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ARTIC LE REPRINT VOL. 37 NO. 9

CONTINUING EDUCATION 1

LASER VESTIBULOPLASTY

Use of a 10,600-nm CO2

Laser Mandibular Vestibular Extension in a Patient With a Chromosomal Abnormality Robert Levine, DDS; and Peter Vitruk, PhD, MlnstP, CPhys, DABLS

Abstract: Vestibuloplasty involves a series of surgical procedures designed to

restore alveolar ridge height by lowering the muscles attached to the buccal, labial,

and lingual aspects of the jaws. The technique is indicated in cases of insufficient

vestibular depth that may result from atrophy ofthe alveolar r idge and/ or high

attachment of muscle or movable mucosa. This article focuses on a carbon eli­

oxide (CO) laser vestibular extension procedure performed in a patient with

Klinefelter syndrome, which is caused by a chromosomal abnormality. The

10,600-nm C02

laser is shown to offer several advantages over a conventional

scalpel and other laser wavelengths for soft-tissue pre-prosthetic surgery, in­

cluding vestibular extension.

LEARNING OBJECTIVES

• describe the purpose

and characteristics o f

vestibuloplasty

· discuss the significance

of laser wavelength, laser

pulsing, laser beam spot

size, and power density

for soft-tissue surgery

· explain the advantages of

a C02

laser fo r soft-tissue

surgery

·describe the difference

in wound-hea ling

mechanisms

DISCLOSURE: Peter Vitruk, PhD, is an owner of Luxarcare, LLC, and

LightScalpel, LLC.

S oft-tissue pre-prosthetic surgery encompasses a number of procedures, such as epulis and denture hyperplasia removal, soft-tissue tuberosity reduction, frenectomy, vestibular deepening, and others. This ar­ticle focuses on a carbon dioxide (C0

2) laser vestibular

structures to preserve the function of the tongue and oropharyn­geal musculature.' The main goal ofvestibuloplasty is to enlarge the denture-bearing area and to ensure the comfort, function, and stability ofthe denture.

A sufficient amount of alveolar bone should be present. extension procedure performed in a patient with Klinefelter syn­drome, which is caused by a chromosomal abnormality.

Sometimes the severity of the alveolar bone resorption makes deepening of the vestibule impossible. In such cases, a bone graft may be required. Among other factors precluding vestibular deep­ening are the condition, amount, and/ or composition of the mucosa. When extensive resorption ofthe mandible or maxilla occurs, the amount of stable surface bone may be insufficient to allow for an ad­equate denture to be made. Muscles in the mandibular such as the mylohyoid and genioglossus can interfere with the stability of the lower denture. In cases of poor mucosa condition, soft-tissue au­togenous grafting or allografting may be necessary.2 Vestibuloplasty performed with grafting is associated with munerous postsurgical complications. Moreover, the need for a graft makes certain surgi­cal modalities inapplicable for vestibular deepening (ie, grafts do

Vestibuloplasty is defined as any of a series of surgical procedures designed to restore alveolar ridge height by lowering the muscles at­tached to the buccal, labial , and lingual aspects ofthejaws.1 This pro­cedure is indicated in cases of insufficient vestibular depth that may result from atrophy ofthe alveolar ridge and/ or high attaclunent of muscle or movable mucosa.2

•3 Most vestibuloplasty techniques

involve vestibular deepening on the buccal-labial side of the man­dible. In some patients with severe alveolar bone resorption or high genioglossus and mylohyoid musculature attachment, the floor-of-the-mouth procedure could increase the lingual vestibular depth. In this case, extra attention should be paid to the underlying

l COM PENDIUM September 2016 - ARTICLE REP HI NT Volume 37, Number 9

CONTINUING EDUCATION 1 I LASER VESTIBULOPLASTY

FIGl .

Absorption Spectra

10,000 -

E ~ ~

~ 1,000 u

;;::: "-<lJ 0 u c 0

Soft-t issue coagu lation by C02

lasers is 10 t imes more effic ient than by erb ium lasers.

