Top Ten Myths About CO₂ Dental and Surgical Lasers Used For Frenectomies

Article in review:
Incision and Coagulation/Hemostasis Depth Control During a CO₂ Laser Lingual Frenectomy
by Cara Riek, DNP, RN, FNP-BC, IBCLC, and Peter Vitruk, PhD, MInstP, CPhys

Dent Sleep Practice. Spring 2018:32-38.

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Myth #1: The CO₂ laser is too powerful for dentistry or surgery.

The electromagnetic spectrum illustrates that the CO₂ laser wavelength (10.6 micrometers) actually carries less energy per quant than any of the other wavelengths used in dentistry. However, water molecules absorb this wavelength extremely well and, since oral soft tissue is 70-90% water, the CO₂ laser wavelength is the one best absorbed by soft tissue. This means that the CO₂ laser isn’t the most powerful, but instead has a highly efficient wavelength for use in soft tissue in dentistry and surgery.

Myth #2: CO₂ lasers are not different from other lasers e.g. NIR diode lasers.

As can be seen from Figure 3 in the article, both Erbium laser (approx. 3,000 nm) and CO₂ laser (approx. 10,000 nm) wavelengths are highly efficiently absorbed by the soft tissue and are efficient at cutting and ablating the soft tissue purely radiantly (non-contact). At the same time, diode lasers (approx. 800-1,100 nm) are highly inefficiently absorbed by the soft tissue and, therefore, cannot be used radiantly (non-contact) for cutting and ablating the soft tissue. Near-IR diode laser light circa 1,000 nm is not used to optically ablate the oral soft tissue; instead, the diode laser optical energy is used to heat up the charred distal end of the fiber glass tip to 500-900ºC which then heats up the soft tissue through heat conduction from hot glass tip: soft tissue is burned off on contact with the hot charred glass tip, while the margins of the burn are coagulated. Unlike non-contact surgical lasers (such as CO₂ or Erbium), the soft tissue ablative diodes are contact thermal non-laser wavelength-independent devices.

Myth #3: There is nothing a CO₂ laser can do that can’t be done with a scalpel.

A combination of the CO₂ laser wavelength, and SuperPulse settings, and tightly focused laser beam allows for a char-free and bloodless surgery with sub-100 µm coagulation/hemostasis depth, which closely matches the blood capillary diameters. It allows for instant hemostasis during high-speed ablation and cutting. It affords the clinician with the improved visibility of the surgical field and therefore allows for more precise and accurate tissue removal with highly controllable speed and depth of incision with a dynamic range from micrometers to millimeters (the depth is proportional to laser power and inversely proportional to laser beam diameter and hand speed).

Myth #4: There is no difference between CO₂ lasers and scalpel as far as post-operative pain and healing.

Healing with the CO₂ laser is markedly different from the other surgical modalities such as scalpel (scissors), it is uncomplicated and predictable and with minimal post-operative pain, discomfort, and swelling, significantly reduced post-surgery production of myofibroblasts, diminished wound contraction and scarring.

Myth #5: CO₂ lasers are not different from other lasers e.g. Erbium and Er:YSGG lasers.

For Erbium and Er:YSGG laser wavelengths, the optical absorption and coagulation depths are significantly smaller than blood vessel diameters; coagulation takes place on relatively small spatial scale and cannot prevent bleeding from the blood vessels severed during tissue ablation, which is not acceptable for soft tissue laser surgeries. The key to the success of soft tissue lasers is their ability to cut and coagulate the soft tissue at the same time, which makes many soft tissue procedures much simpler and far more enjoyable for practitioners: consider bloodless laser blepharoplasty or laser frenectomy, etc. performed by modern-day surgical CO₂ lasers with sub-100-µm coagulation depths that extend just deep enough into a severed blood vessel to stop the bleeding.

Myth #6: Lingual frenectomies with CO₂ laser are as efficient as with diode.

A reported case study in this article, the patient had initial tongue-tie release two years before, with a diode hot tip (technically not a laser procedure) and the tongue restriction returned with the bunching scar tissue. A year after the diode frenectomy, she had an arthrocentesis of the TMJ by an oral surgeon due to pain and damage of the joint. She reported that the minimal relief from the procedure did not last long. The surgeon encouraged continued stretching to keep the jaw opening at 44 mm. Since the procedure, she continued stretching and noted the ongoing reduction in the jaw range of motion; and at the time of the tongue-tie release in Dr. Riek’s office, the jaw opening measurement was at just 36 mm. Immediately after the tongue-tie release with LightScalpel CO₂ laser, the patient could open her mouth to 46 mm. With postoperative OMT exercises, chiropractic care, and CST work from a trained professional, the patient was able to open the jaw to 52 mm. Her Mallampati score changed from II/III (pre-release) to I/II (post-release followed by OMT).

Myth #7: CO₂ lasers are too difficult for fine tissue procedures in highly vascular tissues, such as lingual frenectomies.

A reported case study in this article, the entire laser procedure took approximately 20 seconds with a few stops. There was no bleeding, despite the fact that the area is heavily vascularized. With the above-stated laser settings, the incision with a 0.25 mm diameter focused laser beam is only 0.3 mm – 0.4 mm deep. Such shallow incision depth, combined with sub-100-µm coagulation depth, allows for excellent and progressive visualization of larger diameter blood vessels. Due to the shallow depth of incision, multiple laser passes are needed to complete the required depth of the incision in a safe and controlled fashion.

Myth #8: Purchase an “all tissue laser” instead of a CO₂ laser.

The so-called “all tissue laser” terminology does not apply outside dentistry. Indeed, Erbium lasers are best suited for hard tissue, but not for the soft tissue due to very limited hemostasis ability. Diode lasers are best suited for deep coagulation but are far from being useful for radiant non-contact incisions. Only the CO₂ lasers are able to cut and coagulate the soft tissue efficiently at the same time, with sub-100-µm coagulation depths that extend just deep enough into a severed blood vessel to stop the bleeding.

Myth #9: CO₂ lasers always char tissue.

In the 1980s, when the CO₂ laser surgery was in its infancy, the original CO₂ laser temporal emission modes were either CW or gated pulse. The SuperPulse mode, invented in the 1990s, features high peak power and fast pulsing, so CO₂ lasers no longer deliver long pulses of laser energy that can overheat and char tissue. SuperPulse CO₂ lasers minimize collateral heating of adjacent tissue and speed the healing process.

Myth #10: All lasers, including CO₂, are too expensive.

Simple ROI math easily overturns this myth. Try our ROI calculator.

References

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2. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014: 7:6. pp. 19-27.
3. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003:103:2. pp. 577-644.
4. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. Incision properties and thermal effects of three CO₂ lasers in soft tissue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):685-91.
5. Willems PWA, Vandertop WP, Verdaasdonk RM, van Swol CFP, Jansen GH. Contact laser-assisted neuroendoscopy can be performed safely by using pretreated ‘black’ fibre tips: Experimental data. Lasers in Surgery and Medicine. 2001;28(4):324-9.
6. Vitruk P. Laser Education, Science and Safety – A review of dental laser education standards. Dentaltown. 2017 June;17(6):62-67.
7. Wuertz K, Vitruk P. Superpulse 10,600 nm CO₂ Laser Revision of Lingual Frenum Previously Released with a Diode Hot Glass Tip. Dent Sleep Practice. Winter 2017:40-42.
8. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004:48(4):861-888.