and the
sound tooth tissue begins. I find this especially useful
when removing old luting cement in veneer re-treatment
cases and I use the laser to take the old veneers off.
I can preserve the maximum amount of underlying
sound enamel and also be sure I have removed all of
the old cement so I have an optimum bond site for the
replacement restorations. I find this application particularly
useful when removing old fibre glass and composite
periodontal splints, removing residual luting cements and
orthodontic brackets.
The lasered tooth tissue is an ideal bonding site as
the dentine is left without a smear layer and any enamel
is pristine clean. Providing the cut surfaces are finished
at the correct settings there are no issues with sub-
surface cracking. By comparison when one applies a
In crown and bridge work it is convenient to trough
the gingival sulcus prior to taking impressions.

turbine to a tooth there is very considerable trauma to

the tissues caused by mechanical vibration. If a burr is
blunt or there is any wear in the handpiece cartridge the
drilled tooth surfaces can be thermally damaged and
micro-fractured. This can result in a cusp fracture at the
time of cavity preparation which is a complication which
most experienced practitioners will have experienced
at one time or another. Laser cut tooth surfaces avoid
these problems and as a result there is little if any post
treatment sensitivity plus the mechanical integrity of the
tooth is not accidentally compromised.
The Waterlase MD is an all tissue laser so amongst the
many advantages of using it in restorative dentistry is the
ability to switch applications between cutting hard and soft
tissues. Cavities often extend sub-gingivally or there may
be hypertrophic tissue to remove. At a touch of a button
the laser can be reset into soft tissue settings which allow
the rapid effective and highly accurate removal of any soft
tissues that are in the way. These cut tissues do not bleed
so it is possible to complete bonding procedures without
any contamination. If more extensive crown lengthening
surgery is required it is easily achieved with the minimum
amount of fuss. As a matter of routine I use a Cerec
3D in my practice and I frequently find myself switching
between cavity preparation and crown lengthening, all
with the same laser tip; I merely switch settings between
hard and soft tissues. In crown and bridge work it is
Reader Enquiry 11
 61 The Dentist April 2010

equipment

convenient to trough the gingival sulcus prior to

taking impressions. This saves a lot of time as it is
not necessary to use retraction cords to obtain clear
margins on the impressions. In this application the
laser is used to create a trough in the gingival sulcus
allowing the flow of the impression materials to clearly
demarcate preparation margins. Post treatment the
lasered gingival tissues heal without any recession.
One obstacle to the uptake of lasers by dentists
for restorative work has been the speed of the cuts
as historically the drill has been faster. The latest
generation of lasers however now cuts as fast as a
conventional turbine and it is even possible to cut
crown preparations if desired. A striking case example
of this can be found on the Biolase website at www.
biolase.com/clinical.php where a case is presented of
a full mouth reconstruction by Mark Colonna: 28 units
of full ceramic crowns prepared and fitted all on the
same day using lasers and CADCAM, without a local
anaesthetic. Of course this called for a high degree

My clinical preference is to use the laser more for

its outstanding surgical applications.

of operator skill. There is also the issue of operator

preference as at the end of the day the laser is merely
a tool and most experienced clinicians prefer to stick to
the more familiar armamentarium out of habit. Faced
with a patient who is severely medically compromised
and unable to have a local anaesthetic or is a drill and
needle phobe the possibility of using the laser as an
alternative is there if desired, and a lot can be achieved
as is admirably demonstrated by the case previously
described.
The clinical experience of cutting tissues with a laser
is entirely different to the standard turbine as there is
no physical contact with the target tissue. It is advisable
to use high powered loupes and to have appropriate
training to achieve good consistent results. This is a
mature technology with a considerable body of clinical
experience particularly from the US where there are
currently over 3,500 Waterlase MD units in practices
today. As a mature practitioner I am very comfortable
using the standard turbine due to its familiarity for
restorative treatment and my clinical preference is
to use the laser more for its outstanding surgical
applications. However this is a patient and market led
revolution and without doubt the restorative applications
of the all tissue Erbium lasers will become a common
feature of clinical practice in the UK.

For more information visit www.henryschein.co.uk or

www.biolase.com
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