~ 100

Soft-ti ssue ab lat ion (excision, inc ision) by C0

2 lasers is 1,000

ti m es more e ffi cient than ._-t-~-------f-------'\"7'"-------------,p-----:-::-

0 Vl .0 <(

Vl

d iode lasers . 9,300-nm C0

2 10,600 -n m C02

~ 0 .r. Q. 0 E e

- Absorption by Hb 10 - "---·1\------------+-- l----f---------------i @ 1SOg/ L; Blood @ 10% in soft tissue

.r. u c co 2: aj ::J Vl Vl

1-...., 0 (/)

o.1 L I I I

- Absorption by Hb02 @ lSOg/L; Blood @ 10% in soft tissue

- Absorption by HbO @ 7S% concentration in soft tissue

1,064-nm diode & Nd:YAG

I I 500 1,000 1,500 3,000

W ave lengt h, nm

5,000 9,000 10,000

Fig 1. A n arti st 's interpretation o f optica l absorp tion coeffi c ient sp ec t ra at d iffe rent histo log ica lly relevant concentrat ions o f wa ter, hemog lo­b in ( Hb) and oxyhem og lobin. Loga rithm ic sca les are in use.

not take on lasered epithelium, likely due to the insufficient exudate for nourishing the graft5).

Prior to the vestibular procedure, taking a thorough history and performing a physical examination (visual, palpation, and radio­graph) are necessary. Factors the clinician should consider include the patient's age, physical condition, family history, the amount and condition ofthe mucosa and underlying bone, and placement and tension of adj acent muscul ature.

Surgical Modalities Traditionally, vestibular extension has been performed with a scalpeJ.l·4•6 NeckeF conducted a study comparing scalpel and C0

2

laser vestibuloplasty. The results of the study indicated that both techn iques ensured good vestibular depth gain. However, the pa­tients receiving treatment with the C0

2 laser reported less pain and

discomfort postoperatively than those receiving treatment \vith the scalpel.

In another shtdy, Haytac and Ozcelik8 compared patient percep­tions after frenectomies performed with the C0

2 laser and scalpel

techniques. Patients perceived the C02 laser surgery more positively in terms of postoperative pain and function than traditional scal­pel surgery. The article concluded that "the C0

2 laser offers a safe,

2 COM PE N D! M Se1He mbe r 2016 - ARTI CLE RE PRI NT

effective, acceptable, and impressive alternative" to the scalpeJ.S In the present authors' opinion, one of the disadvantages of a scalpel procedure compared to a C02 laser is intraoperative hemorrhage that needs to be managed.

In the past, electrosurgery has also been used fo rvestibuloplasty,9 but no modern sh1dies support the use of this modality for vestibular extension. This is possibly due to the small thickness of the soft tis­sue and close proximity to the bone. In a sh1dy comparing thermal damages of the C0

2 laser vvith those created by electrosurgery in

different types of soft tissue, Pogrel and colleagues5 concluded that the relatively narrow \vidth of vhermal tissue necrosis makes the C0

2 laser excision superior fo r histologic examination of excised

specimens than those created by electrosurgery.

C02

Laser Soft-Tissue Oral Surgery Not all lasers are equally effi cient at both tissue vaporization (ie, ablation, cutting) and coagulation. The difference is illustrated in the absorption spectra for main soft-t issue chromophores10

•11 in Figme

l. Some dental laser wavelengths (approximately 3000 nm, such as erbium lasers) are well absorbed by the water-rich soft tissue and are excellent for ablation but not as effi cient at coagulation. 11 Other dental laser wavelengths (approximately 1,000 nm, such as diode

Volume 37, N umber 9

FIG 2.

Coagulation Depth, H

H, mm

Widespread thermal damage

d iameters

FIG 4 .

Nozzle-to-tissue distance 1 mm-3 mm maintains 260-~m focal-beam

size on the tissue

Coagulation depth of the margins of incision

< 100 ~m

Waveleng th , nm

Width of incision approx . 250-~m depth of incision

is proportional to laser fluence (joules/em')

FIG 3.

Power Density, W fcm2, on Tissue for 0-25-mm Rx:used-Bearu Spot Diameter

FIG 5 .

Sof t-tissue ablation th reshold at 10.6 11m = 3 joules/ em'

Pulse energy density on tissue >20 joules/ em' » 3 jou les/ em '

......__ Laser pulse width approx. 0.25 msec is much shorter than therma l relaxation t ime

I 1.6 msec I ~oft-tissu:

thermal relaxation time

Laser pulse spacing is much greater than thermal . . .. . .................. .. ............... ..

relaxation time for efficient tissue cooling between pulses

0 .5 1.5 2.5 3.5 4.5 5.5 6.5

Time, msec

Incision Depth vs. Handspeed for Handpiece at 4 W Super Pulse F2-3 Setting

1.0

E E 0.8

.s:: 0. Q)

0 0 .6

c 0

0.4 'iii u c

0.2

2

0.4-mm spot size at 5-mm tip-to-tissue distance

~ 2.5 3 3.5 4

Handspeed, mm/ sec

4.5

7.5

5

Fig 2. Coagulation depth spectrum for pulsed laser ablat ion (TR =thermal relaxat ion time). Fig 3. High peak power and short laser-pulse dura· tion of the super p ulse maximizes soft-ti ssue removal rate and limits co llateral damage to the adjacent ti ssue. Fig 4 . Laser-tissue incision w ith focused (0.25-mm spot) laser beam. Defocused beam (approximately 0.8-mm spot with nozzle approximately 10 mm from the ti ssue) wi th reduced fluence coagulates the tissue. Fig 5. Ab latio n depth in water-ri ch soft ti ssue w ith 10-W. 10,600-nm CO, dental laser at 3 W in the super pulse (150 Hz, 26.7 mJ; repea t Fl-6, 20 Hz, 30 m sec) mode.

and Nd:YAG lasers) are efficient at coagulation but inefficient at ablation' 2 because they are poorly absorbed by the soft tissue.

The 10,600-nm CO 2laser wavelength is efficient at vaporizing and

coagulating the soft tissue simultaneously (Figure l), although it does not perform as well as an erbitm1laser at ablation or a diode/ Nd:YAG laser at coagulation. Most importantly, the C02 laser's coagulation depth closely matches the blood capilla.ty dia.tneters, 11 as discussed in Wilder-Smith et al13 a.tld illush·ated in Figure 2.

Laser pulsing is as important as wavelength; for cutting, short and powerful pulses a.t·e superior to long a.t1d weak ones. In the physics of pulsed laser surgery, thermal relaxation time is an important con­cept.u·12 Thermal relaxation time depends both on the tissue's light absorption coefficient (Figure l) and the tissue's thermal diffusivity, as first described by Einstein.14 The irradiated tissue is vaporized

www.dentalaegis.co mj cced

with the highest efficiency if the thermal relaxation time is much longer than the pulse dmation. The most efficient cooling of the tis­sue adjacent to the ablated zone is achieved when the period between laser pulses sig11ificantly exceeds the thermal relaxation time. Such laser pulsing specifications are referred to as a super pulse. A super pulse (Figme 3) minimizes collateral thermal da.tnage, which makes it a.t1 essential featme of any state-of-the-a.tt soft -tissue sm gical C02 laser. 11 The optimal combination ofthe C0

2 laser wavelength and

these specific pulsing pa.t·runeters ensures chat·-free, scm-free, a.tld bloodless sm gery with uncomplicated healing.

Laser Beam Spot Size Just as the sha.t·pness ofthe steel blade defines the quality ru1d ease of the cut for traditional sm gery, the size of the laser beru11 focal spot

ARTICLE REPRfNT - September 2016 COMPENDIUM 3

CONTINUING EDUCATION 1 I LASER VESTIBULOPLASTY

Fig 6. Preoperative view. Strong muscle at tachments extended onto the crest of the r idge. Fig 7. A horizonta l co, laser incision was made across muscle attachments starting at the left second premolar level toward t he ri ght second premolar. Note tension applied to the lower lip. Fig 8. Immediately after t he vest ibular extension procedure with sutu res in place. Fig 9. Two weeks pos topera t ively. Note good healing . Fig 10. Four weeks postoperati ve ly. Note the absence of scarri ng. Fig 11. Final delivery. Patient with new dentures.

4 COMPENDIUM September 2016 - AHTICLE HEP IU NT Volume 37, Number 9

determines the quality of the cut in laser surgery. The smaller (or shm-per) the focal spot of the beam, the nmrower and deeper the inci­sion. A dull blade cmmotproduce a quality incision; similm·ly, an over­sized laser bem11 spot cmmot produce a precise m1d nmrow incision.

For cutting, a 10,600-nm C02 laser is maintained l mm to 3 111111

away from the tissue m1d is moved at a "hand speed" of a few mil­limeters per second (Figure 4). For a rapid switch from cutting to photocoagulation, the laser beam can be defocused. Defocusing cm1 be achieved by simply moving the handpiece away fi·om the tissue (by approrimately lO nun for tip less laser hm1dpieces), and "painting" the "bleeder" for enhm1ced hemostasis (Figure 4).

Laser Power Density and Depth of Incision For a laser, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a traditional scalpel blade. In other words, greater laser flu ence 11 (ie, greater power density, slower hand speed) results in greater depth and rate of soft tissue removal. When repetitive pulses are scanned across the soft tissue, the fluence is defined by the pulse fi·equency and the hm1d­speed; in other words, the depth of incision depends on laser power settings, spot size, m1d the surgeon's hand speed 10•

15 (Figure 5).

Advantages of Soft-Tissue Oral Surgery With a C0

2 Laser

Efficient Hemostasis The C0

2 laser's excellent hemostasis and coagulation (due to the

close match between coagulation depth and gingival blood-vessel diameters) allows practitioners to perform surgery even on ex­tremely vasculm·ized areas. The clinician benefits from improved visibility of the surgical field, which allows for highly precise and accurate tissue removal. Due to the efficient hemostasis, intraoral surgical wounds often do not require suturing or surgical dressing and can be left to heal by secondary intention.'6

Minimal Postoperative Swelling Minimal postoperative swelling and edema can be expected with the C0

2 laser due to the intraoperative closure oflymphaticvessels

on the margins ofthe laser incision. Lymphatic vessels regenerate approximately 8 to 10 days after capi ll ary vessel proliferation. 17

Reduced Postoperative Pain Although pain is generally difficult to evaluate, patients have reported moderate levels of pain with C0

2 laser surgery and

often do not require analges ics.'8 In the study by Niccoli- Filho et al,19 patients reported minimal discomfort only during the first 24 hours after the C02 laser surgery. Based on patient pain perceptions during frenectomies performed with a C0

2 laser,

Haytac and Ozcelic8 concluded that laser trea tment was less painful than when performing the procedure conventionally with a scalpel.

In Neckel's study/ vestibu loplasty was performed on 40 pa­tients, divided into two groups-one rece iving a conventional blade and the other a C02 laser. Both showed a similar increase in the vestib ular height, but patients in t he C0

2 laser gro up re­

ported less pain and discomfort. Strauss and Fallon20 and Deppe

www.de ntalaegis.com/ cced

and Horch2' compared the recovery process following C0

2 laser

surgery, cryosurgery, and electrosurgery and reported healing was faster and less painful with the C02 laser.

Healing and Less Risk of Scarring lVIinimized wound contraction m1el reduced risk for scar formation are mnong the biggest advantages ofC0

2laser smgery.'6•22' 24 Healing

of C02

laser-irradiated wounds is characterized by a higher prolif­eration of fibroblasts that actively produce collagen. The findings of several studies2"""26 indicate that in comparison with scalpel wounds, only a small number ofmyofibroblasts are present in the C0

2 laser

surgical sites; reduced count of myofibroblasts results in minimal wound contraction and scar formation or fibrosis in laser-treated areasY Seventy-two hours after C0

2 laser surgery, the superficial

necrotic layer of the laser-irradiated site is replaced by a fibrose­reus membrane.28•29 Approximately 2 weeks after surgery, wound epithelialization begins fi·om the periphery towm·d the center. The epithelial covering of the laser wound is parakeratotic; it is also thinner than the epithelium that forms after scalpel resection. The aforementioned factors could explain the good cosmesis after C0

2

laser smge1y, which is characterized by smooth, elastic, new tissue and no fibrosis or scarring, whereas conventional surgery cm1 result in some scarring.23 The combination of diminished wound contrac­tion, minimized lateral tissue damage, precise conb·ol over the depth of incision, and excellent hemostatic efficiencymal<es the C0

2 laser

a safe and effective alternative to the use of a traditional scalpel.

Case Presentation A30-year-old patient with Klinefeltersynclrome (KS) requested a com­plete dentme prosthesis. One of the most common chromosomal disor­ders in htm1ans, KS is chm·acterized by hypogonadism and genetically determined infertility.30·3' KS afl'ects only men, occmringin individuals who have two or more X chromosomes (eg, 47,XXY or48,)CXXY instead of 46,)CY). KS is associated with cog11itive disorders, osteoporosis, tau­rodontism, and dentofacial abnormalities.32 In cases of a rm·e vm·iant ofKS(49,XXXXY),permanentdentitionmaybecompletelyabsent.33

The patient was high functioning but had a cognitive develop­mental disorder. Visual examination revealed bilateral microtia and hemifacial nlicrosomia associated with this genetic disorder. He displayed minimal anriety.

Examination and Initial Findings The examination consisted of visual intraoral and extra oral in­spection m1d palpation followed by radiography. The following m·eas were assessed: the presence of soft- or hard-tissue pathologies, the relationships ofthejaws and remaining teeth, the amount and condi­tion of the alveolar bone of soft tissue covering the denture-bearing area, the contour of the alveolm· ridge, vestibulm· depth, and muscle attaclunents.

The examination revealed that the patient's mandibular muscle attachment e>..1:ended on to the crest of the ridge (Figme 6). The muscle fibers created considerable tension. Radiographic findings showed mild alveolm· bone resorption as well. Such muscle place­ment and condition of the bone made the mandibular vestibule space inadequate for substantial denture foundation and inhibited

ARTICLE HEPIU NT - Se ptember 20 16 COMPENDIUM 5

CONTINUING EDUCATION 1 I LASER VESTIBULOPL AST Y

fabrication of a complete denture. The patient's bilateral lingual tori had been previously removed, which provided adequate vestibular height on the lingual side ofthe mandibular ridge. Therefore, lingual vestibular extension was not required. To take a good impression and ensure a comfmtable fit with satisfactory retention and stability of the denture, it was decided to perform buccal-labial vestibular extension with the C02 laser. The crest of the ridge and the soft­tissue condition did not require any grafting.

Procedure Equipment and Anesthesia The procedure was performed in 1 session with a 10-W, 10,600-nm C0

2 dental laser with an angled tip less handpiece.A 27-gauge needle

and 5-0 chromic catgut sutures were used. The laser was set to a focal laser spot of0.25-mm diameter and a power setting of 4 W. A super pulse laser eli.1JOSure mode was used (repeat pulse F2-3, 29Hz, 15 msec, 44% duty cycle), and the average po·wer to tissue was 1.76 W (ie, 44 % of 4 W). Anesthesia consisted of 2 cm·pules of 4% artic­a.ine with 1:100,000 epinephrine and bilateral mental nerve blocks.

Technique The clinician pulled the lower lip outward to maintain tension and facilitate soft-tissue incision. A horizontal C0

2 laser incision

was made starting at the left second premolar area and contin­ued along the mucogingival junction line toward the second premolar of the contralateral side. The clinician made sure to extend the incision to the level of, but not through, the peri­osteum (Figure 7) . Importantly, the trajectory of the incision was parallel to the bone surface. The small penetration depth of the C0

2 laser wavelength enabled the clinician to remove

very thin layers of tissue without collateral thermal changes or mechanical trauma to the adjacent lateral and underlying tissues. Severing thicker muscle fibers required multiple laser passes rather than a single incision.

The small penetration depth is important for the vestibular ex­tension procedure, because it gives the surgeon precise control over the depth of the incision. The surgeon, therefore, is able to deepen the incision until the level of periosteum is reached without inadvertently cutting through it.

The freely movable mucosa flap was then carefully lowered to the level ofthe deepened vestibule and immobilized with resorb­able sutures. The patient did not have a preexisting denture to hold retracted muscle tissue in the desired position. Therefore, the tissues were tacked down, as far apical as possible, using in­dividual sutures. Connecting the suture in a continuous manner was not an option. If one had separated the tissue, it might have folded back. Sutures were left to resorb on their own (Figure 8). No bleeding vvas present, so no additional manipulations of the smgical site were needed.

Postoperative Care The patient was released from the clinic immediately after the procedure and placed on amoxicillin (250 mg four times daily for 10 days) . He was given vitamin E in gel form to place on tissue twice daily using a11 extremely gentle, nonabrasive 12,000-bristle surgical brush. Thepatientwas also given an organic, alcohol-free

6 CO MP E ' DlUM September 2016 - ARTICLE HEP HI NT

irrigation product to debride the area before rinsing it vvith salt water twice daily. Dietary instructions included the restriction of rough or abrasive foods, such as potato chips or crackers.

Follow-up Examinations Follow-up exmnination 2 weeks postoperatively showed good epi­thelialization (Figure 9). Four weeks after the vestibulm· extension procedure, the surgical site had healed completely with smooth pliable tissue and no scarring (Figure 10). Impressions were taken 6 weeks after the surgery.

The vestibule depth increased by 8 mm. The achieved vestibule height allowed for efficient stable denh1re placement (final delive1y is shown in Figure 11). The patient was satisfied with the result.

Conclusion The 10,600-nm C0

2 laser offers munerous advantages over a con­

ventional scalpel m1d other laser wavelengths for soft-tissue pre­prosthetic surge1y, including the vestibular extension procedure. The benefits, which include speed, excellent hemostasis, absence of inflammation, reduced pain, and good patient acceptance, are especially important in patients with various developmental dis­orders, such as in the case reported in this article.

CKNOWLEDGMENT

The authors greatly appreciate the suppmt of and conh·ibution from Alma (AI1ya) Glazkova, PhD, in preparing this material for publication.

BOUT THE AUTHORS

Robert Levine, DDS Director ofLaser Dentist!)\ A rizona School of Dentisll)' & Oral Health, Mesa, A rizona; Founde1; Global Laser Oral Health LLC, Scottsdale, Arizona

Peter Vitruk, PhD, j\1InstP, CPhys, DABLS Founde1; Ligl!tScalpel LLC, Woodinville, Washington; Membe1; Science and Research Committee, Academy of Laser Dentist!)\ Coral Springs, Florida; Faculf); California Implant Jnstilule, San Diego, California; Faculty, Global Laser Oral H ealth LLC, Scottsdale, A rizona

Queries to the authors regarding this course may be submitted to authorqueries@aegiscomm.com.

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www.de ntalaegis.comjcced